Clare G. Giuffrida

Cognitive-Motor Interference During Functional Mobility After Stroke: State of the Science and Implications for Future Research

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 a 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 poststroke with and without a history of falls, patterns and magnitude of CMI were similar for fallers and nonfallers. 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.

Predictors of agitated behavior during inpatient rehabilitation for traumatic brain injury

OBJECTIVE To identify predictors of the severity of agitated behavior during inpatient traumatic brain injury (TBI) rehabilitation. DESIGN Prospective, longitudinal observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Consecutive patients enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, who exhibited agitation during their stay (n=555, N=2130). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Daytime Agitated Behavior Scale scores. RESULTS Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. CONCLUSIONS Further support is provided for the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose and for giving careful consideration to the effects of any intervention on underlying cognition when attempting to control agitation. Cognitive functioning was found to predict agitation, medications that have been found in previous studies to enhance cognition were associated with less agitation, and medications that can potentially suppress cognition were associated with more agitation. There could be factors other than the interventions that account for these relations. In addition, the study provides support for treatment of underlying disorders as a possible first step in management of agitation. Although the results of this study cannot be used to draw causal inferences, the associations that were found can be used to generate hypotheses about the most viable interventions that should be tested in future controlled trials.

Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge

OBJECTIVE To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN Prospective, longitudinal observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. CONCLUSIONS At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.

Occupational, Physical, and Speech Therapy Treatment Activities During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury. DESIGN Multisite prospective observational cohort study. SETTING Inpatient rehabilitation settings. PARTICIPANTS Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined. RESULTS Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay. CONCLUSIONS The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups.