Age-Based Heuristics Bias Treatment of Displaced Femoral Neck Fractures in the Elderly.

Background: Surgeons performing arthroplasty for femoral neck fractures may rely on mental shortcuts (heuristics) when choosing total hip arthroplasty (THA) vs hemiarthroplasty (HA). We sought to quantify the extent to which age-based heuristics drive decision-making. Methods: We identified all Medicare beneficiaries from 2017-2018 with femoral neck fractures who underwent THA or HA. We compared the likelihood of THA vs HA among patients admitted within 4 weeks before vs 4 weeks after their birthday for each age under the hypothesis that these cohorts would be similar except for numerical age. We controlled for race/ethnicity, sex, comorbidities, poverty status, and hospital census region in a multivariable regression that included facility-level cluster effects. We generated predicted/adjusted probabilities for THA vs HA for different age transition points. Results: Thirteen thousand three hundred sixty-six elderly patients were included. One thousand eight hundred sixty-five (14%) received THA and 11,501 (86%) received HA. The likelihood of THA decreased from 50.3% among patients almost 67 to 8% among those ≥85 (P < .001). We found significant decreases in likelihood of THA across age transitions. The largest decrement was at age transition 69 (THA likelihood 28.7% for newly 69 vs 43.3% for almost 69, 33.7% relative change). Female gender, Black race, higher comorbidity burden, and lower socioeconomic status were also associated with a lower likelihood of THA. Conclusions: Our data demonstrate that patient age transitions seem to influence the choice of THA vs HA. Further research is needed to develop data-driven surgical decision aids for this population.

Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fracture in Elderly Patients: Twelve-Month Risk of Revision and Dislocation in an Instrumental Variable Analysis of Medicare Data.

BACKGROUND: There is practice variation in the selection of a total hip arthroplasty (THA) or a hemiarthroplasty (HA) for the treatment of displaced femoral neck fractures in elderly patients. Large data sets are needed to compare the rates of rare complications following these procedures. We sought to examine the relationship between surgery type and secondary hip surgery (revision or conversion arthroplasty) at 12 months following the index arthroplasty, and that between surgery type and dislocation at 12 months, among elderly Medicare beneficiaries who underwent THA or HA for a femoral neck fracture, taking into account the potential for selection bias. METHODS: We performed a population-based, retrospective study of elderly (>65 years of age) Medicare beneficiaries who underwent THA or HA following a femoral neck fracture. Two-stage, instrumental variable regression models were applied to nationally representative Medicare medical claims data from 2017 to 2019. RESULTS: Of the 61,695 elderly patients who met the inclusion criteria, of whom 74.1% were female and 92.2% were non-Hispanic White, 10,268 patients (16.6%) underwent THA and 51,427 (83.4%) underwent HA. The findings from the multivariable, instrumental variable analyses indicated that treatment of displaced femoral neck fractures with THA was associated with a significantly higher risk of dislocation at 12 months compared with treatment with HA (2.9% for the THA group versus 1.9% for the HA group; p = 0.001). There was no significant difference in the likelihood of 12-month revision/conversion between THA and HA. CONCLUSIONS: The use of THA to treat femoral neck fractures in elderly patients is associated with a significantly higher risk of 12-month dislocation, as compared with the use of HA, although the difference may not be clinically important. A low overall rate of dislocation was found in both groups. The risk of revision/conversion at 12 months did not differ between the groups. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Psychological and Cognitive Functioning Among Patients Receiving Outpatient Rehabilitation for Post-COVID Sequelae: An Observational Study.

