Measuring Soldier Performance During the Patrol-Exertion Multitask: Preliminary Validation of a Postconcussive Functional Return-to-Duty Metric.

OBJECTIVE: To assess the discriminant validity of the Patrol-Exertion Multitask (PEMT), a novel, multidomain, functional return-to-duty clinical assessment for active duty military personnel. DESIGN: Measurement development study. SETTING: Nonclinical indoor testing facility. PARTICIPANTS: Participants (N=84) were healthy control (HC) service members (SMs; n=51) and military personnel (n=33) with persistent postconcussive symptoms receiving rehabilitation (mild traumatic brain injury [mTBI]). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Known-groups discriminant validity was evaluated by comparing performance on the PEMT in 2 groups of active duty SMs: HCs and personnel with mTBI residual symptoms. Participant PEMT performance was based on responses in 4 subtasks during a 12-minute patrolling scenario: (1) accuracy in identifying virtual improvised explosive device (IED) markers and responses to scenario-derived questions from a computer-simulated foot patrol; (2) auditory reaction time responses; (3) rating of perceived exertion during stepping; and (4) self-reported visual clarity (ie, gaze stability) during vertical head-in-space translation while stepping. RESULTS: Significant between-group differences for the PEMT were observed in 2 of 4 performance domains. Postpatrol IED identification task/question responses (P=.179) and rating of perceived exertion (P=.133) did not discriminate between groups. Participant self-report of visual clarity during stepping revealed significant (P<.001) between-group differences. SM reaction time responses to scenario-based auditory cues were significantly delayed in the mTBI group in both the early (P=.013) and late (P=.002) stages of the PEMT. CONCLUSIONS: Findings from this study support the use of a naturalistic, multidomain, complex clinical assessment to discriminate between healthy SMs and personnel with mTBI residual symptoms. Based on this preliminary study, additional research to further refine the PEMT and extend its application to return-to-work outcomes in military and civilian environments is warranted.

Implementation Intentions for Self-Selected Occupational Therapy Goals: Two Case Reports.

OBJECTIVE: We evaluated the feasibility of an intervention combining metacognitive strategy instruction (MSI) with training in implementation intentions for adults with mild traumatic brain injury (mTBI). Implementation intentions are written premade decision statements specifying when, where, and how goal behaviors are to be enacted. METHOD: Two participants with mTBI received a six-session intervention that included setting a daily implementation intention for an occupational therapy goal. A scoring rubric was used to evaluate the quality of implementation intentions; goal achievement was measured using the Canadian Occupational Performance Measure (COPM) and goal attainment scaling. RESULTS: All implementation intentions received perfect quality scores, suggesting participants learned to correctly craft implementation intentions. Improvements in COPM self-ratings exceeded minimal detectable change values; goal attainment levels indicated better-than-expected goal achievement. CONCLUSION: An intervention combining MSI and implementation intention training appears to be feasible. As an adjunct to MSI, implementation intentions may contribute to clients' ability to achieve their own occupational performance goals. Further study is needed.

Delphi Study to Determine Rehabilitation Research Priorities for Older Adults With Cancer.

OBJECTIVE: To solicit expert opinions and develop consensus around the research that is needed to improve cancer rehabilitation for older adults. DESIGN: Delphi methods provided a structured process to elicit and prioritize research questions from national experts. SETTING: National, Web-based survey. PARTICIPANTS: Members (N=32) of the American Congress of Rehabilitation Medicine completed at least 1 of 3 investigator-developed surveys. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: In the first survey, participants identified up to 5 research questions that needed to be answered to improve cancer rehabilitation for older adults. In 2 subsequent surveys, participants viewed the compilation of questions, rated the importance of each question, and identified the 5 most important questions. This generated priority scores for each question. Consensus scores were created to describe the degree of agreement around the priority of each question. RESULTS: Highest priority research concerns the epidemiology and measurement of function and disability in older adult cancer survivors; the effects of cancer rehabilitation interventions on falls, disability, participation, survival, costs, quality of care, and health care utilization; and testing models of care that facilitate referrals from oncology to rehabilitation providers as part of coordinated, multicomponent care. CONCLUSIONS: A multipronged approach is needed to fill these gaps, including targeted funding opportunities developed with an advisory panel of cancer rehabilitation experts, development of a research network to facilitate novel collaborations and grant proposals, and coordinated efforts of clinical groups to advocate for funding, practice change, and policy change.

