Outpatient Neurorehabilitation Research Articles

Evaluation of Posthospital Brain Injury Rehabilitation Outcomes With Quasi-Experimental Controls.

To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study (n =2120). Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI). Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating. Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating. Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category. Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score (F =77.21, P <.001; partial η2=0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group. These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

The Use of Telerehabilitation to Improve Movement-Related Outcomes and Quality of Life for Individuals With Parkinson Disease: Pilot Randomized Controlled Trial.

Individuals with Parkinson disease (PD) can improve their overall mobility and participation in daily activities as they engage in frequent exercise. Despite the need for individually tailored exercises, persons with PD often face barriers to accessing physical rehabilitation professionals who can provide them. Telerehabilitation (TR) may facilitate access to necessary and individually tailored rehabilitation for individuals with PD. The purpose of this study was to assess the feasibility of TR for individuals with PD and explore clinical outcomes compared to in-person care. This was a pilot randomized controlled trial conducted at 2 outpatient neurorehabilitation clinics with 3 study groups: clinic+TR, TR-only, and usual care (UC). TR was administered using a web-based application with a mobile app option. One-hour interventions were performed weekly for 4 weeks, in-person for the clinic+TR and UC groups and virtually for the TR-only group. Home exercises were provided on paper for the UC group and via the web-based platform for the clinic+TR and TR-only groups. Feasibility was assessed by recruitment and retention success and patient and therapist satisfaction, as rated in surveys. Clinical outcomes were explored using performance and patient-reported measures in between- and within-group analyses. Of 389 patients screened, 68 (17.5%) met eligibility criteria, and 20 (29.4% of those eligible) were enrolled (clinic+TR, n=6; TR-only, n=6; and UC, n=8). One patient (TR-only) was withdrawn due to a non-study-related injurious fall. Regardless of group allocation, both patients and therapists generally rated the mode of care delivery as "good" or "very good" across all constructs assessed, including overall satisfaction and safety. In the analysis of all groups, there were no differences in clinical outcomes at the discharge visit. Within-group differences (from baseline to discharge) were also generally not significant except in the UC group (faster 5-time sit-to-stand time and higher mini balance evaluation systems test balance score) and clinic+TR group (higher mini balance evaluation systems test balance score). High satisfaction amongst patients and clinicians regardless of group, combined with nonsignificant between-group differences in clinical outcomes, suggest that TR is feasible for individuals with PD in early-moderate stages. Future trials with a larger sample are necessary to test clinical effectiveness. As larger trials enroll patients with diverse characteristics (eg, in terms of age, disease progression, caregiver support, technology access and capacity, etc), they could begin to identify opportunities for matching patients to the optimal utilization of TR as part of the therapy episode. ClinicalTrials.gov NCT06246747; https://clinicaltrials.gov/study/NCT06246747.

Outcomes of Six Specific Types of Post-Hospital Brain Injury Rehabilitation Programs.

Evaluate outcomes of intensive posthospital brain injury rehabilitation programs compared to supported living (SL) programs; explore variations in outcome by diagnostic category (traumatic brain injury, stroke, and other acquired brain injury [ABI]) and specific program type. Data were obtained from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and SL programs serving individuals with ABI. A total of 2120 individuals with traumatic brain injury, stroke, or other ABI participated in this study. The main measures are sex, age, time since injury, and Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). Retrospective analyses of demographic variables and MPAI-4 Total, index, and subscale Rasch-derived T-scores on admission and discharge. Gains on MPAI-4 Total T-scores were significantly greater for the intensive rehabilitation (IR) group in comparison to stable functioning in the SL group (F =236.69, P <.001, partial η2=.101) while controlling for admission/time 1 scores; similar results were found for MPAI-4 indices and subscales. For the IR cohort, discharge scores differed by diagnostic category after controlling for admission scores for the Total MPAI-4 T-score (F =22.65, P <.001, partial η2=.025), as well as all indices and subscales. A statistically significant interaction between program type and diagnostic group on discharge MPAI-4 Total T-scores (F =2.55, P =.018, partial η2=.01) after controlling for admission scores indicated that differing outcomes across diagnoses also varied by program type. Varying significant main effects and interactions were apparent for MPAI-4 indices and subscales with generally small effect sizes. Significant gains on MPAI-4 variables across IR program types compared to no change over a comparable period of time for SL programs supports the effectiveness of posthospital brain injury rehabilitation. This finding in the presence of small effect sizes on outcome variables for program type and for significant interactions between program type and diagnostic category suggests that participants generally were appropriately matched to program type and benefited from interventions provided through specific program types.

