Bryn Mawr Rehabilitation Hospital

BACKGROUND: Amantadine hydrochloride is one of the most commonly prescribed medications for patients with prolonged disorders of consciousness after traumatic brain injury. Preliminary studies have suggested that amantadine may promote functional recovery. METHODS: We enrolled 184 patients who were in a vegetative or minimally conscious state 4 to 16 weeks after traumatic brain injury and who were receiving inpatient rehabilitation. Patients were randomly assigned to receive amantadine or placebo for 4 weeks and were followed for 2 weeks after the treatment was discontinued. The rate of functional recovery on the Disability Rating Scale (DRS; range, 0 to 29, with higher scores indicating greater disability) was compared over the 4 weeks of treatment (primary outcome) and during the 2-week washout period with the use of mixed-effects regression models. RESULTS: During the 4-week treatment period, recovery was significantly faster in the amantadine group than in the placebo group, as measured by the DRS score (difference in slope, 0.24 points per week; P=0.007), indicating a benefit with respect to the primary outcome measure. In a prespecified subgroup analysis, the treatment effect was similar for patients in a vegetative state and those in a minimally conscious state. The rate of improvement in the amantadine group slowed during the 2 weeks after treatment (weeks 5 and 6) and was significantly slower than the rate in the placebo group (difference in slope, 0.30 points per week; P=0.02). The overall improvement in DRS scores between baseline and week 6 (2 weeks after treatment was discontinued) was similar in the two groups. There were no significant differences in the incidence of serious adverse events. CONCLUSIONS: Amantadine accelerated the pace of functional recovery during active treatment in patients with post-traumatic disorders of consciousness. (Funded by the National Institute on Disability and Rehabilitation Research; ClinicalTrials.gov number, NCT00970944.).

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether the Berg balance test could be used to predict an elderly person's risk of falling. SUBJECTS: Sixty-six residents of two independent life-care communities, aged 69 to 94 years (X = 79.2, SD = 6.2), participated. METHODS: Subjects completed a questionnaire pertaining to their fall history and activity level. The Berg balance test, consisting of 14 functional subtests, was then administered. Six months later, subjects again completed the questionnaire. RESULTS: Performance of activities of daily living predicted 43% of the subjects' scores. There was a difference between the subjects who were prone to falling and those who were not prone to falling, but the test demonstrated poor sensitivity for predicting who would fall. The specificity of the test was very strong. The use of an assistive device was a strong predictor of performance on the Berg balance test. No relationship was noted between increasing age and decreasing performance on the Berg balance test. CONCLUSION AND DISCUSSION: Although the Berg balance test demonstrated only 53% sensitivity, the results support the test developers' use of 45 (out of 56) as a generalized cutoff score. Older adults who scored higher than the cutoff score on the test were less likely to fall than were those adults who scored below the cutoff score. Decreased scores, however, did not predict increased frequency of falls. Results must be viewed cautiously because self-report was the sole means of documenting fall history.

Organized youth sports are highly popular for youth and their families, with approximately 45 million children and adolescent participants in the US. Seventy five percent of American families with school-aged children have at least one child participating in organized sports. On the surface, it appears that US children are healthy and happy as they engage in this traditional pastime, and families report higher levels of satisfaction if their children participate. However, statistics demonstrate a childhood obesity epidemic, with one of three children now being overweight, with an increasingly sedentary lifestyle for most children and teenagers. Increasing sports-related injuries, with 2.6 million emergency room visits a year for those aged 5-24 years, a 70%-80% attrition rate by the time a child is 15 years of age, and programs overemphasizing winning are problems encountered in youth sport. The challenges faced by adults who are involved in youth sports, from parents, to coaches, to sports medicine providers, are multiple, complex, and varied across ethnic cultures, gender, communities, and socioeconomic levels. It appears that an emphasis on fun while establishing a balance between physical fitness, psychologic well-being, and lifelong lessons for a healthy and active lifestyle are paramount for success.

The purpose of this study was to examine the value of a clinical driving assessment battery in predicting performance on an on-road driving test. 43 participants referred to the Bryn Mawr Rehab Adapted Driving Program for evaluation of driving ability underwent an evaluation consisting of a predriver screening and an on road driving test. The predriver screening included a vision screening, a reaction rime task, a split-attention task, the Hooper Visual Organization Test, verbal and symbolic sign recognition, and assessment of Useful Field of View. Logistic regression analyses were applied to identify which predriver screening variables could be used to predict outcome on the on road driving test (pass/fail); UFOV was that best single predictor. The addition of screening tests beyond UFOV alone did not increase predictive validity. These findings suggest that UFOV may serve as an indicator of the need for further driving assessment.

