Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems.

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.

Detecting early recovery of consciousness: a comparison of methods.

Early detection of the return of consciousness has important implications for prognosis and rehabilitation access. The aim of this study was to compare the Coma Recovery Scale-Revised (CRS-R) with individualised quantitative behavioural assessments (IQBA) to determine which method is capable of detecting command-following earlier and more consistently in persons with disorders of consciousness (DoC). Data from 27 patients with DoC, who underwent both assessments concurrently during inpatient rehabilitation, were retrospectively analysed. For each person, performance trajectories on the CRS-R auditory subscale item and IQBA dual command protocols were graphed together to identify earlier and more consistent evidence of consciousness; grouped data were analysed statistically. For 22 patients, IQBA more consistently documented consciousness than the CRS-R, whereas no patients showed the reverse pattern. For 14 of 20 analysable patients, IQBA provided earlier evidence of consciousness, for two patients CRS-R provided earlier evidence, and for four patients both methods provided initial evidence on the same day. These findings suggest that IQBA approaches can provide more consistent and earlier evidence of command-following than the comparable item on the CRS-R. Whether this advantage is due to the individualisation of IQBA or the greater volume of data gathered requires further research.

Gender, bullying victimization, and education.

School bullying has detrimental consequences for its victims, including undermining students' educational outcomes. Furthermore, gender has been shown to play a significant role in determining the type of bullying victimization experienced and educational outcomes. This research examines whether an interaction between gender and bullying victimization exists as well as its impact on educational outcomes (i.e., academic self-efficacy and educational achievement). Multivariate regression analyses, drawing on the Educational Longitudinal Study of 2002, reveal that the interaction between gender and bullying victimization is linked to disparate educational outcomes. The findings and their implications are discussed regarding understanding the relationship between gender, bullying victimization, and education.

The 4-Element Movement System Model to Guide Physical Therapist Education, Practice, and Movement-Related Research.

The movement system has been adopted as the key identity for the physical therapy profession, and recognition of physical therapists' primary expertise in managing movement dysfunction is an important achievement. However, existing movement system models seem inadequate for guiding education, practice, or research. Lack of a clear, broadly applicable model may hamper progress in physical therapists actually adopting this identity. We propose a model composed of 4 primary elements essential to all movement: motion, force, energy, and control. Although these elements overlap and interact, they can each be examined and tested with some degree of specificity. The proposed 4-element model incorporates specific guidance for visual, qualitative assessment of movement during functional tasks that can be used to develop hypotheses about movement dysfunction and serve as a precursor to more quantitative tests and measures. Human movement always occurs within an environmental context and is affected by personal factors, and these concepts are represented within the model. The proposed scheme is consistent with other widely used models within the profession, such as the International Classification of Functioning, Disability and Health and the Patient Management Model. We demonstrate with multiple examples how the model can be applied to a broad spectrum of patients across the lifespan with musculoskeletal, neurologic, and cardiopulmonary disorders.

Adaptation of postural responses during different standing perturbation conditions in individuals with incomplete spinal cord injury.

Incomplete spinal cord injury (ISCI) frequently disrupts afferent and efferent neural pathways underlying co-requisite voluntary and involuntary muscle activation required for functional standing and walking. To understand involuntary postural control mechanisms necessary for standing, we compared eight individuals with ISCI to eight controls with no impairment. The aim of this study was to investigate anticipatory and reactive balance responses in individuals with ISCI. The ability to adapt to changes in balance conditions was assessed by monitoring automatic postural responses (APRs) during a series of expected and unexpected changes in perturbation direction (backward translation versus toes-up rotation). Both groups were able to modulate appropriately within one or two trials following an unexpected change in condition. Onset times of anterior tibialis and medial gastrocnemius (MG) were significantly slower in the ISCI group during expected and unexpected conditions. These findings demonstrate that persons with mild to moderate lower extremity sensorimotor deficits are able to generate and adapt APRs to a rapid and unexpected contextual change during a simple standing balance task.

Foot placement variability as a walking balance mechanism post-spinal cord injury.

BACKGROUND: Spinal cord injury affects walking balance control, which necessitates methods to quantify balance ability. The purposes of this study were to 1) examine walking balance through foot placement variability post-injury; 2) assess the relationship between measures of variability and clinical balance assessments; and 3) determine if spatial parameter variability might be used as a clinical correlate for more complex balance measurements. METHODS: Ten persons with spinal cord injury walked without devices on a split-belt treadmill at self-selected speeds. Ten healthy controls walked at 0.3 and 0.6m/s for comparison. Variability of step width and length, anteroposterior and mediolateral foot placements relative to center-of-mass, and margin-of-stability were calculated. Clinical assessments included Berg Balance Scale and Dynamic Gait Index. FINDINGS: Participants with spinal cord injury demonstrated significantly different variability in all biomechanical measures compared to controls (P ≤ 0.007). Berg Balance Scale scores were significantly inversely associated with step length as well as anteroposterior and mediolateral foot placement variability (P ≤ 0.05). Dynamic Gait Index scores were significantly inversely associated with mediolateral foot placement variability (P ≤ 0.05). Participants with spinal cord injury showed significant correlations between spatial parameter variability and all other measures (P ≤ 0.005), except between step length and margin-of-stability (P=0.068); controls revealed fewer correlations. INTERPRETATION: Persons post-spinal cord injury exhibit an abnormal amount of stepping variability when challenged to walk without devices, yet preserve the ability to avoid falling. When complex laboratory measures of variability are unavailable clinically, spatial parameter variability or standardized balance assessments may be plausible indicators of walking balance control.