Karen McCulloch

Reliability and Validity of the Upper-Extremity Motor Activity Log-14 for Measuring Real-World Arm Use

Background and Purpose— In research on Constraint-Induced Movement (CI) therapy, a structured interview, the Motor Activity Log (MAL), is used to assess how stroke survivors use their more-impaired arm outside the laboratory. This article examines the psychometrics of the 14-item version of this instrument in 2 chronic stroke samples with mild-to-moderate upper-extremity hemiparesis. Methods— Participants (n=41) in the first study completed MALs before and after CI therapy or a placebo control procedure. In addition, caregivers independently completed a MAL on the participants. Participants (n=27) in the second study completed MALs and wore accelerometers that monitored their arm movements for 3 days outside the laboratory before and after an automated form of CI therapy. Results— Validity of the participant MAL Quality of Movement (QOM) scale was supported. Correlations between pretreatment-to-posttreatment change scores on the participant QOM scale and caregiver MAL QOM scale, caregiver MAL amount of use (AOU) scale, and accelerometer recordings were 0.70, 0.73, and 0.91 (P<0.01), respectively. Internal consistency (α>0.81), test–retest reliability (r>0.91), stability, and responsiveness (ratio >3) of the participant QOM scale were also supported. The participant AOU and caregiver QOM and AOU scales were internally consistent, stable, and sensitive, but were not reliable. Conclusions— The participant MAL QOM scale can be used exclusively to reliably and validly measure real-world, upper-extremity rehabilitation outcome and functional status in chronic stroke patients with mild-to-moderate hemiparesis.

Lessons Learned in Participant Recruitment and Retention: The EXCITE Trial

Participant recruitment is considered the most difficult aspect of the research process. Despite the integral role of recruitment in randomized clinical trials, publication of data defining the recruitment effort is not routine in rehabilitation initiatives. The recruitment process for the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial illustrates obstacles to and strategies for participant accrual and retention that are inherent in rehabilitation clinical trials. The purpose of this article is to increase awareness of the multiple facets of recruitment necessary for successful clinical trials, thus supporting the continued development of evidence-based practice in physical therapy. The Recruitment Index is presented as a variable to measure recruitment efficacy. In addition, ethical aspects of recruitment are explored, including informed consent and the concept of therapeutic misconception.

Balance, attention, and dual-task performance during walking after brain injury: associations with falls history.

ObjectiveTo examine the relationship between balance, attention, and dual-task performance in individuals with acquired brain injury. DesignCross-sectional study. SettingRehabilitation center and supported living program. ParticipantsTwenty-four individuals aged 18 to 58 years (mean = 39 years) with acquired brain injury who were able to ambulate 40 ft with (29%) or without an assistive device. Fifty-eight percent were independent community ambulators. Fifty-four percent had fallen in the past 6 months; and 42% reported feeling unsteady with standing or walking. InterventionsParticipants completed a battery of balance, attention, and dual-task assessments. Main Outcome MeasuresBalance: Berg Balance Scale (BBS), Four Square Step Test (FSST), High Level Mobility Assessment Test (HiMAT); Attention: Symbol Digit Modalities Test (SDMT), Moss Attention Rating Scale (MARS), modified for a single test session; and a walking dual-task assessment, the Walking and Remembering Test. ResultsMean scores: BBS, 48 of 56; FSST, 19.6 seconds; HiMAT, 20 of 54; SDMT, 30 correct; and MARS, 80. Dual-task costs were observed with variable patterns across subjects: 48% demonstrated primarily motor slowing, 9% had reduced cognitive accuracy without motor slowing, and 35% demonstrated decrements in both tasks. Subjects with a falls history had more impaired balance (HiMAT, BBS, and FSST, all P <.026) but were not significantly different in dual-task performance or attention measures. ConclusionsThe test battery matched the range of motor and cognitive abilities of the sample. Balance was more strongly related to falls history than measures of attention or dual-task performance. Injury chronicity may have allowed some subjects to develop strategies to optimize dual-task performance. Alternatively, motor slowing in dual-task conditions may be an adaptive strategy, allowing performance of multiple tasks with reduced safety risk. Further investigation in this area is warranted to clarify the utility of dual-task methods in identifying falls risk after brain injury.

