Research Accelerator Program: A Strategic Initiative to Facilitate Interdisciplinary Collaboration That Advances Translational Research.

ABSTRACT: Developing a culture of innovative thinking and one that emphasizes clinician-researcher interaction is critical for the future of rehabilitation. We designed and implemented a strategy to build a culture of interdisciplinary communication and collaboration that facilitates translational research across several disciplines in our inpatient rehabilitation hospital. We colocated clinicians and researchers in workspaces within a new hospital and created the Research Accelerator Program-a collection of team-focused initiatives that promote communication and collaboration among researchers, clinicians, and other staff. The purpose of this article is to disseminate this strategy, which has increased staff participation in research activities and increased scientific productivity of interdisciplinary research teams over the past 8 yrs.

ICF classification of therapeutic goals for outpatient episodes of neurorehabilitation in post-stroke and Parkinson disease.

PURPOSE: To understand therapeutic priorities, a secondary data analysis on a retrospective cohort was conducted to classify rehabilitation goals according to the International Classification of Functioning, Disability, and Health (ICF). MATERIALS AND METHODS: Therapeutic goals from an initial outpatient physical or occupational therapy evaluation for patients post-stroke or with Parkinson disease, were classified into Level 1 of the ICF. Goals in the Activity and Participation component were further sub-classified as activity capacity or activity performance (self-report or direct) in daily life. RESULTS: 776 goals across 104 participants were classified into Level 1 of the ICF. The majority, 73% (563/776) were classified as Activity and Participation, 20% (155/776) as Body Function and 2% (17/776) as Environmental Factors. Fifty-two percent (400/776) of all goals were classified as activity capacity and 21% (163/776) as activity performance in daily life, with 21% (160/776) of goals measuring self-report activity performance in daily life and less than 1% (3/776) of goals measuring direct activity performance in daily life. CONCLUSIONS: While the majority of therapeutic goals were classified into the Activity and Participation component, less than 1% of goals measured direct activity performance in daily life. If people seek outpatient rehabilitation to improve functioning in their real-world environment, therapeutic goal setting should reflect this.

The majority of therapeutic goals for an episode of outpatient neurorehabilitation were classified into the Activity and Participation component of the International Classification of Functioning, Disability, and Health.However, less than 1% of therapeutic goals measured direct activity performance in daily life.If people with neurological diagnoses seek out outpatient rehabilitation to improve functioning in their real-world environment, than therapeutic goal setting should reflect this.

The Value of High Intensity Locomotor Training Applied to Patients With Acute-Onset Neurologic Injury.

Long-standing research in animal models and humans with stroke or incomplete spinal cord injury (iSCI) indicate that specific physical training variables, such as the specificity and amount of practice, may influence neurologic recovery and locomotor function. More recent data highlight the contributions of exercise intensity, as estimated indirectly by cardiovascular exertion, as potentially more important than previously considered. The effects of exercise intensity are well described in neurologically intact individuals, although confusion regarding the definitions of intensity and safety concerns have limited its implementation during physical rehabilitation of patients with neurologic injury. The purpose of this review is to delineate some of the evidence regarding the effects of exercise intensity during locomotor training in patients with stroke and iSCI. We provide specific definitions of exercise intensity used within the literature, describe methods used to ensure appropriate levels of exertion, and discuss potential adverse events and safety concerns during its application. Further details on the effects of locomotor training intensity on clinical outcomes, and on neuromuscular and cardiovascular function will be addressed as available. Existing literature across multiple studies and meta-analyses reveals that exercise training intensity is likely a major factor that can influence locomotor function after neurologic injury. To extend these findings, we describe previous attempts to implement moderate to high intensity interventions during physical rehabilitation of patients with neurologic injury, including the utility of specific strategies to facilitate implementation, and to navigate potential barriers that may arise during implementation efforts.

Contributions of Stepping Intensity and Variability to Mobility in Individuals Poststroke.

