Rehabilitation medicine

Permanent URI for this collectionhttps://digital.lib.washington.edu/handle/1773/19663

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Outcomes After Lower Limb Amputation Among Medicare Beneficiaries: Post-Acute Care Settings, Readmission, and Mortality
(2026-02-05) Rosen, Rachael E; Mroz, Tracy
Major lower limb amputation is a life-altering procedure associated with high rates of hospital readmission and mortality, particularly among older adults with complex health conditions. Despite the critical role of post-acute care in supporting recovery after major lower limb amputation, limited evidence exists on how post-acute care access and outcomes vary within this vulnerable population. This dissertation examined post-acute discharge destinations following acute hospitalization and modeled adverse post-discharge outcomes, using national Medicare claims data from 2018 to 2021. Together, the three studies described in this dissertation provide a comprehensive evaluation of post-acute care settings, as well as readmission and mortality outcomes following major lower limb amputation among Medicare fee-for-service beneficiaries. The first study identified disparities in post-acute care discharge destinations following hospitalization for major lower limb amputation based on Medicare beneficiary sociodemographic and clinical characteristics. Despite clinical guidelines suggesting patients receive post-acute care from an inpatient rehabilitation facility after major lower limb amputation, findings demonstrate fewer than one in four beneficiaries were discharged to this post-acute care setting, with discharge patterns varying significantly by age, race/ethnicity, sex, rurality, and clinical complexity. Beneficiaries who are female, Black, Native American, dually eligible for Medicare and Medicaid, or residing in rural areas were less likely to receive post-acute care from an inpatient rehabilitation facility. These findings demonstrate inequities in post-acute care access following lower limb amputation among Medicare beneficiaries. Building on the first study, the second study focused on predicting 180-day hospital readmission after lower limb amputation. A traditional competing risk model was compared to a machine learning model to assess readmission risk. Results showed that machine learning improved prediction accuracy and identified non-linear relationships between beneficiary characteristics and readmission. High-risk subgroups were identified based on clinical complexity, including end-stage renal disease, increased comorbidity burden, prolonged hospitalizations, and an intensive care unit stay. Identifying high-risk beneficiary profiles may guide targeted post-acute care planning, including closer monitoring and increased support following hospital discharge after lower limb amputation. The third study modeled post-discharge mortality following lower limb amputation. A traditional survival model was compared to a machine learning model to predict mortality risk. Both methods demonstrated similar predictive accuracy, but a key assumption of the traditional survival model was violated, therefore the machine learning model was the better choice for prediction. Patients discharged to hospice, skilled nursing facilities, or home without post-acute care services had the highest mortality, while those discharged to inpatient rehabilitation facilities or home health care experienced comparatively lower mortality risk. High-risk subgroups were identified based on key sociodemographic and clinical predictors, including post-acute care discharge setting, increased comorbidity burden, older age, and a diagnosis of end-stage renal disease. Together, these studies highlight variation in post-acute care access and clinical outcomes following major lower limb amputation among Medicare beneficiaries. Machine learning methods improved readmission prediction and identified non-linear risk predictors that could not be captured by traditional statistical models. Mortality prediction was comparable across models; however, a violation of a key assumption in the traditional survival model favored the use of machine learning to predict mortality. These findings demonstrate the utility of machine learning as a flexible modeling approach to support risk-informed clinical decision-making following major lower limb amputation. Results from these analyses also support efforts to develop equitable post-acute care planning strategies and guide Medicare policy toward more standardized and supportive care pathways following major lower limb amputation.
LAMFit: A Digital Fitness Program for Individuals with Lymphangioleiomyomatosis
(2025-10-02) Child, Claire Elise; Brown, Mary Beth
Background: Daily physical activity is reported to be substantially reduced in individuals with the rare lung disease lymphangioleiomyomatosis (LAM). This important modifiable risk factor can be reduced using proven behavioral change and exercise interventions. Using a digital health platform with remote monitoring to deliver a structured exercise regimen in the home setting may be feasible and safe for individuals with LAM that are medically appropriate to participate.Methods: In this dissertation, we describe the design and pilot testing of 'LAMFit,' a fully remote, digital fitness program for individuals with LAM living in the United States. First, we convened a group of experts in LAM and conducted a 2-round, modified Delphi study to develop an expert consensus LAMFit exercise preparticipation screening tool for providers to use to determine medical appropriateness prior to patient enrollment in LAMFit. Next, we conducted a retrospective analysis of in-person clinical exercise testing during two prior exercise studies our research team as conducted among patients with interstitial lung disease (ILD) [n=15 LAM and n=15 idiopathic pulmonary fibrosis (IPF)]. To determine the utility of using peak heart rate (HR) on six minute walk test (6MWT) for exercise prescription in higher-functioning individuals with ILD in the absence of maximal cardiopulmonary exercise test (CPET), we evaluated the agreement between peak HR on 6MWT and HR at the first ventilatory threshold on CPET, the criterion standard for aerobic exercise prescription. We identified a 'cutoff' threshold at or above 85% pred. 6MWT distance where it becomes inappropriate to use of peak HR on 6MWT to estimate aerobic exercise threshold in ILD. Lastly, we pilot tested LAMFit over a period of 6 months using LAM medical provider prescreening, a custom digital health platform with a fitness tracker, a medical-grade pulse oximeter, a novel, in-app remote 6MWT, and patient-reported outcome measures administered during baseline, midpoint, and final remote study visits. Results: All 25 participants with LAM (100%) completed the first 12-week exercise program of the LAMFit pilot study, including baseline, and midpoint study visits. Twenty-two participants (88%) completed the second 12-week exercise program and final study visit, with 3 discontinuations for reasons unrelated to the study intervention. No serious or non-serious study-related adverse events occurred. High adherence to aerobic exercise during the two 12-week intervention periods of LAMFit was achieved (intervention period 1: 81±18%; intervention period 2: 79±18%). In the first 12 weeks of the exercise program, the mean daily minutes of moderate-to-vigorous physical activity (MVPA) increased by an average of 51% (25.6 ± 32.6 min to 52.5 ± 59.2 min; p=0.0318) compared to the run-in period. Distance achieved in 6MWT increased by an average of 7.1% (36.2 ± 9.1m, p=0.0021) from baseline to midpoint, and continued benefit was seen after completion of the second exercise intervention, with an average increase of 8.5% distance walked on 6MWT (43.4 ± 10.9, p=0.0021) at final study visit compared to baseline. Significant improvements in fatigue, health-related quality of life, and dyspnea were observed after participation in the first 12 weeks. Participants expressed a high level of satisfaction and acceptability of the LAMFit digital fitness program. Conclusion: A fully-remote approach to delivering a home-based exercise program in LAM is feasible and safe. The pilot feasibility study of LAMFit was a noteworthy success. Stakeholder interest in the LAM community is very high for continuing to scale access to the LAMFit program nationally and internationally.