This study describes the development of a 21-item, parent report measure for assessing the quality of life (QOL) of children with cancer. The Pediatric Oncology Quality of Life Scale (POQOLS) provides a total score and three factor scores that assess physical function and role restriction, emotional distress, and reaction to current medical treatment. Internal consistency reliabilities of the total scale and the three factors were high, as was interparent agreement. In addition, POQOLS scores demonstrated good concurrent and discriminant relationships with scores on measures of adjustment hypothesized to covary with the dimensions of QOL assessed

A systematic review of the benefits of horticultural therapy (HT) on persons with mental health conditions was conducted. A review of research from 1992 through 2015 located 14 studies. The studies were analyzed using the McMaster’s Critical Review Form for Quantitative Studies (MQCRF), a scale by Barras (2005 Barras, S. (2005). A systematic and critical review of the literature: The effectiveness of occupational therapy home assessment on range of outcome measures. Australian Occupational Therapy Journal, 52, 326–336. doi:10.1111/j.1440-1630.2005.00496.x[Crossref] , [Google Scholar]), and the Levels of Evidence for Occupational Therapy Outcomes Research. Eleven of 14 studies reported statistically significant findings in support of HT for at least one dependent variable. The findings were found in a variety of settings, mental health conditions, and with both genders. This review found moderate initial evidence that HT can improve client factors and performance skills.

In patients with severe traumatic brain injury (TBI), a growth hormone deficiency (GHD) is frequent and may contribute to the cognitive sequelae and reduction in quality of life (QoL). Recent studies have suggested that GH replacement therapy (GHRT) can improve processing speed and memory. The aim of the study was to analyze the efficacy of GHRT on cognition, activities of daily living (ADL), and QoL and the factors that predicted and contributed to these effects. We included patients at least 1 year after their TBI and assessed pituitary functions (with stimulation tests), cognition (attention, memory, and executive function), participation in ADL and QoL. GHD was treated for at least 1 year in 23 patients, who were compared with 27 non-treated patients. Other deficiencies were also treated. Measurements were performed at baseline and 1 year later. An analysis of variance of the factors group and session (p ≤ 0.05) showed that most cognitive parameters had improved at 1 year (evidencing a session effect). A stronger effect of GHRT (i.e. a group x session interaction) was found for Rey Osterrieth complex figure recall and 2/6 domains in the QoL questionnaire ("personal" and "functional"). Trends (p ≤ 0.07) were also found for spatial orientation and immediate recall in the verbal memory test. Greatest improvements were associated with lower performance before treatment. The magnitude of the improvements in ADL and QoL was moderately correlated with the improvement in cognition. In conclusion, replacement therapy can improve cognition and QoL in patients with TBI who have GHD, especially in those with severe disabilities.

The extent of behavioral recovery that occurs in patients with traumatic disorders of consciousness (DoC) following discharge from the acute care setting has been under-studied and increases the risk of overly pessimistic outcome prediction. The aim of this observational cohort study was to systematically track behavioral and functional recovery in patients with prolonged traumatic DoC following discharge from the acute care setting. Standardized behavioral data were acquired from 95 patients in a minimally conscious (MCS) or vegetative state (VS) recruited from 11 clinic sites and randomly assigned to the placebo arm of a previously completed prospective clinical trial. Patients were followed for 6 weeks by blinded observers to determine frequency of recovery of six target behaviors associated with functional status. The Coma Recovery Scale-Revised and Disability Rating Scale were used to track reemergence of target behaviors and assess degree of functional disability, respectively. Twenty percent (95% confidence interval [CI]: 13–30%) of participants (mean age 37.2; median 47 days post-injury; 69 men) recovered all six target behaviors within the 6 week observation period. The odds of recovering a specific target behavior were 3.2 (95% CI: 1.2–8.1) to 7.8 (95% CI: 2.7–23.0) times higher for patients in MCS than for those in VS. Patients with preserved language function (“MCS+”) recovered the most behaviors ( p ≤ 0.002) and had the least disability ( p ≤ 0.002) at follow-up. These findings suggest that recovery of high-level behaviors underpinning functional independence is common in patients with prolonged traumatic DoC. Clinicians involved in early prognostic counseling should recognize that failure to emerge from traumatic DoC before 28 days does not necessarily portend unfavorable outcome.

Giacino, Joseph T.; Whyte, John; Bagiella, Emilia; Kalmar, Kathleen; Childs, Nancy; Khademi, Allen; Eifert, Bernd; Long, David; Katz, Douglas I.; Cho, Sooja; Yablon, Stuart A.; Luther, Marianne; Hammond, Flora M.; Nordenbo, Annette; Novak, Paul; Mercer, Walt; Maurer-Karattup, Petra; Sherer, Mark Author Information

Families of individuals who have survived brain injuries experience significant distress, and may resist accepting their relative's neurobehavioural deficits. Staff who work with brain-injured patients and their relatives are charged with the seemingly paradoxical task of helping families support rehabilitative efforts and be goal-oriented, while simultaneously communicating often negative realities about prognosis. In the midst of what may be an intermittently conflict-laden relationship, families and staff must become synergistically involved in a therapeutic partnership. This paper defines aspects of this 'adversarial alliance' which is often established between families and staff. The relationship between patient discharge outcome and perceived family stress and satisfaction with the rehabilitation programme was reviewed. Data analyses yielded the following conclusions: families evaluated retrospectively to have been 'highly stressed' were also perceived to experience more conflict with the rehabilitation team; family stress was related to poorer adjustment to the patient's disability (at admission); greater family/team conflict correlated with lower cognitive and physical functioning at admission, longer length of stay, younger patient age, and lower programme satisfaction. Implications for programme development and treatment guidelines are discussed.

PURPOSE: This mixed-methods pilot study examined the impact of a psychoeducational intervention (PEI) to expand coping skills and identify themes for focused nursing strategies to assist poststroke couples. DESIGN: Outcome variables, including dyadic coping, quality of life, depression, and self-care self-efficacy, were measured in experimental and control groups initially and after PEI was created with experimental couples in six home sessions. METHOD: Repeated measures analysis of variance compared control (n = 5 stroke survivors; n = 5 spouses) and experimental groups' (n = 5 stroke survivors; n = 5 spouses) on outcomes. FINDINGS: Significant increase occurred in experimental group stroke survivors in coping by oneself and quality of life; depressive symptoms decreased. Significant increase in positive dyadic coping occurred for experimental group spouses. PEI intervention generated a major theme. CONCLUSIONS: Nurse-initiated cognitive coping intervention was supported by experimental group's elements. CLINICAL RELEVANCE: Nurses may use psychoeducational techniques to motivate stroke couples.

The purpose of this study was to assess the perceptual role of brief synthetic consonant-vowel syllables as cues for vowel perception in children and adults. Nine types of consonant-vowel syllables comprised of the stops [b d g] followed by the vowels [i a u] were synthesized. Stimuli were generated with durations of 10, 30, or 46 ms, and with or without formant transition motion. Eight children at each of five age levels (5, 6, 7, 9, and 11 years) and a control group of eight adults were trained to identify each vowel in a three-alternative forced-choice (3AFC) paradigm. The results showed that children and adults extracted vowel information at a generally high level from stimuli as brief as 10 ms. For many stimuli, there was little or no difference between the performance of children and adults. However, developmental effects were observed. First, the accuracy of vowel perception was more influenced by the consonant context for children than for adults. Whereas perception was similar across age levels for stimuli in the alveolar context, the youngest children perceived vowels in the labial and velar contexts at significantly lower levels than adults. Second, children were more affected by variations in stimulus duration than were adults. This finding was particularly prominent for the syllable [ga], where the dependency on duration decreased with age in a nearly linear fashion. These findings are discussed in relation to current hypotheses of vowel perception in adults, and hypotheses of speech perception development.

A patient with a post-traumatic midbrain haemorrhagic lesion documented by magnetic resonance imaging (MRI) presented with a combined resting-kinetic contralateral upper extremity tremor. The resting tremor component responded to levodopa/carbidopa, while the kinetic component improved with the addition of carbamazepine.

The family plays an important role in facilitating positive rehabilitation outcomes with a disabled client. Thus, families must be involved in the rehabilitation process. For this to occur, the nurse must identify the characteristics of the family unit. This article presents a framework that supports the assessment of the family unit.

BACKGROUND: One of the well-established methods used to determine endurance training intensity for patients in outpatient cardiac rehabilitation (CR) is to take a percentage (70%-85%) of the maximal or peak heart rate (HRmax) from a recent postevent symptom-limited graded exercise test (GXT). Because many patients are referred to CR without having had a maximal GXT, a current practice is to use 30% to 50% above resting heart rate (RHR) to estimate endurance training intensity. OBJECTIVE: The purpose of this study was to determine if a target heart rate (THR) of 30% to 50% above RHR approximated a THR of 70% to 85% of the HRmax achieved on GXT (HRmax GXT) and provided equivalent exercise intensity based on ratings of perceived exertion (RPE) and metabolic equivalency thresholds (METs). METHODS: A retrospective chart review of 53 patients enrolled in CR and had documentation of postevent GXT was conducted to determine the patient's mean exercise heart rate (HR) achieved at each session to percentage above RHR and percentage HRmax GXT. Analysis was conducted to determine and compare patients' HRs, RPE, and MET levels when patients were exercising within the THR ranges of 30% to 50% above RHR and 70% to 85% HRmax GXT. RESULTS: A THR range of 30% to 50% above RHR approximated 60% to 70% HRmax GXT. Mean exercise HRs progressed from 39% to 49% above RHR sessions 2 to 6 with mean (SD) RPE of 10.58 (0.55) to 11.44 (0.68) on the Borg scale and mean (SD) MET level of 2.91 (0.55) to 3.31 (0.6). Mean exercise HRs progressed to 54% to 65% above RHR sessions 7 to 18 and approximated 70% to 73% HRmax GXT. Mean (SD) RPE at this intensity ranged from 11.57 (0.58) to 12.21 (0.53) with a mean (SD) MET level of 3.47 (0.6) to 3.8 (0.77). CONCLUSION: In the observed population, a THR of 30% to 50% above RHR underestimated the THR range of 70% to 85% HRmax GXT but provided adequate exercise intensity for patients at the beginning of a CR program based on percentage HRmax GXT, RPE and MET levels.

Significant concern exists regarding occupational stress among nurses; the present study explored the ways in which nurses' clinical symptoms and coping styles may relate to their working on a brain injury unit or a general rehabilitation unit within an acute physical rehabilitation hospital. A comparison of rehabilitation nurses' responses with those of physical therapists within the same setting was also completed. Staff members completed questionnaires related to job stress and satisfaction, coping (Ways of Coping Checklist) and adjustment (Symptom Checklist-90). Staff groups differed with regard to symptomatology. Brain injury nurses reported higher psychological distress than physical therapists on subscales including depression, interpersonal sensitivity and the global severity index. While brain injury nurses' distress in several areas was higher than other staff groups and than a normal non-patient sample, it did not approach the levels reported by a psychiatric outpatient normative group. Although the three staff groups did not differ notably with regard to most styles of coping, data suggest that work with brain injury patients may foster use of a problem-solving style. Lower physical and cognitive functioning of brain patients as compared with general rehabilitation patients may influence the greater psychological distress reported by brain injury nurses. Job stress appears to relate specifically to the perceived stressfulness of cognitive behavioural aspects of care for all staff groups. Implications of these findings, particularly with regard to support interventions, are discussed.

Purpose: A phenomenological investigation was conducted of the experiences of long-term care residents as they planned, participated and reflected on their engagement in an altruistic activity. Procedures: Eight residents planned and engaged in the creation of flower arrangements and greeting cards for local hospice patients. Data were collected via in-depth group and individual interviews, as well as field notes. The process of data analysis was guided by the empirical, phenomenological and psychological method. Findings: A grand theme of ‘connectedness’ emerged and was supported by four underlying subthemes: (a) creative and thoughtful activity, (b) sense of community, (c) facilitation of reminiscence and (d) reciprocity. Conclusion: Through engagement in an altruistic activity, the participants developed a sense of connection with their pasts, the others in the group, the recipients and the activity itself. The findings suggest that occupational therapy services should include altruistic activities to help to facilitate a greater sense of connection for their clients.

Independent medical examinations (IMEs) are requested most commonly for conditions related to musculoskeletal problems. This chapter thoroughly delineates the IME process, illustrating points with universal applicability, but focusing on assessment of musculoskeletal disease. The functional capacity evaluation, for determination of task performance ability, also is addressed.

This article offers ways to be spiritual in the public workplace. First, this article is not about religion but spirituality. Second, this article explains the current American context including the fact that we are a nation of seekers of spirituality. Thirdly, this article presents the elements of spirituality and the attitudes and traits of spiritual people. And finally, this article explains what it means to have spirituality in the public workplace.

The Visual Response Evaluation (VRE) was developed to meet the need for a formal and in-depth measure of visual responses in low-level brain-injured persons (Rancho Levels II and III) and to monitor and document minute changes in the recovery of these patients. Often, patients at these low functional levels exhibit little to no motoric or cognitive interaction with the environment, except that which occurs in response to sensory stimulation. Other tools have been developed to document responses to various types of stimulation; however, none contain the sensitivity to consistency and type of response that is necessary to show the small but vital progress that is characteristic of the Rancho II and II type patient. The VRE consists of 10 items separated into two general categories: (1) Observations. and (2) Response to Stimuli. The five items in the Observations section assess a patient's spontaneous responses, while the five items in the Response to Stimuli section document responses directly related to the presentation of a hierarchical order of stimuli. The VRE was administered to 10 patients with a mean age of 39.8 years at a mean time of 4.2 months post-injury. Statistical analyses of the pilot-study data show the VRE to be both internally reliable and criterion-related valid at the p less than 0.025 level of significance. The data supports further investigation in the areas of prognostic ability and implications for treatment. The VRE can be a useful tool for studying the recovery process and evaluating treatment programmes for low-level brain-injured persons.