Michael Weinrich

Community-Based Adaptive Physical Activity Program for Chronic Stroke: Feasibility, Safety, and Efficacy of the Empoli Model

Objective. To determine whether Adaptive Physical Activity (APA-stroke), a community-based exercise program for participants with hemiparetic stroke, improves function in the community. Methods. Nonrandomized controlled study in Tuscany, Italy, of participants with mild to moderate hemiparesis at least 9 months after stroke. Forty-nine participants in a geographic health authority (Empoli) were offered APA-stroke (40 completed the study). Forty-four control participants in neighboring health authorities (Florence and Pisa) received usual care (38 completed the study). The APA intervention was a community-based progressive group exercise regimen that included walking, strength, and balance training for 1 hour, thrice a week, in local gyms, supervised by gym instructors. No serious adverse clinical events occurred during the exercise intervention. Outcome measures included the following: 6-month change in gait velocity (6-Minute Timed Walk), Short Physical Performance Battery (SPPB), Berg Balance Scale, Stroke Impact Scale (SIS), Barthel Index, Hamilton Rating Scale for Depression, and Index of Caregivers Strain. Results. After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, SPPB, and SIS social participation domains. These between-group comparisons were statistically significant at P < .00015. Individuals with depressive symptoms at baseline improved whereas controls were unchanged (P < .003). Oral glucose tolerance tests were performed on a subset of participants in the intervention group. For these individuals, insulin secretion declined 29% after 6 months (P = .01). Conclusion. APA-stroke appears to be safe, feasible, and efficacious in a community setting.

A competitive distribution theory of neocortical dynamics

Peristimulus inhibition in sensory pathways is generally attributed to lateral inhibitory connections. However, in the neocortex circuitry is incompletely understood at present, and in some cases there is an apparent mismatch between observed inhibitory effects and intracortical inhibitory connections. This paper studies the hypothesis that an additional mechanism, competitive distribution of activation, underlies some inhibitory effects in cortex. Analysis of a mathematical model based on this hypothesis predicts that per stimulus inhibitory effects can be caused by competitive distribution of activation, and computer simulations confirm these predictions by demonstrating Mexican Hat patterns of lateral interactions, transformation of initially diffuse activity patterns into tightly focused islands of activation, and edge enhancement. The amount of inhibition can be adjusted by varying the intensity of the underlying competitive process. The concept of competitive distribution of activation provides an important perspective for interpreting neocortical and thalamocortical circuitry and can serve as a guide for further morphological and physiological studies. For example, it provides an explanation for the existence of recurrent cortex-to-thalamus connections that perform a logical AND-operation, and predicts the existence of analogous neocortical circuitry.

Home- and Community-Based Long-Term Care Lessons From Denmark

PURPOSEnDenmark is cited as a model in the development of home- and community-based systems for the frail elderly population. We examined the results of this natural experiment and considered implications for U.S. policy.nnnDESIGN AND METHODSnWe used international comparative policy analysis, including site visits and semistructured interviews with Danish leadership in conjunction with a review of published literature, reports, and administrative data from Denmark and the United States.nnnRESULTSnAfter 12 years of implementing integrated systems for home- and community-based services in 275 municipalities, growth in Danish long-term care expenditures has leveled off; expenditures appear to be decreasing for the over-80 population and have dropped as a percentage of the gross domestic product. Access to and quality of long-term care services appear to remain generally satisfactory. During this period, comparable expenditures in the United States have increased, and deficits in access and quality persist.nnnIMPLICATIONSnThese findings should be of interest to state and federal policy makers considering strategies to reduce the rate of growth in Medicaid and Medicare expenditures for elders and to expand home- and community-based services.

Timing, Intensity, and Duration of Rehabilitation for Hip Fracture and Stroke: Report of a Workshop at the National Center for Medical Rehabilitation Research

This article summarizes the proceedings of an NIH workshop on timing, intensity, and duration of rehabilitation for acute stroke and hip fracture. Participants concentrated on methodological issues facing investigators and suggested priorities for future research in this area.