The club-level road cyclist: injury, pain, and performance.

OBJECTIVE: The aims of this study were to (1) examine riding habits of injured cyclists, (2) identify factors related to seeking medical treatment, (3) investigate performance of recreational road cyclists compared with established norms regarding strength and flexibility measures, and (4) propose cycling-specific injury risk factors. DESIGN: Observational and prospective study. SETTING: Cycling store and bicycle distribution company. PARTICIPANTS: Sixty-three experienced road cyclists. ASSESSMENT OF RISK FACTORS: Initial data collection included a questionnaire. A 2-week training diary and 8 weekly follow-up injury questionnaires were also collected. MAIN OUTCOME MEASURES: Training habits and injury history, bike fit, flexibility, and isometric, dynamic, and plyometric strength measures. RESULTS: Participants were likely to have an injury at baseline, and chronic pain was common. Cyclists trained for an equal quantity of time irrespective of experiencing pain. Injury severity in terms of pain level and participant age were factors in seeking medical care. Our participants performed poorly on our testing protocol compared with available norms. Flexibility, strength, and bike fit measures did not predict injury. Previous injury predicted prospective injury. The knee and lumbar region were most frequently injured. CONCLUSIONS: Cycling is a sport in which injury risk and prevention need to be further studied. Cyclists are frequently injured but continue to participate in cycling at volumes equal to their healthy peers. CLINICAL RELEVANCE: This study outlines a clinically reproducible cyclist assessment and discusses behaviors common to the cycling patient.

Composition of a vision screen for servicemembers with traumatic brain injury: consensus using a modified nominal group technique.

Vision impairment is common in the first year after traumatic brain injury (TBI), including among service members whose brain injuries occurred during deployment in Iraq and Afghanistan. Occupational therapy practitioners provide routine vision screening to inform treatment planning and referral to vision specialists, but existing methods are lacking because many tests were developed for children and do not screen for vision dysfunction typical of TBI. An expert panel was charged with specifying the composition of a vision screening protocol for servicemembers with TBI. A modified nominal group technique fostered discussion and objective determinations of consensus. After considering 29 vision tests, the panel recommended a nine-test vision screening that examines functional performance, self-reported problems, far-near acuity, reading, accommodation, convergence, eye alignment and binocular vision, saccades, pursuits, and visual fields. Research is needed to develop reliable, valid, and clinically feasible vision screening protocols to identify TBI-related vision disorders in adults.

Development and preliminary reliability of a multitasking assessment for executive functioning after concussion.

OBJECTIVES. Executive functioning deficits may result from concussion. The Charge of Quarters (CQ) Duty Task is a multitask assessment designed to assess executive functioning in servicemembers after concussion. In this article, we discuss the rationale and process used in the development of the CQ Duty Task and present pilot data from the preliminary evaluation of interrater reliability (IRR). METHOD. Three evaluators observed as 12 healthy participants performed the CQ Duty Task and measured performance using various metrics. Intraclass correlation coefficient (ICC) quantified IRR. RESULTS. The ICC for task completion was .94. ICCs for other assessment metrics were variable. CONCLUSION. Preliminary IRR data for the CQ Duty Task are encouraging, but further investigation is needed to improve IRR in some domains. Lessons learned in the development of the CQ Duty Task could benefit future test development efforts with populations other than the military.

Long-term effects of safe patient handling program on staff injuries.

