Critical Period After Stroke Study (CPASS): A phase II clinical trial testing an optimal time for motor recovery after stroke in humans.

Restoration of human brain function after injury is a signal challenge for translational neuroscience. Rodent stroke recovery studies identify an optimal or sensitive period for intensive motor training after stroke: near-full recovery is attained if task-specific motor training occurs during this sensitive window. We extended these findings to adult humans with stroke in a randomized controlled trial applying the essential elements of rodent motor training paradigms to humans. Stroke patients were adaptively randomized to begin 20 extra hours of self-selected, task-specific motor therapy at ≤30 d (acute), 2 to 3 mo (subacute), or ≥6 mo (chronic) after stroke, compared with controls receiving standard motor rehabilitation. Upper extremity (UE) impairment assessed by the Action Research Arm Test (ARAT) was measured at up to five time points. The primary outcome measure was ARAT recovery over 1 y after stroke. By 1 y we found significantly increased UE motor function in the subacute group compared with controls (ARAT difference = +6.87 ± 2.63, P = 0.009). The acute group compared with controls showed smaller but significant improvement (ARAT difference = +5.25 ± 2.59 points, P = 0.043). The chronic group showed no significant improvement compared with controls (ARAT = +2.41 ± 2.25, P = 0.29). Thus task-specific motor intervention was most effective within the first 2 to 3 mo after stroke. The similarity to rodent model treatment outcomes suggests that other rodent findings may be translatable to human brain recovery. These results provide empirical evidence of a sensitive period for motor recovery in humans.

The Critical Period After Stroke Study (CPASS) Upper Extremity Treatment Protocol.

Objective: To present the development of a novel upper extremity (UE) treatment and assess how it was delivered in the Critical Periods After Stroke Study (CPASS), a phase II randomized controlled trial (RCT). Design: Secondary analysis of data from the RCT. Setting: Inpatient and outpatient settings the first year after stroke. Participants: Of the 72 participants enrolled in CPASS (N=72), 53 were in the study groups eligible to receive the treatment initiated at ≤30 days (acute), 2-3 months (subacute), or ≥6 months (chronic) poststroke. Individuals were 65.1±10.5 years of age, 55% were women, and had mild to moderate UE motor capacity (Action Research Arm Test=17.2±14.3) at baseline. Intervention: The additional 20 hours of treatment began using the Activity Card Sort (ACS), a standardized assessment of activities and participation after stroke, to identify UE treatment goals selected by the participants that were meaningful to them. Treatment activities were broken down into smaller components from a standardized protocol and process that operationalized the treatments essential elements. Main Outcome Measures: Feasibility of performing the treatment in a variety of clinical settings in an RCT and contextual factors that influenced adherence. Results: A total of 49/53 participants fully adhered to the CPASS treatment. The duration and location of the treatment sessions and the UE activities practiced during therapy are presented for the total sample (n=49) and per study group as an assessment of feasibility and the contextual factors that influenced adherence. Conclusions: The CPASS treatment and therapy goals were explicitly based on the meaningful activities identified by the participants using the ACS as a treatment planning tool. This approach provided flexibility to customize UE motor therapy without sacrificing standardization or quantification of the data regardless of the location and UE impairments of participants within the first year poststroke.

Interpreting the CPASS Trial: Do Not Shift Motor Therapy to the Subacute Phase.

The Critical Periods After Stroke Study (CPASS, n = 72) showed that, compared to controls, an additional 20 hours of intensive upper limb therapy led to variable gains on the Action Research Arm Test depending on when therapy was started post-stroke: the subacute group (2-3 months) improved beyond the minimal clinically important difference and the acute group (0-1 month) showed smaller but statistically significant improvement, but the chronic group (6-9 months) did not demonstrate improvement that reached significance. Some have misinterpreted CPASS results to indicate that all inpatient motor therapy should be shifted to outpatient therapy delivered 2 to 3 months post-stroke. Instead, however, CPASS argues for a large dose of motor therapy delivered continuously and cumulatively during the acute and subacute phases. When interpreting trials like CPASS, one must consider the substantial dose of early usual customary care (UCC) motor therapy that all participants received. CPASS participants averaged 27.9 hours of UCC occupational therapy (OT) during the first 2 months and 9.8 hours of UCC OT during the third and fourth months post-stroke. Any recovery experienced would therefore result not just from CPASS intensive motor therapy but the combined effects of experimental therapy plus UCC. Statistical limitations also did not allow direct comparisons of the acute and subacute group outcomes in CPASS. Instead of shifting inpatient therapy hours to the subacute phase, CPASS argues for preserving inpatient UCC. We also recommend conducting multi-site dosing trials to determine whether additional intensive motor therapy delivered in the first 2 to 3 months following inpatient rehabilitation can further improve outcomes.

