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1.  Disparities in Post-Acute Rehabilitation Care for Stroke 
Objective
To use population-based, hospital discharge data to determine the extent to which demographic and geographic disparities exist in the use of PARC following stroke.
Design
Cross-sectional analysis of two years (2005-2006) of population-based, hospital discharge data.
Setting
All short-term acute care hospitals in four demographically and geographically diverse states (AZ, FL, NJ, WI).
Participants
Individuals 45 years and older (mean age of 72.6 years) admitted to the hospital with a primary diagnosis of stroke, who survived their inpatient stay and who were not transferred to a hospice or other short-term, acute care facility (N=187,188). The sample was 52.4 percent female, 79.5 percent White, 11.4 percent Black, and 9.1 percent Hispanic.
Interventions
Not applicable.
Main Outcome Measures
1) Discharge to an institution versus home. 2) For those discharged home, discharge home with or without home health (HH). 3) For those discharged to an institution, discharge to an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply.
Results
Blacks, females, older individuals, and those with lower incomes were more likely to be discharged to an institution; Hispanic individuals and the uninsured were less likely. Racial minorities, females, older individuals, and those with lower incomes were more likely to receive HH; uninsured individuals and rural residents were less likely. Blacks, females, older individuals, the uninsured, and those with lower incomes were more likely to use SNF vs IRF care. PARC use varied significantly by state and by hospital.
Conclusions
Several demographic and geographic disparities in PARC use were identified.
doi:10.1016/j.apmr.2011.03.019
PMCID: PMC4332528  PMID: 21807141
stroke; healthcare disparities; rehabilitation
2.  Ethical Perspectives on Knowledge Translation in Rehabilitation 
Although the literature on the ethical dimensions of knowledge creation, use, and dissemination is voluminous, it has not particularly examined the ethical dimensions of knowledge translation in rehabilitation. Yet, whether research is done in a wet lab or treatments are provided to patients in therapeutic settings, rehabilitation professionals commonly use (as well as create) knowledge and disseminate it to peers, patients, and various others. This article will refer to knowledge creation, use, and transfer as knowledge translation and examine some of its numerous ethical challenges. Three ethical dimensions of knowledge translation will particularly attract our attention: (1) the quality of knowledge disseminated to rehabilitationists; (2) ethical challenges in being too easily persuaded by or unreasonably resistant to putative knowledge; and (3) organizational barriers to knowledge translation. We will conclude with some recommendations on facilitating the ethical soundness of knowledge translation in rehabilitation.
doi:10.1016/j.apmr.2012.08.218
PMCID: PMC4325989  PMID: 23168302
Ethics; Rehabilitation
3.  Comorbidity and Functional Mobility in Persons with Parkinson’s Disease 
Objective
To report the frequency, severity, and types of comorbidities in people with Parkinson’s disease (PD) using a validated self-report comorbidity-screening tool and to determine the relationship between comorbidity and functional mobility.
Design
A secondary analysis and cross-sectional observational study design.
Setting
University hospital; outpatient Balance Disorders Laboratory.
Participants
Seventy-six persons with mild to moderate idiopathic PD.
Intervention
Not Applicable.
Main outcome measures
The Cumulative Illness Rating Scale-Geriatric (CIRS-G) and a comprehensive mobility assessment including gait (distance walked in 3 minutes), balance (Mini-BESTest), and physical function (Physical Performance Test).
Results
All participants reported comorbidities in addition to their diagnosed PD. The average number of comorbidities was 6.96 ± 2.0 (range 2–11) and total CIRS-G score was 12.7 (±4.8). The most commonly reported organ systems with comorbidity were Eyes & Ears (89%), Psychiatric (68%), Musculoskeletal (64%), Lower GI (62%), Respiratory (60.5%), Upper GI (59.2%), and Genitourinary (53.9%). The total CIRS-G score was significantly related to functional mobility: gait (r=−0.53; p=0.0001), balance (r=−0.43; p=0.0003) and Physical Performance (r=−0.36; p=0.0041). Of the original 14 organ systems measured, there were 7 systems that, when combined, best predicted gait performance; 6 systems combined best-predicted balance performance and 4 systems combined that predicted functional performance.
Conclusion
This study reports high frequency of multiple medical system comorbidity in people with mild to moderate PD. Furthermore, comorbidity scores were associated with mobility disability: gait, balance and physical function. Early intervention is important to delay mobility disability in PD and we recommend that people with PD found to have comorbidities should be screened for balance and gait deficits.
doi:10.1016/j.apmr.2014.07.396
PMCID: PMC4322903  PMID: 25102383
Parkinson’s disease; comorbidity; comorbidities; CIRS-G; mobility
4.  [No title available] 
PMCID: PMC3946862  PMID: 24231402
5.  A systematic review of patient-reported outcome measures in clinical vestibular research 
Objective
To identify the most commonly-used patient-reported outcome (PRO) measures in clinical vestibular research, and assess their test characteristics and applicability to study age-related vestibular loss (ARVL) in clinical trials.
Data Sources
We performed a systematic review of the PubMed, CINAHL, and PsycINFO databases from 1950 to August 13, 2013.
Study Selection
PRO measures were defined as outcomes that capture the subjective experience of the patient, such as symptoms, functional status, health perceptions, and quality of life. Two independent reviewers selected studies that used PRO measures in clinical vestibular research. Disparities were resolved with consensus between the reviewers. Of 2260 articles initially found on literature search, 255 full-text articles were retrieved for assessment. One-hundred and four studies met inclusion criteria for data collection.
