Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series.

BACKGROUND: When a new guideline is published there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings. METHODS: Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change. RESULTS: Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location. CONCLUSIONS: The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model. TRIAL REGISTRATION: This study does not report the results of a health care intervention on human participants.

A Reaching Performance Scale for 2 Wolf Motor Function Test Items.

OBJECTIVE: To adapt the Reaching Performance Scale for Stroke (RPSS) for the Wolf Motor Function Test (WMFT) "Lift Can" (Can) and "Hand to Box" (Box) items. DESIGN: Retrospective analysis of video-recorded WMFT assessment performed by 3 raters on 2 occasions. SETTING: Not applicable. PARTICIPANTS: Participants (N=29) with mild to moderate upper extremity impairment less than 3 months after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Inter- and intra-rater agreement, concurrent validity of WMFT-RPSS. RESULTS: Mean ± SD inter-rater Gwet's agreement coefficient (AC2) was 0.61±0.05 for Can WMFT-RPSS and 0.56 (0.03) for Box. Mean ± SD intra-rater AC2 for Can was 0.63±0.05 and 0.70±0.04 for Box. WMFT-RPSS Can and Box scores correlated with log mean WMFT time (C, -0.73; B, -0.48), Functional Ability Scale (C, 0.87; B, 0.62), Upper Extremity Fugl-Meyer Motor Score (C, 0.69; B, 0.51), and item movement rate (C, 0.74; B, 0.71) (P<.05 for all). Mean ± SD WMFT-RPSS score across the 29 participants was 12.7±3.5 for Can (max score, 19) and 11.4±3.0 for Box (max score, 16). CONCLUSIONS: WMFT-RPSS demonstrated moderate intra-rater and weak-to-moderate inter-rater agreement for individuals with mild-moderate impairment. For construct validity, Can and Box WMFT-RPSS were significantly correlated with 4 standardized measures. Average WMFT-RPSS scores revealed that some participants may have relied on compensatory movements to complete the task, a revelation not discernable from movement rate alone. The WMFT-RPSS is potentially useful as a valid and reliable tool to examine longitudinal changes in movement quality after stroke.

Dosage Matters.

Background and Purpose- For stroke rehabilitation, task-specific training in animal models and human rehabilitation trials is considered important to modulate neuroplasticity, promote motor learning, and functional recovery. Little is known about what constitutes an effective dosage of therapy. Methods- This is a parallel group, 4 arms, single-blind, phase IIb, randomized controlled trial of 4 dosages of arm therapy delivered in an outpatient setting chronically after stroke. Participants were randomized into groups that varied in duration of scheduled therapy (ie, 0, 15, 30, or 60 hours). Forty-one participants completed the study. Planned primary analyses used linear mixed effects regression to model changes from baseline to postintervention in the Motor Activity Log-Quality of Movement rating and the Wolf Motor Function Test time score over 3 weeks of training as a function of therapy dosage. Results- We observed a dose response for the Motor Activity Log-Quality of Movement: the model that included dose and dose by week interaction significantly better fit the data than the model that included week only (log-likelihood test, P=0.0026). In addition, the greater the dosage of training, the greater the change in Motor Activity Log-Quality of Movement, with the dose by week interaction parameter equal to 0.0045 ( P=0.0016; 95% CI, 0.0018-0.0071). Over the 3 weeks of therapy, there was a gain of 0.92 in Motor Activity Log-Quality of Movement for the 60-hour group compared to the 0-hour group. There was no dose response for the Wolf Motor Function Test. Conclusions- For mild-to-moderately impaired stroke survivors, the dosage of patient-centered, task-specific practice systematically influences the gain in quality of arm use but not functional capacity. We caution that we may have been underpowered for the functional capacity outcome. These findings highlight the importance of recovery outcomes that capture arm use in the natural environment. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01749358.

Wearable Sensors to Monitor, Enable Feedback, and Measure Outcomes of Activity and Practice.