PURPOSE: This study evaluated the effectiveness of a safe patient handling program (STEPS) at an inpatient rehabilitation unit in reducing injury due to patient transfers. Our objectives were to compare number of staff injuries during the 1.5-year period post training to pre training (baseline) and to determine whether reduction in injuries was sustained long term during a 2.5-year post training period. METHODS: All nursing and therapy staff as well as new hires received STEPS training. Periodic retraining was not provided. FINDINGS: The number of injuries was significantly reduced at post training compared to baseline (p = 0.01). However, the reductions in injuries were not sustained long term. CONCLUSION: We estimated a cost benefit of $3.71 for every dollar invested in retraining based on injury reduction realized during the post training period. CLINICAL RELEVANCE: Retraining is likely to have a positive cost benefit when it results in maintaining reduction in staff injuries.

Which management strategy do parents prefer for their head-injured child: immediate computed tomography scan or observation?

OBJECTIVE: The objectives of this study were to determine which method of head injury evaluation, immediate computed tomography (CT) or observation, parents would prefer for their child when given the opportunity to make an informed decision and to determine factors influencing preference. METHODS: Parents of head-injured children 2 years or older who presented to a pediatric emergency department were eligible. After triage evaluation, and before physician assessment, research assistants presented educational materials regarding the method, risks, and benefits of both immediate CT and observation. Parents then completed a survey asking them their preference, reasons for preference, details of their child's injury, and demographic information. RESULTS: One hundred thirty-four parents participated. After reviewing the educational materials, 53 (40%) preferred immediate CT; 77 (57%) preferred observation; 4 (3%) did not indicate a preference. Of those parents who preferred immediate CT, the leading reason given was, "I need to be 100% sure there is no bleeding in my child's brain." Of those parents who preferred observation, the 2 leading reasons given were, "I don't want my child to have a test unless he/she absolutely has to" and "I am concerned about the possibility of radiation causing a brain tumor." Injury mechanism, time between injury and presentation, time of day, child's age, worst symptom, previous CT, and demographic markers were not statistically associated with preference. CONCLUSIONS: When given the opportunity to make an informed decision regarding the evaluation of their head-injured child, parents were divided as to their preference. A small majority preferred observation.

Predicting surgical outcomes in pediatric cervicofacial nontuberculous mycobacterial lymphadenitis.

OBJECTIVES: We examined surgical outcomes in children with cervicofacial nontuberculous mycobacterial lymphadenitis and attempted to identify predictors of complications. METHODS: A retrospective chart review from 2 tertiary pediatric centers was used to identify .11 presentation or operative variables (age at surgery, gender, symptom duration, pain, violaceous skin changes, skin breakdown, fluctuance, purified protein derivative positivity, operative procedure, use of nerve integrity monitoring, and use of skin flap advancement) and to compare these to 5 postoperative complications (facial nerve dysfunction [paresis or paralysis], poor scarring, recurrence, wound infection, and wound dehiscence without infection). RESULTS: The 45 patients analyzed for presentation or operative variables (28 female, 17 male; average age, 31.2 months) typically presented with painless masses averaging 8.2 weeks in duration, along with violaceous skin changes in 29 of the 45 cases (64%) and skin breakdown in 9 cases (20%). The surgical procedures included parotidectomy with or without selective lymphadenectomy in 38 of the 45 cases (84%) and lymphadenectomy alone in 7 cases (16%). Skin resection and cervicofacial advancement flap reconstruction was performed in 20 cases (44%). Nerve integrity monitoring was utilized in 32 cases (71%). In the 44 patients analyzed for postoperative complications, we found facial nerve paresis in 14 (31.8%), poor scarring in 9 (20.5%), wound infection in 6 (13.6%), recurrence in 4 (9.1%), and facial nerve paralysis in 2 (4.5%). Nine of the 14 cases (64.3%) of initial facial nerve paresis resolved. At final follow-up, facial nerve paresis persisted in 5 of the 14 children (35.7%) with initial postoperative paresis and in 1 of the 2 children (50.0%) with initial postoperative paralysis. Facial nerve paralysis persisted in the other child with initial postoperative paralysis. Overall, 6 of these 7 patients (85.7%) with persistent facial nerve dysfunction had follow-up of less than 1 month. All transient and permanent facial nerve dysfunction was in the distribution of the marginal mandibular nerve only. No statistically significant predictors of complications were identified. CONCLUSIONS: We report acceptable but not insignificant rates of marginal mandibular distribution facial nerve injury, poor scarring, wound infection, and recurrence following resection of cervicofacial nontuberculous mycobacterial lymphadenitis in children that must be discussed with patients and parents before operation. No presentation or operative variables predicted the complications.