Inter-rater agreement among physical therapists in using Neurologic Movement System Diagnosis (N-MSD)
(2025-08-01) Farhadi, Hoda; Pradhan, Sujata
Movement optimization was adopted by the American Physical Therapy Association (APTA) as the core of physical therapy practice in 2013. While Physical Therapists (PTs) observe, assess, diagnose, and treat movement impairments in clinical practice, evidence-based clinical practice guidelines are centered around neurological medical diagnoses rather than movement deficits. Therefore, in physical therapy practice, pathophysiological impairments and health conditions often guide assessment, treatment, and prognosis instead of the movement deficits.To make movement the focus of the clinical decision-making process, several movement system diagnoses were developed. While some of the previously published frameworks were commonly used in clinical practice and educational settings, few studies have examined the reliability, validity, and clinical application of any of these systems. This dissertation study examined the agreement among PTs in utilizing the Neurologic Movement System Diagnosis (N-MSD) framework in individuals with various neurological health conditions. The N-MSD includes frameworks for movement observation and analysis of key functional tasks as well as movement-based diagnoses. This body of work examined the agreement among PTs, between experienced and early-career PTs and against an expert considered as the gold standard. The findings demonstrated that experienced PTs with prior knowledge about the Movement System were in higher agreement with an expert when making movement system diagnoses. Moreover, PTs demonstrated greater agreement, a narrower range of scores, with assessments of static tasks as compared to their assessments of dynamic tasks. Among dynamic tasks however, assessment of transitional movements such as Sit to Stand and Step Up showed more scattered results across PTs compared to gait. Subsequently, agreement among PTs in selecting movement system diagnoses with key features related to dynamic tasks was lower as compared to other diagnoses. The collective results of these studies suggest that with proper training on N-MSD, physical therapists could come to moderate to strong agreement when assessing certain functional tasks and consensus on a primary movement diagnosis. These research findings also lay the groundwork for future research efforts, including development of a more uniform process for analyzing tasks with emphasis on dynamic tasks, psychometric evaluation of the new evaluation framework, and insight into the underlying clinical reasoning during the examination process and for a movement system diagnosis.
Healthcare Transitions for Middle Eastern Youth with Disabilities in Washington State: Access, Facilitators, Barriers, Quality of Life, and Transition Resources
(2025-05-12) Abuatiq, Reham; Feldner, Heather A
This three-article dissertation aimed to explore the experiences of Middle Eastern youth with intellectual and developmental disabilities (YIDD) during the healthcare transition (HCT) process. Despite the growing literature in HCT and unmet minority healthcare needs globally, there is limited data about the Middle Eastern YIDD experiences during this critical phase. A mixed methods approach was used to investigate the Middle Eastern YIDD and their caregivers' experiences during HCT in Washington State. The first article "Exploring an Understudied Population: Healthcare Access and Transitions of Middle Eastern Youth with Disabilities in Washington" was a qualitative study design using semi-structured interviews with 12 Middle Eastern YIDD and their caregivers. Inductive thematic analysis using NVivo software was conducted. Four main themes emerged: Utilizing resources and support structure to access care, hurdles to care access, key concerns and priorities in navigating HCT, and key needs during HC. These highlight that despite the availability of supportive local disability resources, there are several challenges during HCT. Emphasizing the need for more culturally- sensitive approaches and comprehensive care while addressing insurance coverage is needed to improve the experiences of this population. The second article titled "Healthcare Transitioning Barriers and Facilitators from the perspectives of Middle Eastern Youth with Disabilities and their families in Washington State" investigated the HCT facilitators and barriers of this same population using photovoice narrative method with 11 participants, as one family dropped off due to availability issues. Interviews were analyzed using NVivo software and inductive thematic analysis followed by member checking. Results showed that the key HCT facilitators were healthcare providers' support; supportive healthcare facilities and clinics; independence and personal growth; and providers' cultural competence. However, health insurance coverage issues; lack of HCT planning, preparation, resources; independence and readiness to lead challenges; and gender-specific preferences were the main barriers to HCT. These highlight the need for implementing HCT best practice and guidelines to improve the HCT experiences for this sample. Further, the photovoice narrative method may be a powerful tool to empower families and communicate their needs. The final article "Health-Related Quality of Life of Middle Eastern Youth with Disabilities during Healthcare Transition in Washington State" aimed to identify and investigate how health-related quality of life (HRQOL) changes over short-term period during HCT process of this population. The current HCT literature has limited evidence about healthcare access and HRQOL of Middle Eastern YIDD during HCT. A short healthcare access survey and the World Health Quality of Life – BREF (WHOQOL-BREF) measure were collected. The WHOQOL-BREF was collected twice, at study enrollment and after photovoice narratives interviews. Descriptive statistics and the Mann Whitney U test were conducted using R software. All participants had access to healthcare services. No statistical significance was detected between the initial and second assessments of the WHQOL-BREF raw scores. This study provided key data about healthcare access and HRQOL during HCT of this population. Future research is needed with a larger sample size to better understand Middle Eastern YIDD HRQOL levels during HCT in the United States.
Spinal stimulation for upper and lower extremity motor recovery after spinal cord injury
(2025-01-23) Henderson, Richard; Moritz, Chet T
Paralysis as a result of spinal cord injury severely impairs control and movement of the extremities. Individuals living with spinal cord injury report significant difficulty with activities of daily living, which can lead to limited mobility and participation within the community. Depending upon the level of injury, restoring movement in the upper and lower extremities is a top priority. Current clinical practice uses exercise-based rehabilitation strategies to facilitate motor recovery after spinal cord injury. The overall effectiveness of exercise alone for movement restoration, however, is limited. Recently, neuromodulation of the spinal cord through electrical and optogenetic stimulation has shown promise as technologies enabling greater movement recovery. Therefore, the aims of this dissertation are to 1) review the history and use of electrical and optogenetic stimulation after spinal cord injury, 2) explore the immediate effects of transcutaneous spinal stimulation on exoskeleton-assisted walking, 3) develop a filtering technique to remove stimulation artifact in surface electromyography recordings, and 4) compare the long-term effects of epidural electrical vs. optogenetic spinal stimulation for forelimb recovery. The immediate effects of transcutaneous electrical spinal stimulation on exoskeleton-assisted walking were assessed in six participants. Stimulation enabled most participants to improve their walking performance, as evidenced by faster gait speeds, reductions in exoskeleton-assistance for stepping, and better muscle coordination. Additionally, we adapted a filtering approach to specifically remove stimulation artifacts while preserving electromyography signals in the same six participants. Lastly, we compared forelimb recovery after a cervical spinal cord injury in rats across three groups: exercise alone, epidural electrical stimulation with exercise, and optogenetic stimulation with exercise. Both stimulation approaches facilitated more recovery compared to exercise alone, with optogenetic stimulation demonstrating a nearly two-fold improvement compared to electrical stimulation. The evidence in this dissertation shows that stimulation of the spinal cord is effective for enabling greater recovery of movement and control of the extremities after spinal cord injury.
Vestibular Function in People with Parkinson Disease and the Effects of Dopaminergic Medication
(2024-10-16) Brodsky, Jennifer Lynn; Kelly, Valerie
There is growing evidence suggesting that Parkinson disease (PD) affects the vestibular system, which senses head accelerations including gravity. People with PD report symptoms consistent with vestibular dysfunction that may begin prior to their PD diagnosis. Vestibular dysfunction may also contribute to postural instability which is common with disease progression. In addition to the otolithic and semicircular canal (SCC) end organs in the periphery, the vestibular system has broad sub-cortical and cortical connectivity leading to multiple potential routes for PD pathology to affect vestibular function. However, it is unclear if vestibular dysfunction in PD is disease-specific, age-related, or both. Furthermore, it is unknown how dopaminergic medications used to treat PD may affect vestibular function. Due to the distributed nature of vestibular connections and the inability to record from the end organs directly, localization of vestibular pathology in humans requires a comprehensive examination. The overarching objective of this dissertation is to understand how Parkinson disease and dopaminergic medications used to treat PD affect peripheral and central vestibular function in people with PD. This objective was met through the completion of two projects: a retrospective review of vestibular test records, and a prospective comparison of comprehensive vestibular testing in healthy controls and participants with PD, off-medication and on-medication.First, a retrospective records review was performed to examine the results of comprehensive vestibular testing completed by people with PD at the University of Washington Dizziness and Balance Center. The record review aimed to characterize vestibular function in people with PD referred for vestibular testing compared to adults without PD who also completed testing at the center. It was hypothesized based on prior literature that vestibular test results would show specifically otolithic dysfunction in the periphery and a pattern of central vestibular involvement across disease stages. Records that included a diagnosis of PD were categorized based on the timing of the PD diagnosis relative to the date of vestibular testing as prodromal (vestibular assessment before PD diagnosis) or clinical (vestibular assessment within one year of or any time after PD diagnosis). Age and gender matching of PD records to non-PD control group (CG) records at a 1:2 ratio was then performed. The primary comparison was to determine if there were significant differences in vestibular test results between PD and CG, based on the presence of a diagnosis of PD. Secondary comparisons determined if there were differences based on disease severity. Comparisons were made for CG and prodromal PD, CG and clinical PD, and between the two PD groups. Results were partially aligned with the expected outcome. Unlike expectations, there were no differences between CG and PD records for otolithic function. Consistent with expectations, central signs were present for the PD groups suggesting vestibulo-cerebellar dysfunction in all 3 three comparisons where sufficient data was available. All groups showed poor postural control performance. These findings suggest that peripheral otolithic dysfunction may not be more prevalent in PD than in typical aging, but central vestibular dysfunction that includes the cerebellum may be present in PD even at early disease stages. Second, a prospective study used comprehensive vestibular testing to determine if vestibular function in PD is different from healthy older adults and to examine the effects of dopaminergic medication on vestibular function in PD. For the first aim, it was anticipated that, compared to healthy controls (HC), people with PD would have abnormalities in otolithic function, vestibular nucleus complex (VNC) functions, and vestibular sensory integration. For the second aim, it was anticipated that dopaminergic medication would improve otolithic function and inhibit central functions. To test this, 15 HC and 15 participants with PD completed comprehensive vestibular testing. Participants with PD completed testing when functionally off their dopaminergic medications for PD (OFF), and while on-medication (ON). Both aims used the same primary variables representing otolithic function, SCC function, VNC function, and vestibular sensory integration for postural control. Secondary variables were also collected and compared to provide context to interpret primary test results. To test for PD-specific vestibular deficits without any potential medication effects, vestibular test results for participants with PD, OFF, were compared to HC. It was expected that otolithic function would be abnormal in PD, however, the comparison found that otolithic function in PD was not significantly different from HC. Instead, there was evidence for reduced SCC function. The primary central function variables were not significantly different in PD. However, for secondary variables, there were significant signs of dysfunction of the VNC and cerebellum, abnormal visual verticality perception, and well-known saccadic eye movement abnormalities. The second aim of the prospective project, to determine the effects of dopaminergic medication on vestibular function in PD, used a quasi-experimental design. The results of participants with PD, OFF, were compared to ON. It was anticipated that medication would improve otolithic function and impair central vestibular functions. The results of comparisons showed no effect of medication on either peripheral or central vestibular function. However, there was a high prevalence of abnormal test results both OFF and ON. These findings indicate that there may be disease-specific VNC, cerebellar, and cortical vestibular processing abnormalities in PD affecting non-dopaminergic pathways. In conclusion, the work of this dissertation demonstrates that disease-related central vestibular dysfunction may exist in people with PD, potentially at early disease stages. Additionally, the evidence that vestibular dysfunction in PD is not responsive to dopaminergic medications indicates potential non-dopaminergic pathway involvement in PD. Further research is needed to determine if this vestibular dysfunction is related to postural control and gait deficits, or non-motor symptoms in PD. Finally, examination and individualized treatment using established vestibular rehabilitation techniques and the development of novel interventions targeting vestibular function should be considered for people with PD.
Community Participation and Environmental Influences Among People with Multiple Sclerosis: Challenges and Solutions from a Community-Engaged Perspective
(2024-10-16) Yang, Bishan; Lee, Danbi
Multiple sclerosis (MS) is the most common non-traumatic neurodegenerative disease among young adults. It is affecting nearly one million adults in the US and two million adults worldwide. Participation in meaningful and important activities as desired is highly valued by people with MS (PwMS) and is an important clinical outcome indicating quality of life and well-being. However, research has shown that PwMS experience significant declines in participation after their diagnosis, and they report fewer barriers to participating in activities at home but more barriers outside the home. Although numerous conceptual frameworks and empirical studies with other diagnostic groups highlight the role of environments in affecting participation, specific environmental impacts on community participation of PwMS have not been thoroughly explored. Using mixed-methods design and community-engaged research approaches, this dissertation broadly aims to understand community participation experiences among PwMS and how physical, societal, and attitudinal environments affect these experiences. In addition, the dissertation also focuses on advocacy for system-level improvements for enhancing community participation. The dissertation includes three phases: (1) a secondary analysis of quantitative data on person factors, environment, and community participation of people with MS, (2) focus group discussions with individuals with MS, and (3) a community engagement meeting with the broader MS community. In this dissertation, Chapter 1 presents a literature review on the conceptualization of participation and environmental influences, as well as empirical evidence relevant to multiple sclerosis, community participation measurement, and environmental impact, revealing research gaps and justifying the content and design of this dissertation. Chapters 2-4 are the three main articles that jointly achieve the overarching purpose of this dissertation with various specific aims. Chapter 5 is a conclusion chapter summarizing the study findings and implications. The first article (Chapter 2), “Is Doing More Always Better? A Mixed Methods Study Examining