Concurrent validity of machine learning-classified functional upper extremity use from accelerometry in chronic stroke.

Objective: This study aims to investigate the validity of machine learning-derived amount of real-world functional upper extremity (UE) use in individuals with stroke. We hypothesized that machine learning classification of wrist-worn accelerometry will be as accurate as frame-by-frame video labeling (ground truth). A second objective was to validate the machine learning classification against measures of impairment, function, dexterity, and self-reported UE use. Design: Cross-sectional and convenience sampling. Setting: Outpatient rehabilitation. Participants: Individuals (>18 years) with neuroimaging-confirmed ischemic or hemorrhagic stroke >6-months prior (n = 31) with persistent impairment of the hemiparetic arm and upper extremity Fugl-Meyer (UEFM) score = 12-57. Methods: Participants wore an accelerometer on each arm and were video recorded while completing an "activity script" comprising activities and instrumental activities of daily living in a simulated apartment in outpatient rehabilitation. The video was annotated to determine the ground-truth amount of functional UE use. Main outcome measures: The amount of real-world UE use was estimated using a random forest classifier trained on the accelerometry data. UE motor function was measured with the Action Research Arm Test (ARAT), UEFM, and nine-hole peg test (9HPT). The amount of real-world UE use was measured using the Motor Activity Log (MAL). Results: The machine learning estimated use ratio was significantly correlated with the use ratio derived from video annotation, ARAT, UEFM, 9HPT, and to a lesser extent, MAL. Bland-Altman plots showed excellent agreement between use ratios calculated from video-annotated and machine-learning classification. Factor analysis showed that machine learning use ratios capture the same construct as ARAT, UEFM, 9HPT, and MAL and explain 83% of the variance in UE motor performance. Conclusion: Our machine learning approach provides a valid measure of functional UE use. The accuracy, validity, and small footprint of this machine learning approach makes it feasible for measurement of UE recovery in stroke rehabilitation trials.

Grade inflation: a problem in nursing?

This article examines grade inflation in higher education and in nursing education. The factors related to grade inflation and consequences of grade inflation are explored. Actions that address grade inflation and recommendations for future research in nursing education are provided.

Machine Learning Improves Functional Upper Extremity Use Capture in Distal Radius Fracture Patients.

Current outcome measures, including strength/range of motion testing, patient-reported outcomes (PROs), and motor skill testing, may provide inadequate granularity in reflecting functional upper extremity (UE) use after distal radius fracture (DRF) repair. Accelerometry analysis also has shortcomings, namely, an inability to differentiate functional versus nonfunctional movements. The objective of this study was to evaluate the accuracy of machine learning (ML) analyses in capturing UE functional movements based on accelerometry data for patients after DRF repair. In this prospective study, six patients were enrolled 2-6 weeks after DRF open reduction and internal fixation (ORIF). They all performed standardized activities while wearing a wrist accelerometer, and the data were analyzed by an ML algorithm. These activities were also videotaped and evaluated by visual inspection. Our novel ML algorithm was able to predict from accelerometry data whether the limb was performing a movement rated as functional, with accuracy of 90.4% ± 3.6% for within-subject modeling and 79.8% ± 8.9% accuracy for between-subject modeling. The application of ML algorithms to accelerometry data allowed for capture of functional UE activity in patients after DRF open reduction and internal fixation and accurately predicts functional UE use. Such analyses could improve our understanding of recovery and enhance routine postoperative rehabilitation in DRF patients.

Institute of Medicine recommendations for the prevention and control of hepatitis B and C.