The complex association of race and leaving the pediatric emergency department without being seen by a physician.

OBJECTIVES: This study examined the influence of race and language on leaving the emergency department (ED) without complete evaluation and treatment (LWCET). METHODS: This retrospective, case-cohort study examined LWCET among patients discharged home from 2 EDs between March 2, 2009, and March 31, 2010. Race and language were obtained by family self-report. We also explored wait time to see a physician as an explanation of racial disparities. RESULTS: One thousand two hundred eighty-five (1.7%) of 76,931 ED encounters ended in LWCET. Factors increasing LWCET were high ED activity, low acuity, and medical assistance (MA) insurance. American Indian, biracial, African American, and Hispanic races were also associated with higher odds of LWCET among visits by MA insurance patients compared with those of white patients on private insurance. Restricting the analysis to visits by MA insurance patients, only American Indian race was associated with LWCET compared with white race. Visits by patients using an interpreter or speaking a language other than English at home had lower odds of ending in LWCET. Sensitivity analyses in subgroups confirmed these findings. We developed a measure of ED activity that correlated well with wait time to see a physician (correlation coefficient = 0.993; P < 0.001). Among non-LWCET visits, wait time to see a practitioner did not correlate with racial disparities in LWCET. CONCLUSIONS: Race, language, and insurance status interact to form a complex relationship with LWCET. Medical assistance insurance status appears to account for much of the excessive instances of LWCET seen in nonwhites. After restricting the analysis to MA insurance patients, only visits by American Indian patients had higher odds of LWCET compared with whites on MA insurance. Wait time to see a physician did not explain racial differences in LWCET.

How well does serum bicarbonate concentration predict the venous pH in children being evaluated for diabetic ketoacidosis?

OBJECTIVE: The objective of the study was to determine whether serum bicarbonate (HCO3) concentration can accurately predict venous pH in the evaluation of diabetic ketoacidosis (DKA). METHODS: A retrospective review of patients who presented to a children's hospital emergency department and received an International Classification of Diseases, Ninth Revision code related to DKA or diabetes mellitus was performed. To be eligible for inclusion and data abstraction, patients had blood sampled simultaneously for venous blood gas and metabolic panel. A linear regression model was created using pH (dependent variable) and HCO3 (predictor). The diagnostic performance and accuracy of HCO3 to discriminate abnormal pH were evaluated using receiver operating characteristic curve analysis. RESULTS: Three hundred patients met the inclusion criteria. The linear relationship between pH and HCO3 using the Pearson correlation coefficient was found to be R = 0.89 (confidence interval [CI], 0.83-0.95; R = 0.79). Receiver operating characteristic curve analysis that maximized sensitivity and specificity demonstrated that a HCO3 18.5 or less predicts pH less than 7.3 (area under the curve = 0.97; CI, 0.94-0.99; sensitivity, 93%; specificity, 91%), and a HCO3 10.5 or less predicts pH less than 7.1 (area under the curve = 0.97; CI, 0.95-0.99; sensitivity, 97%; specificity, 88%). CONCLUSIONS: Serum bicarbonate accurately predicts abnormal venous pH in children with DKA. Venous pH determination may not be necessary for all patients being evaluated for DKA.

Perspectives on poststroke sexual issues and rehabilitation needs.