The effect of an exercise-based balance intervention on physical and cognitive performance for older adults: a pilot study

Background:Several exercise-based falls prevention interventions produced significant long-term reductions in fall rate, but few demonstrate long-term improvements in falls risk factors. A strong body of evidence supports a protective effect of aerobic or strength-training exercise on cognition. Individuals participating in an exercise-based balance improvement program may also experience this protective effect. This may contribute to the decreased rate of falls reported in the literature. Purpose:To determine if individuals participating in an evidence-based exercise program to reduce falls would demonstrate improvements in both physical and cognitive performance. Methods:In this nonexperimental, pretest, posttest design study, 76 adults (65-93 years) participated in a scripted 12-week, 24 session exercise-based balance improvement program. Each 60 minute class incorporated balance, strength, endurance, and flexibility exercises. Participants completed baseline assessments of physical and cognitive performance measures 1 week prior and 1 week following the intervention. Results:Fifty-two participants completed posttest measures. There were significant improvements in 3 physical performance measures (chair rise time, 360° turn, and 4 square step test). There also was similar improvement in the Symbol Digit Modality Test, a measure of processing speed and mental flexibility. When participants were dichotomized into 2 groups based on achieving/not achieving, a baseline walking speed of at least 1.0 meters/second, secondary analysis revealed greater improvements in cognitive performance measures of Trails A and Trails B tests by faster walkers compared to slower walkers. Conclusions:Participation in balance programs can have a positive impact on cognition and physical outcomes. This may provide insight about how exercise influences fall risk. Therapists can utilize this information clinically by educating patients about the potential positive effect of balance exercises on cognition.

development of a Clinical Measure of Dual-task Performance in Walking : reliability and Preliminary Validity of the Walking and Remembering Test

Objectives: (1) To examine the reliability of a new clinical measure of simultaneous walking with performance of a working memory task, the Walking and Remembering Test (WART). (2) To compare older adult to younger adult WART performance to illustrate preliminary validity. Subjects: Convenience sample of 25 young adults (ages 22‐35) and 25 older adults (ages 65‐86) performed the WART twice. Methods: Subjects walked 6.1 meters at their fastest safe speed along a path requiring a narrowed base of support in both single and dual‐task (with simultaneous digit span task) conditions. Reductions in walking and cognitive performance were examined in the dual‐task condition for older adults as compared to younger adults. Main outcome measures: Walking time, step accuracy, digit span memory accuracy, and dual‐task costs for walking and cognitive tasks. Results: Inter‐rater reliability ICC (2,1) values were ≥ .97 for walking time and digit span accuracy. Rater agreement of steps off the path was excellent (93%) for young adults and good (76%) for older adults. Test‐retest reliability ICC (2,1) values for walking time were ≥ .79. Older adults were slower and remembered shorter digit spans, and demonstrated greater dual‐task costs for digit span accuracy and steps off the path than younger adults, but relative dual‐task costs for walking time were not significantly different between groups. Conclusions: The WART is a reliable clinical measure of dual‐task memory and walking that can be administered safely with community‐dwelling older adults. Expected greater dual‐task costs for older adults were observed, but not as strongly as anticipated in this group of very active subjects. The WART provides information that may be useful in targeting patients for intervention to reduce risk of falls in dual‐task conditions, but needs validation with older adults across a greater range of walking ability.

Physical therapy recommendations for service members with mild traumatic brain injury.

Mild traumatic brain injuries (MTBIs) are of increasing concern in both the military and civilian populations as the potential long-term effects and costs of such injuries are being further recognized. Injuries from conflicts in Afghanistan and Iraq have increased public awareness and concern for TBI. The Proponency Office for Rehabilitation and Reintegration, Office of the Surgeon General, US Army tasked a team of physical and occupational therapists to assemble evidence-informed guidelines for assessment and intervention specific to MTBI. Given the paucity of specific guidelines for physical therapy related to MTBI, we focused on literature that dealt with the specific problem area or complaint of the Service member following MTBI. Recommendations, characterized as practice standards or practice options based on strength of evidence, are provided relative to patient/client education, activity intolerance, vestibular dysfunction, high-level balance dysfunction, posttraumatic headache, temporomandibular disorder, attention and dual-task performance deficits, and participation in exercise. While highlighting the need for additional research, this work can be considered a starting point and impetus for the development of evidence-based practice in physical therapy for our deserving Service members.