Provision and use of assistive products in patients after stroke and spinal cord injury in Germany: a qualitative interview study

Purpose Mobility impairments are a common consequence of stroke and spinal cord injury (SCI). Assistive products (APs) such as wheelchairs are often needed for activities and participation. The aim of the study was to explore the provision and use of APs in Germany and to identify associated factors underlying this practice. Materials and methods Semi-structured interviews were conducted with 19 professionals from outpatient neurorehabilitation services (three general practitioners, five physical therapists, five occupational therapists, one speech therapist, one neuropsychologist, two outpatient nurses, one rehab technician and one social worker), two patient advocates (long-term survivors, each stroke and SCI) and 20 patients (10 each after stroke and SCI with mobility impairment, and first-ever affected). Analysis was performed by qualitative content analysis. Results Reported experiences were mixed, varying from high satisfaction to unusable APs and unmet needs. Identified factors associated with these experiences were related to care pathways, care coordination, inter-professional collaboration, professionals’ knowledge and patient information, cost coverage, and approval procedures. Conclusion Overall, patients seem satisfied with the APs they receive, but patients with more severe mobility impairments in particular experience deficits in the provision and use of APs. Further research is needed to develop and test strategies for the provision and use of APs.

Implementation of a Patient-Reported Outcome Measure: A Quality Improvement Project.

Patient-reported outcome measures (PROMs) are seen as increasingly beneficial to patient-centered clinical practice, but implementation of routine collection and utilization into clinical care can be challenging. Our interdisciplinary quality improvement (QI) team used the Institute for Health Care Improvement Model for Improvement methodology to address this problem in our outpatient neurorehabilitation program. We used a participatory approach to identify the PROM rehabilitation stakeholders found to be most appropriate to implement in the outpatient settings; chart audits were conducted to determine the extent to which clinicians implemented the PROM and documented a PROM-related goal. Opportunistic clinician feedback was collected to determine single PROM usefulness and acceptability. Our 4-month initiative demonstrated increased collection of a PROM, the Patient-Specific Functional Scale (PSFS), and incorporation into patient-centered goal. Use of QI methodology was beneficial when planning and executing our initiative. Future work is needed to examine factors to sustain PSFS use, incorporation into patient-centered goal setting, and maximize meaningful patient outcomes.

Distinguishing Characteristics of Admissions to Various Types of Posthospital Brain Injury Rehabilitation Programs.

Describe and compare the demographic characteristics and disability profiles of individuals admitted to 6 types of posthospital brain injury rehabilitation (PHBIR) programs. Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and Supported Living programs serving individuals with acquired brain injury (ABI). Two thousand twenty-eight individuals with traumatic brain injury (TBI), stroke, or other ABI. Sex, age, time since injury, and Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4). Retrospective analyses of demographic variables and MPAI-4 Total, Index, and subscale Rasch-derived T-scores on admission comparing diagnostic categories and program types within diagnostic categories. Participants with TBI were predominantly male, and those with stroke were generally older. Admissions to more intensive and supervised programs (residential neurobehavioral and residential neurorehabilitation) generally showed greater disability than admissions to home and community programs who were more disabled than participants in day treatment and outpatient programs. Residential neurobehavioral and supported living program participants generally were male and had TBI. Home and community admissions tended to be more delayed than residential neurorehabilitation admissions. The majority of those with other ABI were admitted to outpatient rather than more intensive programs. Additional analyses demonstrated significant differences in MPAI-4 profiles among the various program types. Admissions with TBI, stroke, and other ABI to PHBIR differ in demographic factors and disability profiles. When examined within each diagnostic category, demographic features and disability profiles also distinguish among admissions to the various program types. Results provide insights about decision-making in referral patterns to various types of PHBIR programs, although other factors not available for analysis (eg, participant/family preference, program, and funding availability) likely also contribute to admission patterns.

Components of self-awareness affecting caregiver burden: a long-term follow-up study

ABSTRACT Objective Studies utilizing the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) have commonly used the cognitive and physical domains to estimate self-awareness. This study included other aspects of self-awareness such as awareness of one’s social and emotional status and daily functioning to explore their effects on caregiver burden for ABI survivors. Methods We studied 64 patient-caregiver pairs up to 29 years post-discharge from a holistic, milieu-oriented outpatient neurorehabilitation program. Discrepancy scores between ABI survivors’ and caregivers’ reports on the MPAI-4 subscales (i.e. Abilities, Adjustment, and Participation) and Total Score were used to determine self-awareness. Caregiver burden was measured using the Zarit Burden Interview (ZBI). Results Exploratory linear regression analyses revealed that caregiver burden derived from the ZBI was predicted by the discrepancy scores generated from the Abilities (p < 0.0001), Adjustment (p < 0.01), Participation subscales (p = 0.01), and Total Score (p < 0.001), respectively. Among the exploratory models generated, the Total Score model had the highest predictive value (R2 = .33) for caregiver burden. Conclusions Measures of self-awareness should be comprehensive by considering diverse components of self-awareness. Increasing ABI survivors’ self-awareness in different domains has the potential to effectively alleviate caregiver burden.

Interdisciplinary cooperation in the outpatient practice: results from a focus group interview with occupational therapists, speech and language therapists and physiotherapists / Gestaltung der interdisziplinären Zusammenarbeit in der ambulanten Therapie: Resultate eines Fokusgruppeninterviews mit Ergotherapeut*innen, Logopäd*innen und Physiotherapeut*innen

Abstract The complexity and diversity of healthcare conditions, as well as the financial and personnel challenges requires effective interdisciplinary collaboration (IDC) among various healthcare professionals (Robert-Bosch-Stiftung, 2011; Robert Koch Institute, 2015). In contrast to the inpatient practice, IDC has not established yet in primary care settings. There is a lack of concrete solutions that illustrate how IDC can be implemented in outpatient practice (Schmitz, Atzeni &amp; Berchtold, 2020). The study aims to present realization possibilities of the IDC among occupational therapists, speech and language therapists and physiotherapists based on case examples from outpatient neurorehabilitation practices. Necessary framework conditions and support factors should be identified from successful applications. In an online focus group, five therapists from three outpatient therapy centers were interviewed about the interdisciplinary measures taking place at their workplace. The therapy centers implemented interdisciplinary team meetings, collaborative target setting and therapy planning as well as co-therapies in their everyday primary care practice. Digital communication channels and the use of digital practice software represent support measures that enable communication independent of location and time. Educational policy changes are needed to impart the corresponding attitudes, knowledge and skills to the healthcare professionals during the vocational training/study. The results of the study show that IDC can be implemented in the outpatient setting under appropriate conditions. Legal requirements are needed to enable the application of interdisciplinary measures through adequate remuneration systems and available time slots. Further calls address content in vocational trainings/studies to provide a basis for readiness and competencies for IDC.

A - 168 Self-Awareness in Survivors of Acquired Brain Injury and the Impact on Family Burden.