UNLABELLED: Despite federal, state, and local public health efforts to prevent and control hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, these diseases remain serious health problems in the United States. About 1%-2% of the U.S. population has chronic HBV or HCV infections, and each year about 15,000 people die from liver cancer or liver disease related to these preventable infections. The Institute of Medicine formed an expert committee to determine ways to reduce new HBV and HCV infections and the morbidity and mortality related to chronic viral hepatitis and released its findings in a report. The major factor found to impede current efforts to prevent and control HBV and HCV is lack of knowledge and awareness about these diseases among healthcare and social-service providers, members of the public, and policy makers. Because the extent and seriousness of this public health problem is not appreciated, inadequate resources are being allocated to prevention, control, and surveillance programs. This situation has led to continued transmission of HBV and HCV and inadequate identification of and medical management for chronically infected people. CONCLUSION: To address the situation, the Institute of Medicine report makes recommendations in four areas: improved surveillance for HBV and HCV; improved knowledge and awareness among healthcare and social-service providers and the public, especially at-risk people; improved HBV vaccine coverage; and improved viral hepatitis services and access to those services.

Characterizing upper extremity motor behavior in the first week after stroke.

BACKGROUND: Animal models of brain recovery identify the first days after lesioning as a time of great flux in sensorimotor function and physiology. After rodent motor system lesioning, daily skill training in the less affected forelimb reduces skill acquisition in the more affected forelimb. We asked whether spontaneous human motor behaviors of the less affected upper extremity (UE) early after stroke resemble the animal training model, with the potential to suppress clinical recovery. METHODS: This prospective observational study used a convenience sample of patients (n = 25, mean 4.5 ±1.8) days after stroke with a wide severity range; Controls were hospitalized for non-neurological conditions (n = 12). Outcome measures were Accelerometry, Upper-Extremity Fugl-Meyer (UEFM), Action Research Arm Test (ARAT), Shoulder Abduction/ Finger Extension Test (SAFE), NIH Stroke Scale (NIHSS). RESULTS: Accelerometry indicated total paretic UE movement was reduced compared to controls, primarily due to a 44% reduction of bilateral UE use. Unilateral paretic movement was unchanged. Thus, movement shifted early after stroke; bilateral use was reduced and unilateral use of the non-paretic UE was increased by 77%. Low correlations between movement time and motor performance prompted an exploratory factor analysis (EFA) revealing a 2-component solution; motor performance tests load on one component (motor performance) whereas accelerometry-derived variables load on a second orthogonal component (quantity of movement). CONCLUSIONS: Early after stroke, spontaneous overall UE movement is reduced, and movement shifts to unilateral use of the non-paretic UE. Two mechanisms that could influence motor recovery may already be in place 4.5 ± 1.8 days post stroke: (1) the overuse of the less affected UE, which could set the stage for learned non-use and (2) skill acquisition in the non-paretic limb that could impede recovery. Accurate UE motor assessment requires two independent constructs: motor performance and quantity of movement. These findings provide opportunities and measurement methods for studies to develop new behaviorally-based stroke recovery treatments that begin early after onset.

Are leader stereotypes masculine? A meta-analysis of three research paradigms.

This meta-analysis examined the extent to which stereotypes of leaders are culturally masculine. The primary studies fit into 1 of 3 paradigms: (a) In Schein's (1973) think manager-think male paradigm, 40 studies with 51 effect sizes compared the similarity of male and leader stereotypes and the similarity of female and leader stereotypes; (b) in Powell and Butterfield's (1979) agency-communion paradigm, 22 studies with 47 effect sizes compared stereotypes of leaders' agency and communion; and (c) in Shinar's (1975) masculinity-femininity paradigm, 7 studies with 101 effect sizes represented stereotypes of leadership-related occupations on a single masculinity-femininity dimension. Analyses implemented appropriate random and mixed effects models. All 3 paradigms demonstrated overall masculinity of leader stereotypes: (a) In the think manager-think male paradigm, intraclass correlation = .25 for the women-leaders similarity and intraclass correlation = .62 for the men-leaders similarity; (b) in the agency-communion paradigm, g = 1.55, indicating greater agency than communion; and (c) in the masculinity-femininity paradigm, g = 0.92, indicating greater masculinity than the androgynous scale midpoint. Subgroup and meta-regression analyses indicated that this masculine construal of leadership has decreased over time and was greater for male than female research participants. In addition, stereotypes portrayed leaders as less masculine in educational organizations than in other domains and in moderate- than in high-status leader roles. This article considers the relation of these findings to Eagly and Karau's (2002) role congruity theory, which proposed contextual influences on the incongruity between stereotypes of women and leaders. The implications for prejudice against women leaders are also considered.