OBJECTIVES: To describe the characteristics of individuals receiving outpatient rehabilitation for post-acute sequelae of SARS-CoV-2 infection (PASC). Further, to examine factors associated with variation in their psychological and cognitive functioning and health-related quality of life. DESIGN: Observational study. SETTING: Outpatient COVID-19 recovery clinic at a large, tertiary, urban health system in the US. PARTICIPANTS: COVID-19 survivors with persistent sequelae (N=324). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Multivariable logistic and linear regression models were used to examine factors associated with COVID survivors' experience of severe anxiety, severe depression, post-traumatic stress disorder (PTSD), cognitive impairment, and self-reported health-related quality of life. RESULTS: About 38% of survivors seeking care for their persistent COVID symptoms suffered from severe anxiety, 31.8% from severe depression, 43% experiencing moderate to severe PTSD symptomology, and 17.5% had cognitive impairment. Their health-related quality of life was substantially lower than that of the general population (-26%) and of persons with other chronic conditions. Poor and African American/Black individuals experienced worse psychological and cognitive sequelae after COVID19 infection, even after controlling for age, sex, initial severity of the acute infection, and time since diagnosis. CONCLUSIONS: Evidence of consistent disparities in outcomes by the patients' race and socioeconomic status, even among those with access to post-acute COVID rehabilitation care, are concerning and have significant implications for PASC policy and program development.

A Prospective Assessment of an Adjustable, Immediate Fit, Subischial Transfemoral Prosthesis.

Objective: To assess the feasibility of an adjustable, subischial transfemoral prosthesis by comparing self-reported outcome measures regarding socket comfort, fit and utility relative to a persons' conventionally made socket. Assessing limb compressibility was another aim of this study. Design: A single-group pre-post intervention design. Setting: Physical medicine and rehabilitation biomechanics laboratory. Participants: All 18 enrolled participants (N = 18) completed the feasibility trial. There were 16 men and 2 women with an average age of 59.4 (±7) years. Most of the participants (61.1%) had worn a socket for 1 to 10 years before the trial, 22.2% of the participants had worn one for less than a year, and 16.7% of the participants had worn a prosthesis for more than 10 years. Intervention: Participants were fit with the study prosthesis and used it for a 2-week home trial. Main Outcome Measures: A Prosthetic Comfort and Utility Questionnaire was completed on the participant's conventional prosthetic device and the subischial socket system after the trial. Results: The adjustable subischial prostheses were rated superior overall to the participant's conventional sockets (40.9 ± 7.2 vs 32.8 ± 10.8; P=.004). Six of the 10 parameters measured (adjustability, overall fit, prosthesis weight, sitting comfort, standing comfort, and standing stability) were rated higher for the adjustable prostheses compared to the conventional sockets. Compression of the soft tissues of the thigh ranged from 5.6 ± 4.2 cm at the distal end to 7.3 ± 3.6 cm at the proximal site. There were no falls, skin breakdown, or limb ischemia. At the 2-month telephone follow-up, 61% of subjects had transitioned to using the adjustable subischial socket most of the time. Conclusions: The adjustable, immediate fit, subischial prosthesis provided safe, comfortable, and functional ambulation for persons with transfemoral limb loss in this short-term feasibility study. This study supports the consideration of a new paradigm in transfemoral prosthetics-adjustable subischial sockets. These devices should be tested in a larger multi-center study.

Race, ethnicity, and utilization of outpatient rehabilitation for treatment of post COVID-19 condition.

INTRODUCTION: Outpatient rehabilitation is recommended in the treatment of post coronavirus disease 2019 (COVID-19) condition. Although racial and ethnic disparities in the incidence and severity of COVID-19 have been well documented, little is known about the use of outpatient rehabilitation among patients with post COVID-19 condition. OBJECTIVE: To examine factors associated with outpatient rehabilitation use following COVID-19 and to ascertain whether differential incidence of sequelae explain variation in post COVID-19 rehabilitation utilization by race and ethnicity. DESIGN: Case-control study. SETTING: Community. PARTICIPANTS: U.S. adults with COVID-19 during 2020 in the TriNetX database. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Receipt of outpatient rehabilitation services within 6 months of COVID-19 diagnosis and incidence of post COVID-19 condition symptoms (weakness, fatigue, pain, cognitive impairment, mobility difficulties, and dyspnea). RESULTS: From 406,630 laboratory-confirmed COVID-19 cases, we identified 8724 individuals who received outpatient rehabilitation and matched 28,719 controls. Of rehabilitation users, 43.3% were 40 years old or younger, 54.8% were female, 58.2% were White, 17.9% were African American/Black, 2.1% were Asian, 13.0% were Hispanic, 39.2% had no comorbidities, and 40.3% had been hospitalized for COVID-19. Dyspnea (20.4%), fatigue (12.4%), and weakness (8.2%) were the most frequently identified symptoms. Although there were no racial differences in the incidence of the six post COVID-19 condition symptoms considered, African American/Black individuals were significantly less likely than their White counterparts to receive outpatient rehabilitation (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.84-0.96; p = .003). Hispanic individuals had higher outpatient rehabilitation utilization (OR = 1.22; 95% CI: 1.11-1.33; p < .001) and a significantly higher incidence of post COVID-19 fatigue. CONCLUSIONS: In this large nationally representative study, African American/Black race was associated with lower utilization of outpatient rehabilitation services despite a similar incidence of post COVID-19 condition symptoms. Further research is needed to better understand access barriers to rehabilitation services for post COVID-19 condition recovery care and address racial inequalities in receipt of care.

The Effect of CMS's Comprehensive Care for Joint Replacement Bundled Payment Model on Trajectories of Post-acute Rehabilitation Care After Total Hip Arthroplasty.

OBJECTIVE: To evaluate the effect of the Comprehensive Care for Joint Replacement (CJR) policy on the 90-day trajectory of post-acute care after a total hip arthroplasty (THA). DESIGN: Multivariable difference-in-difference models applied to Medicare beneficiaries undergoing a THA prior to (2014-2015) and post-CJR implementation (2017) in areas subjected to or exempt from the policy. SETTING: Hospitals in standard metropolitan statistical areas. PARTICIPANTS: 357,844 elderly Medicare patients nationwide undergoing THA (N=357,844). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Escalation in care to institutionalization (ie, admission to an inpatient rehabilitation or skilled nursing facility during 90-days postdischarge for those initially discharged to the community and return to the community at the end of the episode of care among those initially discharged to an institutional setting). RESULTS: Of the 357,844 elderly Medicare patients nationwide undergoing THA during the study period, 47.6% were discharged directly to the community and 52.4% received post-acute care in an institution. Patients discharged to an institution post-policy in a CJR area were about 10% less likely to return to the community (odds ratio=0.91; 95% confidence interval, 0.84-0.98; P=.02) at the end of the 90-day episode of care than those treated in policy-exempt areas. Despite the large magnitude, estimates of escalation in care among patients treated in bundling areas post-CJR implementation were not statistically significant. CONCLUSIONS: Our findings support further exploration of unanticipated effects of mandatory bundled payment policies on outcomes, as well as further examination of outcomes among policy-relevant subgroups of patients undergoing hip replacement in the United States.

The Impact of Femoral Component Cementation on Fracture and Mortality Risk in Elective Total Hip Arthroplasty: Analysis from a National Medicare Sample.

BACKGROUND: Complications following elective total hip arthroplasty (THA) are rare but potentially devastating. The impact of femoral component cementation on the risk of periprosthetic femoral fractures and early perioperative death has not been studied in a nationally representative population in the United States. METHODS: Elective primary THAs performed with or without cement among elderly patients were identified from Medicare claims from 2017 to 2018. We performed separate nested case-control analyses matched 1:2 on age, sex, race/ethnicity, comorbidities, payment model, census division of facility, and exposure time and compared fixation mode between (1) groups with and without 90-day periprosthetic femoral fracture and (2) groups with and without 30-day mortality. RESULTS: A total of 118,675 THAs were included. The 90-day periprosthetic femoral fracture rate was 2.0%, and the 30-day mortality rate was 0.18%. Cases were successfully matched. The risk of periprosthetic femoral fracture was significantly lower among female patients with cement fixation compared with matched controls with cementless fixation (OR = 0.83; 95% CI, 0.69 to 1.00; p = 0.05); this finding was not evident among male patients (p = 0.94). In contrast, the 30-day mortality risk was higher among male patients with cement fixation compared with matched controls with cementless fixation (OR = 2.09; 95% CI, 1.12 to 3.87; p = 0.02). The association between cement usage and mortality among female patients almost reached significance (OR = 1.74; 95% CI, 0.98 to 3.11; p = 0.06). CONCLUSIONS: In elderly patients managed with THA, cemented stems were associated with lower rates of periprosthetic femoral fracture among female patients but not male patients. The association between cemented stems and higher rates of 30-day mortality was significant for male patients and almost reached significance for female patients, although the absolute rates of mortality were very low. For surgeons who can competently perform THA with cement, our data support the use of a cemented stem to avoid periprosthetic femoral fracture in elderly female patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Biomarkers in the Degenerative Human Intervertebral Disc Tissue and Blood.

ABSTRACT: Patients with back pain comprise a large proportion of the outpatient practice among physiatrists. Diagnostic tools are limited to clinical history, physical examinations, and imaging. Nonsurgical treatments are largely empirical, encompassing medications, physical therapy, manual treatments, and interventional spinal procedures. A body of literature is emerging confirming elevated levels of biomarkers including inflammatory cytokines in patients with back pain and/or radiculopathy, largely because the protein assay sensitivity has increased. These biomarkers may serve as tools to assist diagnosis and assess outcomes.The presence of inflammatory mediators in the intervertebral disc tissues and blood helped to confirm the inflammatory underpinnings of back pain related to intervertebral disc degeneration. Literature reviewed here suggests that biomarkers could assist clinical diagnosis and monitor physiological outcomes during and after treatments for spine-related pain. Biomarkers must be measured in a large and diverse asymptomatic population, in the context of age and comorbidities to prevent false-positive tests. These levels can then be rationally compared with those in patients with back disorders including discogenic back pain, radiculopathy, and spinal stenosis. While studies reviewed here used "candidate marker" approaches, future nonbiased approaches in clearly defined patient populations could uncover novel biomarkers in clinical management of patients.

Inpatient Rehabilitation Outcomes After Severe COVID-19 Infections: A Retrospective Cohort Study.

OBJECTIVE: The aim of the study was to describe the characteristics and functional outcomes of patients undergoing acute inpatient rehabilitation after hospitalization for COVID-19. DESIGN: Using a retrospective chart review, patients were identified who were admitted to inpatient rehabilitation after COVID-19. Patient information collected included sociodemographic characteristics, comorbidities, length of stay, discharge disposition, self-care, mobility, and cognitive functioning. These patients were compared with patients (controls) without COVID-19 with similar impairment codes treated at the same facility before the COVID-19 pandemic. RESULTS: There were 43 patients who were admitted to the inpatient rehabilitation hospital after COVID-19 infection and 247 controls. Patients who had COVID-19 were significantly more likely to be African American and to have been admitted to a long-term acute care hospital. They also had a longer length of rehabilitation stay. The groups did not differ by age, sex, or insurance. Functionally, although presenting with significantly worse mobility, self-care, and motor scores, the patients previously infected with COVID-19 had similar functional outcomes at time of discharge to the control group. CONCLUSIONS: Although patients with a history of COVID-19 had worse function at time of admission to acute rehabilitation, inpatient rehabilitation significantly improved their function to comparable levels as patients who did not have COVID-19. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Identify how characteristics of patients with COVID-19 admitted to acute rehabilitation differ from those with similar admission codes but without COVID-19; (2) Describe changes in functional measures at admission and discharge of COVID-19 patients compared with patients without COVID-19; and (3) Recognize how inpatient rehabilitation may help reduce inequities in outcomes after severe COVID-19 infection. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

MXene-infused bioelectronic interfaces for multiscale electrophysiology and stimulation.