Caregiver burden is commonly experienced by family members of survivors of acquired brain injury (ABI). Research has demonstrated that self-awareness of survivors of ABI impacts family member burden (Rubin et al. 2020). This study utilized the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) to measure self-awareness by calculating a discrepancy score from self and family member-rated MPAI-4 total score. We examined the relationship between family member burden, time since injury, and level of self-awareness of survivors of ABI at discharge following holistic neurorehabilitation. This retrospective study analyzed data on 28 individuals with heterogeneous ABI's who participated in a holistic milieu-oriented outpatient neurorehabilitation program from 2020-2023. Demographic information (age, education, race/ethnicity), injury history (injury type, age at injury, chronicity), program variables (length of program participation), functionality (MPAI-4), and family burden (Zarit Burden Interview) at discharge were collected. A multiple linear regression analysis was run to predict family burden from self-awareness of survivors of ABI and time since injury. The multiple regression model statistically significantly predicted family burden, F(2, 24) = 6.698, p < 0.005, adj. R2 = 0.305. Only self-awareness added statistically significantly to the prediction, p < 0.002. Self-awareness accounted for 33.4% of the variance in family burden. Among family members of survivors of ABI, self-awareness of the survivor is an important predictor of burden experienced by family. Self-awareness, as measured by utilizing the MPAI-4 discrepancy model, explained a significant proportion of the variance in family burden regardless of time since injury.

Current practice of outpatient rehabilitation services in patients with mobility-impaired paralysis due to stroke or spinal cord injury: a qualitative interview study in Germany

Purpose When mobility deficits persist after stroke or spinal cord injury (SCI), outpatient neurorehabilitation services are required. This study aimed to explore the current practice of German outpatient neurorehabilitation services and identify factors associated to this practice. Methods This was a qualitative observational study in which semi-structured interviews were conducted with professionals from outpatient neurorehabilitation services and mobility-impaired patients. A qualitative content analysis with a data-driven coding process was used. Results Three general practitioners, five physical, five occupational, and one speech therapist, one neuropsychologist, two outpatient nurses, one rehabilitation technician, one social worker, two patient advocates (long-term survivors, each stroke and SCI), and 20 patients (10 after stroke, 10 after SCI, all first-ever affected since approximately one year) participated. The reported experiences ranged from high satisfaction to perceived deficits in participation-oriented, evidence-based, and coordinated care. Identified associated factors were: (a) availability of specialised therapists and professional education, (b) outpatient service catalogue, (c) cost coverage, (d) setting rehabilitation goals, and (e) physician as care coordinator. Conclusion Areas of improvement identified focused on: setting rehabilitation goals towards participation, training therapists on evidence-based treatments and shared decision-making, updating the outpatient service catalogue, and implementing coordination actions. Implementation of these recommendations should be evaluated.

Clinical Implementation of Noninvasive Brain Stimulation in an Outpatient Neurorehabilitation Program

Motor, speech, and cognitive impairments are the most common consequences of neurological disorders. There has been an increasing interest in the use of noninvasive brain stimulation techniques such as transcranial direct current stimulation and transcranial magnetic stimulation to augment the effects of neurorehabilitation. Numerous research studies have shown that transcranial direct current stimulation and transcranial magnetic stimulation are highly promising neuromodulation tools that can work as adjuvants to standard neurorehabilitation services, including physical therapy, occupational therapy, and speech-language pathology. However, to date, there are vast differences in methodology in studies including noninvasive brain stimulation parameters, patient characteristics, time point of intervention after injury, and outcome measures, making it difficult to translate and implement transcranial direct current stimulation and transcranial magnetic stimulation in the clinical setting. Despite this, a series of principles are thought to underlie the effectiveness of noninvasive brain stimulation techniques. We developed a noninvasive brain stimulation rehabilitation program using these principles to provide best practices for applying transcranial direct current stimulation and/or transcranial magnetic stimulation as rehabilitation adjuvants in the clinical setting to help improve neurorehabilitation outcomes. This article outlines our approach, philosophy, and experience.

Effectiveness of the Pelvic Clock and Static Bicycle Exercises on Wisconsin Gait Scale and Trunk Impairment Scale in Chronic Ambulatory Hemiplegic Patients: A Single Group Pre-Post Design.