PURPOSE: To study the perspectives and experiences of stroke survivors and partners of stroke survivors regarding sexual issues and perceived rehabilitation needs. METHODS: Using semi-structured interviews, 15 stroke survivors and 14 partners of stroke survivors (median age of 65 years, range 29 to 85) provided information about sexual issues experienced after stroke and their perspectives on how to address sexual concerns in a rehabilitation setting. A qualitative thematic analysis was applied to transcribed interviews to identify and describe common themes within the data relevant to the aim of the study. A quantitative analysis was utilized to elucidate the frequency of themes by demographic characteristics that were not readily apparent using a qualitative method alone. RESULTS: Seven themes were identified. Two related to the effects of stroke on sexual life: physical/functional changes and relationship changes. Five related to addressing sexual issues in the process of rehabilitation: (1) difficulty in patients and providers talking about sexual matters, (2) little to no discussion of poststroke sexuality, (3) need for tailoring education to an individual or couple's unique needs, (4) provider rapport and competence, and (5) timing of poststroke sexual education. CONCLUSIONS: Poststroke sexual issues are complex and suggest the need for the development of a biopsychosocial model of education and treatment intervention. Rehabilitation programs need to evaluate the level of training and services provided to address poststroke sexual issues. Development of clinically useful poststroke sexual adjustment assessment tools and interventions is warranted.

Pediatric safe patient handling.

Patient-handling tasks have historically been recognized as the primary cause for musculoskeletal disorders among the nursing workforce. Children's Hospitals and Clinics of Minnesota (Children's) implemented an innovative and industry-leading pediatric safe patient-handling program to minimize the frequency of occupational injuries associated with patient-handling tasks. An analysis of workers' compensation claims revealed that the rate of postimplementation incidents was reduced by 71.4% when compared with Children's preimplementation incidence rate. A review of risk perception surveys illustrated that most patient-handling tasks at Children's were perceived to be significantly less risky after implementation.

Hoarseness in children with cleft palate.

OBJECTIVE: Determine the rate of hoarseness in children with cleft palate (CP). Understand the relationship between velopharyngeal insufficiency (VPI) and hoarseness in children with CP. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Retrospective chart review of 185 patients with CP treated by a Children's Hospital Cleft Team and born between 1991 and 2001. RESULTS: Of total patients, 54.1 percent were male and 45.9 percent female. All types of CP were represented. The overall rate of hoarseness was 20.0 percent at age 3-4 and 18.4 percent at age 6-7. The presence of VPI did not correlate with the presence of hoarseness or dysphonia. VPI decreased when comparing age 3-4 (58.4%) with age 6-7 (30.2%, P < 0.001), but the hoarseness rates did not change, 20.8 percent at age 3-4 and 19.5 percent at age 6-7 (P = 0.56). CONCLUSION: Patients with CP are thought to have increased risk of voice disturbances due to compensatory articulation mechanisms used when a patient has VPI. However, this study of 185 patients with CP showed no relationship between VPI and hoarseness. The overall rate of hoarseness of this population with CP was within the reported range for the normal population of children. These findings suggest that the theory that VPI causes hoarseness due to compensatory speech mechanisms may be incorrect.

Symptom duration and CT findings in pediatric deep neck infection.

OBJECTIVE: To investigate whether children with less than 48 hours of localized symptoms of deep neck infection are less likely to have an abscess on CT scan. STUDY DESIGN: Case series. SUBJECTS AND METHODS: The charts of children seen in a tertiary children's hospital for deep neck infections between 2000 and 2007 were reviewed. RESULTS: Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck of which 102 (61.1%) were positive for abscess. There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1 percent and 58.3 percent, respectively (P = 0.98). Furthermore, there was no significant difference in age, gender, C-reactive protein levels, disease location, or length of stay between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group (P = 0.01); however, the median white blood cell count in both groups was above normal. CONCLUSION: Because duration of symptoms does not predict finding of abscess on CT, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for neck abscess.

Parental preference for rehydration method for children in the emergency department.