Data Extraction
PRO measures were identified by two independent reviewers. The four most commonly used PROs were evaluated for their applicability to the condition of ARVL. Specifically, for these four PROs, data were collected pertaining to instrument test-retest reliability, item domains, and target population of the instrument.
Data Synthesis
A total of 50 PRO instruments were identified. The four most frequently utilized PROs were the Dizziness Handicap Inventory (DHI), the Activities-specific Balance Confidence (ABC) scale, the Vertigo Symptom Scale (VSS), and the Visual Analogue Scale (VAS). Of these four PROs, three were validated for use in patients with vestibular disease, and one was validated in community-dwelling older individuals with balance impairments. Items across the four PROs were categorized into three domains based on the International Classification of Functioning, Disability and Health: Activity, Participation, and Body Functions and Structures.
Conclusions
None of the most commonly-used PRO instruments were validated for use in community-dwelling older adults specifically with ARVL. Nevertheless, the three common domains of items identified across these four PRO instruments may be generalizable to older adults and provide a basis for developing a PRO instrument designed to evaluate the effectiveness of interventions targeted to ARVL.
doi:10.1016/j.apmr.2014.09.017
PMCID: PMC4306632  PMID: 25305629
vertigo; vestibular rehabilitation; outcome research; outcome measures; systematic review
6.  Effectiveness of Multidisciplinary Rehabilitation Services in Postacute Care: State-of-the-Science. A Review 
Objectives
To summarize the efficacy of postacute rehabilitation and to outline future research strategies for increasing knowledge of its effectiveness.
Data Sources
English-language systematic reviews that examined multidisciplinary therapy-based rehabilitation services for adults, published in the last 25 years and available through Cochrane, Medline, or CINAHL databases. We excluded multidisciplinary biopsychosocial rehabilitation programs and mental health services.
Study Selection
Using the search term rehabilitation, 167 records were identified in the Cochrane database, 1163 meta-analyses and reviews were identified in Medline, and 226 in CINAHL. The Medline and CINAHL search was further refined with 3 additional search terms: therapy, multidisciplinary, and interdisciplinary. In summary, we used 12 reviews to summarize the efficacy of multidisciplinary, therapy-based postacute rehabilitation; the 12 covered only 5 populations.
Data Extraction
Two reviewers extracted information about study populations, sample sizes, study designs, the settings and timing of rehabilitation, interventions, and findings.
Data Synthesis
Based on systematic reviews, the evidence for efficacy of postacute rehabilitation services across the continuum was strongest for stroke. There was also strong evidence supporting multidisciplinary inpatient rehabilitation for patients with rheumatoid arthritis, moderate to severe acquired brain injury, including traumatic etiologies, and for older adults. Heterogeneity limited our ability to conclude a benefit or a lack of a benefit for rehabilitation in other postacute settings for the other conditions in which systematic reviews had been completed. The efficacy of multidisciplinary rehabilitation services has not been systematically reviewed for many of the diagnostic conditions treated in rehabilitation. We did not complete a summary of findings from individual studies.
Conclusions
Given the limitations and paucity of systematic reviews, information from carefully designed nonrandomized studies could be used to complement randomized controlled trials in the study of the effectiveness of postacute rehabilitation. Consequently, a stronger evidence base would become available with which to inform policy decisions, guide the use of services, and improve patient access and outcomes.
doi:10.1016/j.apmr.2007.06.768
PMCID: PMC4309994  PMID: 17964900
Evidence-based medicine; Rehabilitation; Review [publication type]
7.  Comparison of Complex versus Simple Activity of Daily Living Staging: Validation of Simple Stages 
OBJECTIVE
To compare simple activities of daily living (ADL) staging with complex ADL staging and to assess the face, construct and predictive validity of simple ADL stages. Activities of Daily Living (ADL) staging is an innovative, partially hierarchical approach to ADL difficulty measurement. Initial staging validation studies used four-level responses to ADL difficulty questions to derive stages (complex ADL staging). Simple ADL stages are based on two-level responses to ADL difficulty questions.
DESIGN
Analysis of the second Longitudinal Study of Aging, a prospective cohort study, using descriptive statistics and logistic regression.
SETTING
United States
PARTICIPANTS
9,447 community dwelling persons ≥ age 70 years in 1994.
INTERVENTIONS
Not applicable
MAIN OUTCOME MEASURES
Agreement & Face Validity: Baseline simple ADL stage
Construct Validity: Baseline health, difficulty and need characteristics
Prognostic Comparison (determined at the Wave 2 interview): Primary: nursing home use and/or death; Secondary: death
RESULTS
The systems showed good agreement (kappa = 0.75). The simple ADL stages stratified people into distinct groups and reflected the expected step-wise increases from Stage 0 to Stage IV in health and need characteristics, such as the prevalence of home-related challenges (2.9% to 84.5%) and perceived need for home modifications (2.1% to 33.6%). In comparing the prognostic ability using the primary outcome, the complex system model demonstrated slightly increased discrimination between milder stages and a slightly higher C-statistic (0.666 vs. 0.664)
CONCLUSION
Although complex staging appears slightly better at classifying people into distinct prognostic strata with respect to nursing home use and/or death at Wave 2, simple ADL stages demonstrate strong, clinically relevant associations with health and need characteristics.