Most Hemiplegic patients achieve ambulatory function during the sub-acute stage of stroke. Though ambulatory, they still perform an unpleasant awkward gait with remarkable compensations requiring more energy expenditure. Fatigue arises at an early duration as a result of increased energy expenditure. The walking pattern becomes circumduction, featured by asymmetry with an extensor synergy of the lower limb. Each step is rotated away from the body then towards the body, forming a semicircle. This leads to changes in various parameters of gait (spatiotemporal, kinematic, and kinetic) in hemiparetic patients. Many studies reveal the effectiveness of various therapeutic techniques in managing hemiplegic circumduction gait. Pelvic clock exercises aid in improving pelvic rotation components and cause dissociation in impaired pelvic mobility due to spasticity. A static bicycle helps in enhancing proper control between the hamstrings and quadriceps. It also helps in improving knee flexion range. As the patient places the foot in the cycle's petals, it helps to enhance dorsiflexion and eversion functions as well. As the lower body is exercised, there could be relative changes in the upper body, i.e., the trunk. Thus, this study aimed to determine the changes in gait functions and trunk performance of chronic ambulatory hemiplegic patients in response to the above therapies for four weeks. Twenty-five subjects (post-stroke duration (2.8 ± 0.6) years) who could walk 10 m independently without assistance or support of aid participated in a pelvic clock and static bicycle exercise intervention. The session duration was 30 min a day, and therapy was delivered six days a week and continued for four weeks. The entire program was carried out in an outpatient neurorehabilitation center. After the intervention with pelvic clock and static bicycle exercises, there was a remarkable change in gait and trunk functions in chronic hemiplegic patients. The exercises comprising pelvic clock and static bicycle showed positive differences in gait and trunk functions in chronic stage hemiplegic patients. Later, randomized controlled studies involving larger sample sizes, advanced activation techniques, and increased intervention duration will explore in-depth information on their effectiveness and clinical significance.

Vocational/educational prognosis in adolescents and young adults with acquired brain injury: a nationwide cohort study

ABSTRACT Objective To determine prognostic factors for work ability and employment/educational status among young patients referred to outpatient neurorehabilitation clinics after an acquired brain injury. Methods A nationwide cohort study of 471 15–30-year-old patients who attended an interdisciplinary clinical assessment and provided questionnaire data at baseline and after one year. The outcomes were the Work Ability Score (WAS, 0–10 (best)) and employment/educational status after one year. Prognostic performance was analyzed using univariable regression and multivariable Ridge regression in a five-fold cross-validated procedure. Results Preinjury, 86% of the patients were employed, while the percentage had decreased to 55% at baseline and 52% at follow-up. The model, which included clinical measures of function, showed moderate prognostic performance with respect to WAS (R2=0.29) and employment/educational status (area under the curve (AUC)=0.77). Glasgow Outcome Scale Extended (R2=0.15, AUC=0.68) and the cognitive subscale of the Functional Independence Measure (R2=0.09, AUC=0.64), along with fatigue measured with the Multidimensional Fatigue Inventory (R2=0.15, AUC=0.60) were the single predictors with the highest predictive performance. Conclusion Despite generally high scores in motor and cognitive tests, only about half of the patients were employed at baseline and this proportion remained stable. Global disability, cognitive sequelae and fatigue had the highest prognostic performance.

A case of Kernohan-Woltman notch phenomenon caused by an epidural hematoma: the diagnostic and prognostic value of PET/CT imaging

BackgroundKernohan-Woltman notch phenomenon (KWNP) classically occurs when a lesion causes compression of the contralateral cerebral peduncle against the tentorium, resulting in ipsilateral hemiparesis. It has been studied clinically, radiologically and electrophysiologically which all confirmed to cause false localizing motor signs. Here, we demonstrate the potential use of fluorine-18 fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) to identify KWNP caused by an epidural hematoma.Case presentationA 29-year-old male patient post right-sided traumatic brain injury presenting with persistent ipsilateral hemiparesis. Patient underwent decompressive craniotomy and intracranial hematoma evacuation. Brain magnetic resonance imaging in the postoperative period showed a subtle lesion in the left cerebral peduncle. PET/CT was performed to exclude early brain tumor and explain his ipsilateral hemiparesis. PET/CT imaging demonstrated a focal region of intense 18 F-FDG uptake in the left cerebral peduncle. Throughout the treatment in outpatient neurorehabilitation unit, the patient exhibited a gradual recovery of his right hemiparesis.ConclusionIn our case report, for the first time, PET/CT offered microstructural and functional confirmation of KWNP. Moreover, our case suggests that 18 F-FDG PET/CT may serve as an important reference for the probability of functional recovery.