Relationship Between Subjective and Objective Dimensions of Community Participation among Individuals with Multiple Sclerosis,” utilized results from the first and second phases of this project to examine the relationship between subjective perspective of participation and objective community mobility performance both quantitatively and qualitatively. Results show that subjective and objective dimensions of community participation are positively related, but the association is generally weak, indicating that better perceptions of participation outcomes do not require high quantities of community engagement, such as frequency, distance, and duration of community outings. The study also found that personal factors (e.g., symptoms, preference, lifestyle, resilience) and environmental factors influence subjective and objective aspects of participation differently, which supported the distinction between the two dimensions. These findings emphasized the need for rehabilitation professionals to measure both subjective and objective dimensions of participation and identify contributors to the divergence in order to fully understand individual community participation experiences and to inform interventions. The second article (Chapter 3), “Environmental Influences on Community Participation among People with Multiple Sclerosis: A Mixed Methods Study,” has three specific aims: (1) To quantitatively assess the impact of environmental factors (EFs) on community participation among people with MS; (2) To quantitatively explore the effect modification of EFs on the relationship between symptom severity and community participation; (3) To qualitatively understand participant perspectives on environmental influences and identify needs for system-level changes to facilitate community participation. This study also used results from the first two phases of the dissertation project to address these three aims. Quantitative results showed that EFs (e.g., perceived social support, financial resources, neighborhood safety, and use of wheeled aid) were significantly associated with both subjective and objective participation measures, however, only perceived financial resources demonstrated a moderate association with subjective participation, and other associations were weak. EFs independently explained a portion of the variation in satisfaction with participation and radius of gyration, but not in other participation outcomes. Statistical analyses revealed that compared to environmental factors, person factors had stronger impacts on community participation among PwMS and did not support the role of EFs in moderating the association between symptoms and participation. Focus group participants, however, highlighted the enabling role of environmental supports that facilitated their community participation while living with functional limitations. They also described barriers in physical, societal, and attitudinal environments and advocated for system-level improvements in four areas: accessibility in the built environment, information access, MS specialty care, and public attitudes toward people with disabilities. The final article (Chapter 4), “Identifying Collective Efforts to Support Community Participation: A Community Engagement Meeting with the Multiple Sclerosis Community” described the practice of community-engaged approaches throughout the dissertation research process and reported findings from the final phase—an online MS community engagement meeting. The paper focuses on introducing the roles of community partners, their involvement in various research stages, and strategies researchers use to support their engagement. The findings from the final phase are action-oriented recommendations generated by community engagement meeting attendees for achieving system-level changes in four areas identified in the second article (i.e., improving accessibility in the built environment, information access, MS specialty care, and public attitudes towards people with disabilities). Together, these articles provide valuable insights for clinicians and researchers on measuring community participation among PwMS to enhance understanding of their experiences and the importance of understanding what environmental factors support or hinder community participation experience of PwMS and how. The studies also offer potential solutions for clinicians, organizations, and policymakers to support community participation of PwMS through increasing environmental support. Last but not least, the dissertation highlights the meaningfulness of community-engaged research centering the community’s voices and needs and provides an example for engaging the MS community and other disability communities in research process.
Underrepresented Voices: Experiences of Asian American Speech-Language Pathologists in Graduate Training and Clinical Practice
(2023-09-27) Jin, Jingyu; Baylor, Carolyn
Purpose: Currently, speech-language pathology lacks diversity in its membership. Asian Americans are especially underrepresented among speech-language pathologists (SLPs) compared to other health professions. This phenomenon suggests that there may be unique factors that Asian Americans face in this discipline. The purpose of this study was to investigate the experiences of Asian American SLPs as trainees and as clinicians, and to explore whether these experiences vary based on their cultural affinity to Asian and American identities.Methods: The study is a qualitative study drawing on the phenomenological tradition. Twenty-six Asian American SLPs who work with adults participated in one-on-one semi-structured interviews. The interviews included open-ended questions about participants’ paths to the profession, their experiences as trainees and clinicians in speech-language pathology that related to their Asian identities, and the influence of their Asian identity on clinical interactions with clients. Participants also completed the Suinn-Lew Asian Self-Identity Acculturation (SL-ASIA) scale and other demographic questions regarding their ethnicity, language, education and work history. Thematic analysis was conducted with a team approach to develop themes and subthemes from codes derived from the interview transcripts. Descriptive measures were used to identify trends between qualitative and quantitative data. Results: Two sets of themes emerged from the interviews. The first set of themes focused on Asian American SLPs’ experiences as trainees during graduate school and clinical fellowship. Participants described how personal factors, including their personal motivation, family influence, and existing perceptions of SLPs played roles in their decisions to pursue graduate study. Once participants entered these graduate programs, they felt constrained by the existing norms within the program. The social environment within their programs that both positively and negatively influenced their experiences included program diversity, peer support, cultural adjustments, and feelings of isolation. The second set of themes explored their experiences in clinical practice. Participants described that their minority background and cross-cultural experiences served as assets for building strong relationships with Asian and other culturally and linguistically diverse (CLD) clients. They were also aware of the positive and negative impact of their language skills on clinical practice. They also faced challenges related to questioning their belonging in the profession from clients, peers, and themselves. Comparing qualitative findings with SL-ASIA responses data showed that experiences varied among participants based on their generational status and their language familiarity with English and Asian languages. While most participants identified as bicultural and comfortable navigating between cultures, they still faced racial stereotypes and discrimination that affected their sense of belonging. Conclusions: Previous research in speech-language pathology and other health professions demonstrates that underrepresented minority members experience sociocultural barriers to career entry, a limited sense of belonging, cultural dissonance in their professional identity, and perceived cross-cultural differences in clinical encounters. While minority SLPs may face many challenges similar to those of other professions, there are two findings highlighted in this study pertaining to Asian American SLPs’ experiences. SLPs coming from CLD backgrounds bring clinical strengths for working with CLD clients, but they also face discrimination from their clients and peers because of these differences. The significant role that speech and language plays in the profession, and existing racial stereotyping of Asians may also point to why Asian Americans are uniquely underrepresented in speech-language pathology compared to other healthcare disciplines. More research that centers on the experiences of minority SLPs is needed to address professional ideologies that hinder diversity and inclusion in the field.
Spinal Neuromodulation and Gait Training for Children with Cerebral Palsy: From Laboratory to Community
(2023-08-14) Shrivastav, Siddhi R.; Moritz, Chet T
Abstract Spinal Neuromodulation and Gait Training for Children with Cerebral Palsy: From Laboratory to Community Siddhi R. Shrivastav Chair of the Supervisory Committee: Chet T. Moritz Department of Rehabilitation Medicine, Electrical & Computer Engineering, and Physiology & Biophysics Cerebral Palsy (CP) is a movement disorder that is caused due to an injury to the developing brain around the time of birth. CP leads to abnormal posture, muscle tone and movement, that negatively affects physical function. Children with CP are less active than typically developing children. They experience participation restrictions due to impaired mobility. Currently, there are no non-invasive medical or surgical treatments that can improve children’s muscle tone along with mobility. Moreover, the effects of current physical therapy, medical and surgical interventions on children’s community walking, participation and quality of life is less known.Non-invasive neuromodulation, such as transcutaneous spinal cord stimulation (tSCS) may improve children’s muscle tone, walking function and mobility. tSCS, when combined with appropriate task-specific exercises, can harness neuroplasticity and thereby lead to long-term improvement in function. There is growing evidence of functional recovery in people with spinal cord injuries. tSCS may normalize the brain-spinal cord connectivity in CP, thereby leading to positive changes in movement and function. These functional gains may translate into children’s community walking, participation and on quality of life. First, we review background on CP and discuss about impairments associated with CP. We then present on current medical and surgical standard of care for muscle tone management, and discuss physical therapy and rehabilitation practices to improve function in children with CP. We also summarize evidence on high-intensity treadmill training, the short burst interval treadmill training or SBLTT to improve walking function in children with CP. We discuss the potential mechanisms of tSCS in CP and summarize previous evidence of this technique for CP rehabilitation. We provide evidence on the effects of tSCS combined with SBLTT on improving muscle tone, while simultaneously improving lab-based walking function in two children with CP. We then demonstrate the long-term effects of the combination of tSCS and SBLTT on muscle tone, walking function, along with a pre- post-treatment comparison of self-reported walking and health-related outcomes. Lastly, we explore the use of StepWatch device to measure community walking performance after two interventions, SBLTT only and tSCS combined with SBLTT in children with CP. Specifically, we evaluate six variables of walking performance: (1) average strides per day, (2) percent time and (3) number of strides intensities at low, moderate, and high stride rates, (4) percentage of total strides at low, medium, and high intensities, (5) average peak stride rate, and (6) activity index.
Eating Together After Cancer
(2023-01-21) Pryor, Jan Carol; Yorkston, Kathryn
Abstract Eating Together After Cancer Jan C. Pryor Kathryn YorkstonDepartment of Rehabilitation Medicine Introduction: Although treatment for medical aspects of dysphagia due to head and neck cancer is well established, knowledge of the range and extent of psychosocial issues related to the impact of dysphagia on social eating specifically has not been clearly determined. Objectives: The primary objective of this study was to explore the psychosocial impact of eating with others on people with dysphagia due to head and neck cancer. Methods: This was a mixed-methods study that utilized focus groups of people with dysphagia to identify key topics related to social eating. These data were used to develop a survey to quantify the range and extent of the psychosocial impact of dysphagia on social eating. Results: Survey data from 53 participants with dysphagia due to head and neck cancer were collected. Findings revealed psychosocial issues related to social eating were common in this participant sample (average time since completion of treatment, 6 years, range 6 months—23 years). Data analysis revealed there were no statistically significant differences in the extent of psychosocial impact between home and public settings. In addition, statistically significant differences in psychosocial impact were not found across a range of topics by people of different swallowing severity levels, with two exceptions. People with severe dysphagia reported that family members went out to eat less frequently due to dysphagia (p < 0.05), and perceived that swallowing problems embarrassed people they eat with in public more than people with mild or moderate dysphagia respectively (p <0.05). People with dysphagia also noticed family members were impacted by dysphagia. Conclusion: Negative social consequences of dysphagia related to eating with others were commonly reported in this study. The persistence of social consequences for years after treatment by people with all levels of swallowing severity suggests the importance of screening for psychosocial issues related to social eating. Investigators hope this study provides increased awareness of the social consequences of dysphagia as well as useful strategies to support people with dysphagia. This study may assist in the development of future assessment tools.
Rehabilitation Processes in Skilled Nursing Facilities in the Context of Shifting Policy
(2022-07-14) Prusynski, Rachel Ann; Mroz, Tracy
The purpose of this dissertation is to explore relationships between Medicare policy, rehabilitation practice, and patient outcomes within the fragmented and complex Skilled Nursing Facility (SNF) industry. United by a conceptual framework that connects Medicare policy with the structures, processes, and outcomes of rehabilitation in SNFs, the articles included in this dissertation were motivated in part by the implementation of a new Medicare reimbursement model, the Patient Driven Payment Model (PDPM), in October 2019. In response to rising intensity and costs of what Medicare considered clinically unnecessary rehabilitation, PDPM drastically shifted incentives for physical and occupational therapy provision in SNFs. However, the design of the PDPM reimbursement system does not account for potential policy impacts on patient outcomes. The first article, “Is More Always Better? Financially motivated therapy and patient outcomes in Skilled Nursing Facilities,” is a pre-PDPM secondary analysis of 2018 patient data from SNFs in the United States. The purpose of the study was to examine whether a financially motivated therapy billing practice known as thresholding was associated with patient functional improvement and community discharge outcomes. Thresholding, which occurred when SNFs provided ten or fewer minutes of therapy above weekly reimbursement thresholds under the previous payment system, is a unique metric that allows for specific study of financially motivated therapy that can be examined separately from intensive therapy, which may be clinically indicated. Results of this study indicate that extra minutes of therapy received by patients who experienced thresholding were associated with small positive effects on functional improvement and community discharge rates, even when controlling for overall therapy intensity. While PDPM was designed to disincentivize both thresholding and intensive therapy overall, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients. Using a similar cohort and study design, the second article, “Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in Skilled Nursing Facilities,” establishes pre-PDPM relationships between multiparticipant therapy and patient outcomes. Provision of multiparticipant therapy – including two or more patients per therapy provider per session– is known to have increased over 300-fold immediately after PDPM implementation, as SNFs reduced intensive individualized therapy and utilized more multiparticipant sessions to reduce therapy staffing costs. Until post-PDPM data become available, this article used 2018 data to help predict possible implications for patients experiencing drastic shifts from individualized to multiparticipant therapy in SNFs. Models compared different levels of multiparticipant therapy provision as a proportion of total therapy. Compared to patients receiving no multiparticipant therapy, we found positive associations between low (below the median of 5%) and medium (median to <25%) multiparticipant therapy levels and outcomes. However, associations disappeared with high (≥25%) levels of multiparticipant therapy. Results indicate that providing up to 25% of physical and occupational therapy in multiparticipant sessions may be both efficient and beneficial for patients. The final article, “Variability in Therapy Staffing Changes in Skilled Nursing Facilities Under the Patient Driven Payment Model,” used 2019-2020 publicly available SNF staffing data to test whether changes in physical and occupational therapy staffing under PDPM varied by SNF organizational characteristics. Using longitudinal models, we detected larger relative staffing declines in for-profit SNFs and facilities with more rural and Medicare patients, SNFs employing more therapy assistants, and SNFs providing more intensive therapy prior to policy change. Facilities serving more racially diverse patients lost more skilled therapists than SNFs with less diverse populations. Contract therapy declined more than in-house therapy in non-profit and high-quality facilities. Results indicate that SNFs that engaged in profit-maximizing behaviors under the previous payment model were more responsive to PDPM in terms of implementing larger therapy staffing reductions. The organizational characteristics identified in this article should be specifically targeted in quality monitoring and policy evaluation efforts to better understand the impacts of PDPM on patient outcomes, especially for vulnerable groups. Together, these articles provide information for key stakeholders, including clinicians, SNF administrators, and policymakers to help inform practice, guide future research on the impacts of PDPM on patient outcomes, and inform patient-centered policy.
Gait Coordination: Controlling Footwear and Lower Limb Dimensions in Clinical Gait Study
(2022-04-19) Yu, Binnan; Kramer, Patricia
This three-article dissertation investigate the relation between gait coordination and footwear and lower limb dimensions. The studies in this dissertation are united by two motivations: 1) improve the rigor of clinical gait study that estimates gait coordination of patients, and 2) bridge the knowledge gap between evolutionary anthropologists and motor control scientists. The first article in this dissertation, “Walking Speed Alters Barefoot Gait Coordination and Variability,” addressed whether walking speed would interact with footwear to affect gait coordination. We examined the pattern and variability of gait coordination in barefoot and shod walking in 20 women at three speeds: SLOW (SWS), FAST (FWS), and comfortable walking speed (CWS). We found that the walking speed interacted with footwear conditions to affect the gait coordination and suggested that barefoot and shod walking used different coordination strategies to cope with increasing walking speed. The second and third articles were designed as secondary analyses of existing data collected by the Primate Evolutionary Biomechanics Lab at the University of Washington. The second article, “Pelvic Breadth, Limb Length and Proportion Associate with Gait Coordination,” examined the association between lower limb dimensions and gait coordination at CWS. We found pelvic breadth, lower limb length, and crural index were associated with thigh-shank and hip-ankle coordination. This association was also dependent on the methods to obtain gait coordination. The adjusted r2 ranged from 0.28-0.78 with an average of 0.50. Therefore, we recommend researchers take into account lower limb dimensions when designing and reporting clinical gait study. The third article, “Can Lower Limb Dimensions Modulate Motor Stress in Non-optimal Walking Speed?”, built on the second article and strived to understand the relation among lower limb dimensions, walking speeds, and gait coordination. We hypothesize that lower limb dimensions can modulate the motor stress in non-optimal walking speed (SWS and FWS). Our result partially supported this hypothesis. However, the influence of the lower limb dimensions is small and less dominant than other factors.
Toward Earlier Identification and Strengths-Based Intervention for Infants and Toddlers with Prenatal Alcohol Exposure: Evidence from the Washington State Fetal Alcohol Syndrome Diagnostic & Prevention Network Clinical Database
(2021-10-29) Pruner, Misty Leigh; Jirikowic, Tracy
The purpose of this two-article dissertation was to describe the early developmental outcomes of infants/toddlers with prenatal alcohol exposure (PAE) based on results from 10 years of retrospective clinical data, toward the goal of earlier identification. Although there is extensive research on school-age children and youth, there is a limited body of research describing the developmental delays, sensory processing differences and challenging behaviors among infants/toddlers with PAE. In addition, little research has focused on the positive attributes and strengths of young children with PAE, which can provide direction for a strengths-based approach to assessment and intervention. The first article in the dissertation, “Developmental, Sensory and Behavioral Outcomes Among Infants and Toddlers with Prenatal Alcohol Exposure” was a retrospective analysis of diagnostic clinical data from the University of Washington Fetal Alcohol Syndrome Diagnostic and Prevention Network (FASDPN). Descriptive statistics were used to document the proportion of infants/toddlers classified with typical, at-risk, or delayed development on three measures used in the FASD diagnostic evaluation. Empirical analyses were conducted to examine relationships between outcomes, PAE and/or other postnatal risk factors. Results showed that a majority of infants/toddlers presented with clinically significant delays in development, sensory processing and/or behavioral functioning. Adverse developmental outcomes were significantly correlated with PAE and/or postnatal risk factors. Present findings, considered with similar studies reported in the literature, suggest that several domains of child functioning may be vulnerable to the teratogenic impact of PAE, and that these delays are evident in the first years of life. The second article in the dissertation, “Concerns and Strengths: Caregiver Perceptions of Their Infant/Toddler with Prenatal Alcohol Exposure”, described caregiver-reported concerns and strengths in the same clinical sample of infants/toddlers. Using a directed approach to content analysis, caregivers’ written responses to open-ended questions on two parent-report questionnaires were coded and analyzed. Results indicate the caregivers’ most frequently reported concerns were related to aggressive behavior, language/communication, and sensory processing. Frequently reported strengths included happiness, sociability, and love. These findings demonstrate the value of eliciting and understanding caregiver perspectives as an aid to identifying the needs of infants/toddlers with PAE within the context of their families, and for informing a strengths-based approach to assessment and intervention.
Evaluating use of a robotic prosthetic foot emulator to test-drive prosthetic feet in people with lower limb amputation: mechanical validation and qualitative interviews
(2021-08-26) Halsne, Elizabeth Gabrielle; Morgenroth, David C
Selection of a prosthetic foot is an important decision for lower limb prosthesis prescription. Without objective evidence to guide foot prescription, clinicians (i.e., physicians and prosthetists) rely on their expertise to best match a foot to a patient’s functional goals. However, persons with lower limb amputation typically cannot usually try different prosthetic feet before one is ultimately selected. The robotic prosthetic foot emulator (PFE) is a technological advancement that could facilitate a test-driving approach to foot selection, in which the prosthesis user quickly trials several prosthetic feet and then contributes their experiential input to the decision-making process. This dissertation used quantitative and qualitative approaches to assess use of the PFE for test-driving prosthetic feet. First, quantitative procedures to emulate the angular stiffness of commercial feet used in the PFE were developed and validated. Mechanical testing procedures were used to collect angular stiffness data for a variety of commercial prosthetic forefeet. PFE foot profiles were created from these data and mechanical testing was repeated with the emulated feet to evaluate the accuracy of the emulation. Angular stiffness of emulated feet was significantly correlated with that of respective commercial feet. Mean differences in angular stiffness between emulated and commercial feet were less than 1%, and were independent of prosthetic foot type and example foot sizes or intended user body weights. Participants with lower limb amputation (LLA) then used both the PFE and commercial feet to complete a test-driving protocol, before completing qualitative, semi-structured interviews with an investigator. The purpose of the interviews was to develop a grounded theory of the experience of prosthetic foot prescription from the perspective of prosthesis users. The core category was the relationship between knowledge about prosthetic feet and decision-making power. Participants described prosthetic foot prescription as an educational journey. Relationships with clinicians and peers with LLA were recognized as highly valued and capable of influencing the quality of the foot prescription experience. Participants also noted the importance of their individuality and preferences for the extent of being engaged in decision-making. Test-driving accelerated users’ education about feet options and facilitated discussion with clinicians. Therefore, complementary findings from these two studies support the potential for future use of the PFE for test-driving. Further research may be warranted to evaluate the use of the PFE and test-driving to augment prosthetic foot prescription processes.
