Conducting Implementation Research in Stroke Rehabilitation: A Case Example and Considerations for Study Design.

As neurorehabilitation research continues to grow, the field must ensure its scientific discoveries are implemented into routine clinical care. Without targeted efforts to increase the implementation of evidence into practice, patients may never see the benefits of interventions, assessments, and technologies developed in the confines of empirical studies. This article serves as a response to Lynch et al's 2018 Point of View piece in Neurorehabilitation and Neural Repair that underscored the urgent need for implementation studies to expedite the application of neurorehabilitation evidence in practice. To address this need, we provide the following 4 considerations investigators should contemplate when designing their own studies at the intersection of implementation and neurorehabilitation research: (a) consideration of guiding theories, models, and frameworks, (b) consideration of implementation strategies, (c) considerations of target outcomes, and (d) consideration of hybrid effectiveness-implementation designs. To conclude, we also provide a study exemplar to depict how these considerations can be integrated into the neurorehabilitation research field to narrow the evidence-to-practice gap.

Constraint-Induced Movement Therapy for Cerebral Palsy: A Randomized Trial.

OBJECTIVES: With the Children with Hemiparesis Arm and Hand Movement Project (CHAMP) multisite factorial randomized controlled trial, we compared 2 doses and 2 constraint types of constraint-induced movement therapy (CIMT) to usual customary treatment (UCT). METHODS: CHAMP randomly assigned 118 2- to 8-year-olds with hemiparetic cerebral palsy to one of 5 treatments with assessments at baseline, end of treatment, and 6 months posttreatment. Primary blinded outcomes were the assisting hand assessment; Peabody Motor Development Scales, Second Edition, Visual Motor Integration; and Quality of Upper Extremity Skills Test Dissociated Movement. Parents rated functioning on the Pediatric Evaluation of Disabilities Inventory-Computer Adaptive Test Daily Activities and Child Motor Activity Log How Often scale. Analyses were focused on blinded and parent-report outcomes and rank-order gains across all measures. RESULTS: Findings varied in statistical significance when analyzing individual blinded outcomes. parent reports, and rank-order gains. Consistently, high-dose CIMT, regardless of constraint type, produced a pattern of greatest short- and long-term gains (1.7% probability of occurring by chance alone) and significant gains on visual motor integration and dissociated movement at 6 months. O'Brien's rank-order analyses revealed high-dose CIMT produced significantly greater improvement than a moderate dose or UCT. All CIMT groups improved significantly more in parent-reported functioning, compared with that of UCT. Children with UCT also revealed objective gains (eg, 48% exceeded the smallest-detectable assisting hand assessment change, compared with 71% high-dose CIMT at the end of treatment). CONCLUSIONS: CHAMP provides novel albeit complex findings: although most individual blinded outcomes fell below statistical significance for group differences, high-dose CIMT consistently produced the largest improvements at both time points. An unexpected finding concerns shifts in UCT toward higher dosages, with improved outcomes compared with previous reports.

Effects of a Specialized Primary Care Facility on Preventive Service Use Among Autistic Adults: a Retrospective Claims Study.

