Deirdre M. Cooke

Development of a standardized occupational therapy screening tool for visual perception in adults

The School Setting Interview (SSI) is an internationally used client-centred interview assessment that specifically investigates the student–environment fit for students with physical disabilities. In this study the Rasch measurement model was used to examine validity of the SSI; specifically, whether or not the SSI measures a unidimensional construct. Data for analysis included SSI assessments of 87 Swedish students with physical disabilities aged between 8 and 19 years of age. The results of the Rasch analysis revealed that all items had acceptable infit MnSq and z values supporting evidence of construct validity of the SSI. The established order of the difficulty of the items was also shown to be in acceptable congruence with the theoretical basis for item development. In addition, the analysis revealed aspects of the SSI that need improvements, such as the need for more challenging items and refinements of the manual. Further investigations of validity in different cultural contexts are recommended.

The incidence of visual perceptual impairment in patients with severe traumatic brain injury

Primary objectives: To investigate the incidence of visual perceptual impairments in a sample of patients with traumatic brain injury (TBI) using the Occupational Therapy Adult Perceptual Screening Test (OT-APST), compare incidence rates to a normative sample and explore the relationship between the presence of visual perceptual impairment and the severity of cognitive and functional impairment following TBI. Research design: Cohort study using a convenience sample of patients with TBI and a normative sample. Methods and procedures: Thirty-one patients with severe TBI and 195 healthy people were compared on the OT-APST and measures of cognition and function. Main outcomes and results: The most common impairments in the TBI sample were unilateral neglect (45.2%) and impairments of body scheme (25.8%) and constructional skills (25.8%). Significantly higher incidences of agnosia, apraxia, unilateral neglect and impairments in body scheme and constructional skills were found in the TBI sample compared to the normative sample. No significant relationship was found between the presence of visual perceptual impairments and the level of cognitive and functional impairment after TBI. Conclusions: Visual perceptual changes are evident in patients with severe TBI when compared to a normative sample. Routine use of a screening tool such as the OT-APST may help identify visual perceptual impairments in these patients and the need for more detailed assessment.

Construct and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST)

This paper reports on the construct validity (scale design and convergent validity) and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST). The performance of 208 participants following stroke on the OT-APST and a reference tool (either the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) or the LOTCA-Geriatric version (LOTCA-G)) was compared. The OT-APST performance of the stroke sample was compared with a healthy normative sample (n=356). The relationship between the OT-APST performance and the Functional Independence Measure (FIM™) score of the participants following stroke was also examined. Factor analysis and internal consistency results supported the scale design of the OT-APST. Significant correlations between the performance of the participants following stroke on the OT-APST and the reference tool supported the convergent validity of the OT-APST. The ability of the OT-APST to separate the two participant groups provided further evidence of its construct validity. Significant correlations between OT-APST and FIM™ scores supported the ecological validity of this tool. This study shows that the OT-APST is an ecologically valid tool with demonstrated construct validity in the assessment of visual perception.

Criterion validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST).

This paper reports on the criterion validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) including concurrent criterion validity and its sensitivity and specificity. The performance of 208 people following stroke on the OT-APST and a reference tool (either the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) or the LOTCA – Geriatric version (LOTCA-G)) was compared. The OT-APST subscale scores and performance outcome (intact or impaired) on related subscales of the reference tool was analyzed to evaluate the concurrent criterion validity of the OT-APST and its sensitivity and specificity at selected cut-off scores. Significant correlations were found between participants’ performance (intact or impaired) on the reference tool and scores on the OT-APST. The sensitivity and specificity of the OT-APST were analyzed at selected cut-off scores to explore the validity of decisions based on OT-APST performance when compared with the reference tool. This study shows that the OT-APST is a tool with demonstrated concurrent criterion validity for the assessment of visual perception.

The Reliability of the Occupational Therapy Adult Perceptual Screening Test (OT-APST)