Initial Development of a Patient-Reported Item Bank to Assess Mobility of People Who Use Lower Limb Orthoses
(2021-07-07) Balkman, Geoffrey; Hafner, Brian
Item banks are contemporary health survey instruments used to efficiently measure patient-reported outcomes that may be difficult to observe in a clinical or research setting. Item banks designed specifically for measuring outcomes among people who receive a specific intervention often include survey questions that are relevant to the individual and expected to change as a result of the intervention. Lower limb orthotic interventions are designed to improve users’ mobility in a range of environments and real-world situations. An item bank designed to assess mobility of lower limb orthosis users does not currently exist. Such an instrument could be an effective tool for rehabilitation professionals interested in orthotic mobility outcomes. An orthosis user-specific item bank could also benefit the global community of orthotic patient care professionals, as a means by which mobility outcomes data can be collected, pooled, and/or compared across different regions and cultures. Given the need for an orthosis user-specific item bank, the studies in this dissertation aimed to (1) better understand how orthosis users conceptualize mobility, (2) construct a candidate item bank for orthosis users, and (3) develop and apply a process for translating condition-specific item banks into other languages. This body of work represents the initial development of a new item bank and a model for future language translation efforts. The first chapter is a qualitative study designed to explore how lower limb orthosis users describe their mobility using focus groups and thematic analysis. Insights from participants suggest that orthosis users with a variety of underlying health conditions experience many of the same benefits and challenges associated with using a lower limb orthosis. Also, orthosis users can often choose to modify their mobility in different situations by using or not using their orthosis and/or other mobility aid(s). Gaining an understanding of a measurement construct of interest, in this case, mobility of orthosis users, is the first step toward developing a new PRO instrument. The second chapter describes additional steps taken to identify items applicable to orthosis users’ mobility and evaluate their suitability for inclusion in a candidate item bank. Results of this study further clarify the need for an item bank specific to this population as many of the activities and situations described by orthosis users as being important are not included in existing PRO instruments. The candidate items are now ready for further testing in a future study outside the scope of this dissertation. The third chapter is a language translation and linguistic validation study that describes a model for translating condition-specific item banks. As a result of this study, a Japanese translation of the Prosthetic Limb Users Survey of Mobility (PLUS-M) is now available, and a model is prepared for translating the new item bank to other languages in the future. Collectively, the chapters of this dissertation describe insights gained from orthosis users’ perspectives on mobility, initial development of an item bank to designed for measuring mobility of people who receive orthotic interventions, and a model for translating a condition-specific item bank to other languages. These research findings also lay the groundwork for future research efforts, including calibration and psychometric evaluation of the new item bank, and translation of the instrument into other languages to facilitate international efforts to collect orthotic mobility outcomes data.
Intersection of Mechanobiology and Musculoskeletal Regenerative Rehabilitation
(2021-07-07) Fayazi, Maryam; Mack, David Lee
Mechanical stimuli play an essential role in the formation of structurally and functionally appropriate cellular and tissue modeling/remodeling. Musculoskeletal system responds to mechanical stimuli through physical movement in an integrated fashion, transferring forces from tissue to cellular and molecular scales. In the context of rehabilitation, mechanical stimuli are referred to as mechanotherapy and physical therapists use them to treat musculoskeletal disease and/or injury, with the goal to modulate cellular behavior and subsequent tissue adaptation. However, the link between mechanotherapy and subsequent cellular and tissue mechanoadaptation is not well established in the literature. To address this, first, recent literature on how mechanotherapies such as exercise training, stretching, electrical stimulation, and shockwave might activate mechanotransductive and metabolic signaling pathways were evaluated. Although there is sufficient evidence on the regulation of these signaling pathways; however, there is insufficient data on the mechanism of activation of these pathways following mechanotherapy in aged, diseased, and injured skeletal muscle tissues. In the second research study, mechanical stimulation in the form of passive stretch was used to develop in vitro skeletal muscle injury model. Then, the model was applied to both normal and Duchenne Muscular Dystrophy (DMD) skeletal muscle fibers to induce passive stretch-induced injury, and the acute biochemical responses of cytoplasmic and myofibrillar proteins to the selected stretch protocol were measured. The preliminary findings indicated that muscle fibers in DMD were more susceptible to the passive stretch-induced injury protocol than normal. Lastly, in the clinical regenerative rehabilitation pilot study, feasibility and short-term efficacy of rehabilitation program after regenerative therapies was assessed to harness the mechanosensitivity of chondrocyte and better facilitate tissue healing and regeneration. The initial findings demonstrated that the rehabilitation program was clinically meaningful across most Knee injury and Osteoarthritis Outcome Score (KOOS) subscales between 2- and 3-months post-injection in both treatment groups. Future randomized clinical trials are needed to fully understand the role of mechanical stimulation of chondrocyte to facilitate the repair and regeneration following regenerative therapies in knee degenerative joint disorders.
Physical Performance in Adults with Chronic Kidney Disease
(2021-03-19) Johnstone, Laura Marie; McGough, Ellen
Background and Purpose. Chronic kidney disease (CKD) and dialysis dependent end stage renal disease (ESRD-D) are associated with reduced physical performance and functional mobility, though associated factors are not well understood. The overarching purpose of this dissertation is to explore questions related to physical performance in CKD /ESRD-D with 3 studies. “The Relationship of Fatigue with Physical Performance and Mobility Disability in Chronic Kidney Disease“ aimed to examine the association of fatigue with physical performance and mobility disability in adults with CKD (stages 2-4). “Reliability of Physical Performance and Instrumented Measures in Adults with Kidney Disease” aimed to assesses the reliability of physical and inertial sensor measurement units (IMUs) in adults with CKD and ESRD-D and compare differences between these groups. “The Acute Effects of Dialysis on Physical Performance in Adults with Hemodialysis Dependent End Stage Renal Disease” aimed to examine differences in physical performance that occur immediately after a dialysis session and assess the association of dialysis-related factors to observed change. Methods. To assess relationships between physical performance, fatigue, and mobility disability, a cross-sectional study of 293 adults with CKD (stages 2-4) was conducted. Physical performance measures included the short physical performance battery (SBBP), Five Times Sit to Stand (FSTS), gait speed, 6 Minute Walk Test (6MWT) and handgrip strength (HGS). Fatigue was assessed with the SF-36 Energy-Fatigue-Vitality Subscale (SF-EF). Regression analysis was conducted to assess the relationship of fatigue to each physical performance measure controlling for age, BMI, and CKD-related factors. Logistic regression, controlling for age, BMI, and CKD-related factors, assessed the relationship of fatigue and mobility disability (defined by the inability to walk Â¼ mile and/or climb 1 flight of 10 steps) based on established cut-points on the SPPB, gait speed and FSTS. Test-retest reliability was assessed 1-week apart in a group of 21 CKD (n=11) and ESRD-D (n=10) patients on standard physical performance measures (SPPB, gait speed, FSTS, 2-Minute Walk Test (2MWT), quadricep strength (QS), and GS) and on inertial measurement unit (IMU) measures of gait (stride length and gait speed), turns (turn duration, number of steps in turn, and turn velocity), sit-stand duration, and postural sway (root mean squared, pathlength, velocity, jerkiness). Intraclass correlation coefficients were assessed for reliability and differences between CKD and ESRD-D groups were assessed with paired t-tests. To assess the immediate effects of hemodialysis, standard physical performance measures (SPPB, gait speed, FSTS, 2MWT, QS, GS), the IMU measures previously described, and a fatigue numeric rating were collected immediately pre and post a hemodialysis session in 11 adults with ESRD-D. Paired t-tests were used to assess differences in physical performance pre-post dialysis and Pearson correlations were examined to assess the relationship between pre-post HD changes in physical performance, post-dialysis fatigue rating (PDF) and dialysis-related variables (Kt/V, pre-post HD weight change, # of months on HD, and intradialytic hemodynamic instability (HI)). Results. Fatigue was significantly associated with FSTS and gait speed and contributed to 2.1% and 3.1% of the variance in FSTS and gait speed, respectively. This relationship remained even after adjusting for covariates. Mobility disability was not associated with fatigue. Good-excellent test-retest reliability was demonstrated in the following standard physical performance measures: SPPB (ICC = .91), FSTS (ICC = .95), gait speed (ICC = .89), 2MWT (ICC = .94), NSB (ICC = .81), QS (ICCright = .94 and ICCleft =.90), GS (ICC = .96). Good reliability was found for the following IMU measures: steps in turn (ICC=.75), FSTS sit-stand duration (ICC=.87), postural sway PATH (ICC=.77usual and .85narrow), and sway JERK (ICCnarrow=.70). No differences were found between groups on physical performance measures. Statistically significant differences from pre-post HD were found on quadricep strength dynamometry (t (10) = 3.35, p <.01). There were significant positive correlations between HI and post-dialysis fatigue (PDF) (r = 0.72), indicating that PDF was associated with increased HI. There was a significant positive correlation between FSTS and HI instability (r = 0.63) indicating that poorer performance on the FSTS was related to increased HI. Conclusions. This dissertation identified a relationship between fatigue and physical performance in those with CKD, a set of clinically reliable physical performance measures for use with CKD/ESRD-D, and evidence that strength may decline immediately following a hemodialysis session. Future research directions include detection of the direction of causal relationships between fatigue and physical performance, development of a psychometrically strong composite physical performance outcome measure for CKD/ESRD, and identification of pathophysiological mechanisms related to strength decline following dialysis.
