Feasibility and Validity of the Coma Recovery Scale-Revised for Accelerated Standardized Testing: A Practical Assessment Tool for Detecting Consciousness in the Intensive Care Unit.

We developed and validated an abbreviated version of the Coma Recovery Scale-Revised (CRS-R), the CRS-R For Accelerated Standardized Testing (CRSR-FAST), to detect conscious awareness in patients with severe traumatic brain injury in the intensive care unit. In 45 consecutively enrolled patients, CRSR-FAST administration time was approximately one-third of the full-length CRS-R (mean [SD] 6.5 [3.3] vs 20.1 [7.2] minutes, p < 0.0001). Concurrent validity (simple kappa 0.68), test-retest (Mak's ρ = 0.76), and interrater (Mak's ρ = 0.91) reliability were substantial. Sensitivity, specificity, and accuracy for detecting consciousness were 81%, 89%, and 84%, respectively. The CRSR-FAST facilitates serial assessment of consciousness, which is essential for diagnostic and prognostic accuracy. ANN NEUROL 2023;94:919-924.

Cognitive Demands Influence Upper Extremity Motor Performance During Recovery From Acute Stroke.

OBJECTIVE: To test the hypothesis that cognitive demands influence motor performance during recovery from acute stroke, we tested patients with acute stroke on 2 motor tasks with different cognitive demands and related task performance to cognitive impairment and neuroanatomic injury. METHODS: We assessed the contralesional and ipsilesional upper extremities of a cohort of 50 patients with weakness after unilateral acute ischemic stroke at 3 time points with 2 tasks: the Box & Blocks Test, a task with greater cognitive demand, and Grip Strength, a simple and ballistic motor task. We compared performance on the 2 tasks, related motor performance to cognitive dysfunction, and used voxel-based lesion symptom mapping to determine neuroanatomic sites associated with motor performance. RESULTS: Consistent across contralesional and ipsilesional upper extremities and most pronounced immediately after stroke, Box & Blocks scores were significantly more impaired than Grip Strength scores. The presence of cognitive dysfunction significantly explained up to 33% of variance in Box & Blocks performance but was not associated with Grip Strength performance. While Grip Strength performance was associated with injury largely restricted to sensorimotor regions, Box & Blocks performance was associated with broad injury outside sensorimotor structures, particularly the dorsal anterior insula, a region known to be important for complex cognitive function. CONCLUSIONS: Together, these results suggest that cognitive demands influence upper extremity motor performance during recovery from acute stroke. Our findings emphasize the integrated nature of motor and cognitive systems and suggest that it is critical to consider cognitive demands during motor testing and neurorehabilitation after stroke.

Arm Motor Recovery After Ischemic Stroke: A Focus on Clinically Distinct Trajectory Groups.

BACKGROUND AND PURPOSE: Recovery of arm function poststroke is highly variable with some people experiencing rapid recovery but many experiencing slower or limited functional improvement. Current stroke prediction models provide some guidance for clinicians regarding expected motor outcomes poststroke but do not address recovery rates, complicating discharge planning. This study developed a novel approach to defining recovery groups based on arm motor recovery trajectories poststroke. In addition, between-group differences in baseline characteristics and therapy hours were explored. METHODS: A retrospective cohort analysis was conducted where 40 participants with arm weakness were assessed 1 week, 6 weeks, 3 months, and 6 months after an ischemic stroke. Arm recovery trajectory groups were defined on the basis of timing of changes in the Fugl-Meyer Assessment Upper Extremity (FMA-UE), at least the minimal clinically important difference (MCID), 1 week to 6 weeks or 6 weeks to 6 months. Three recovery trajectory groups were defined: Fast (n = 19), Extended (n = 12), and Limited (n = 9). Between-group differences in baseline characteristics and therapy hours were assessed. Associations between baseline characteristics and group membership were also determined. RESULTS: Three baseline characteristics were associated with trajectory group membership: FMA-UE, NIH Stroke Scale, and Barthel Index. The Fast Recovery group received the least therapy hours 6 weeks to 6 months. No differences in therapy hours were observed between Extended and Limited Recovery groups at any time points. DISCUSSION AND CONCLUSIONS: Three clinically relevant recovery trajectory groups were defined using the FMA-UE MCID. Baseline impairment, overall stroke severity, and dependence in activities of daily living were associated with group membership and therapy hours differed between groups. Stratifying individuals by recovery trajectory early poststroke could offer additional guidance to clinicians in discharge planning.(See Supplemental Digital Content 1 for Video Abstract, available at: http://links.lww.com/JNPT/A337.).

Corticospinal Tract Injury Estimated From Acute Stroke Imaging Predicts Upper Extremity Motor Recovery After Stroke.