doi:10.1016/j.apmr.2012.11.046
PMCID: PMC4310001  PMID: 23313353
activities of daily living; staging; disability; home environment; Longitudinal Study on Aging II
8.  Perspectives on the State-of-the-Science in Rehabilitation Medicine and Its Implications for Medicare Postacute Care Policies 
Better measurement of the case-mix complexity of patients receiving rehabilitation services is critical to understanding variations in the outcomes achieved by patients treated in different postacute care (PAC) settings. The Medicare program recognized this issue and is undertaking a major initiative to develop a new patient-assessment instrument that would standardize case-mix measurement in inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, and home health agencies. The new instrument, called the Continuity Assessment Record and Evaluation Tool, builds on the scientific advances in measurement to develop standard measures of medical acuity, functional status, cognitive impairment, and social support related to resource need, outcomes, and continuity of care for use in all PAC settings.
doi:10.1016/j.apmr.2007.09.025
PMCID: PMC4310210  PMID: 18047896
Health care reform; Medicare; Prospective payment system; Rehabilitation; Treatment outcomes
9.  Standing Data Disproves Biomechanical Mechanism for Balance-Based Torso-Weighting 
Objective
To test a proposed mechanism for the effect of Balance-Based Torso-Weighting (BBTW) in people with multiple sclerosis and healthy controls. The application of light weights to the trunk may result in a biomechanical shift of postural sway in the direction of weighting, mechanically facilitating maintenance of center of mass over the base of support.
Design
Non-randomized controlled trial
Setting
motion analysis laboratory
Participants
20 participants with multiple sclerosis (average EDSS 4.1) and 18 sex-, age-, height- and weight-matched controls
Intervention
Light weights strategically placed according to the BBTW protocol were applied to all participants following at least three walking trials and 10 seconds of quiet standing with feet together eyes open (EO) and eyes closed (EC). Measures were repeated after weighting.
Main Outcome Measure
Force plate center of pressure (COP) changes greater than one standard error of measurement (SEM).
Results
With BBTW, people with MS had larger maximum changes in COP than healthy controls in the left-right direction but not in the anterior-posterior direction. COP changes greater than one SEM occurred in the same direction of weighting 20% of the time (95% confidence interval 5%, 34%), ranging from 10% to 28% across conditions and directions of postural sway. Direction of greatest weight placement did not match the direction of change in average COP in the majority of participants with multiple sclerosis or the healthy controls in EO or EC conditions (p<.0001).
Conclusions
If BBTW worked via a biomechanical shift of the center of mass, COP changes should match the direction of greatest weighting with BBTW. Our data allowed us to reject this hypothesis. Future research may explore alternative mechanisms of action underlying this intervention.
doi:10.1016/j.apmr.2013.08.235
PMCID: PMC3918424  PMID: 24001445
Multiple sclerosis; rehabilitation; balance; theory
10.  Exercise for Improving Age-Related Hyperkyphotic Posture: A Systematic Review 
Objective
To evaluate previous research to determine if exercise can improve preexisting hyperkyphosis by decreasing the angle of thoracic kyphosis in adults aged ≥45 years.
Data Sources
PubMed, Embase, and the Cumulative Index to Nursing and Allied Health Literature databases were searched for studies related to posture, exercise, and age ≥45 years. Online conference proceedings of the American Society for Bone and Mineral Research, American Physical Therapy Association, and Gerontological Society of America were also searched.
Study Selection
Two independent reviewers screened the titles and abstracts and selected studies that tested the effect of exercise on measures of kyphosis, or forward head posture, in individuals with hyperkyphosis at baseline (defined as angle of kyphosis ≥40°). Reviews, letters, notes, and non-English language studies were excluded.
Data Extraction
A pilot-tested abstraction form was used by each reviewer to extract data from each study regarding details of exercise intervention, participant characteristics, safety, adherence, and results. The Cochrane Collaboration’s tool for assessing risk of bias was used to assess methodologic quality. Discrepancies on the abstraction forms between the 2 reviewers were resolved by a third reviewer. A formal meta-analysis was not performed.
Data Synthesis
Thirteen studies were abstracted and included in the review; of these, 8 studies saw improvements in ≥1 measure of posture. The main sources of bias were related to blinding participants and incomplete outcome data. The adherence reported across studies suggests that exercise is an acceptable intervention for individuals with age-related hyperkyphosis.
Conclusions
The scarcity and quality of available data did not permit a pooled estimate of the effect of exercise on hyperkyphotic posture; however, the positive effects observed in high-quality studies suggest some benefit and support the need for an adequately designed randomized controlled trial examining the effect of exercise on hyperkyphosis.
doi:10.1016/j.apmr.2013.06.022
PMCID: PMC3997126  PMID: 23850611
Aged; Exercise; Kyphosis; Rehabilitation
11.  Regional Variation in Stroke Rehabilitation Outcomes 
Objective
To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation.
Design
Retrospective cohort design.
Setting
Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation (UDSMR) from the United States.
Participants
143,036 patients with stroke discharged from inpatient rehabilitation during 2006 and 2007.
Interventions
Not applicable.
Main Outcome Measures
Community discharge, length of stay, discharge functional status ratings (motor, cognitive), across ten geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS).
Results
Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the southwest (CMS 9) to 59.4% in the northeast (CMS 2). Adjusted length of stay varied by 2.1 days with CMS 1 having the longest length of stay at 18.3 days and CMS 5 and 9 being the shortest at 16.2 days.