The Occupational Therapy Adult Perceptual Screening Test (OT-APST) is designed to screen for impairments in visual perception and apraxia in adults following stroke. The OT-APST is a comprehensive battery that contains 25 items in the following seven subscale areas: agnosia (5 items); visuospatial relations covering elements of body scheme (4 items) and unilateral neglect (5 items); constructional skills (3 items); apraxia (6 items); acalculia (1 item); and functional skills (5 items). Several OT-APST items contribute to more than one subscale, hence there is a difference in the number of items in each subscale and the overall number of items. This study reports three aspects of the reliability of the OT-APST: interrater, intrarater and test-retest reliability. The participants in the interrater and intrarater reliability study were 15 people following stroke. Videotaped OT-APST performance was scored by nine occupational therapists and the results compared with the scores of the first author as the gold-standard rater. The participants in the test-retest reliability study were 10 people who were neurologically stable one year after stroke and were assessed 2 weeks apart on the OT-APST. The results obtained for each of the 25 OT-APST items included intraclass correlation coefficients (Type 3,1) for interrater reliability ranging from 0.66 to 1.0, for intrarater reliability ranging from 0.64 to 1.0, and for test-retest reliability ranging from 0.76 to 0.95. These results indicate that the OT-APST has good interrater, intrarater and test-retest reliability and offers a reliable screening tool for use by occupational therapists working in the area of stroke.

Factors affecting the number and type of impairments of visual perception and praxis following stroke

AIM This study aimed to examine the effect of clinical factors including side of stroke, region of affected cerebral circulation, type of stroke and time since stroke, as well as age on the number and type of impairments of visual perception and praxis in patients following stroke. METHODS Two hundred and eight participants with stroke were conveniently sampled from 12 hospitals in Brisbane and the Gold Coast. Background information was collected and each participant was assessed for impairments of visual perception and praxis using the Occupational Therapy Adult Perceptual Screening Test. RESULTS Participants with left-hemisphere stroke were more likely to have impaired body scheme than participants with right-hemisphere stroke. Additionally, participants with right-hemisphere stroke were more likely to have unilateral neglect and impaired constructional skills than those with left-hemisphere stroke. There was a significant relationship between region of affected cerebral circulation and the occurrence of agnosia, unilateral neglect and constructional skill impairment. Moreover, the number of visual perceptual impairments experienced by participants was associated with the region of affected cerebral circulation. Increasing age was significantly related to the occurrence of constructional skill impairment and acalculia. CONCLUSIONS Side of stroke, region of affected cerebral circulation and age affected the type of impairments of visual perception and praxis experienced by patients following stroke. Furthermore, region of affected cerebral circulation also influenced the number of impairments of visual perception and praxis in patients after stroke. The results have implications for more specific targeting of assessment and treatment practices following stroke.

Life without limbs: Technology to the rescue.

Background: This article reports a rare and inspirational case of a four-limb amputee, the range of integrated technology solutions that enable him to be a productive member of his family and the process and pitfalls of seeking technology solutions. Case description and methods: A complex case of bilateral transhumeral amputation and bilateral transfemoral amputation with residual upper limbs too short to oppose is presented. The multiple ‘high-tech’ and ‘low-tech’ devices used on a daily basis to move around his house and community, control his environment, communicate and feed himself without the use of limbs, prostheses or a second person are outlined. Findings and outcomes: Recent advances in electronics, computing and telecommunications technologies provide him with capabilities not possible 10 years ago. Conclusion: The process and pitfalls in sourcing technology solutions and the innovative solutions to meet the unique functional needs of this individual provide guidance to those with similarly severe and profound limitations to independence. Clinical relevance Descriptions of technology solutions to improve independent functioning of those with quadruple amputation without prostheses as well as those with high-level spinal cord injury are of value to occupational therapists, patients and families alike.

Understanding evidence-based behavior change interventions to improve evidence-based clinical practice

