Prognosis of Individual-Level Mobility and Daily Activities Recovery From Acute Care to Community, Part 2: A Proof-of-Concept Single Group Prospective Cohort Study.

OBJECTIVE: To demonstrate a proof-of-concept for prognostic models of post-stroke recovery on activity level outcomes. DESIGN: Longitudinal cohort with repeated measures from acute care, inpatient rehabilitation, and post-discharge follow-up to 6 months post-stroke. SETTING: Enrollment from a single Midwest USA inpatient rehabilitation facility with community follow-up. PARTICIPANTS: One-hundred fifteen persons recovering from stroke admitted to an acute rehabilitation facility (N=115). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Activity Measure for Post-Acute Care Basic Mobility and Daily Activities domains administered as 6 Clicks and patient-reported short forms. RESULTS: The final Basic Mobility model defined a group-averaged trajectory rising from a baseline (pseudo-intercept) T score of 35.5 (P<.001) to a plateau (asymptote) T score of 56.4 points (P<.001) at a negative exponential rate of -1.49 (P<.001). Individual baseline scores varied by age, acute care tissue plasminogen activator, and acute care length of stay. Individual plateau scores varied by walking speed, acute care tissue plasminogen activator, and lower extremity Motricity Index scores. The final Daily Activities model defined a group-averaged trajectory rising from a baseline T score of 24.5 (P<.001) to a plateau T score of 41.3 points (P<.001) at a negative exponential rate of -1.75 (P<.001). Individual baseline scores varied by acute care length of stay, and plateau scores varied by self-care, upper extremity Motricity Index, and Berg Balance Scale scores. CONCLUSIONS: As a proof-of-concept, individual activity-level recovery can be predicted as patient-level trajectories generated from electronic medical record data, but models require attention to completeness and accuracy of data elements collected on a fully representative patient sample.

Prognosis of Individual-Level Mobility and Self-Care Stroke Recovery During Inpatient Rehabilitation, Part 1: A Proof-of-Concept Single Group Retrospective Cohort Study.

OBJECTIVE: To demonstrate feasibility of generating predictive short-term individual trajectory recovery models after acute stroke by extracting clinical data from an electronic medical record (EMR) system. DESIGN: Single-group retrospective patient cohort design. SETTING: Stroke rehabilitation unit at an independent inpatient rehabilitation facility (IRF). PARTICIPANTS: Cohort of 1408 inpatients with acute ischemic or hemorrhagic stroke with a mean ± SD age of 66 (14.5) years admitted between April 2014 and October 2019 (N=1408). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: 0-100 Rasch-scaled Functional Independence Measure (FIM) Mobility and Self-Care subscales. RESULTS: Unconditional models were best-fit on FIM Mobility and Self-Care subscales by spline fixed-effect functions with knots at weeks 1 and 2, and random effects on the baseline (FIM 0-100 Rasch score at IRF admission), initial rate (slope at time zero), and second knot (change in slope pre-to-post week 2) parameters. The final Mobility multivariable model had intercept associations with Private/Other Insurance, Ischemic Stroke, Serum Albumin, Motricity Index Lower Extremity, and FIM Cognition; and initial slope associations with Ischemic Stroke, Private/Other and Medicaid Insurance, and FIM Cognition. The final Self-Care multivariable model had intercept associations with Private/Other Insurance, Ischemic Stroke, Living with One or More persons, Serum Albumin, and FIM Cognition; and initial slope associations with Ischemic Stroke, Private/Other and Medicaid Insurance, and FIM Cognition. Final models explained 52% and 27% of the variance compared with unconditional Mobility and Self-Care models. However, some EMR data elements had apparent coding errors or missing data, and desired elements from acute care were not available. Also, unbalanced outcome data may have biased trajectories. CONCLUSIONS: We demonstrate the feasibility of developing individual-level prognostic models from EMR data; however, some data elements were poorly defined, subject to error, or missing for some or all cases. Development of prognostic models from EMR will require improvements in EMR data collection and standardization.

Randomized Trial of Two Exercise Programs to Increase Physical Activity and Health-Related Quality of Life for Persons With Spinal Cord Injury.

Objectives: To compare the effectiveness of two different interventions that promote physical activity in individuals with traumatic spinal cord injury (SCI) and determine the effect of relapse prevention. Methods: A sequential, multiple assignment, randomized trial was conducted at a universally designed community-based exercise facility. Participants were individuals with traumatic SCI, >3 months post injury, levels C5 to T12, age ≥18 years (N = 79). After randomization, Bridge Program participants completed an 8-week personalized, less intense, exercise program informed by American College of Sports Medicine (ACSM) guidelines and supported with hands-on peer mentoring, exercise of choice, and caregiver training. Structured Exercise participants completed an 8-week program in a group format based on ACSM guidelines. After intervention, participants were randomized to receive or not receive relapse prevention for 6 months. The time and intensity of physical activity and psychological change in depression, anxiety, self-efficacy, and function were assessed with self-reported measures. Results: Compared to baseline, physical activity increased post intervention for both the Bridge and Structured Exercise programs. Compared to baseline, participants in the Bridge Program recorded fewer anxiety symptoms. No significant changes were noted for either program in depressive symptoms, self-efficacy, or function. There was no difference in relapse prevention between the two groups at 6 months. Conclusions: The Bridge Program, a novel personalized exercise program with peer support, exercise of choice, and caregiver training, and a structured exercise program both improved self-reported physical activity, but the Bridge Program also reduced anxiety symptoms. This study provides important insight into the limitations of commonly used measures of physical activity and psychosocial domains in people with SCI.

Exploratory examination of the scale structure of the Moorong Self-Efficacy Scale: Application of Rasch Measurement Theory.

OBJECTIVE: Exploratory application of the Rasch Measurement (RM) Model for evidence for reproducibility, conceptual/content validity, and structural validity of the Moorong Self-Efficacy Scale (MSES). STUDY DESIGN: Secondary RM analysis of data collected in a randomized controlled trial comparing two exercise interventions for persons living with spinal cord injury (SCI). SETTING: Community-dwelling persons living with SCI enrolled in an exercise study. PARTICIPANTS: Adults (n = 79) enrolled in the parent study had a traumatic SCI > 3 months prior, injury level C5 to T12. INTERVENTIONS: Not applicable. OUTCOME MEASURE: The original MSES is a 16-item measure of self-efficacy with a 7-level response scale for un/certainty which was developed for use with persons living with SCI. RESULTS: We addressed item misfit, infrequent category endorsement, and category step disorder by removing two items and reorganizing the rating scale. Rating scale changes removed category 4 (Neutral), combined categories 1-3 (Very Uncertain, Somewhat Uncertain, and Uncertain) for all items, and further combined certainty categories for two items. Principal components analysis of the residuals indicated a possible second dimension with a first-contrast Eigenvalue of 2.4. However, the contrasted item groups had explained variance <10% and a dis-attenuated correlation = 0.92 indicating they measure the same underlying trait. The small sample size precluded examination of differential item functioning. CONCLUSIONS: Exploratory RM analysis of MSES produced a 14-item Rasch version which identified structural and content validity evidence concerns inherent in the original MSES. However, results could be biased by a small sample size and further study should examine the item content and rating scale structure with larger, more diverse samples of persons living with SCI.