Computers in the rehabilitation of chronic, severe aphasia: C-VIC 2.0 cross-modal studies

Abstract We describe the C-VIC 2.0 system for use by severe, chronic aphasic patients, and give an account of its use in helping a globally aphasic patient in a cooking-related task. In this controlled study, we conducted cross-modal comparisons of acontextual execution of single steps, delivered in C-VIC, spoken, and written modalities. We report results of the experiment, and discuss the findings along with some of their possible implications.

Review Article : Protecting the Most Vulnerable: Home Mechanical Ventilation as a Case Study in Disability and Medical Care: Report from an NIH Conference

Patients requiring chronic mechanical ventilation represent a particularly vul nerable segment of the expanding population of individuals with chronic disabilities Many of these individuals can live successfully at home, but face significant obsta cles. Current policies m health care coverage, durable medical equipment coverage, eligibility for assisted living, and licensing of caregivers all restrict the abilities of these individuals to live in the community. Prolonged home mechanical ventilation was pioneered m France, where a current international best practice provides a model for developing comprehensive, cost-effective care for these individuals.

Narrative and procedural discourse production by severely aphasic patients.

Five chronically aphasic subjects were trained on a computerized iconographic communication system (C-VIC). Their performance in producing single sentences, scripts, and narratives was assessed using both spoken English and C-VIC. The requisite vocabulary necessary and the narrative complexity of the target productions were controlled. Subject performance using C-VIC indicates that the ability to construct discourse at the macrostructural level is largely intact. Despite significant improvements in spoken production after C-VIC training, especially at the single sentence level, the subjects’ spoken discourse remains severely impaired by their failures at the microlinguistic level. These results point to the limits of currently available approaches to the remediation of aphasia and suggest avenues for future research.

Rules for Rehabilitation: An Agenda for Research

Rehabilitation services have grown tremendously in the United States over the past 2 decades. Rules originally designed to guide Medicare reimbursement policies have had substantial effects in shaping the design of clinical services. This article traces the development of the most significant federal rules regarding rehabilitation, outlines the existing empirical evidence to support these rules, and discusses an agenda for research to improve the evidence for future policy development.

Coverage Policy for Neurorehabilitation An International Perspective

Background. Coverage policy ultimately determines the delivery of services. This article summarizes the authors’ effort to ascertain the extent of publically available information on coverage for neurorehabilitation services internationally. Objective. Present available data on neurorehabilitation coverage and examine the needs for further research in this area. Methods. Review of published literature, review of government Web sites, survey of World Federation of NeuroRehabilitation (WFNR) program chairs, and attendees of the 2010 World Congress of NeuroRehabilitation. Results. A wide variation in coverage was found internationally. Data are not routinely accessible. Conclusions. Informed policy requires current data. There is an opportunity for the WFNR to provide leadership in policy for neurorehabilitation services by assembling and maintaining current data on coverage policy internationally.

Home- and Community-Based Long-Term Care

PURPOSEnDenmark is cited as a model in the development of home- and community-based systems for the frail elderly population. We examined the results of this natural experiment and considered implications for U.S. policy.nnnDESIGN AND METHODSnWe used international comparative policy analysis, including site visits and semistructured interviews with Danish leadership in conjunction with a review of published literature, reports, and administrative data from Denmark and the United States.nnnRESULTSnAfter 12 years of implementing integrated systems for home- and community-based services in 275 municipalities, growth in Danish long-term care expenditures has leveled off; expenditures appear to be decreasing for the over-80 population and have dropped as a percentage of the gross domestic product. Access to and quality of long-term care services appear to remain generally satisfactory. During this period, comparable expenditures in the United States have increased, and deficits in access and quality persist.nnnIMPLICATIONSnThese findings should be of interest to state and federal policy makers considering strategies to reduce the rate of growth in Medicaid and Medicare expenditures for elders and to expand home- and community-based services.