PURPOSE OF REVIEW: Measurements obtained during real-world activity by wearable motion sensors may contribute more naturalistic accounts of clinically meaningful changes in impairment, activity, and participation during neurologic rehabilitation, but obstacles persist. Here we review the basics of wearable sensors, the use of existing systems for neurological and rehabilitation applications and their limitations, and strategies for future use. RECENT FINDINGS: Commercial activity-recognition software and wearable motion sensors for community monitoring primarily calculate steps and sedentary time. Accuracy declines as walking speed slows below 0.8 m/s, less so if worn on the foot or ankle. Upper-extremity sensing is mostly limited to simple inertial activity counts. Research software and activity-recognition algorithms are beginning to provide ground truth about gait cycle variables and reveal purposeful arm actions. Increasingly, clinicians can incorporate inertial and other motion signals to monitor exercise, activities of daily living, and the practice of specific skills, as well as provide tailored feedback to encourage self-management of rehabilitation. Efforts are growing to create a compatible collection of clinically relevant sensor applications that capture the type, quantity, and quality of everyday activity and practice in known contexts. Such data would offer more ecologically sound measurement tools, while enabling clinicians to monitor and support remote physical therapies and behavioral modification when combined with telemedicine outreach.

Constraining movement reveals motor capability in chronic stroke: an initial study.

OBJECTIVE: To determine if persons with chronic stroke and decreased hip and knee flexion during swing can walk with improved swing-phase kinematics when the task demands constrained gait to the sagittal plane. DESIGN: A one-day, within-subject design comparing gait kinematics under two conditions: Unconstrained treadmill walking and a constrained condition in which the treadmill walking space is reduced to limit limb advancement to occur in the sagittal plane. SETTING: Outpatient physical therapy clinic. SUBJECTS: Eight individuals (mean age, 64.1 ±9.3, 2 F) with mild-moderate paresis were enrolled. MAIN MEASURES: Spatiotemporal gait characteristics and swing-phase hip and knee range of motion during unconstrained and constrained treadmill walking were compared using paired t-test and Cohen's d ( d) to determine effect size. RESULTS: There was a significant, moderate-to-large effect of the constraint on hip flexion ( p < 0.001, d = -1.1) during initial swing, and hip ( p < 0.05, d = -0.8) and knee ( p < 0.001, d = -1.1) flexion during midswing. There was a moderate effect of constraint on terminal swing knee flexion ( p = 0.238, d = -0.6). Immediate and significant changes in step width ( p < 0.05, d = 0.9) and paretic step length ( p < 0.05, d = -0.5) were noted in the constrained condition compared with unconstrained. CONCLUSION: Constraining the treadmill walking path altered the gait patterns among the study's participants. The immediate change during constrained walking suggests that patients with chronic stroke may have underlying movement capability that they do not preferentially utilize.

Structural constraints on learning in the neural network.

Recent research suggests the brain can learn almost any brain-computer interface (BCI) configuration; however, contrasting behavioral evidence from structural learning theory argues that previous experience facilitates, or impedes, future learning. A study by Sadtler and colleagues (Nature 512: 423-426, 2014) used BCI to demonstrate that neural network structural characteristics constrain learning, a finding that might also provide insight into how the brain responds to and recovers after injury.

Early physical rehabilitation dosage in the IntensiveCare Unit predicts hospital outcomes after criticalCOVID-19.