Intensive Multi-Disciplinary Outpatient Rehabilitation for Facilitating Return-to-Work after Acquired Brain Injury: A Case-Control Study.

ObjectiveReturn-to-work is often the most important objective of working-age patients with acquired brain injury, but is often difficult to achieve. There is a lack of evidence for effective treatment. This study aimed to assess the benefit of a multi-disciplinary neurorehabilitation in a daytime hospital on return-to-work after an acquired brain injury.DesignRetrospective case-control study.PatientsAcquired brain injury patients between 18 and 65 years of age.MethodsTwo periods, before (n = 82 patients) and after (n = 89 patients) the implementation of a daytime hospital in our neuro-rehabilitation unit were compared. Patients followed in the daytime hospital received intensive, interdisciplinary, coordinated, individual and group-level physical, cognitive, and vocational rehabilitation. During the control period, patients received outpatient neurorehabilitation with less intensive treatment without interdisciplinary coordination. The main outcome was the proportion of patients returning to > 50% of their premorbid work activity.ResultsFifty-five percent of patients were able to resume more than 50% of their premorbid work level in the daytime hospital period vs 41% in the control period (p = 0.076).ConclusionIntensive and coordinated outpatient neurorehabilitation may facilitate return-to-work after an acquired brain injury.LAY ABSTRACTAcquired brain injury is a common health issue, most frequently caused by head trauma or stroke. Acquired brain injury patients of working age often have difficulties in returning to work, which greatly impairs their quality of life. They often receive insufficient rehabilitation care, partly also because of a lack of evidence regarding intensive rehabilitation in this patient group. This study aimed to assess the benefit of multi-disciplinary neurorehabilitation in a daytime hospital on return-to-work after acquired brain injury. The study compared the rate of return-to-work during the first 2 years after implementation of a daytime hospital to a control period of 2 years before. The daytime hospital provided intensive, interdisciplinary, coordinated, individual and group-level physical, cognitive, and vocational rehabilitation. During the control period, patients received outpatient neurorehabilitation with less intensive treatment without interdisciplinary coordination. The results show that more patients were able to resume work, at more than 50% of their premorbid work level, since the introduction of the daytime hospital.

A-191 The Relationship between Demographic and Injury-Related Factors and Return to Driving following Holistic Milieu-Oriented Neurorehabilitation

Abstract Objective: Return to driving (RTD) following an acquired brain injury (ABI) positively impacts an individual’s productivity, quality of life, and community re-integration. Research illustrates that the return to driving is a complex process influenced by personal, cognitive, psychological, medical, neurological, and environmental factors. This study examined the association between demographic and injury factors and RTD at discharge following intensive neurorehabilitation. Method: This retrospective study analyzed the medical records of 178 individuals with heterogeneous acquired brain injuries who participated in a holistic milieu-oriented outpatient neurorehabilitation program from 2012 to 2022. Demographic information (age, education, race/ethnicity), injury history (injury type, age at injury, chronicity), program participation variables (length of program participation, age at participation), and driving status at discharge were collected. Results: Individuals with more chronic injuries were less likely to present with a RTD goal at admission, (p = .004). 71% (N = 88) of individuals met their RTD goal by discharge. There was no significant relationship between age at injury, age at admission, chronicity, days in treatment, or education and successful RTD at discharge. Type of brain injury (traumatic brain injury, stroke, or other [i.e., anoxia, seizure, and infection]), gender, and race/ethnicity were not related to successful RTD at discharge. Conclusions: The majority of ABI survivors met their RTD goal at discharge. Findings illustrate that the holistic milieu-oriented treatment approach is effective with regard to addressing RTD goals across a variety of brain injury etiologies, demographics factors, and injury variables.