Returning Service Members to Duty Following Mild Traumatic Brain Injury: Exploring the Use of Dual-Task and Multitask Assessment Methods

Within the last decade, more than 220,000 service members have sustained traumatic brain injury (TBI) in support of military operations in Iraq and Afghanistan. Mild TBI may result in subtle cognitive and sensorimotor deficits that adversely affect warfighter performance, creating significant challenges for service members, commanders, and clinicians. In recent conflicts, physical therapists and occupational therapists have played an important role in evaluating service member readiness to return to duty (RTD), incorporating research and best practices from the sports concussion literature. Because premorbid (baseline) performance metrics are not typically available for deployed service members as for athletes, clinicians commonly determine duty readiness based upon the absence of postconcussive symptoms and return to “normal” performance on clinical assessments not yet validated in the military population. Although practices described in the sports concussion literature guide “return-to-play” determinations, resolution of symptoms or improvement of isolated impairments may be inadequate to predict readiness in a military operational environment. Existing clinical metrics informing RTD decision making are limited because they fail to emphasize functional, warrior task demands and they lack versatility to assess the effects of comorbid deficits. Recently, a number of complex task-oriented RTD approaches have emerged from Department of Defense laboratory and clinical settings to address this gap. Immersive virtual reality environments, field-based scenario-driven assessment programs, and militarized dual-task and multitask-based approaches have all been proposed for the evaluation of sensorimotor and cognitive function following TBI. There remains a need for clinically feasible assessment methods that can be used to verify functional performance and operational competence in a variety of practice settings. Complex and ecologically valid assessment techniques incorporating dual-task and multitask methods may prove useful in validating return-to-activity requirements in civilian and military populations.

Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.

Objective:Previously published mild traumatic brain injury (mTBI) management guidelines provide very general recommendations to return individuals with mTBI to activity. This lack of specific guidance creates variation in military rehabilitation. The Office of the Army Surgeon General in collaboration with the Defense and Veterans Brain Injury Center, a component center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, convened an expert working group to review the existing literature and propose clinical recommendations that standardize rehabilitation activity progression following mTBI. Participants:A Progressive Activity Working Group consisted of 11 Department of Defense representatives across all service branches, 7 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury representatives, and 8 academic/research/civilian experts with experience assessing and treating individuals with mTBI for return to activity. An expert working group meeting included the Progressive Activity Working Group and 15 additional subject matter experts. Methods:In February 2012, the Progressive Activity Working Group was established to determine the need and purpose of the rehabilitation recommendations. Following literature review, a table was created on the basis of the progression from the Zurich consensus statement on concussion in sport. Issues were identified for discussion with a meeting of the larger expert group during a July 2012 conference. Following development of rehabilitation guidance, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury coordinated a similar process for military primary care providers. Results:End products for rehabilitation and primary care providers include specific recommendations for return to activity after concussion. A 6-stage progression specifies activities in physical, cognitive, and balance/vestibular domains and allows for resumption of activity for those with low-level or preinjury symptom complaints. Conclusions:The clinical recommendations for progressive return to activity represent an important effort to standardize activity progression across functional domains and offer providers duty-specific activities to incorporate into intervention. Recommendations were released in January 2014.

Development and preliminary reliability of a multitasking assessment for executive functioning after concussion.

OBJECTIVES. Executive functioning deficits may result from concussion. The Charge of Quarters (CQ) Duty Task is a multitask assessment designed to assess executive functioning in servicemembers after concussion. In this article, we discuss the rationale and process used in the development of the CQ Duty Task and present pilot data from the preliminary evaluation of interrater reliability (IRR). METHOD. Three evaluators observed as 12 healthy participants performed the CQ Duty Task and measured performance using various metrics. Intraclass correlation coefficient (ICC) quantified IRR. RESULTS. The ICC for task completion was .94. ICCs for other assessment metrics were variable. CONCLUSION. Preliminary IRR data for the CQ Duty Task are encouraging, but further investigation is needed to improve IRR in some domains. Lessons learned in the development of the CQ Duty Task could benefit future test development efforts with populations other than the military.

Outcome Measures for Persons With Moderate to Severe Traumatic Brain Injury: Recommendations From the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force.

Background and Purpose: The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work. Methods: An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided. Results: The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain. Discussion and Conclusions: Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable. Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).