Background and Purpose- The amount of task-specific stepping practice provided during rehabilitation poststroke can influence locomotor recovery and reflects one aspect of exercise dose that can affect the efficacy of specific interventions. Emerging data suggest that markedly increasing the intensity and variability of stepping practice may also be critical, although such strategies are discouraged during traditional rehabilitation. The goal of this study was to determine the individual and combined contributions of intensity and variability of stepping practice to improving walking speed and distance in individuals poststroke. Methods- This phase 2, randomized, blinded assessor clinical trial was performed between May 2015 and November 2018. Individuals between 18 and 85 years old with hemiparesis poststroke of >6 months duration were recruited. Of the 152 individuals screened, 97 were randomly assigned to 1 of 3 training groups, with 90 completing >10 sessions. Interventions consisted of either high-intensity stepping (70%-80% heart rate reserve) of variable, difficult stepping tasks (high variable), high-intensity stepping performing only forward walking (high forward), and low-intensity stepping in variable contexts at 30% to 40% heart rate reserve (low variable). Participants received up to 30 sessions over 2 months, with testing at baseline, post-training, and a 3-month follow-up. Primary outcomes included walking speeds and timed distance, with secondary measures of dynamic balance, transfers, spatiotemporal kinematics, and metabolic measures. Results- All walking gains were significantly greater following either high-intensity group versus low-variable training (all P<0.001) with significant correlations with stepping amount and rate (r=0.48-60; P<0.01). Additional gains in spatiotemporal symmetry were observed with high-intensity training, and balance confidence increased only following high-variable training in individuals with severe impairments. Conclusions- High-intensity stepping training resulted in greater improvements in walking ability and gait symmetry than low-intensity training in individuals with chronic stroke, with potential greater improvements in balance confidence. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466.

Cardiopulmonary Responses During Clinical and Laboratory Gait Assessments in People With Chronic Stroke.

Background: The 6-Minute Walk Test (6MWT) is a common clinical assessment used to evaluate locomotor function in patients after stroke. Previous work suggests the 6MWT can estimate peak metabolic capacity (VO2peak) without cardiorespiratory assessments during graded exercise tests (GXTs), which may assist with exercise prescription. However, selected research also indicated increased heart rates (HRs) during 6MWTs beyond levels considered safe without GXTs. Objective: The goal of this study was to examine cardiorespiratory responses during 6MWTs and GXTs in individuals with chronic stroke and their associations with demographic or clinical characteristics. Design: The study used a cross-sectional observational design. Methods: Cardiorespiratory responses were assessed during 6MWTs at self-selected velocity (SSV) and fastest velocity (FV), and during GXTs. Secondary assessments included the lower extremity Fugl-Meyer Assessment, Functional Gait Assessment, gait speeds, and daily stepping activity. Correlation and regression analyses were used to evaluate associations between locomotor performance, cardiorespiratory responses, and clinical and demographic characteristics. Results: Average HRs during 6MWT-FV were 72% to 76% of the age-predicted maximum (HRmax), with 20% of participants exceeding 85% predicted HRmax. When normalized to HRs during GXTs, HRs during 6MWT-FV were 86% to 88% of observed HRmax. Primary predictors of increased HRs during 6MWTs were resting HR, body mass index, and daily stepping. Distance during 6MWT-FV was a significant predictor of VO2peak in combination with other variables. Electrocardiographic abnormalities were observed in >80% of participants at rest and 31% demonstrated distinct abnormalities during GXTs, which were not related to 6MWT or GXT performance. Limitations: In addition to sample size, a primary limitation involved the ability to accurately predict or measure HRmax in patients with motor dysfunction after stroke. Conclusions: Cardiac responses were higher than anticipated during 6MWTs and often exceeded recommended HR thresholds. Clinicians should closely monitor cardiorespiratory responses during 6MWTs.

Effects of Training Intensity on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study.

BACKGROUND: Many physical interventions can improve locomotor function in individuals with motor incomplete spinal cord injury (iSCI), although the training parameters that maximize recovery are not clear. Previous studies in individuals with other neurologic injuries suggest the intensity of locomotor training (LT) may positively influence walking outcomes. However, the effects of intensity during training of individuals with iSCI have not been tested. OBJECTIVE: The purpose of this pilot, blinded-assessor randomized trial was to evaluate the effects of LT intensity on walking outcomes in individuals with iSCI. METHODS: Using a crossover design, ambulatory participants with iSCI >1 year duration performed either high- or low-intensity LT for ≤20 sessions over 4 to 6 weeks. Four weeks following completion, the training interventions were alternated. Targeted intensities focused on achieving specific ranges of heart rate (HR) or ratings of perceived exertion (RPE), with intensity manipulated by increasing speeds or applying loads. RESULTS: Significantly greater increases in peak treadmill speeds (0.18 vs 0.02 m/s) and secondary measures of metabolic function and overground speed were observed following high- versus low-intensity training, with no effects of intervention order. Moderate to high correlations were observed between differences in walking speed or distances and differences in HRs or RPEs during high- versus low-intensity training. CONCLUSION: This pilot study provides the first evidence that the intensity of stepping practice may be an important determinant of LT outcomes in individuals with iSCI. Whether such training is feasible in larger patient populations and contributes to improved locomotor outcomes deserves further consideration.