The Contributions of Spatial Processing and Selective Attention to the Deficits in Patients with Spatial Neglect and Neglect Dyslexia
(2020-10-26) Rich, Timothy John; Powell, Janet M
Many patients with right hemisphere stroke fail to read words closest to the left margin of text and/or commit within-word errors on left-sided letters while correctly reading right-sided letters, a condition known as neglect dyslexia. These patients also show non-spatial deficits of selective attention, which may be a contributing factor to these errors. The purpose of this study was to determine the relative contributions of spatial processing deficits and selective attention deficits on reading errors in neglect dyslexia. In Experiment 1, we replicated studies that showed poorer reading accuracy for words when presented alongside a competitive distractor word than when presented solitarily. This deficit was larger for words on the left. In Experiment 2, we modified the paradigm so that the target word was positioned centrally at fixation in all conditions, in an effort to minimize spatial effects. We found that patients performed worse under conditions with a distractor word regardless of the side on which the distractor was presented. These findings suggest that the errors in neglect dyslexia are at least partly due to a selective attention deficit.
LGBTQ+ Considerations Related to Physical Therapy: A Qualitative Study in Washington State
(2020-10-26) Lent, Kathryn; Kartin, Deborah
There is little known of lesbian, gay, bisexual, transgender, queer or questioning and other sexual and gender minorities’ (LGBTQ+) experiences and recommendations related to physical therapy services. The LGBTQ+ community is a collective of people with diverse identities related to gender identity and sexuality. As a broadly defined group, this community has faced marginalization and health disparities, though has also demonstrated resiliency. This study aimed to use community-based engagement and a strengths-based approach to answer the following research questions: 1) How do people who identify as LGBTQ+ describe experiences related to the utilization of physical therapy services?; and 2) In what ways can the physical therapy profession support equitable health and provide equitable health care for people who identify as LGBTQ+? The study used a grounded theory approach was informed by the Standards for Reporting Qualitative Research (SRQR). Data were collected via recorded semi-structured interviews. Eligibility criteria included adults who identified as LGBTQ+, had either had physical therapy or tried to access physical therapy, spoke English, and resided in Washington State. Analysis used coded transcriptions to develop a theoretical model. Nineteen participants completed interviews. The first question resulted in a theoretical model describing interrelated overall themes of ‘quality of care,’ ‘intersectionality,’ and ‘patient safety.’ This emphasized patient treatment and access for high quality health, diverse experiences as whole human beings, and safety related to emotional, psychological, and physical well-being in the physical therapy environment. The second question resulted in recommendations for implementing an ‘inclusive organizational environment,’ ‘establishing trust,’ and being involved in ‘the bigger picture’ as it relates to health and physical therapy. Recommendations included trauma-informed practices, having options that respond to peoples’ preferences for disclosure and environmental safety considerations, authentically carrying out practices, gender and sexuality training for providers and personnel, actively engaging in continuing education and engagement with the LGBTQ+ community, and working collaboratively for financial, holistic, and preventive care that promotes equitable LGBTQ+ health. By targeting those in the LGBTQ+ community as experts, this research acknowledges the importance of stakeholder engagement related to physical therapy utilization and can inform future clinical practice, research, policy, and professional education.
Neuromodulation through Spinal Cord Stimulation for Functional Restoration and Rehabilitation after Cervical Spinal Cord Injury
(2020-10-26) Samejima, Soshi; Moritz, Chet T
Spinal cord injury (SCI) results in permanent neurological deficits. The limited physical function impacts quality of life and socioeconomic engagement. Up to now, we have no effective interventions to restore impaired function. Activity-dependent plasticity holds great promise to promote recovery of motor and autonomic function. Neuromodulation via electrical stimulation of the spinal cord has shown growing evidence of promoting activity-dependent plasticity and functional gains following SCI. First, we review the background information about the burden and recovery process of SCI. We also summarize current advances of pharmacological, cellular, and neuromodulation approaches. Emerging evidence with stimulation technologies demonstrates potential to facilitate neuroplasticity bridging the lesion. In the second part, we demonstrated a cost- and time-efficient experimental tool to assess forelimb function in a rodent model with severe cervical SCI. This novel strategy for the behavior task may accelerate preclinical trials. By using the behavior tasks, in the third part, we present a clinically viable brain-computer spinal interface to reanimate paralyzed forelimb function in rodents with cervical SCI. We demonstrate a stable and computationally efficient local field potential decoder enabling graded forelimb movements via epidural stimulation. Consequently, the brain-controlled epidural stimulation led to functional improvements in freely moving rats with cervical SCI. The closed-loop algorithm was implemented in an implantable size circuit capable of onboard computing, providing a clinically viable strategy to accelerate the translation of brain-computer interfaces to human use. In the fourth part, we investigate the efficacy of transcutaneous spinal stimulation paired with intensive locomotor training in two individuals with cervical SCI. We present the additive effect of transcutaneous spinal stimulation for locomotor recovery with more coordinated movements. Furthermore, we demonstrate the first evidence of transcutaneous spinal stimulation for restoring bowel function. Lastly, we discuss the potential of these neurotechnology approaches. We address the current limitations of scientific understanding and technology to guide future research to restore sensorimotor and autonomic function following cervical SCI.

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