Conclusion
Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and length of stay remained after adjusting for demographic and clinical characteristics.
doi:10.1016/j.apmr.2013.07.018
PMCID: PMC4006274  PMID: 23921200
Rehabilitation; Quality of healthcare; Health services
12.  Health-Related Quality of Life in Caregivers of Individuals with Traumatic Brain Injury: Development of a Conceptual Model 
Objective
To identify aspects of health-related quality of life (HRQOL) that are relevant to caregivers of individuals with traumatic brain injury (TBI) and propose an integrated conceptual framework based on this information.
Design
Nine focus groups with caregivers of individuals with moderate-to-severe TBI were qualitatively analyzed to ascertain the effect that caring for an individual with a TBI has on caregiver HRQOL.
Setting
Focus groups were conducted at three rehabilitation centers across the United States (Michigan, New Jersey, and Texas).
Participants
55 caregivers of individuals with moderate-to-severe TBI
Interventions
Not Applicable.
Main Outcome Measures
Not Applicable.
Results
Qualitative analysis indicated that caregivers were most concerned about their social health (42% of comments); other important issues were emotional health (34%), physical health (11%), cognitive health (3%), and feelings of loss (9%; feelings of loss related to changes in the future/potential of the care recipient or related to the caregiver). Areas of concern that were discussed that were specific to the caregiver and not fully evaluated by existing patient-reported outcomes (PROs) included feelings of loss, anxiety related to the caregiver role (reinjury concerns, worry about leaving the person alone, etc.), and caregiver strain (burden, stress, feeling overwhelmed, etc.).
Conclusion
Although existing PROs capture relevant aspects of HRQOL for caregivers, there are HRQOL domains that are not addressed. A validated and sensitive HRQOL tool for caregivers of individuals with TBI will facilitate initiatives to improve outcomes in this underserved group.
doi:10.1016/j.apmr.2014.08.021
PMCID: PMC4276526  PMID: 25239281
Caregiver; Outcome Assessment (Health Care); Traumatic Brain Injury; Health-Related Quality of Life; Underserved Populations
13.  Recumbent Cross-Training Is a Feasible and Safe Mode of Physical Activity for Significantly Motor-Impaired Adults With Cerebral Palsy 
Objective
To examine the feasibility and potential benefits of using recumbent cross-training for nonambulatory adults with cerebral palsy (CP).
Design
Observational.
Setting
Clinical center for CP treatment and rehabilitation.
Participants
Significantly motor-impaired adults with CP (NZ = 11) with a mean age ± SD of 36.3 ± 13.2 years and Gross Motor Function Classification System (GMFCS) III and IV.
Interventions
Participants completed a 40-minute session of aerobic exercise using the NuStep Recumbent Cross Trainer, in which resistance was progressively increased at 5-minute intervals.
Main Outcome Measures
Every 5 minutes during the exercise session, heart rate, blood pressure, oxygen consumption (V.O2), energy expenditure, and respiratory exchange ratios (RERs) were recorded along with rating of perceived exertion. Immediately after, and 24 hours postexercise, participants received a standard survey to assess levels of pain and discomfort.
Results
All participants were able to complete the 40-minute exercise protocol. Five of the 11 participants achieved a heart rate of at least 60% maximum throughout the duration, 10 participants had a significant elevation in V.O2 from baseline, and all participants had elevated RER values. Six participants reported pain during exercise, but only 2 reported pain after exercise was over.
Conclusions
The NuStep Recumbent Cross Trainer is a feasible exercise modality for significantly motor-impaired adults with CP, GMFCS III and IV. Moreover, this mode was sufficient to stimulate a significant cardiorespiratory response in all participants, and thus it and similar devices may serve as a viable option for aerobic exercise interventions in this population, to prevent obesity and related cardiometabolic consequences.
doi:10.1016/j.apmr.2012.09.027
PMCID: PMC4265464  PMID: 23063881
Aerobic exercise; Cerebral palsy; Gait dysfunction; Pain; Rehabilitation
14.  Cognitive-Motor Interference during Functional Mobility after Stroke: State of the Science and Implications for Future Research 
Archives of physical medicine and rehabilitation  2013;94(12):10.1016/j.apmr.2013.08.002.
Cognitive-motor interference (CMI) is evident when simultaneous performance of a cognitive task and a motor task results in deterioration in performance in one or both of the tasks, relative to performance of each task separately. The purpose of this review is to present a framework for categorizing patterns of CMI and to examine the specific patterns of CMI evident in published studies comparing single-task and dual-task performance of cognitive and motor tasks during gait and balance activities after stroke. We also examine the literature for associations between patterns of CMI and history of falls, as well as evidence for the effects of rehabilitation on CMI after stroke. Overall, this review suggests that during gait activities with an added cognitive task, people with stroke are likely to demonstrate significant decrements in motor performance only (cognitive-related motor interference) or decrements in both motor and cognitive performance (mutual interference). In contrast, patterns of CMI were variable among studies examining balance activities. Comparing people post-stroke with and without a history of falls, patterns and magnitude of CMI were similar for fallers and non-fallers. Longitudinal studies suggest that conventional rehabilitation has minimal effects on CMI during gait or balance activities. However, early phase pilot studies suggest that dual-task interventions may reduce CMI during gait performance in community-dwelling stroke survivors. It is our hope that this innovative and critical examination of the existing literature will highlight the limitations in current experimental designs and inform improvements in the design and reporting of dual-task studies in stroke.
doi:10.1016/j.apmr.2013.08.002
PMCID: PMC3842379  PMID: 23973751
gait; balance; dual task; rehabilitation
15.  Which neuromuscular attributes are most associated with mobility among older primary care patients? 
Archives of physical medicine and rehabilitation  2013;94(12):10.1016/j.apmr.2013.07.026.