BACKGROUND: While in some studies, the patient-centered medical home has been linked with increased receipt of preventive services among other populations, there is a paucity of literature testing the effectiveness of medical homes in serving the healthcare needs of autistic adults. OBJECTIVE: To compare the receipt of preventive services by patients at a patient-centered medical home specifically designed for autistic adults (called the Center for Autism Services and Transition "CAST") to US national samples of autistic adults with private insurance or Medicare. DESIGN: Retrospective study of medical billing data. SAMPLE: The study sample included CAST patients (N = 490) who were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years old, 79% were male, and the median duration of observation was 2.2 years. MAIN MEASURES: The primary outcome measure was the receipt of any preventive service, as defined by the Medicare Learning Network and AAPC (formerly the American Academy of Professional Coders). Secondary outcome measures included receipt of specific preventive service types (i.e., general health and wellness services, screenings, counseling and therapies, vaccinations, and sexual/reproductive health services). KEY RESULTS: CAST patients had significantly greater odds of receiving any preventive service than Medicare-enrolled (OR = 10.3; 95% CI = 7.6-13.9) and privately insured (OR = 3.1; 95% CI = 2.3-4.2) autistic adults. CAST patients were also significantly more likely to receive screenings and vaccinations than either Medicare beneficiaries (screenings OR = 20.3; 95% CI = 14.7-28.0; vaccinations OR = 5.5; 95% CI = 4.3-7.0) or privately insured beneficiaries (screenings OR = 2.0; 95% CI = 1.6-2.5; vaccinations OR = 3.3; 95% CI = 2.6-4.1). CONCLUSIONS: Autistic adults receiving care through CAST were significantly more likely to recieve preventive care services than national samples of autistic adults. Future comparative effectiveness trials are needed to rigorously assess the impact of primary care-based initiatives to improve care for autistic adults.

Specialized primary care medical home: A positive impact on continuity of care among autistic adults.

LAY ABSTRACT: There is a nationally recognized need for innovative healthcare delivery models to improve care continuity for autistic adults as they age out of pediatric and into adult healthcare systems. One possible model of care delivery is called the "medical home". The medical home is not a residential home, but a system where a patient's healthcare is coordinated through a primary care physician to ensure necessary care is received when and where the patient needs it. We compared the continuity of care among autistic adult patients at a specialized primary care medical home designed to remove barriers to care for autistic adults, called the CAST, to matched national samples of autistic adults with private insurance or Medicare. Continuity of primary care among CAST patients was significantly better than that of matched national samples of autistic adult Medicare beneficiaries and similar to that of privately insured autistic adults. Our findings suggest that medical homes, like CAST, are a promising solution to improve healthcare delivery for the growing population of autistic adults.

Patient and caregiver experiences at a specialized primary care center for autistic adults.

Background: Little is known about the extent to which patient-centered medical homes meet the needs of autistic adults. Materials & methods: We conducted a cross-sectional survey of autistic adult patients (n = 47) and caregivers of autistic adult patients (n = 66) receiving care through one patient-centered medical home specifically designed to meet the needs of this population. We performed post hoc comparisons of our results to previously published data from a national sample of autistic adults. Results: Participants reported high levels of satisfaction with care, frequent preventive healthcare use and few unmet healthcare needs. Autistic adults in our sample reported significantly higher satisfaction and fewer unmet healthcare needs. Conclusion: A patient-centered medical home tailored to the needs of autistic adults is a promising approach to healthcare delivery for meeting this population's needs.

Evaluating Home Healthcare Workers' Safety Hazard Detection Ability Using Virtual Simulation.

Home healthcare workers (HHWs) are routinely exposed to occupational safety hazards when servicing patients in their homes that put them at risk for injury. These hazards can be broadly classified as "electric, fire and burn," "environmental," or "slip, trip, and lift" hazards. To better train HHWs regarding their potential exposure to these hazards, a home healthcare virtual simulation training system (HH-VSTS) was developed. The HH-VSTS contains three training modules, corresponding to the aforementioned hazard categories, and an assessment module. In each training module, the trainee must navigate the virtual space, via a mouse click, and identify items or conditions that represent hazards. Once an item has been clicked on, the HH-VSTS asks the user if the item or condition is a hazard. For items or conditions that are hazards, additional text boxes present material to the user as to why the item constitutes a hazard and potential remediation approaches. Thus, it is important that hazards be identified and clicked on for the trainee to receive the educational component of the training system. This article evaluated the ability of 49 HHWs to find hazards in each of the three categories. In all modules, participants found the most salient hazards (e.g., clutter on stairs, unattended candles, biohazard stains) but struggled to find some of the less salient hazards. Several less salient hazards included the pet food bowls in the path of travel, the frayed electrical cord, oxygen tube leaking into a mattress, hot water that was too hot, and elevated room temperatures. Overall, this analysis found that most of the hazards within the training modules could be found by naïve HH-VSTS users. These data suggest the need for including hints that guide users toward hazards with which they are less familiar.

