Marianjoy Rehabilitation Hospital

Throughout the mid to late 1970's considerable research was conducted on the properties of Rasch fit mean squares. This work culminated in a variety of transformations to convert the mean squares into approximate t-statistics. This work was primarily motivated by the influence sample size has on the magnitude of the mean squares and the desire to have a single critical value that can generally be applied to most cases. In the late 1980's and the early 1990's the trend seems to have reversed, with numerous researchers using the untransformed fit mean squares as a means of testing fit to the Rasch measurement models. The principal motivation is cited as the influence sample size has on the sensitivity of the t-converted mean squares. The purpose of this paper is to present the historical development of these fit indices and the various transformations and to examine the impact of sample size on both the fit mean squares and the t-transformations of those mean squares. Because the sample size problem has little influence on the person mean square problem, due to the relatively short length (100 items or less), this paper focuses on the item fit mean squares, where it is common to find the statistics used with sample sizes ranging from 30 to 10,000.

This paper reports the results of a blinded study comparing videofluoroscopy with bedside clinical evaluations by speech/language pathologists in the diagnosis of aspiration. One hundred and seven inpatients from a general rehabilitation hospital were evaluated over a four-month period. Of the total patient population, 43 (40%) aspirated at least one consistency of food during videofluoroscopy. Bedside evaluation identified only 18 (42%) of these patients. The positive predictive value of bedside assessment was 0.75; negative predictive value was 0.70. Aspirators on videofluoroscopy were more likely to have brainstem or multilobe central nervous system involvement than nonaspirators. However, there was no statistically significant difference in lesion sites between clinically detected and "silent" aspirators. While the significance of aspiration noted on videofluoroscopy is debatable, it is clear that bedside evaluation alone underestimates the frequency of aspiration in patients with neurologic dysfunction.

Abstract This study compares the Rasch item fit approach for detecting multidimensionality in response data with principal component analysis without rotation using simulated data. The data in this study were simulated to represent varying degrees of multidimensionality and varying proportions of items representing each dimension. Because the requirement of unidimensionality is necessary to preserve the desirable measurement properties of Rasch models, useful ways of testing this requirement must be developed. The results of the analyses indicate that both the principal component approach and the Rasch item fit approach work in a variety of multidimensional data structures. However, each technique is unable to detect multidimensionality in certain combinations of the level of correlation between the two variables and the proportion of items loading on the two factors. In cases where the intention is to create a unidimensional structure, one would expect few items to load on the second factor and the correlation between the factors to be high. The Rasch item fit approach detects dimensionality more accurately in these situations.

BACKGROUND: Exercise has many benefits for survivors of breast cancer, yet only half of this population regularly exercise. Fear has been identified as a barrier to exercise for people with neuromusculoskeletal conditions but has been minimally explored in women with breast cancer. OBJECTIVES: The purposes of this study were: (1) to investigate factors that affected decisions about physical activity and exercise in survivors of breast cancer and (2) to determine whether fear was a factor. DESIGN: This investigation was a grounded-theory qualitative study. Qualitative data were triangulated with data from 2 quantitative scales that measured participants' beliefs about exercise and their activity levels. METHODS: Thirty-four survivors of breast cancer in 8 focus groups participated in semistructured interviews that were recorded, transcribed, and coded. Concept maps created for each group were merged to develop themes. Beliefs about physical activity and exercise were assessed with the Decisional Balance Scale. The Rapid Assessment of Physical Activity was used to assess behaviors regarding physical activity and exercise before and after the breast cancer diagnosis. RESULTS: Participants generally believed that exercise was beneficial (Decisional Balance Scale score: X=28.1 [of a maximum score of 44], SD=7.6, range=10-43). Participants decreased the amount of physical activity or exercise during treatment but increased the amount of exercise beyond prediagnosis levels after treatment (Rapid Assessment of Physical Activity score: median=6, range=2-7). Three prominent themes described participants' behaviors regarding physical activity or exercise: values and beliefs about exercise, facilitators and barriers that were both similar to those affecting the general population and cancer specific, and lack of or inaccurate information about safe exercise. CONCLUSIONS: Survivors who were active were not afraid to exercise. However, concern about lymphedema and knowledge about safe and effective exercise programs influenced choices regarding physical activity and exercise.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. OBJECTIVE: To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. METHODS: In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. RESULTS: A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. CONCLUSIONS: Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