Improvement in the Capacity for Activity Versus Improvement in Performance of Activity in Daily Life During Outpatient Rehabilitation.

Background and Purpose: We addressed questions about the potential discrepancy between improvements in activity capacity and improvements in activity performance in daily life. We asked whether this discrepancy is: Common in routine, outpatient care, or an artifact of intervention studies?Unique to upper limb (UL) rehabilitation, or is it seen in walking rehabilitation too?Only seen in persons with stroke, or a broader neurorehabilitation problem? Methods: A longitudinal, observational cohort of 156 participants with stroke or Parkinson disease (PD) receiving outpatient rehabilitation at 5 clinics was assessed around admission and monthly during their episode of care. Individual, longitudinal capacity (Action Research Arm Test or walking speed) and performance (wearable sensor measurements of use ratio or steps/day) data were modeled to extract predicted change scores. Simulation methods were used to determine whether an individual's change was greater than 1 standard error. Participants were classified into categories based on whether or not they improved in capacity (C+ or C−) and/or performance (P+ or P−). Results: A majority (59%) were classified as C+P−. Smaller portions of the sample were classified as C+P+ (20%) and C−P− (21%), with 1 participant (&lt;1%) classified as C−P+. The proportions in the C+P− category were significantly larger in the stroke (χ2 = 48.7, P &lt; 0.0001) and PD (χ2 = 24.3, P &lt; 0.0001) walking subgroups than in the stroke UL subgroup. Discussion and Conclusions: The discrepancy between improvements in capacity and performance is a problem in routine, outpatient neurorehabilitation. If performance information were available, patients and clinicians could act to address it. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A396).

Virtual Reality as a Therapy Tool for Walking Activities in Pediatric Neurorehabilitation: Usability and User Experience Evaluation.

BackgroundMany essential walking activities in daily life, such as crossing a street, are challenging to practice in conventional therapeutic settings. Virtual environments (VEs) delivered through a virtual reality (VR) head-mounted display (HMD) would allow training such activities in a safe and attractive environment. Furthermore, the game-like character and high degree of immersion in these applications might help maintain or increase children’s motivation and active participation during the rehabilitation process.ObjectiveThis study aimed to investigate the usability, user experience, and acceptability of an immersive VE experienced through a VR HMD to train everyday life walking activities in pediatric neurorehabilitation.MethodsIn a cross-sectional study, 21 youths (median age 12.1 years; range 6.8-17.7 years) with a neuromotor impairment undergoing inpatient or outpatient neurorehabilitation tested a VE experienced through the VR HMD Oculus Quest. The participants, accompanied by their physiotherapists, moved freely around a 4.4 by 10-meter VE, displaying a magical forest and featuring various gamified everyday activities in different game designs. Using their hands, represented in the VE, the participants could interact with the virtual objects placed throughout the VE and trigger visual and auditory feedback. Symptoms of cybersickness were checked, and usability, user experience, and acceptability were evaluated using customized questionnaires with a visual analog scale for youths and a 5-point Likert scale for their therapists.ResultsNone of the participants reported any signs of cybersickness after 20 minutes of VR HMD exposure time. They rated comfort (median 10/10) and movement ability (median 10/10) with the VR HMD as high. The VE was perceived as being really there by the majority (median 8/10), and the participants had a strong feeling of spatial presence in the VE (median 9.5/10). They enjoyed exploring the virtual world (median 10/10) and liked this new therapy approach (median 10/10). Therapists’ acceptance of the VR HMD was high (4/5). There were 5 patients that needed more support than usual, mainly for supervision, when moving around with the VR HMD. Otherwise, therapists felt that the VR HMD hardly affected their patients’ movement behavior (median 4.75/5), whereas it seemed to increase their level of therapy engagement (median 4/5) compared to conventional physiotherapy sessions.ConclusionsThis study demonstrates the usability of an immersive VE delivered through a VR HMD to engage youths in the training of everyday walking activities. The participants’ and therapists’ positive ratings on user experience and acceptance further support the promising application of this technology as a future therapeutic tool in pediatric neurorehabilitation.