Objective
To identify the neuromuscular attributes that are associated with self reported mobility status among older primary care patients
Design
Cohort Study
Setting
Metropolitan based health care system
Participants
Community-dwelling primary care patients age ≥ 65 years (N=430), with self-reported modification of mobility tasks resulting from underlying health conditions.
Interventions
Not applicable
Main Outcome Measures
Basic and Advanced Lower Extremity Function as measured by the Late Life Function and Disability Instrument
Results
We constructed multivariable linear regression models evaluating both outcomes. For Basic-Lower Extremity Function, leg strength, leg velocity, trunk extensor muscle endurance and ankle range of motion were statistically significant predictors (p<.001 R2 = .21). For Advanced-Lower Extremity Function, leg strength, leg strength asymmetry, leg velocity, trunk extensor muscle endurance and knee flexion range of motion were statistically significant predictors (p<.001, R2 =.39). Sensitivity analyses conducted using multiple imputations to account for missing data confirmed these findings.
Conclusions
This analysis highlights the relevance and importance of 5 categories of neuromuscular attributes: strength, speed of movement, range of motion, asymmetry and trunk stability. It identifies novel attributes (leg velocity and trunk extensor muscle endurance) relevant to mobility and highlights that impairment profiles vary by the level of mobility assessed. These findings will inform the design of more thorough and potentially more effective disability prevention strategies.
doi:10.1016/j.apmr.2013.07.026
PMCID: PMC3874862  PMID: 23973445
Aged; Rehabilitation; Mobility Limitation; Primary Health Care
16.  Home-Based Treadmill Training to Improve Gait Performance in Persons With a Chronic Transfemoral Amputation 
Objective
To investigate the effectiveness of a home-based multiple-speed treadmill training program to improve gait performance in persons with a transfemoral amputation (TFA).
Design
Repeated measures.
Setting
Research laboratory.
Participants
Individuals with a TFA (N=8) who had undergone a unilateral amputation at least 3 years prior as a result of limb trauma or cancer.
Intervention
Home-based treadmill walking for a total of 30 minutes a day, 3 days per week for 8 weeks. Each 30-minute training session involved 5 cycles of walking for 2 minutes at 3 speeds.
Main Outcome Measures
Participants were tested pretraining and after 4 and 8 weeks of training. The primary measures were temporal-spatial gait performance (symmetry ratios for stance phase duration and step length), physiological gait performance (energy expenditure and energy cost), and functional gait performance (self-selected walking speed [SSWS], maximum walking speed [MWS], and 2-minute walk test [2MWT]).
Results
Eight weeks of home-based training improved temporal-spatial gait symmetry at SSWS but not at MWS. A relative interlimb increase in stance duration for the prosthetic limb and proportionally greater increases in step length for the limb taking shorter steps produced the improved symmetry. The training effect was significant for the step length symmetry ratio within the first 4 weeks of the program. Energy expenditure decreased progressively during the training with nearly 10% improvement observed across the range of walking speeds. SSWS, MWS, and 2MWT all increased by 16% to 20%.
Conclusions
Home-based treadmill walking is an effective method to improve gait performance in persons with TFA. The results support the application of training interventions beyond the initial rehabilitation phase, even in individuals considered highly functional.
doi:10.1016/j.apmr.2013.08.001
PMCID: PMC4005601  PMID: 23954560
Amputees; Energy metabolism; Exercise; Locomotion; Rehabilitation
17.  Association between disease-specific quality-of-life and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis 
Archives of physical medicine and rehabilitation  2013;94(11):10.1016/j.apmr.2013.06.025.
Objective
To assess the relationship between knee osteoarthritis (KOA)-specific quality-of-life (QoL) and intra-articular cartilage volume (CV) in participants treated with prolotherapy. KOA is characterized by CV loss and multifactorial pain. Prolotherapy is an injection therapy reported to improve KOA-related QoL compared to blinded saline injections and at-home exercise but the mechanism of action is unknown.
Design
Two-arm (Prolotherapy, Control), partially blinded, controlled trial.
Setting
Outpatient.
Participants
37 adults with ≥3 months of symptomatic KOA.
Intervention
Prolotherapy: 5 monthly injection sessions; Control: blinded saline injections or at-home exercise.
Outcome Measures
Primary: KOA-specific QoL scores (baseline, 5, 9, 12, 26, 52 weeks; Western Ontario McMaster University Osteoarthritis Index, WOMAC). Secondary: KOA-specific pain, stiffness, function (WOMAC subscales), magnetic resonance imaging (MRI)-assessed CV (baseline, 52 weeks).
Results
Knee-specific QoL improvement among Prolotherapy participants exceeded that of Controls (17.6±3.2 versus 8.6±5.0 points, p=0.05) at 52 weeks. Both groups lost CV over time (p<0.05); no between-group differences were noted (p=0.98). While Prolotherapy participants lost CV at varying rates, those who lost the least CV (“Stable CV”) had the greatest improvement in pain scores. Among Prolotherapy, but not Control participants, the change in CV and the change in pain (but not stiffness or function) scores were correlated; each 1% CV loss was associated with 2.7% less improvement in pain score (p<0.05).