The purpose of this prospective study was to investigate the predictive value of oropharyngeal secretions by use of 5-point and modified 3-point secretion scales for aspiration of food or liquid and diet recommendation outcomes. One hundred consecutive patients and 4 control subjects participated. The 5-point secretion severity scale correlated highly to aspiration (Spearman's rho = .516, p < .0001) and to diet recommendation outcomes (Spearman's rho = .72, p < .0001). Patients who received tube feedings were more likely to demonstrate a higher secretion level than patients who received oral feedings (Pearson chi squared analysis value = 25.461, p < .0001). Patients with a tracheotomy tube tended to demonstrate higher secretion levels than patients without a tracheotomy tube (Spearman's rho = .446, p < .0001). The relationship of the 3-point secretion severity scale level with aspiration was .488, p < .0001 (Spearman's rho), and that with diet recommendation outcomes was .746, p < .0001 (Spearman's rho).

Evidence of a right-posterior brain anomaly was found in a study of 19 individuals with major depression and 15 controls. Participants performed a recognition-memory task involving positive, neutral, and negative face and word stimuli. Scalp brain wave topography suggested a region-specific anomaly in the depressed group. Individuals with major depression demonstrated a reduction in the N200 component of the event-related brain potential to faces and not words. Furthermore, results indicate that the regional anomaly is specific to positive facial stimuli. Findings are interpreted in light of a model of regional brain specialization in emotion and psychopathology.

The relationship of medical variables and discharge functional status to vocational and educational outcomes was examined in 79 closed head-injured patients who were consecutively admitted to an inpatient rehabilitation hospital during a two-year period. A follow-up study, conducted after hospital discharge (median, 16.5 months), found that 66% (n = 52) of the patients had returned to work or school, while 34% (n = 27) did not. Patients were divided into return and non-return to work groups. Traditional variables included age, severity of brain-damage as characterized by CT head scan, duration of post-traumatic amnesia, duration of coma, length of stay and acute inpatient rehabilitation program. Discharge functional scores were analysed by t-tests and chi-square analysis. Results suggest that traditional factors of younger age, shorter length of coma, minimal CT head scan findings and shorter length of stay were significant contributors to educational/vocational outcome. Their significance was enhanced by discharge functional profile measurement of medical, physical and psychological/neuropsychological integrity. Those functional measures not significant were in social, vocational, recreational and communication areas. These factors may continue to improve over a longer period of time and should be tracked in the post-acute rehabilitation phase for their significance in return to work/school.

BACKGROUND: Sensory stimulation is often provided to persons incurring severe traumatic brain injury (TBI), but therapeutic effects are unclear. OBJECTIVE: This preliminary study investigated neurobehavioral and neurophysiological effects related to sensory stimulation on global neurobehavioral functioning, arousal, and awareness. METHODS: A double-blind randomized placebo-controlled trial where 15 participants in states of disordered consciousness (DOC), an average of 70 days after TBI, were provided either the Familiar Auditory Sensory Training (FAST) or Placebo of silence. Global neurobehavioral functioning was measured with the Disorders of Consciousness Scale (DOCS). Arousal and awareness were measured with the Coma-Near-Coma (CNC) scale. Neurophysiological effect was measured using functional magnetic resonance imaging (fMRI). RESULTS: FAST (n = 8) and Placebo (n = 7) groups each showed neurobehavioral improvement. Mean DOCS change (FAST = 13.5, SD = 8.2; Placebo = 18.9, SD = 15.6) was not different, but FAST patients had significantly (P = .049; 95% confidence interval [CI] = -1.51, -.005) more CNC gains (FAST = 1.01, SD = 0.60; Placebo = 0.25, SD = 0.70). Mixed-effects models confirm CNC findings (P = .002). Treatment effect, based on CNC, is large (d = 1.88, 95% CI = 0.77, 3.00). Number needed to treat is 2. FAST patients had more fMRI activation in language regions and whole brain (P values <.05) resembling healthy controls' activation. CONCLUSIONS: For persons with DOC 29 to 170 days after TBI, FAST resulted in CNC gains and increased neural responsivity to vocal stimuli in language regions. Clinicians should consider providing the FAST to support patient engagement in neurorehabilitation.