OBJECTIVE: To determine which rehydration method, oral or intravenous, parents would choose for their child when given the opportunity to make an informed decision and to determine factors influencing preference. METHODS: Parents of children, aged 6 months to 5 years, who presented to a pediatric emergency department with a chief complaint of vomiting and/or diarrhea were eligible. After triage evaluation and before physician assessment, research assistants presented educational materials regarding the method, risks, and benefits of both oral and intravenous rehydration. Parents were then asked to complete a survey asking them their preference, reasons for their preference, questions about their child's current illness, and demographic information. RESULTS: Two hundred sixty parents completed the study. Ninety eight (38%) preferred oral rehydration, and 162 (62%) preferred intravenous rehydration. Time of day, presence of siblings in the ED requiring parental attention, presence of another adult to provide support, parental age, educational attainment, and employment status were not statistically associated with the stated preference. Of those parents who selected intravenous rehydration, 53% stated that they would choose oral rehydration if there was an oral medication available that would significantly decrease vomiting. Of those parents who selected oral rehydration, 32% stated that they would choose intravenous rehydration if there was a topical medication available that would significantly decrease the pain of intravenous catheter placement. CONCLUSIONS: When given the opportunity to make an informed decision, more parents chose intravenous rehydration. However, the prospect of an effective oral antiemetic medication might lead more parents to choose oral rehydration.

Sinus surgery in cystic fibrosis patients: comparison of sinus and lower airway cultures.

OBJECTIVE: The aim of this study is to determine whether cross-infection occurs between infections in the sinuses and lower airways in Cystic Fibrosis patients, and to determine whether the infections begin in the sinuses before spreading to the lungs. METHODS: Retrospective study of pediatric Cystic Fibrosis patients who underwent simultaneous sinus surgery and bronchial washings. The results of the cultures were reviewed to determine if the same organisms colonized both the sinuses and lower airways. RESULTS: Staphylococcus aureus (Staph. Aureus) was found in 40.7% of the sinuses but only 33.3% of the lower airways. One patient had Staph. Aureus in the lower airway but not the sinuses. Pseudomonas, Hemophilus Influenza, and Moraxella showed similar patterns: multiple instances of positive sinus cultures and negative bronchial cultures, but only a small number of cases with positive lower airway cultures and negative sinus cultures. CONCLUSION: The data showed that as patients age, they are more likely to have infections in both upper and lower airways, but infections start in the upper airways at a younger age. In many cases, organisms were cultured from sinuses in patients who had negative lower airway cultures. In only a few instances, organisms grew in the lower airways and not the sinuses. In most cases, the bacteria that caused sinus infections at a young age caused the lung infections in older patients. This is the paper to show that bacteria spread from the sinuses to the lungs to cause infections in Cystic Fibrosis patients, and not vice-versa.

Impact of changes in infant death classification on the diagnosis of sudden infant death syndrome.

This study evaluates the hypothesis that a decline in sudden infant death syndrome in Minnesota is associated with increases in other categories of sudden unexpected infant death. Matched birth and death certificates, autopsy reports, and home visit questionnaires were reviewed for 722 sudden unexpected infant deaths that occurred from January 1, 1996 through December 31, 2002. Descriptive data and cause of death were recorded. Cause of death was compared for 2 periods: early (1996-1998) and late (2000-2002). The age of the infant at death, sex, race, and infant death rates were similar between the 2 periods ( P = .637). Sudden infant death syndrome declined by 50.1% (P < .001). Overlay deaths increased 235.5% (P < .01). Asphyxia related deaths increased 259.6% (P < .001). Injury-related deaths increased 840.0% (P < .001). A decline in sudden infant death syndrome in Minnesota was associated with increased deaths in categories that are asphyxial in nature and are potentially preventable.

The impact of positioning on fear during immunizations: supine versus sitting up.

This study explored the impact of a child's position on the level of fear and perception of pain during an immunization injection. One hundred seven children, ages 4-6, participated in a random-assignment, two-group design study to evaluate the effect of positioning on fear and perceived pain. Group 1 was placed in the supine position and Group 2 in the sitting position prior to immunizations. The results substantiated the belief that children are significantly less fearful about receiving an injection when they are sitting up as compared to when they are lying down. There was no difference in perception of pain.