Objective: to examine the relationship between physical rehabilitation parameters including a novel approach to quantifying dosage with hospital outcomes for patients with critical COVID-19. Design: Retrospective practice analysis from March 5, 2020, to April 15, 2021. Setting: Intensive care units (ICU) at four medical institutions. Patients: n = 3,780 adults with ICU admission and diagnosis of COVID-19. Interventions: We measured the physical rehabilitation treatment delivered in ICU and patient outcomes: 1) mortality; 2) discharge disposition; and 3) physical function at hospital discharge measured by the Activity Measure-Post Acute Care (AM-PAC) "6-Clicks" (6-24, 24=greater functional independence). Physical rehabilitation dosage was defined as the average mobility level scores in the first three sessions (a surrogate measure of intensity) multiplied by the rehabilitation frequency (PT + OT frequency in hospital). Measurements and Main Results: The cohort was a mean 64 ± 16 years old, 41% female, mean BMI of 32 ± 9 kg/m2 and 46% (n=1739) required mechanical ventilation. For 2191 patients with complete data, rehabilitation dosage and AM-PAC at discharge were moderately, positively associated (Spearman's rho [r] = 0.484, p < 0.001). Multivariate linear regression (model adjusted R2= 0.68, p <0.001) demonstrates mechanical ventilation (ß = -0.86, p = 0.001), average mobility score in first three sessions (ß = 2.6, p <0.001) and physical rehabilitation dosage (ß = 0.22, p = 0.001) were predictive of AM-PAC scores at discharge when controlling for age, sex, BMI, and ICU LOS. Conclusions: Greater physical rehabilitation exposure early in the ICU is associated with physical function at hospital discharge.

Activation of the aryl hydrocarbon receptor inhibits neuropilin-1 upregulation on IL-2-responding CD4+ T cells.

Neuropilin-1 (Nrp1), a transmembrane protein expressed on CD4+ T cells, is mostly studied in the context of regulatory T cell (Treg) function. More recently, there is increasing evidence that Nrp1 is also highly expressed on activated effector T cells and that increases in these Nrp1-expressing CD4+ T cells correspond with immunopathology across several T cell-dependent disease models. Thus, Nrp1 may be implicated in the identification and function of immunopathologic T cells. Nrp1 downregulation in CD4+ T cells is one of the strongest transcriptional changes in response to immunoregulatory compounds that act though the aryl hydrocarbon receptor (AhR), a ligand-activated transcription factor. To better understand the link between AhR and Nrp1 expression on CD4+ T cells, Nrp1 expression was assessed in vivo and in vitro following AhR ligand treatment. In the current study, we identified that the percentage of Nrp1 expressing CD4+ T cells increases over the course of activation and proliferation in vivo. The actively dividing Nrp1+Foxp3- cells express the classic effector phenotype of CD44hiCD45RBlo, and the increase in Nrp1+Foxp3- cells is prevented by AhR activation. In contrast, Nrp1 expression is not modulated by AhR activation in non-proliferating CD4+ T cells. The downregulation of Nrp1 on CD4+ T cells was recapitulated in vitro in cells isolated from C57BL/6 and NOD (non-obese diabetic) mice. CD4+Foxp3- cells expressing CD25, stimulated with IL-2, or differentiated into Th1 cells, were particularly sensitive to AhR-mediated inhibition of Nrp1 upregulation. IL-2 was necessary for AhR-dependent downregulation of Nrp1 expression both in vitro and in vivo. Collectively, the data demonstrate that Nrp1 is a CD4+ T cell activation marker and that regulation of Nrp1 could be a previously undescribed mechanism by which AhR ligands modulate effector CD4+ T cell responses.

Activation of the aryl hydrocarbon receptor inhibits neuropilin-1 upregulation on IL-2 responding CD4 + T cells.