OBJECTIVE: To investigate the results of the modified Evans blue dye test (MEBD) aspiration detection rate to the video nasal endoscopic examination of the swallow (VEES) during simultaneous studies with direct viewing of the subglottis through the tracheostomy site opening by means of endoscopy. STUDY DESIGN: Prospective, consecutive. METHODS: Fifteen consecutive simultaneous MEBD and VEES studies were completed on patients with tracheostomies at an acute care rehabilitation hospital over a 4-month period. All patients were referred to the swallowing center for a video nasal endoscopic examination who had known or suspected dysphagia. RESULTS: Aspiration was present in 53% (8) of the studies as documented by the VEES. The MEBD showed an overall 50% false-negative error rate for the detection of aspiration as compared with the VEES. The MEBD identified aspiration in 67% of patients who aspirated more than trace amounts but failed to identify aspiration of trace amounts (0%). CONCLUSION: The results of the current investigation suggest that the MEBD, at best, should be viewed only as a screening tool for the presence of gross amounts of aspiration in patients with a tracheostomy.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. OBJECTIVE: Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. METHODS: Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). RESULTS: A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. CONCLUSIONS: At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

BACKGROUND: Self-management of complex medication regimens for chronic illness is challenging for many older adults. OBJECTIVES: The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology. DESIGN: This study used a randomized controlled trial with three arms and longitudinal outcome measurement. SETTING: Older adults having difficulty in self-managing medications (n = 414) were recruited at discharge from three Medicare-certified home healthcare agencies in a Midwestern urban area. METHODS: All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (the Geriatric Depression Scale, Mini Mental Status Examination, Physical Performance Test, and SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline and at 3, 6, 9, and 12 months. RESULTS: After covariate and baseline health status adjustment, time × group interactions for the MD.2 and medplanner groups on health status outcomes were not significant. Time × group interactions were significant for the medplanner and control group comparisons. DISCUSSION: Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.

While rehabilitation providers are facing increasing pressure to document treatment outcomes, critics have warned against the inappropriate use of ordinal functional assessment data in arithmetic operations. Two salient criticisms concern the combination of items representing multidimensional abilities into a single total score, and the indeterminate distances between hierarchical functional assessment scale categories. In this initial study, the factor structure of the Patient Evaluation and Conference System (PECS) was studied to assess the potential for unidimensional measurement. Factor analysis of a multidiagnostic dataset (n = 3,564) yielded eight factors accounting for 60% of the variance among 68 PECS items. The factors indicate that several unidimensional measures may underlie the PECS. These factors are delineated, and further studies of unidimensionality and additivity are recommended.

STUDY DESIGN: Clinical trial. OBJECTIVE: To demonstrate that a 12-week exoskeleton-based robotic gait training regimen can lead to a clinically meaningful improvement in independent gait speed, in community-dwelling participants with chronic incomplete spinal cord injury (iSCI). SETTING: Outpatient rehabilitation or research institute. METHODS: Multi-site (United States), randomized, controlled trial, comparing exoskeleton gait training (12 weeks, 36 sessions) with standard gait training or no gait training (2:2:1 randomization) in chronic iSCI (>1 year post injury, AIS-C, and D), with residual stepping ability. The primary outcome measure was change in robot-independent gait speed (10-meter walk test, 10MWT) post 12-week intervention. Secondary outcomes included: Timed-Up-and-Go (TUG), 6-min walk test (6MWT), Walking Index for Spinal Cord Injury (WISCI-II) (assistance and devices), and treating therapist NASA-Task Load Index. RESULTS: Twenty-five participants completed the assessments and training as assigned (9 Ekso, 10 Active Control, 6 Passive Control). Mean change in gait speed at the primary endpoint was not statistically significant. The proportion of participants with improvement in clinical ambulation category from home to community speed post-intervention was greatest in the Ekso group (>1/2 Ekso, 1/3 Active Control, 0 Passive Control, p < 0.05). Improvements in secondary outcome measures were not significant. CONCLUSIONS: Twelve weeks of exoskeleton robotic training in chronic SCI participants with independent stepping ability at baseline can improve clinical ambulatory status. Improvements in raw gait speed were not statistically significant at the group level, which may guide future trials for participant inclusion criteria. While generally safe and tolerable, larger gains in ambulation might be associated with higher risk for non-serious adverse events.