Session 1: ICH/TIA 1100–1230 Management of unruptured intracranial arteriovenous malformations in pediatric patients with stereotactic radiosurgery D Ding, Z Xu, C-P Yen, R M Starke, J P Sheehan University of Virginia, Charlottesville, Virginia, USA Background: Unruptured intracranial arteriovenous malformations (AVM) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs. Therefore, the efficacy of stereotactic radiosurgery (SRS) for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following SRS for unruptured pediatric AVMs. Methods: We evaluated a prospective, institutional AVM SRS database, from 1989 to 2013. Patients with age <18 years at the time of SRS, unruptured nidi, and at least two years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. Results: In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure (53%). The median nidus volume, radiosurgical margin dose, and radiologic follow-up were 3.2 cm, 21.5 Gy, and 45 months, respectively. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29%, 54%, and 72%, respectively. In the multivariate Cox regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55%, 16%, and 2%, respectively. The annual post-radiosurgery hemorrhage rate was 1.3%. Conclusion: Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach. 1. Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 2014; 311:1661–1669. 2. Ding D, Xu Z, Yen CP, Starke RM, Sheehan JP. Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients. Acta Neurochir (Wien) 2014. DOI: 10.1007/s00701-0142305-4. 3. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383:614–621. Subclinical ischemic lesions in patients with intracranial haemorrhage S Singhal, J V Ly, R V Chandra, J Zhou, C Soufan, H Ma, B Clissold, V Srikanth, T G Phan Monash Health, Clayton, VIC, Australia Background and Purpose: Subclinical ischemic lesions on diffusion weighted MR imaging (MRI-DWI) have been recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH). Such lesions are postulated to be part of the amyloid angiopathy spectrum. We hypothesized that the frequency of these MRI-DWI lesions may differ between patients presenting with cSAH, lobar ICH and basal ganglia ICH. Methods: Retrospective study of patients presenting between 2011–2014 with cSAH and/or ICH and subsequent MRI. Patients with an aneurysm, arteriovenous malformation, or hemorrhagic infarct were excluded. ICH topography was classified as lobar or basal ganglia; MRI-DWI lesions were classified as subclinical if there were no associated symptoms; contrast enhanced scans were assessed for leptomeningeal contrast enhancement. Results: Of 115 eligible patients, 56 patients had MRI within 14 days of hemorrhage (mean age 69.4 ± 11.5 years; 48% male). Overall, 21% (n = 12/56) patients with cSAH and/or ICH had subclinical MRI-DWI lesions. MRI-DWI lesions occurred more frequently in patients with cSAH than basal ganglia ICH (n = 5/12 vs 2/30; p = 0.006) and in patients with lobar ICH than basal ganglia ICH (n = 5/18 vs 2/30; p = 0.04). There was no significant difference in MRI-DWI lesions between cSAH and lobar ICH. Patients with MRI-DWI lesions had more frequent adjacent leptomeningeal contrast enhancement (p < 0.001). Conclusion: Subclinical ischemic lesions occur more frequently in patients with cSAH and lobar ICH than basal ganglia ICH. More frequent leptomeningeal contrast enhancement in these patients may point to a common underlying amyloid-related small vessel vasculopathy. Impact of haematoma shape and density on 90-day outcome after intracerebral haemorrhage: The INTERACT2 study C Delcourt, S Zhang, H Arima, S Sato, R A-S Salman, X Wang, C Stapf, T Robinson, P Lavados, J Chalmers, E Heeley, C Anderson Neurology and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia The University of Sydney, Sydney, NSW, Australia Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia University of Edinburgh, NHS Lothian, Edinburg, United Kingdom Université Paris Diderot – Sorbonne Paris, AP-HP Hôpital Lariboisière, Paris, France Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom Departamento de Medicina, Clínica Alemana, Universidad del Desarrollo (P.M.L.), Santiago, Chile The George Institute for Global Health, Sydney, NSW, Australia Background: Irregularity of shape and heterogeneous density suggest multiple bleeding foci and different periods of bleeding, respectively, in acute intracerebral hemorrhage (ICH). These features predict hematoma expansion but with uncertain significance on patient outcome. The aim of this study was to assess the association of shape and density on outcome among participants of INTERACT2, an open-label randomized controlled trial. Method: Shape and density were measured in 2066 patients with baseline CT. The Barras scale was used to categorize the appearance of the ICH, on the largest axial slice, into ‘regular’ (1 to 2) vs ‘irregular’ (3 to 5); density variation into ‘homogeneous’ (1 to 2) vs ‘heterogeneous’ (3 to 5). Logistic regression models were used to assess hematoma parameters on the primary outcome defined as death or major disability (mRS 3–6) at 90 days. Secondary outcomes were death and major disability, separately. Results: Shape irregularity was associated with poor outcome (OR 1.64, 95%CI 1.33–2.03), and separately only on major disability (OR 1.5, 95% CI 1.24–1.83). Density heterogeneity was not associated with poor outcome (OR 1.09, 95%CI 0.87–1.36), or the separate components of death or disability. Abstracts