Conclusions
Prolotherapy resulted in safe, substantial improvement in KOA-specific QoL compared to Control over 52-weeks. Among prolotherapy participants, but not Controls, MRI-assessed CV change (CV stability) predicted pain severity score change, suggesting prolotherapy may have pain-specific disease-modifying effect. Further research is warranted.
doi:10.1016/j.apmr.2013.06.025
PMCID: PMC3812343  PMID: 23850615
knee osteoarthritis; prolotherapy; dextrose; cartilage volume; magnetic resonance imaging
18.  Upper-Extremity and Mobility Subdomains From the Patient-Reported Outcomes Measurement Information System (PROMIS) Adult Physical Functioning Item Bank 
Archives of physical medicine and rehabilitation  2013;94(11):10.1016/j.apmr.2013.05.014.
Objective
To create upper-extremity and mobility subdomain scores from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning adult item bank.
Design
Expert reviews were used to identify upper-extremity and mobility items from the PROMIS item bank. Psychometric analyses were conducted to assess empirical support for scoring upper-extremity and mobility subdomains.
Setting
Data were collected from the U.S. general population and multiple disease groups via self-administered surveys.
Participants
The sample (N=21,773) included 21,133 English-speaking adults who participated in the PROMIS wave 1 data collection and 640 Spanish-speaking Latino adults recruited separately.
Interventions
Not applicable.
Main Outcome Measures
We used English- and Spanish-language data and existing PROMIS item parameters for the physical functioning item bank to estimate upper-extremity and mobility scores. In addition, we fit graded response models to calibrate the upper-extremity items and mobility items separately, compare separate to combined calibrations, and produce subdomain scores.
Results
After eliminating items because of local dependency, 16 items remained to assess upper extremity and 17 items to assess mobility. The estimated correlation between upper extremity and mobility was .59 using existing PROMIS physical functioning item parameters (r=.60 using parameters calibrated separately for upper-extremity and mobility items).
Conclusions
Upper-extremity and mobility subdomains shared about 35% of the variance in common, and produced comparable scores whether calibrated separately or together. The identification of the subset of items tapping these 2 aspects of physical functioning and scored using the existing PROMIS parameters provides the option of scoring these subdomains in addition to the overall physical functioning score.
doi:10.1016/j.apmr.2013.05.014
PMCID: PMC3812258  PMID: 23751290
Lower extremity; Psychometrics; Rehabilitation; Upper extremity
19.  Change in Inpatient Rehabilitation Admissions for Individuals With Traumatic Brain Injury After Implementation of the Medicare Inpatient Rehabilitation Facility Prospective Payment System 
Objective
To evaluate the impact of Medicare’s inpatient rehabilitation facility (IRF) prospective payment system (PPS) on use of inpatient rehabilitation for individuals with traumatic brain injury (TBI).
Design
Retrospective cohort study of patients with TBI.
Setting
One hundred twenty-three level I and II trauma centers across the U.S. who contributed data to the National Trauma Data Bank.
Participants
Patients (N = 135,842) with TBI and an Abbreviated Injury Score of the head of 2 or greater admitted to trauma centers between 1995 and 2004.
Interventions
None.
Main Outcome Measure
Discharge location: IRF, skilled nursing facility, home, and other hospitals.
Results
Compared with inpatient rehabilitation admissions before IRF PPS came into effect, demographic characteristics of admitted patients changed. Those admitted to acute care trauma centers after PPS was enacted (January 2002) were older and nonwhite. No differences were found in rates of injury between men and women. Over time, there was a significant drop in the percent of patients being discharged to inpatient rehabilitation, which varied by region, but was found across all insurance types. In a logistic regression, after controlling for patient characteristics (age, sex, race), injury characteristics (cause, severity), insurance type, and facility, the odds of being discharged to an IRF after a TBI decreased 16% after Medicare’s IRF PPS system was enacted.
Conclusions
The enactment of the Medicare PPS appears to be associated with a reduction in the chance that patients receive inpatient rehabilitation treatment after a TBI. The impact of these changes on the cost, quality of care, and patient outcome is unknown and should be addressed in future studies.
doi:10.1016/j.apmr.2012.04.030
PMCID: PMC4207214  PMID: 22840827
Brain injuries; Medicare; Rehabilitation
20.  Subacromial Corticosteroid Injection for Poststroke Shoulder Pain: An Exploratory Prospective Case Series 
Objective:
To assess the effectiveness of subacromial corticosteroid injections for poststroke shoulder pain.
Design:
Exploratory, prospective case series.
Setting:
Ambulatory setting, university-affiliated hospital.
Participants:
Stroke survivors (N=10) with pain in the hemiparetic shoulder.
Intervention:
Consecutive stroke survivors with evidence of supraspinatus impingement, supraspinatus tendonitis, or subacromial bursitis received subacromial corticosteroid injections.
Main Outcome Measures:
The primary outcome measure was the Brief Pain Inventory (BPI) question 12 (BPI 12), which assesses “worst pain” in the previous 7 days. Secondary measures included BPI question 15, which assesses present pain and BPI question 23 (BPI 23), which assesses pain interference with 7 daily activities. Outcomes were assessed at baseline, weekly for the first 4 weeks and then at 8 and 12 weeks postinjection.
Results:
Repeated measure analysis of variance revealed significant within group time effect for BPI 12 (F=7.7, P<.001). Based on absolute means, the largest therapeutic benefit was seen by the second week postinjection with partial loss of effect thereafter. There were significant within group time effects for the general activity (F=3.2, P=.009), sleep (F=3.9, P=.003), and enjoyment of life (F=2.3, P=.044) domains of BPI 23.
Conclusions:
Subacromial corticosteroid injection is associated with significant reduction in poststroke shoulder pain in patients with evidence of supraspinatus impingement, supraspinatus tendonitis, or subacromial bursitis. However, there is a gradual loss of effect with time. Controlled trials are needed to show a cause and effect relationship.
doi:10.1016/j.apmr.2008.10.011
PMCID: PMC4193293  PMID: 19254618
Injections; Rehabilitation; Shoulder pain; Stroke
21.  Effects of Intramuscular Trunk Stimulation on Manual Wheelchair Propulsion Mechanics in Six Subjects with Spinal Cord Injury 
Objective
To quantify the effects of stabilizing the paralyzed trunk and pelvis with electrical stimulation on manual wheelchair propulsion.
Design
Single-subject design case series with subjects acting as their own concurrent controls.
Setting
Hospital-based clinical biomechanics laboratory.
Participants
Six (4M, 2F age 46±10.8yrs) long-time users (6.1±3.9yrs) of implanted neuroprostheses for lower extremity function with chronic (8.6±2.8yrs) mid-cervical or thoracic level injuries (C6-T10).
Interventions
Continuous low level stimulation to the hip (gluteus maximus, posterior adductor or hamstrings) and trunk extensor (lumbar erector spinae and/or quadratus lumborum) muscles with implanted intramuscular electrodes.
Main Outcome Measure(s)
Pushrim kinetics (peak resultant force, fraction effective force), kinematics (cadence, stroke length and maximum forward lean), and peak shoulder moment at preferred speed over 10m level surface; speed, pushrim kinetics and subjective ratings of effort for level 100m sprints and up a 30.5m ramp of approximately 5% grade.
Results
Three out of five subjects demonstrated reduced peak resultant pushrim forces (p≤0.014) and improved efficiency, (p≤0.048) with stimulation during self-paced level propulsion. Peak sagittal shoulder moment remained unchanged in three subjects and increased in two others (p<0.001). Maximal forward trunk lean also increased by 19-26% (p<0.001) with stimulation in these three subjects. Stroke lengths were unchanged by stimulation in all subjects, and two showed extremely small (5%) but statistically significant increases in cadence (p≤0.021). Performance measures for sprints and inclines were generally unchanged with stimulation, however subjects consistently rated propulsion with stimulation to be easier for both surfaces.
Conclusions
Stabilizing the pelvis and trunk with low levels of continuous electrical stimulation to the lumbar trunk and hip extensors can positively impact the mechanics of manual wheelchair propulsion and reduce both perceived and physical measures of effort.
doi:10.1016/j.apmr.2013.04.010
PMCID: PMC4103696  PMID: 23628377
Neural Prostheses; Spinal Cord Injuries; Posture; Electrical Stimulation; Torso
22.  Comparison of muscle and skin perfusion over the ischial tuberosities in response to wheelchair tilt-in-space and recline angles in people with spinal cord injury 
Objective
To compare the efficacy of wheelchair tilt-in-space and recline on enhancing muscle and skin perfusion over the ischial tuberosities in people with spinal cord injury (SCI).
Design
Repeated measures and before-after trial design.
Setting
University research laboratory.
Participants
Power wheelchair users with SCI (N=20).
Interventions
Six combinations of wheelchair tilt-in-space and recline angles were presented to participants in a random order. The testing protocol consisted of a baseline 5 min sitting with no tilt/recline and 5 min positioned in tilted and reclined position at each of 6 conditions, including: (1) 15° tilt-in-space and 100° recline, (2) 25° tilt-in-space and 100° recline, (3) 35° tilt-in-space and 100° recline, (4) 15° tilt-in-space and 120° recline, (5) 25° tilt-in-space and 120° recline, and (6) 35° tilt-in-space and 120° recline.
Main Outcome Measures
Muscle and skin perfusion was assessed by near-infrared spectroscopy and laser Doppler flowmetry, respectively.
Results
Muscle perfusion was significantly increased at 25° and 35° tilt-in-space when combined with 120° recline and skin perfusion was significantly increased at 3 tilt-in-space angles (15°, 25°, 35°) when combined with 120° recline and at 35° tilt-in-space when combined with 100° recline (P<.05). Even in the positions of increased muscle perfusion and skin perfusion (25° and 35° of tilt-in-space combined with 120° of recline), the amount of muscle perfusion change was significantly lower than the amount of skin perfusion change (P<.05).
Conclusions
Our results indicate that a larger angle of tilt-in-space and recline is needed to improve muscle perfusion compared to skin perfusion. A position of 25° tilt-in-space combined with 120° recline is effective in enhancing muscle and skin perfusion of weight-bearing soft tissues at the ischial tuberosities.
doi:10.1016/j.apmr.2013.03.027
PMCID: PMC3787984  PMID: 23602880
deep tissue injury; laser Doppler flowmetry; near-infrared spectroscopy; pressure ulcer prevention; wheelchair seating
23.  Patient-Reported Shoulder Outcome Measures Utilized in Breast Cancer Survivors: A Systematic Review 
Objective
1) To identify English Language published patient-reported upper extremity outcome measures used in breast cancer research and 2) To examine construct validity and responsiveness in patient-reported upper extremity outcome measures used in breast cancer research.