Sexually transmitted infections in privately insured adults with intellectual and developmental disabilities.

Aim: Individuals with intellectual and developmental disabilities (I/DD) may have an increased risk of sexually transmitted infections (STIs) due to limited sexual health education and higher rates of sexual abuse, yet little is known about the prevalence of STIs and STI testing in this population. Methods: This study compared national samples of privately insured individuals with (n = 25,193) and without I/DD (n = 25,193) on the prevalence of STIs and STI testing. Results: In multivariable models, individuals with I/DD were significantly less likely to have an STI diagnosis and no difference was found between groups on the odds of STI testing overall. Conclusion: Findings may, in part, be explained by fewer sexual experiences, increased supervision in social settings and delayed onset of sexual activity among those with I/DD.

Nutrition Counseling for Hypertension Within a Grocery Store: An Example of the Patient-Centered Medical Neighborhood Model.

OBJECTIVE: To evaluate the effectiveness of nutrition counseling for patients with hypertension, provided in a grocery store setting. DESIGN: Single-arm pretest-posttest design implementing a 12-week dietary intervention. SETTING: Grocery store. PARTICIPANTS: Thirty adults with hypertension recruited from a primary care practice. INTERVENTION: Registered dietitian nutritionists provided counseling based on the Dietary Approaches to Stop Hypertension diet. MAIN OUTCOME MEASURES: Dietary intake patterns and Healthy Eating Index-2010 (HEI-2010) scores measured via food-frequency questionnaire. Change in systolic blood pressure (SBP) was a secondary outcome. ANALYSIS: Paired t tests were used to test for differences between HEI-2010 scores, intake of key food pattern components, and SBP at baseline compared with follow-up. Statistical significance was established at P ≤ .05. RESULTS: Eight HEI-2010 component scores increased significantly from baseline to follow-up (a change toward a more desirable eating pattern): total fruit, whole fruit, greens and beans, whole grains, fatty acids, refined grains, and empty calories. Sodium (P < .001), saturated fat (P < .001), discretionary solid fat (P < .001), added sugars (P = .01), and total fat (P < .001) all decreased significantly. The change in SBP was not significant. CONCLUSIONS AND IMPLICATIONS: Grocery store-based counseling for patients with hypertension may be an effective strategy to provide lifestyle counseling that is not typically available within primary care.

Efficacy and Usability of a Virtual Simulation Training System for Health and Safety Hazards Encountered by Healthcare Workers.

OBJECTIVE: This study evaluated the efficacy, usability, usefulness, and desirability (UUD) of a Home Healthcare Interactive Virtual Simulation Training System (HH-VSTS) designed to train home healthcare workers (HHWs) and healthcare students to identify and respond to health and safety hazards in client homes. MATERIALS AND METHODS: Participants were randomly assigned to either the HH-VSTS training group or to the paper-based training group. The HH-VSTS group completed three HH-VSTS Training Modules on a laptop/desktop computer. The training modules addressed hazard identification, hazard rationale, and hazard response to electric/fire/burn, slip/trip/lift, and environmental hazards. The paper-based training group reviewed identical information in a written hard-copy format. Both groups completed an HH-VSTS Assessment module. Participants completed demographic/background and UUD questionnaires, and in-system metrics measured their performance on hazard identification, rationale, and response. RESULTS: Participants (n = 74) were HHWs and students in health profession programs. There were no significant differences in participants' ability to correctly identify hazards, rationale, or how to address them. Participants identified over 90% of hazards, although fewer participants were able to correctly identify what makes an item a hazard or how to manage it. For those in the HH-VSTS group, over 83% found the HH-VSTS easy to use, over 94% agreed the HH-VSTS was useful, and over 80% liked it. CONCLUSION: The HH-VSTS provided and engaging, efficacious training that was as effective as a typical paper-based training. In addition, the HH-VSTS is usable by a variety of end users, regardless of computer or gaming experience.