Background and Purpose- Injury to the corticospinal tract (CST) has been shown to have a major effect on upper extremity motor recovery after stroke. This study aimed to examine how well CST injury, measured from neuroimaging acquired during the acute stroke workup, predicts upper extremity motor recovery. Methods- Patients with upper extremity weakness after ischemic stroke were assessed using the upper extremity Fugl-Meyer during the acute stroke hospitalization and again at 3-month follow-up. CST injury was quantified and compared, using 4 different methods, from images obtained as part of the stroke standard-of-care workup. Logistic and linear regression were performed using CST injury to predict ΔFugl-Meyer. Injury to primary motor and premotor cortices were included as potential modifiers of the effect of CST injury on recovery. Results- N=48 patients were enrolled 4.2±2.7 days poststroke and completed 3-month follow-up (median 90-day modified Rankin Scale score, 3; interquartile range, 1.5). CST injury distinguished patients who reached their recovery potential (as predicted from initial impairment) from those who did not, with area under the curve values ranging from 0.70 to 0.8. In addition, CST injury explained ≈20% of the variance in the magnitude of upper extremity recovery, even after controlling for the severity of initial impairment. Results were consistent when comparing 4 different methods of measuring CST injury. Extent of injury to primary motor and premotor cortices did not significantly influence the predictive value that CST injury had for recovery. Conclusions- Structural injury to the CST, as estimated from standard-of-care imaging available during the acute stroke hospitalization, is a robust way to distinguish patients who achieve their predicted recovery potential and explains a significant amount of the variance in poststroke upper extremity motor recovery.

The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective.

BACKGROUND: Motor functional neurologic disorders (FND)-previously termed "hysteria" and later "conversion disorder"-are exceedingly common and frequently encountered in the acute hospital setting. Despite their high prevalence, patients with motor FND can be challenging to diagnose accurately and manage effectively. To date, there is limited guidance on the inpatient approach to the neuropsychiatric evaluation of patients with functional (psychogenic) neurologic symptoms. OBJECTIVE: The authors outline an inpatient multidisciplinary approach, involving neurology, psychiatry, and physical therapy, for the assessment and acute inpatient management of motor FND. METHODS: A vignette of a patient with motor FND is presented followed by a discussion of general assessment principles. Thereafter, a detailed description of the neurologic and psychiatric assessments is outlined. Delivery of a "rule-in" diagnosis is emphasized and specific guidance for what can be accomplished postdiagnosis in the hospital is suggested. DISCUSSION: We encourage an interdisciplinary approach beginning at the early stages of the diagnostic assessment once an individual is suspected of having motor FND. CONCLUSIONS: Practical suggestions for the inpatient assessment of motor FND are presented. It is also important to individualize the diagnostic assessment. Future research should be conducted to test best practices for motor FND management in the acute inpatient hospital setting.

Physical therapist practice in the emergency department observation unit: descriptive study.

BACKGROUND: An upward trend in the number of hospital emergency department (ED) visits frequently results in ED overcrowding. The concept of the emergency department observation unit (EDOU) was introduced to allow patients to transfer out of the ED and remain under observation for up to 24 hours before making a decision regarding the appropriate disposition. No study has yet been completed to describe physical therapist practice in the EDOU. OBJECTIVE: The objectives of this study were: (1) to describe patient demographics, physical therapist management and utilization, and discharge dispositions of patients receiving physical therapy in the EDOU and (2) to describe these variables according to the most frequently occurring diagnostic groups. DESIGN: This was a descriptive study of patients who received physical therapist services in the EDOU of Massachusetts General Hospital during the months of March, May, and August 2010. METHODS: Data from 151 medical records of patients who received physical therapist services in the EDOU were extracted. Variables consisted of patient characteristics, medical and physical therapist diagnoses, and physical therapist management and utilization derived from billing data. Descriptive statistics were used to analyze data. RESULTS: The leading EDOU medical diagnoses of individuals receiving physical therapist services included people with falls without fracture (n=30), back pain (n=27), falls with fracture (n=22), and dizziness (n=22). There were significant differences in discharge disposition, age, and total physical therapy time among groups. LIMITATIONS: This was a retrospective study, so there was no ability to control how data were recorded. CONCLUSIONS: This study provides information on common patient groups seen in the EDOU, physical therapist service utilization, and discharge disposition that may guide facilities in anticipated staffing needs associated with providing physical therapist services in the EDOU.

Perspective from the practice committee: is autonomous practice in neurologic physical therapy defined differently based on the type of practice setting?

The answer to the question, "Is autonomous practice in neurologic physical therapy defined differently based on the type of practice setting?" is no. Autonomous practice is a characteristic of the physical therapist, embodying excellence, communication and collaboration, and advocacy and caring. It is our belief that many physical therapists already practice autonomously, even though they may not recognize their practice as being autonomous; and it is our hope that physical therapists who are functioning as autonomous practitioners will provide peer mentoring to help bring their colleagues to the same level of practice and the same recognition. The full position statement on autonomous practice is available on the Neurology Section Web site at http://www.neuropt.org/go/healthcareprofessionals/autonomous-practice.

Perspective: impact of the IIISTEP conference on clinical practice.

In July 2005, physical therapy clinicians, educators, and researchers gathered for the IIISTEP (Symposium on Translating Evidence to Practice) conference. The purpose of IIISTEP was to link research and clinical practice through the exchange of ideas and research findings between scientists and clinicians. This paper represents the personal perspective of a group of colleagues who attended IIISTEP as clinicians/educator teams. The purpose of this paper is to illustrate how information from IIISTEP has challenged our existing concepts regarding physical therapy practice and begun to alter our clinical practice. Some key concepts presented by scientists and clinicians at IIISTEP are reviewed including current perspectives on neuroplasticity and frameworks for considering function, health, and the disablement process. Considerations for clinical application are outlined. Patient cases are used to illustrate how integration of this information has altered our approach to patient management.