Rehabilitation of Persistent Symptoms and Neurocognitive Deficits Following Sports-Related Concussion in a Professional Hockey Player: Case Study

To demonstrate decreased post-concussive symptomatology and neurocognitive improvements in a professional hockey player following a multimodal, functional neurology approach to neurorehabilitation. Hockey is one of the top 3 sports in which concussions occur and has one of the top 10 highest participation numbers of sports in the northern hemisphere. The investigation of treatment modalities is warranted given the prevalence of hockey throughout society. This case study presents a 31-year-old male professional hockey athlete who had sustained 5 diagnosed concussions with additional suspected concussions throughout his career. His symptoms remained after independently receiving physical therapy and vestibular rehabilitation, causing an inability to continue playing hockey at a professional level. The patient was prescribed 10 treatment sessions over 5 contiguous days at an outpatient neurorehabilitation center specializing in functional neurology. The C3Logix neurocognitive assessment and graded symptom checklist were utilized at intake and discharge. Multimodal treatment interventions included transcranial photobiomodulation, non-invasive neuromodulation of the lingual branch of the trigeminal nerve, hand-eye coordination training, vestibular rehabilitation utilizing a three-axis whole-body off-axis rotational device, and cognitive training. On intake, their composite symptom score was reported as 16/162, Trail Making Test Part B was 24.1 seconds, Simple Reaction Time was 274 milliseconds, and Choice Reaction Time was 496 milliseconds. On discharge, the patient experienced an 81% in self-reported symptoms, Trail Making Test Part B improved to 17 seconds (+29.46%), Simple Reaction Time was 252 milliseconds (8% faster), and Choice Reaction Time was 465 milliseconds (24% faster). The present case study results demonstrated meaningful improvements in both self-rated concussion symptoms and neurocognitive performance for this patient. The Press suggest further investigation into functional neurology-based, multimodal, intensive approaches to decrease chronic post-concussion symptoms and improve neurocognitive performance in athletes that engage in hockey.

Rehabilitation of Persistent Neurocognitive Deficits Following Sports-Related Concussion in an Amateur Football Athlete: Case Study

Demonstrate neurocognitive improvements in an inactive, amateur football athlete following a functional neurology approach to multimodal neurorehabilitation. American Football has been reported to have one of the highest incidences of concussion in all contact sports. Given the high rate of concussive blows during play, the investigation of treatment modalities is warranted. This case study presents a 23-year-old male amateur football player who has sustained 3 diagnosed concussions with additional suspected concussions throughout his time participating in football. In addition, his symptoms persisted years after ceasing participation in all contact sports. The athlete was prescribed 10 treatment sessions over 5 consecutive days at an outpatient neurorehabilitation center specializing in functional neurology. The C3Logix neurocognitive assessment and Graded Symptom Checklist were utilized on intake and discharge. Multimodal treatment interventions included transcranial photobiomodulation, non-invasive neuromodulation of the lingual branch of the trigeminal nerve, neuromuscular reeducation of the limbs bilaterally, hand-eye coordination training, vestibular rehabilitation utilizing a three-axis whole-body off-axis rotational device, and cognitive training. On intake, composite symptom score was reported as 10/162, Trails Making Test Part A was 20.8 seconds, Part B was 41.9 seconds, Digit Symbol Matching score was 53, Simple Reaction Time was 277 milliseconds, and Choice Reaction Time was 412 milliseconds. On discharge, the patient experienced a 70% in self-reported symptoms, Trails A improved to 14.8 seconds (+29%), Trails B improved to 30.3 seconds (+28%), Simple Reaction Time was 248 milliseconds (10% faster), and Choice Reaction Time was 340 milliseconds (17% faster). The present case study demonstrates a meaningful improvement in symptoms and neurocognitive performance of a patient with multiple sports-related concussions. Therefore, the Press suggest further investigation into a functional neurology approach to multi-modal, intensive care to improve neurocognitive impairment in athletes that sustained concussions participating in footballs.