Neuropilin-1 (Nrp1), a transmembrane protein expressed on CD4 + T cells, is mostly studied in the context of regulatory T cell (Treg) function. More recently, there is increasing evidence that Nrp1 is also highly expressed on activated effector T cells and that increases in these Nrp1-expressing CD4 + T cells correspond with immunopathology across several T cell-dependent disease models. Thus, Nrp1 may be implicated in the identification and function of immunopathologic T cells. Nrp1 downregulation in CD4 + T cells is one of the strongest transcriptional changes in response to immunoregulatory compounds that act though the aryl hydrocarbon receptor (AhR), a ligand-activated transcription factor. To better understand the link between AhR and Nrp1 expression on CD4 + T cells, Nrp1 expression was assessed in vivo and in vitro following AhR ligand treatment. In the current study, we identified that the percentage of Nrp1 expressing CD4 + T cells increases over the course of activation and proliferation in vivo . The actively dividing Nrp1 + Foxp3 - cells express the classic effector phenotype of CD44 hi CD45RB lo , and the increase in Nrp1 + Foxp3 - cells is prevented by AhR activation. In contrast, Nrp1 expression is not modulated by AhR activation in non-proliferating CD4 + T cells. The downregulation of Nrp1 on CD4 + T cells was recapitulated in vitro in cells isolated from C57BL/6 and NOD (non-obese diabetic) mice. CD4 + Foxp3 - cells expressing CD25, stimulated with IL-2, or differentiated into Th1 cells, were particularly sensitive to AhR-mediated inhibition of Nrp1 upregulation. IL-2 was necessary for AhR-dependent downregulation of Nrp1 expression both in vitro and in vivo . Collectively, the data demonstrate that Nrp1 is a CD4 + T cell activation marker and that regulation of Nrp1 could be a previously undescribed mechanism by which AhR ligands modulate effector CD4 + T cell responses.

Human adipose and skeletal muscle tissue DNA, RNA, and protein content.

The purpose of this project was to provide a profile of DNA, RNA, and protein content in adipose tissue, which is relatively understudied in humans, to gain more insight into the amount of tissue that may be required for various analyses. Skeletal muscle tissue was also investigated to provide a direct comparison into potential differences between these two highly metabolically active tissues. Basal adipose and skeletal muscle tissue samples were obtained from 10 (7 M, 3 W) recreationally active participants [25 ± 1 yr; 84 ± 3 kg, maximal oxygen consumption (V̇o2max): 3.5 ± 0.2 L/min, body fat: 29 ± 2%]. DNA, RNA, and protein were extracted and subsequently analyzed for quantity and quality. DNA content of adipose and skeletal muscle tissue was 52 ± 14 and 189 ± 44 ng DNA·mg tissue-1, respectively (P < 0.05). RNA content of adipose and skeletal muscle tissue was 46 ± 14 and 537 ± 72 ng RNA·mg tissue-1, respectively (P < 0.05). Protein content of adipose and skeletal muscle tissue was 4 ± 1 and 177 ± 10 µg protein·mg tissue-1, respectively (P < 0.05). In summary, human adipose had 28% of the DNA, 9% of the RNA, and 2% of the protein found in skeletal muscle per mg of tissue. This information should be useful across a wide range of human clinical investigation designs and various laboratory analyses.NEW & NOTEWORTHY This investigation studied DNA, RNA, and protein contents of adipose and skeletal muscle tissues from young active individuals. A series of optimization steps were investigated to aid in determining the optimal approach to extract high-yield and high-quality biomolecules. These findings contribute to the knowledge gap in adipose tissue requirements for molecular biology assays, which is of increasing importance due to the growing interest in adipose tissue research involving human exercise physiology research.

Development of a novel imaging informatics-based system with an intelligent workflow engine (IWEIS) to support imaging-based clinical trials.

Imaging based clinical trials can benefit from a solution to efficiently collect, analyze, and distribute multimedia data at various stages within the workflow. Currently, the data management needs of these trials are typically addressed with custom-built systems. However, software development of the custom-built systems for versatile workflows can be resource-consuming. To address these challenges, we present a system with a workflow engine for imaging based clinical trials. The system enables a project coordinator to build a data collection and management system specifically related to study protocol workflow without programming. Web Access to DICOM Objects (WADO) module with novel features is integrated to further facilitate imaging related study. The system was initially evaluated by an imaging based rehabilitation clinical trial. The evaluation shows that the cost of the development of system can be much reduced compared to the custom-built system. By providing a solution to customize a system and automate the workflow, the system will save on development time and reduce errors especially for imaging clinical trials.