What do our patients expect after hours

Habitat loss is viewed as a primary cause of pollinator population declines. Managed meadows and gardens provide benefits to wildlife, including pollinating insects. Given the interest in planting flowers for pollinators, lists of recommended varieties have been produced by professional organizations and amateurs alike. These lists serve as a good starting point but are often not grounded in empirical data. Coreopsis is a popular garden plant and a frequent component of commercial pollinator seed mixes. The aim of this study is to compare the ecological role of commercially available Coreopsis plants. It is hypothesized that pollinating insects exhibit preferences based on color and other floral traits. To address this question 4 species of wildtype Coreopsis and 13 cultivars were evaluated for their attractiveness to pollinating insects. Data was collected between June and August 2014 from Coreopsis plants in the Mount Cuba Center trial garden (Hockessin, Delaware). Flower visitors were observed and recorded to morphospecies. To assess which visual floral traits were correlated with pollinator visitation, inflorescence diameter, inflorescences per plant, inflorescence color and pattern, plant height, and number of flowers per inflorescence were measured. Correlating visitation with floral traits may explain the differential attraction of pollinators to Coreopsis flowers. David Ray The Nature Conservancy, MD/DC Chapter Atlantic White-Cedar Stand History and Rehabilitation Prospects Abstract: Efforts to understand the history and dynamics of Atlantic white-cedar (AWC) communities within the Nassawango Creek Watershed were undertaken to help inform various aspects of projects aimed at reestablishing and rehabilitating AWC across the ownership. We used a combination of local knowledge, aerial imagery and ancillary GIS layers (e.g. soils and wetlands), and extensive field transects to identify areas where AWC either currently exists or was known to have been present historically. This information has been assembled using GPS/GIS mapping and spatial analysis, through a dendrochronological study (analysis of tree rings), and observations of natural regeneration. Results presented in this poster suggest there is considerable potential to rehabilitate degraded AWC stands, an aspect of this effort that we have recently begun working on. Efforts to understand the history and dynamics of Atlantic white-cedar (AWC) communities within the Nassawango Creek Watershed were undertaken to help inform various aspects of projects aimed at reestablishing and rehabilitating AWC across the ownership. We used a combination of local knowledge, aerial imagery and ancillary GIS layers (e.g. soils and wetlands), and extensive field transects to identify areas where AWC either currently exists or was known to have been present historically. This information has been assembled using GPS/GIS mapping and spatial analysis, through a dendrochronological study (analysis of tree rings), and observations of natural regeneration. Results presented in this poster suggest there is considerable potential to rehabilitate degraded AWC stands, an aspect of this effort that we have recently begun working on. POSTER PRESENTATIONS Larry Murrell Air Infusion removes Biomat-Lining of Septic Stone-Filled Trench in less than Six Hours: New Protocol to Restore Impaired Septic System Function It is widely recognized that soil decline of residential properties in New Jersey follows a pattern of 1) waterlogging, 2) anaerobic-bacteria-generated toxins impairing plant health, 3) compaction, 4) rapid erosion, and 5) rising water tables. Use of pesticides and inorganic fertilizers accelerate the compaction and erosion in a vicious cycle. These negative impacts on soil health have a domino effect causing chronically high, usually perched water tables, contributing to water-logging and basement flooding. What is not widely recognized is that the soil surrounding the trenches of septic systems, also called drainfields or laterals, is highly susceptible to water-logging and the increasing water tables found all along the Eastern Seaboard. A high water table for septic fields promotes rapid formation of a 1-2” thick black biomat that forms in the surrounding soil. This biomat leads to compromised water flow from the stone-filled trench, or drainfield, into the septic field, and eventually to complete failure of the septic system. We have found that an effective way to attack the biomat of a septic system in a one-step procedure that destroys the biomat and allows the entrained waste water in the gravel train to surge into the soil of the septic field, literally saturating the soil of the field. Once this entrained waste water is transferred to the soil, natural aerobic bacteria digest the remains of the biomat and any toxins present in the field. This new protocol is effective because it saturates void spaces in the trench, and then saturates the entire septic field with aerated water. The restoration process is cost effective and takes only 6 8 hours to complete for each trench of a septic system. With our protocol, the entire biomat is destroyed by uniform air-infusion to the entire trench, and subsequently to the entire field. Samantha Nestory and Judy HoughGoldstein University of Delaware Entomology and Wildlife Ecology Mechanical control methods for Japanese stiltgrass (Microstegium vimineum) Abstract: Japanese stiltgrass (Microstegium vimineum) is an invasive grass that poses a major threat to native biodiversity and restoration efforts in invaded areas. While there are recommended control methods, few studies have scientifically quantified the efficacy of these control methods. A previous study determined that mowing