Soft bioelectronic interfaces for mapping and modulating excitable networks at high resolution and at large scale can enable paradigm-shifting diagnostics, monitoring, and treatment strategies. Yet, current technologies largely rely on materials and fabrication schemes that are expensive, do not scale, and critically limit the maximum attainable resolution and coverage. Solution processing is a cost-effective manufacturing alternative, but biocompatible conductive inks matching the performance of conventional metals are lacking. Here, we introduce MXtrodes, a class of soft, high-resolution, large-scale bioelectronic interfaces enabled by Ti3C2 MXene (a two-dimensional transition metal carbide nanomaterial) and scalable solution processing. We show that the electrochemical properties of MXtrodes exceed those of conventional materials and do not require conductive gels when used in epidermal electronics. Furthermore, we validate MXtrodes in applications ranging from mapping large-scale neuromuscular networks in humans to cortical neural recording and microstimulation in swine and rodent models. Last, we demonstrate that MXtrodes are compatible with standard clinical neuroimaging modalities.

The prevalence of lower limb loss in children and associated costs of prosthetic devices: A national study of commercial insurance claims.

BACKGROUND: Although the incidence of major pediatric lower limb loss secondary to either congenital deficiencies or acquired amputations is relatively low, the prevalence of lower limb loss among children in the United States (US) remains unknown. OBJECTIVES: To estimate the prevalence of major lower limb loss, and the associated prosthetic services use and costs among commercially-insured children in the US. STUDY DESIGN: Observational, retrospective, longitudinal cohort study. METHODS: The IBM MarketScan®Commercial Database was used to identify children (<18 years) with major lower limb loss in the US between 2009 and 2015. Descriptive statistics were used to characterize pediatric cases according to sociodemographic and limb loss characteristics. Multivariate models assessed factors associated with annual prosthetic visits, prosthetic-related costs, and overall medical costs. RESULTS: Of the 36.5 million children in the MarketScan database, 14,038 had a major lower limb loss, yielding a prevalence estimate of 38.5 cases per 100,000 commercially insured children in the US during the 7-year study period. Congenital deficiencies accounted for 84% of cases, followed by 13.5% from trauma. Only 10.1% had at least one prosthesis-related visit during any 12-month period following their cohort entry. Among those, the mean annual prosthetic-related costs ranged from $50 to $29,112 with a median annual cost of $2778 (interquartile range = $4567). Annual coinsurance and copays for prosthetic services accounted for nearly half of the overall annual out-of-pocket outlays with medical care for these children. CONCLUSION: Pediatric lower limb loss results in lifelong prosthetic needs. This study informs insurers and policy-makers regarding the prevalence of these patients and the medical costs for their care.

Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II).

The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.

Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part I).

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed.

In-Bundle Surgeons More Likely Select Cemented Femoral Fixation in Total Hip Arthroplasty for At-Risk Patients: The Medicare Comprehensive Care for Joint Replacement Bundled Model.