1Director, Psychological Medicine, Marianjoy Rehabilitation Center, Wheaton, Illinois; Associate Professor of Psychology and Physical Medicine and Rehabilitation, Rush Medical College, Chicago, Illinois 2Staff Psychologist, Marianjoy Rehabilitation Center, Wheaton, Illinois

PURPOSE: This study was designed to evaluate the effectiveness of the compelled body weight shift (CBWS) therapy approach in the rehabilitation of individuals with chronic stroke. CBWS involves a forced shift of body weight toward a person's affected side by means of a shoe insert that establishes a lift of the nonaffected lower extremity. METHOD: Eighteen individuals with chronic, unilateral stroke (mean age 57.7 ± 11.9 years, with a range of 35-75 years; mean time since stroke 6.7 ± 3.9 years, with a range of 1.1-14.1 years) who showed asymmetrical stance were randomly divided into 2 groups: the experimental group received 6 weeks of physical therapy combined with CBWS therapy, and the control group received only physical therapy. Both groups underwent a battery of identical tests (Fugl-Meyer Assessment, Berg Balance Scale, weight bearing, and gait velocity) before the start of the rehabilitation intervention, following its completion, and 3 months after the end of therapy. RESULTS: After the intervention, weight bearing on the affected side (measured with the Balance Master) increased in the experimental group to a larger degree compared to the control group (9.7% vs 6.4%). Similarly, gait velocity increased 10.5% in the experimental group compared to the control group. Improvements in weight bearing and gait velocity were maintained in the experimental group after the 3-month retention period. CONCLUSION: The study outcome revealed that a 6-week intervention involving CBWS therapy could result in a long-lasting improvement of the symmetry of weight bearing and velocity of gait in individuals with chronic stroke.

This study compared two frequently used brain injury assessment scales with a comprehensive functional scale in their capability to predict return to work in a traumatic brain injured population. Fifty-seven consecutive admissions to an inpatient brain injury program were rated at admission and discharge using the following scales: Patient Evaluation and Conference System (PECS), Disability Rating Scale, and Levels of Cognitive Functioning Scale. Their relative accuracy in predicting return to work or school up to 26 months after the injury was assessed using hierarchical logistic regression analysis. In each analysis, return to work/school was the dependent variable. The independent variables were initial status and discharge status on each rating scale. Overall these scales predicted return to work with 73.5% to 84.4% accuracy. Total PECS and PECS Cognition scores were the most accurate predictors. Analysis of incorrect predictions revealed the importance of additionally tracking the social factors of substance abuse, family/community support and financial need to return to work.

Blood smear analysis has remained a crucial diagnostic tool for pathologists despite the advent of automatic analyzers such as flow cytometers and impedance counters. Though these current methods have proven to be indispensible tools for physicians and researchers alike, they provide limited information on the detailed morphology of individual cells, and merely alert the operator to manually examine a blood smear by raising flags when abnormalities are detected. We demonstrate an automatic interferometry-based smear analysis technique known as diffraction phase cytometry (DPC), which is capable of providing the same information on red blood cells as is provided by current clinical analyzers, while rendering additional, currently unavailable parameters on the 2-D and 3-D morphology of individual red blood cells. To validate the utility of our technique in a clinical setting, we present a comparison between tests generated from 32 patients by a state of the art clinical impedance counter and DPC.

Occupational therapists, like other rehabilitation professionals, have accepted ordinal raw scores as a sufficient basis for developing evaluation tools. This paper summarizes problems commonly found in evaluation methods based on summing ordinal raw item scores and demonstrates how Rasch measurement models provide a solution to the construction of calibrated (linear) measures. Rasch measurement models are contrasted with Steven's lax definition of measurement and Guttman's unreasonably rigid requirements. The simple Rasch model is a probabilistic formulation of the fundamental requirements for additive linear measurement. This formulation retains Guttman's concept of order, but construes it probabilistically, making it neither too lax (random) nor too rigid. When a measure is based on a theory of what counts as an observation of more or less of something, Rasch measurement models are useful for constructing valid measures.

BACKGROUND AND PURPOSE: The purpose of this case report is to describe the examination, intervention, and outcome of a patient with multiple sclerosis (MS) who participated in a comprehensive rehabilitation program that included aquatic therapy with a pool temperature of 94 degrees F. There are few descriptions of aquatic exercise programs on muscle force, exercise tolerance, and functional outcomes in individuals with MS, and most authors recommend a water temperature of less than 85 degrees F to prevent an exacerbation of symptoms. DESCRIPTION: The patient was a 33-year-old woman. Before, during, and after the aquatic program, she was monitored for body temperature, heart rate, blood pressure, and perceived exertion. She was also assessed for muscle force and functional abilities. OUTCOMES: The patient did not experience heat sensitivity or fatigue throughout the program, and her manual muscle test grades and mobility improved. DISCUSSION: This patient's participation in aquatic therapy, in conjunction with land-based interventions, may have been associated with the improvement in functional abilities.