Thoroughness and Psychometrics of Fidelity Measures in Occupational and Physical Therapy: A Systematic Review.

OBJECTIVE: This study evaluated the thoroughness and psychometric properties of fidelity measures used by or of relevance to occupational or physical therapy. METHOD: A systematic review of the literature was completed. Assessments used to measure occupational or physical therapy intervention fidelity were evaluated for thoroughness, reliability, validity, and clinical utility. RESULTS: Eight fidelity measures met inclusion criteria for this systematic review. Most of the measures had moderate levels of thoroughness in the coverage of key aspects of fidelity, reported adequate to excellent reliability and validity, and were highly variable in clinical utility. CONCLUSION: Additional research is recommended to validate existing occupational or physical therapy fidelity measures and to develop novel measures for other occupational therapy and physical therapy interventions. Clinicians and researchers must place greater emphasis on the development and implementation of fidelity measures to ensure uniformity in intervention delivery and high-quality, evidence-based care.

Caregiver Burden Varies by Sensory Subtypes and Sensory Dimension Scores of Children with Autism.

Understanding characteristics associated with burden in caregivers of children with autism spectrum disorder (ASD) is critical due to negative health consequences. We explored the association between child sensory subtype, sensory dimension scores, and caregiver burden. A national survey of caregivers of children with ASD aged 5-13 years was conducted (n = 367). The relationship between variables of interest and indicators of caregiver burden, including health-related quality of life (HRQOL) and caregiver strain, was examined with canonical correlation analyses. Caregiver strain was, but caregiver HRQOL was not, significantly associated with child sensory subtype and sensory dimension scores. Caregiver age, child age, and household income were also associated with caregiver strain. Potential explanatory mechanisms for these findings, derived from published qualitative studies, are discussed.

Behavioral and Physiological Factors Associated With Selective Eating in Children With Autism Spectrum Disorder.

Selective eating is common in children with autism spectrum disorder (ASD), but it is not yet well understood. The objectives of this study were to examine a new definition of selective eating, compare behavioral measures between children with ASD and selective eating and those without selective eating, and determine relationships among behavioral measures and measures of selective eating. Participants were assigned to groups on the basis of number of foods eaten compared with a population-based sample. Results of one-way multivariate analysis of variance indicated no overall effect of group for challenging behaviors, sensory reactivity, or repetitive behaviors. Between-participant tests indicated that scores for compulsive behaviors were significantly lower (p = .036) for the selective eating group. Correlations were moderately strong among variables relating to food intake and behavioral variables, but were not significant between selective eating and behavioral variables. Further research is needed to validate the definition of selective eating and to identify targets for intervention.

Systematic Review of Yoga Interventions for Anxiety Reduction Among Children and Adolescents.

OBJECTIVE: Anxiety disorders are the most prevalent psychological disorders among children and youths. There is growing interest in intervention options for anxiety. Yoga is widely used in clinical, school, and community settings, but consolidated sources outlining its effectiveness in reducing anxiety are limited. METHOD: This systematic review examined the evidence base (1990-2014) for yoga interventions addressing anxiety among children and adolescents (ages 3-18 yr). RESULTS: We identified 2,147 references and found 80 articles that were eligible for full-text review. The final analysis included 16: 6 randomized controlled trials, 2 nonrandomized preintervention-postintervention control-group designs, 7 uncontrolled preintervention-postintervention studies, and 1 case study. CONCLUSION: Nearly all studies indicated reduced anxiety after a yoga intervention. However, because of the wide variety of study populations, limitations in some study designs, and variable outcome measures, further research is needed to enhance the ability to generalize and apply yoga to reduce anxiety.