Data Sources
PubMed, CINAHL and ProQuest MEDLINE® databases were searched up to February 5, 2013.
Study Selection
Studies were included if a patient-reported upper extremity outcome measure was administered, the participants were diagnosed with breast cancer, and published in English.
Data Extraction
Eight hundred and sixty-five articles were screened. Fifty-nine full text articles were assessed for eligibility. A total of 46 articles met the initial eligibility criteria for aim 1. Eleven of these articles reported mean and standard deviations for the outcome scores, and included a comparison group analysis for aim 2.
Data Synthesis
Construct validity was evaluated by calculating effect sizes for known group differences in 6 studies using the Disabilities of Arm, Shoulder and Hand (DASH), Penn Shoulder Score, Shoulder Disability Questionnaire-Dutch, and 10 Questions by Wingate (Wingate). Responsiveness was analyzed comparing a treatment and control group by calculating the coefficient of responsiveness in 5 studies for the DASH and Wingate.
Conclusions
Eight different patient-reported upper extremity outcome measures have been reported in the peer-review literature for women with breast cancer, some (n=3) were specifically developed for breast cancer survivors and others that were not (n=5). Based on the current evidence we recommend administering the DASH to assess patient-reported upper extremity function in breast cancer survivors because the DASH had most consistently large effects sizes for construct validity and responsiveness. Future large studies are needed for more definitive recommendations.
doi:10.1016/j.apmr.2013.07.022
PMCID: PMC4162515  PMID: 23932969
Breast neoplasms; Upper extremity; Outcome assessment; Rehabilitation
24.  Clinician adherence to a standardized assessment battery across settings and disciplines in a post-stroke rehabilitation population 
Objective
1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, IRF, outpatient facility), professional disciplines (PT, OT, SLP), and time of assessment (admission, discharge/monthly), and 2) evaluate how specific implementation events affected adherence.
Design
Retrospective cohort study
Setting
Acute hospital, IRF, outpatient facility with approximately 118 clinicians (PT, OT, SLP).
Participants
2194 participants with stroke who were admitted to at least one of the above settings. All persons with stroke undergo standardized clinical assessments.
Interventions
N/A
Main Outcome Measure
Adherence to Brain Recovery Core assessment battery across settings, professional disciplines and time. Visual inspections of 17 months of time-series data were conducted to see if the events (e.g. staff meetings) increased adherence ≥ 5% and if so, how long the increase lasted.
Results
Median adherence ranged from 0.52 to 0.88 across all settings and professional disciplines. Both the acute hospital and IRF had higher adherence than the outpatient setting (p ≤ .001) with PT having the highest adherence across all three disciplines (p < .004). Of the 25 events conducted across the 17 month period to improve adherence, 10 (40%) resulted in a ≥ 5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least one additional month.
Conclusion
Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines and time. Specific events increased adherence 40% of the time with gains maintained for greater than a month in 60%.
doi:10.1016/j.apmr.2013.02.004
PMCID: PMC4151176  PMID: 23415809
assessment; adherence; rehabilitation
25.  Development of a Self-Report Physical Function Instrument for Disability Assessment: Item Pool Construction and Factor Analysis 
Objectives
To build a comprehensive item pool representing work-relevant physical functioning and to test the factor structure of the item pool. These developmental steps represent initial outcomes of a broader project to develop instruments for the assessment of function within the context of Social Security Administration (SSA) disability programs.
Design
Comprehensive literature review; gap analysis; item generation with expert panel input; stakeholder interviews; cognitive interviews; cross-sectional survey administration; and exploratory and confirmatory factor analyses to assess item pool structure.
Setting
In-person and semi-structured interviews; internet and telephone surveys.
Participants
A sample of 1,017 SSA claimants, and a normative sample of 999 adults from the US general population.
Interventions
Not Applicable.
Main Outcome Measure
Model fit statistics
Results
The final item pool consisted of 139 items. Within the claimant sample 58.7% were white; 31.8% were black; 46.6% were female; and the mean age was 49.7 years. Initial factor analyses revealed a 4-factor solution which included more items and allowed separate characterization of: 1) Changing and Maintaining Body Position, 2) Whole Body Mobility, 3) Upper Body Function and 4) Upper Extremity Fine Motor. The final 4-factor model included 91 items. Confirmatory factor analyses for the 4-factor models for the claimant and the normative samples demonstrated very good fit. Fit statistics for claimant and normative samples respectively were: Comparative Fit Index = 0.93 and 0.98; Tucker-Lewis Index = 0.92 and 0.98; Root Mean Square Error Approximation = 0.05 and 0.04.
Conclusions
The factor structure of the Physical Function item pool closely resembled the hypothesized content model. The four scales relevant to work activities offer promise for providing reliable information about claimant physical functioning relevant to work disability.
doi:10.1016/j.apmr.2013.03.011
PMCID: PMC4046327  PMID: 23542402
Disability Evaluation; Disabled Persons; Insurance; Work Disability; Questionnaires; Factor Analysis; Statistical

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