Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation.

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Back on the Road: Comparing Cognitive Assessments to Driving Simulators in Moderate to Severe Traumatic Brain Injuries.

Objective: To compare established clinical outcome assessments for predicting behind the wheel driving readiness and driving simulator results across age groups and in traumatic brain injury. Methods: Participants included adults who had a traumatic brain injury ranging in age from 31 to 57 years and a non-impaired adult population ranging in age from 18 to 80 years. Physical and cognitive outcomes measures were collected included range of motion and coordination, a "Rules of the Road Test" a "Sign Identification Test," Trails A and B, and the clock drawing test. Visual measures included the Dynavision D2 system and motor-free visual perceptual test-3 (MVPT-3). Finally, the driving simulators (STIÒ version M300) metro drive assessment was used, which consisted of negotiating several obstacles in a metropolitan area including vehicles abruptly changing lanes, pedestrians crossing streets, and negotiating construction zones. Results: Our findings suggest that the standard paper-pencil cognitive assessments and sign identification test significantly differentiate TBI from a non-impaired population (Trails A, B and Clock drawing test p < 0.001). While the driving simulator did not show as many robust differences with age, the TBI population did have a significantly greater number of road collisions (F3, 78 = 3.5, p = 0.02). We also observed a significant correlation between the cognitive assessments and the simulator variables. Conclusions: Paper-pencil cognitive assessments and the sign identification test highlight greater differences than the STI Driving Simulator between non-impaired and TBI populations. However, the driving simulator may be useful in assessing cognitive ability and training for on the road driving.

Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains.

PURPOSE: The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF). MATERIALS AND METHODS: The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data. RESULTS: There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model. CONCLUSIONS: The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.

Bounce-Back: Predicting Acute Readmission From Inpatient Rehabilitation for Patients With Stroke.

OBJECTIVE: The aim of the study was to identify demographic, medical, and functional risk factors for discharge to an acute hospital before completion of an inpatient rehabilitation program and 7- and 30-day readmissions after completion of an inpatient rehabilitation program. DESIGN: This cohort study included 138,063 fee-for-service Medicare beneficiaries with a primary diagnosis of new onset stroke discharged from an inpatient rehabilitation facility from June 2009 to December 2011. Multivariate models examined readmission outcomes and included data from 6 mos before onset of the stroke to 30 days after discharge from the inpatient rehabilitation facility. RESULTS: In the acute discharge model (n = 9870), comorbidities and complications added risk, and the longer the stroke onset to admission to inpatient rehabilitation facility, the more likely discharge to the acute hospital. In the 7-day (n = 4755) and 30-day (n = 9861) readmission models, patients who were more complex with comorbidities, were black, or had managed care Medicare were more likely to have a readmission. Functional status played a role in all three models. CONCLUSIONS: Results suggest that certain demographic, medical, and functional characteristics are associated differentially with rehospitalization after completion inpatient rehabilitation. The strongest model was the discharge to the acute hospital model with concordance statistic (c-statistic) of 0.87.

Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery.

OBJECTIVE: To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature. DATA SOURCES: Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA. STUDY SELECTION: Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded. DATA EXTRACTION: Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer. DATA SYNTHESIS: Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms. CONCLUSIONS: Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.

Preservation of Partially Mixed Selectivity in Human Posterior Parietal Cortex across Changes in Task Context.

Recent studies in posterior parietal cortex (PPC) have found multiple effectors and cognitive strategies represented within a shared neural substrate in a structure termed "partially mixed selectivity" (Zhang et al., 2017). In this study, we examine whether the structure of these representations is preserved across changes in task context and is thus a robust and generalizable property of the neural population. Specifically, we test whether the structure is conserved from an open-loop motor imagery task (training) to a closed-loop cortical control task (online), a change that has led to substantial changes in neural behavior in prior studies in motor cortex. Recording from a 4 × 4 mm electrode array implanted in PPC of a human tetraplegic patient participating in a brain-machine interface (BMI) clinical trial, we studied the representations of imagined/attempted movements of the left/right hand and compare their individual BMI control performance using a one-dimensional cursor control task. We found that the structure of the representations is largely maintained between training and online control. Our results demonstrate for the first time that the structure observed in the context of an open-loop motor imagery task is maintained and accessible in the context of closed-loop BMI control. These results indicate that it is possible to decode the mixed variables found from a small patch of cortex in PPC and use them individually for BMI control. Furthermore, they show that the structure of the mixed representations is maintained and robust across changes in task context.

Intrinsic Variable Learning for Brain-Machine Interface Control by Human Anterior Intraparietal Cortex.

Although animal studies provided significant insights in understanding the neural basis of learning and adaptation, they often cannot dissociate between different learning mechanisms due to the lack of verbal communication. To overcome this limitation, we examined the mechanisms of learning and its limits in a human intracortical brain-machine interface (BMI) paradigm. A tetraplegic participant controlled a 2D computer cursor by modulating single-neuron activity in the anterior intraparietal area (AIP). By perturbing the neuron-to-movement mapping, the participant learned to modulate the activity of the recorded neurons to solve the perturbations by adopting a target re-aiming strategy. However, when no cognitive strategies were adequate to produce correct responses, AIP failed to adapt to perturbations. These findings suggest that learning is constrained by the pre-existing neuronal structure, although it is possible that AIP needs more training time to learn to generate novel activity patterns when cognitive re-adaptation fails to solve the perturbations.

Partially Mixed Selectivity in Human Posterior Parietal Association Cortex.

To clarify the organization of motor representations in posterior parietal cortex, we test how three motor variables (body side, body part, cognitive strategy) are coded in the human anterior intraparietal cortex. All tested movements were encoded, arguing against strict anatomical segregation of effectors. Single units coded for diverse conjunctions of variables, with different dimensions anatomically overlapping. Consistent with recent studies, neurons encoding body parts exhibited mixed selectivity. This mixed selectivity resulted in largely orthogonal coding of body parts, which "functionally segregate" the effector responses despite the high degree of anatomical overlap. Body side and strategy were not coded in a mixed manner as effector determined their organization. Mixed coding of some variables over others, what we term "partially mixed coding," argues that the type of functional encoding depends on the compared dimensions. This structure is advantageous for neuroprosthetics, allowing a single array to decode movements of a large extent of the body.

Use of an algorithm for assessment and treatment of the upper extremity post stroke: a case study.

The objective of this study was to identify movement impairments and plan effective treatments using an evidence-based algorithm. A single subject case study was completed to demonstrate the application of the Neurologic Upper Extremity Recovery Algorithm (NUERA), which integrates the analysis of patient alignment, along with movement of the trunk, ribcage and scapula. The Action Research Arm Test (ARAT) was used for standardized assessment and to assist in analyzing the patient's movement along with the nonstandardized clinicians assessment of movement. Using the NUERA, the patient's upper extremity control improved as demonstrated by a 78% improvement in the ARAT score from a 27 at initial assessment to 48 (57 possible) following 2 months of treatment, along with the achievement of the patient's goals. Use of the NUERA for the assessment and treatment of the upper extremity poststroke has promising utility.