any time after midsummer reduces the M. vimineum population, so we expanded upon this study to determine the effect of mowing height on M. vimineum populations. We established small plots at two sites that were dominated by M. vimineum. Vegetation surveys were conducted for each plot and then plots were mowed at one of three different heights (10 cm, 5 cm, 0 cm) in late summer before seed set. After 5 weeks, prior to senescence, all vegetation in the plots was harvested. Seed spikelets were counted, dried, and weighed. Vegetation was sorted into M. vimineum vegetation and all other vegetation, then dried and weighed. Results show that mowing at any of the three heights significantly reduced seed production and seed biomass of M. vimineum. Mowing at 10 cm reduced seed production by 85.9% and mowing at ground level reduced seed production by 99.5%. Seed biomass was reduced by 92.1% when plots were mowed 10 cm and by 99.5% when mowed at ground level. The results demonstrate that mowing below 10 cm before seeding occurs can significantly reduce M. vimineum reproductive output and could be integrated into an effective management program, which could increase the success of restoration efforts. Japanese stiltgrass (Microstegium vimineum) is an invasive grass that poses a major threat to native biodiversity and restoration efforts in invaded areas. While there are recommended control methods, few studies have scientifically quantified the efficacy of these control methods. A previous study determined that mowing any time after midsummer reduces the M. vimineum population, so we expanded upon this study to determine the effect of mowing height on M. vimineum populations. We established small plots at two sites that were dominated by M. vimineum. Vegetation surveys were conducted for each plot and then plots were mowed at one of three different heights (10 cm, 5 cm, 0 cm) in late summer before seed set. After 5 weeks, prior to senescence, all vegetation in the plots was harvested. Seed spikelets were counted, dried, and weighed. Vegetation was sorted into M. vimineum vegetation and all other vegetation, then dried and weighed. Results show that mowing at any of the three heights significantly reduced seed production and seed biomass of M. vimineum. Mowing at 10 cm reduced seed production by 85.9% and mowing at ground level reduced seed production by 99.5%. Seed biomass was reduced by 92.1% when plots were mowed 10 cm and by 99.5% when mowed at ground level. The results demonstrate that mowing below 10 cm before seeding occurs can significantly reduce M. vimineum reproductive output and could be integrated into an effective management program, which could increase the success of restoration efforts. POSTER PRESENTATIONS Monica Gagliardi Temple University School of Environmental Design ML Architect Student Oxford Wetland Sanctuary: What Nature Intended Abstract: In the era of global climate change, wetlands are a vital resource, providing the link to a resilient social, economic and environmental future. The Oxford Wetland Sanctuary goes beyond simply connecting people to nature, it uses a metric––the Evaluation for Planned Wetlands (EPW)––to restore a wetland, ensuring a highly impactful design based on science. The project incorporates creative social engagement, educational programming and economic opportunities. In the era of global climate change, wetlands are a vital resource, providing the link to a resilient social, economic and environmental future. The Oxford Wetland Sanctuary goes beyond simply connecting people to nature, it uses a metric––the Evaluation for Planned Wetlands (EPW)––to restore a wetland, ensuring a highly impactful design based on science. The project incorporates creative social engagement, educational programming and economic opportunities. Wetland mitigation banking represents an important economic component of the environmental sector, showcasing synergies between effective environmental protection and economic expansion while elevating the value of wetlands in society. The plan uses strategic micro grading and native re-vegetation to create a complex system that absorbs rainwater and slowly releases it to the aquifer; absorbs chem

Interrater Reliability of the Clock Drawing Task in the Occupational Therapy Adult Perceptual Screening Test

The clock drawing item in the Occupational Therapy Adult Perceptual Screening Test (OT-APST) screens for unilateral neglect and impairments in constructional skills. The purpose of this study was to re-evaluate the interrater reliability of the clock drawing item in the OT-APST following the addition of example clock drawings to the manual. This study also compared the interrater reliability for occupational therapy clinicians with that for final year occupational therapy students and examined clocks with poor interrater reliability for the individual scoring criteria. Sixteen occupational therapy students and 15 practising occupational therapists scored 50 clocks drawn by people with stroke, using the OT-APST clock drawing criteria. Interrater reliability was determined for each rater in comparison to the gold standard, using intraclass correlation (ICC) and kappa statistics. Student and clinician interrater reliability were compared using t-tests. The scoring of clocks with poor agreement was examined further in order to identify disparities. The student and clinician groups demonstrated excellent reliability for ICC (0.83 and 0.84 respectively) and moderate reliability for kappa statistics (0.58 and 0.59). The differences between the groups were not significant (p > 0.05). Scoring disparities were seen in the formation of the circle or in the placement of the numbers. The results support reliable scoring for the clock drawing item in the OT-APST.