Background: Bundled payment models for lower-extremity arthroplasty have been shown to lower costs but have not reliably improved quality. It is unknown how the bundled payment model may affect surgeons' decisions that impact the quality of arthroplasty care. The purpose of this study was to compare the utilization of femoral component fixation modes by surgeons performing total hip arthroplasties (THAs) in at-risk patients in areas subject to Medicare's Comprehensive Care for Joint Replacement (CJR) bundled payment model compared with patients treated by surgeons in areas exempt from the policy. Methods: Elective, primary THAs among elderly persons were identified from Medicare claims during 2017 and 2018, including the use of cemented or cementless femoral fixation. Multivariable regression models, applied to samples stratified by sex, were used to assess the association between CJR bundle participation and the use of femoral fixation mode. Analyses were adjusted for patient age, race or ethnicity, comorbidity burden, low-income status, and Census division of the hospital. Results: Of 118,676 Medicare patients who underwent THA, 9.1% received cemented femoral components, and use of cement varied significantly by geographic region (p < 0.001). Patients who received cemented fixation, compared with patients who received cementless fixation, had significant differences in mean age (and standard deviation) at 78.3 ± 6.9 years compared with 74.5 ± 6.1 years (p < 0.001) for female patients and 77.3 ± 6.8 years and 74.2 ± 5.9 years (p < 0.001) for male patients; were more likely to be White at 94.0% compared with 92.7% (p < 0.001) for female patients and 95.1% compared with 93.8% (p = 0.046) for male patients; and had higher mean Elixhauser comorbidity index at 2.6 ± 2.2 compared with 2.3 ± 2.0 (p < 0.001) for female patients and 2.8 ± 2.4 compared with 2.4 ± 2.1 (p < 0.001) for male patients. In adjusted analyses, female patients in the CJR bundled payment model were more likely to have cemented fixation compared with female patients not in the CJR model (odds ratio [OR], 1.11 [95% confidence interval (CI), 1.05 to 1.16]; p < 0.001), whereas male patients in the CJR bundled payment model were less likely to have cemented fixation compared with male patients not in the CJR model (OR, 0.91 [95% CI, 0.83 to 0.99]; p = 0.029). Conclusions: In the bundled environment, surgeons were more likely to choose cemented femoral fixation for elderly female patients. This may be due to in-bundle surgeons being more risk-averse and avoiding cementless fixation in patients at risk for fracture or implant-related complications. Further research is needed to directly examine the impact of the bundle on surgeon decision-making.

Average proportional consecutive interval difference accurately differentiates spontaneous activity from motor unit potentials.

INTRODUCTION: An objective method is required to detect spontaneous activity (SA) for prevalence studies in needle electromyography (EMG). Because of frequent similarities in the morphology of SA and motor unit potentials (MUP), identification of SA depends on assessment of firing regularity, which has not yet been quantitated through a modern interface. METHODS: Prospective recordings obtained from patients referred for electrodiagnostic evaluation were analyzed by using decomposition-based quantitative EMG (DQEMG) customized to calculate descriptive statistics. RESULTS: Forty-four MUP recordings (39 participants) and 80 SA recordings (62 participants) were analyzed. One hundred one of 124 recordings successfully interfaced with DQEMG. The remaining recordings were analyzed in Audacity. Average proportional consecutive interval differences differentiated SA from MUPs with 97.5% sensitivity (confidence interval [CI] 91.3%-99.7%) and 100.0% specificity (CI 92%-100%). There was substantial overlap, however, for SD and mean consecutive differences. DISCUSSION: Average proportional consecutive interval difference accurately differentiates SA from MUPs and may be useful in future prevalence studies of SA.

Music-instruction intervention for treatment of post-traumatic stress disorder: a randomized pilot study.

BACKGROUND: Post-traumatic Stress Disorder (PTSD) is a common sequelae of severe combat-related emotional trauma that is often associated with significantly reduced quality of life in afflicted veterans. To date, no published study has examined the effect of an active, music-instruction intervention as a complementary strategy to improve the psychological well-being of veterans with PTSD. The purpose of this study was to examine the feasibility and potential effectiveness of an active, music-instruction intervention in improving psychological health and social functioning among Veterans suffering from moderate to severe PTSD. METHODS: The study was designed as a prospective, delayed-entry randomized pilot trial. Regression-adjusted difference in means were used to examine the intervention's effectiveness with respect to PTSD symptomatology (primary outcome) as well as depression, perceptions of cognitive failures, social functioning and isolation, and health-related quality of life (secondary outcomes). RESULTS: Of the 68 Veterans who were self- or provider-referred to the program, 25 (36.7%) were ineligible due to (i) absence of a PTSD diagnosis (n = 3); participation in ongoing intense psychotherapy (n = 4) or inpatient substance abuse program (n = 2); current resident of the Domiciliary (n = 8) and inability to participate due to distance of residence from the VA (n = 8). Only 3 (4.4%) Veterans declined participation due to lack of interest. The mean age of enrolled subjects was 51 years old [range: 22 to 76]. The majority was male (90%). One-quarter were African American or Black. While 30% report working full or part time, 45% were retired due to disability. Slightly over one-quarter were veterans of the OEF/OIF wars. Estimates from regression-adjusted treatment effects indicate that the average PTSD severity score was reduced by 9.7 points (p = 0.01), or 14.3% from pre- to post-intervention. Similarly, adjusted depressive symptoms were reduced by 20.4% (- 6.3 points, p = 0.02). There were no statistically significant regression-adjusted effects on other outcomes, although the direction of change was consistent with improvements. CONCLUSIONS: Our findings suggest that the active, music-instruction program holds promise as a complementary means of ameliorating PTSD and depressive symptoms among this population. TRIAL REGISTRATION: Trial registered at ClinicalTrials.gov with protocol number Medical College of Wisconsin PRO00019269 on 11/29/2018 (Retrospectively registered).

iMOVE: Intensive Mobility training with Variability and Error compared to conventional rehabilitation for young children with cerebral palsy: the protocol for a single blind randomized controlled trial.

BACKGROUND: Cerebral palsy (CP) is the most common cause of physical disability in children. The best opportunity to maximize lifelong independence is early in motor development when there is the most potential for neuroplastic change, but how best to optimize motor ability during this narrow window remains unknown. We have systematically developed and pilot-tested a novel intervention that incorporates overlapping principles of neurorehabilitation and infant motor learning in a context that promotes upright mobility skill and postural control development. The treatment, called iMOVE therapy, was designed to allow young children with CP to self-initiate motor learning experiences similar to their typically developing peers. This manuscript describes the protocol for a subsequent clinical trial to test the efficacy of iMOVE therapy compared to conventional therapy on gross motor development and other secondary outcomes in young children with CP. METHODS: The study is a single-blind randomized controlled trial. Forty-two participants with CP or suspected CP between the ages of 1-3 years will be randomized to receive either the iMOVE or conventional therapy group. Distinguishing characteristics of each group are detailed. Repeated measures of gross motor function will be collected throughout the 12-24 week intervention phase and at three follow-up points over one year post therapy. Secondary outcomes include measures of postural control, physical activity, participation and caregiver satisfaction. DISCUSSION: This clinical trial will add to a small, but growing, body of literature on early interventions to optimize the development of motor control in young children with CP. The information learned will inform clinical practice of early treatment strategies and may contribute to improving the trajectory of motor development and reducing lifelong physical disability in individuals with CP. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02340026 . Registered January 16, 2015.

Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations.

INTRODUCTION: To address the need for greater standardization within the field of electrodiagnostic medicine, the Normative Data Task Force (NDTF) was formed to identify nerve conduction studies (NCS) in the literature, evaluate them using consensus-based methodological criteria derived by the NDTF, and identify those suitable as a resource for NCS metrics. METHODS: A comprehensive literature search was conducted of published peer-reviewed scientific articles for 11 routinely performed sensory and motor NCS from 1990 to 2012. RESULTS: Over 7,500 articles were found. After review using consensus-based methodological criteria, only 1 study each met all quality criteria for 10 nerves. CONCLUSION: The NDTF selected only those studies that met all quality criteria and were considered suitable as a clinical resource for NCS metrics. The literature is, however, limited and these findings should be confirmed by larger, multicenter collaborative efforts. Muscle Nerve 54: 371-377, 2016.