Musculoskeletal Discomfort, Physical Demand, and Caregiving Activities in Informal Caregivers.

OBJECTIVES: To characterize the burden of care and musculoskeletal discomfort associated with caring for adults with chronic physical disability among informal caregivers and to describe the most physically demanding caregiving activities and contributing factors, as perceived by informal caregivers of adults with physical disabilities. METHODS: A mixed methods approach was used for the study. Forty-six informal caregivers of adults with physical disability participated. RESULTS: Most caregivers were classified as "high burden" caregivers. They reported high levels of physical strain and musculoskeletal discomfort. Caregivers identified several activities related to mobility and self-care as the most physically demanding. Factors affecting physical demand included caregiver and care-recipient characteristics, activity requirements, and the physical environment. CONCLUSION: Interventions that target high-demand caregiving activities, including all three aspects of caregiving activity performance, are necessary to support adults with disabilities in the home and their caregivers.

Effects of a safe patient handling and mobility program on patient self-care outcomes.

OBJECTIVE. The aim of this study was to determine the effect of a safe patient handling and mobility (SPHM) program on patient self-care outcomes. METHOD. We used a retrospective cohort design. Data were obtained from the electronic medical records of 1,292 patients receiving inpatient rehabilitation services. Self-care scores from the FIM™ for patients who participated in rehabilitation before implementation of an SPHM program were compared with the scores of patients who participated after implementation of the program. RESULTS. Patients who received inpatient rehabilitation services with an SPHM program were as likely to achieve at least modified independence in self-care as those who received inpatient rehabilitation services without an SPHM program. CONCLUSION. SPHM programs may not affect self-care performance in adults receiving inpatient rehabilitation services. However, more work must be done to define specific and effective methods for integrating patient handling technologies into occupational therapy practice.

Effect of a safe patient handling program on rehabilitation outcomes.

OBJECTIVE: To evaluate the effect of a safe patient handling (SPH) program on rehabilitation mobility outcomes. DESIGN: Retrospective cohort study. SETTING: A rehabilitation unit in a hospital system. PARTICIPANTS: Consecutive patients (N=1291) over a 1-year period without an SPH program in place (n=507) and consecutive patients over a 1-year period with an SPH program in place (n=784). INTERVENTIONS: The SPH program consisted of administrative policies and patient handling technologies. The policies limited manual patient handling. Equipment included ceiling- and floor-based dependent lifts, sit-to-stand assists, ambulation aides, friction-reducing devices, motorized hospital beds and shower chairs, and multihandled gait belts. MAIN OUTCOME MEASURES: The mobility subscale of the FIM. RESULTS: Patients rehabilitated in the group with SPH achieved similar outcomes to patients rehabilitated in the group without SPH. A significant difference between groups was noted for patients with initial mobility FIM scores of 15.1 and higher after controlling for initial mobility FIM score, age, length of stay, and diagnosis. Those patients performed better with SPH. CONCLUSIONS: SPH programs do not appear to inhibit recovery. Fears among therapists that the use of equipment may lead to dependence may be unfounded.

Safe-patient-handling equipment in therapy practice: implications for rehabilitation.

OBJECTIVE: To determine how safe-patient-handling (SPH) equipment is used in rehabilitation and how it affects therapists, patients, and therapy practice. METHOD: We used a qualitative, instrumental case study design. Thirty-five occupational and physical therapist practitioners from three facilities participated in the study. RESULTS: Therapists reported a broad range of applications for equipment (e.g., functional mobility and neuromusculoskeletal function). They reported that SPH equipment increased treatment options for therapists and increased participation options for patients, although equipment limitations exist. Three themes emerged from the analysis: choice, potential, and safety. CONCLUSION: SPH equipment has therapeutic applications in rehabilitation, especially for medically complex or bariatric patients. Therapists in this study engaged in a highly individualized, complex process of decision making when selecting and using SPH devices in rehabilitation. More research to refine and test therapeutic uses is necessary.