Showing papers in "Journal of Rehabilitation Research and Development in 2012"

Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature.

Abstract: We systematically reviewed and analyzed the literature to find randomized controlled trials (RCTs) that employed robotic devices in upper-limb rehabilitation of people with stroke. Out of 574 studies, 12 matching the selection criteria were found. The Fugl-Meyer, Functional Independence Measure, Motor Power Scale, and Motor Status Scale outcome measures from the selected RCTs were pooled together, and the corresponding effect sizes were estimated. We found that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy (RT), no difference exists between the intensive CT and RT groups in terms of motor recovery, activities of daily living, strength, and motor control. However, depending on the stage of recovery, extra sessions of RT in addition to regular CT are more beneficial than regular CT alone in motor recovery of the hemiparetic shoulder and elbow of patients with stroke; gains are similar to those that have been observed in intensive CT.

Review of exposure therapy: a gold standard for PTSD treatment.

Abstract: Prolonged exposure (PE) is an effective first-line treatment for posttraumatic stress disorder (PTSD), regardless of the type of trauma, for Veterans and military personnel. Extensive research and clinical practice guidelines from various organizations support this conclusion. PE is effective in reducing PTSD symptoms and has also demonstrated efficacy in reducing comorbid issues such as anger, guilt, negative health perceptions, and depression. PE has demonstrated efficacy in diagnostically complex populations and survivors of single- and multiple-incident traumas. The PE protocol includes four main therapeutic components (i.e., psychoeducation, in vivo exposure, imaginal exposure, and emotional processing). In light of PE's efficacy, the Veterans Health Administration designed and supported a PE training program for mental health professionals that has trained over 1,300 providers. Research examining the mechanisms involved in PE and working to improve its acceptability, efficacy, and efficiency is underway with promising results.

Psychometric study of the Neurobehavioral Symptom Inventory.

Abstract: The Department of Veterans Affairs (VA) uses the Neurobehavioral Symptom Inventory (NSI) to measure postconcussive symptoms in its comprehensive traumatic brain injury (TBI) evaluation. This study examined the NSI's item properties, internal consistency, and external validity. Data were obtained from a federally funded study of the experiences of combat veterans. Participants included 500 Operations Iraqi and Enduring Freedom veterans, 219 of whom sustained at least one TBI. Data were collected at five VA medical centers and one VA outpatient clinic across upstate New York. Measures included neuropsychological interview, NSI, Beck Anxiety Inventory, Beck Depression Inventory-II, and Posttraumatic Stress Disorder Checklist-Military Version. The NSI demonstrated high internal consistency (total alpha = 0.95; subscale alpha = 0.88 to 0.92). Subscale totals based on Caplan et al.'s factor analysis correlated highly with the NSI total score (r = 0.88 to 0.93). NSI scores differentiated veterans with TBI history from those without but were strongly influenced by variance associated with probable posttraumatic stress disorder, depression, and generalized anxiety. Results suggest that the NSI is a reliable and valid measure of postconcussive symptoms. Scale validity is evident in the differentiation of TBI and non-TBI classifications. The scale domain is not limited to TBI, however, and extends to detection of probable effects of additional affective disorders prevalent in the veteran population.

Review of hybrid exoskeletons to restore gait following spinal cord injury.

Abstract: INTRODUCTION Paraplegia resulting from spinal cord injury (SCI) is characterized primarily by the loss of motor and sensory abilities, the severity of which is determined by the level and characteristics of the injury [1]. Among SCI patients, gait impairment constitutes one of the most disabling impairments and may involve the complete loss of voluntary control of the leg muscles. Thus, individuals with paraplegia commonly rely on wheelchairs for their mobility [2]. Recent studies have attempted to identify the most important functions in the SCI population, with a view to enhancing quality of life [3-7]. Although different methods were used in these studies, all identified mobility as one of the main objectives for the injured individuals. Interestingly, several differences between the preferences of patients and those of clinical professionals have been reported [4]. While mobility was a high priority among patients at all stages of rehabilitation, the expert panel selected independent wheelchair mobility as the most important final goal of rehabilitation, which was attributed to the pressure to discharge patients because of time constraints. However, it is important to highlight that restoring the capacity to walk was identified as the highest priority objective, regardless of the lesion level, time since injury, or age [4]. Different approaches to gait restoration are currently available. While orthotic gait involves both passive and active orthotic approaches, FES-based approaches explore the possibilities of electrical stimulation of the user's muscles. We shall consider these here, as well as alternative hybrid functional electrical stimulation (FES)-based approaches. Orthotic Gait The first system to be introduced clinically for gait compensation was a mechanical structure that locked or limited joint movement during the stance phase of gait, such as the ankle-foot orthosis (AFO), the knee-AFO (KAFO), or the hip-KAFO (HKAFO), depending on the specific joint weakness. The traditional KAFO design was developed in the 1950s to assist ambulatory management after poliomyelitis epidemics [8]. KAFOs or HKAFOs allow swing-through mobility with the use of walkers or crutches. The mobility achieved with these devices is aesthetically poor and requires high metabolic energy expenditure. Indeed, the energetic cost associated with this kind of ambulation is up to 43 percent higher than that of wheelchairs [9], which partially explains the low impact of such orthoses compared with wheelchairs. Some years later, in an effort to develop a less demanding gait, dynamic orthoses that allowed passive hip joint movement were developed: the reciprocating gait orthosis (RGO) [10], the advanced RGO [11], the hip guidance orthosis [12], the ParaWalker [13], and the Walkabout [14]. Gait achieved with these orthotic systems was improved with respect to the rigid HKAFOs [15], although problems with slow walking and high energy cost have been identified as reasons for discontinuing their use [16-18]. Recent decades have seen a growing interest in the development of active orthoses capable of adding and controlling power at the joints. The first such example dates from the 1970s, when Vukobratovic et al. developed an active orthosis comprised of actuators at hip, knee, and ankle joints to assist movement in the sagittal plane [19]. Since then, many active exoskeletons have been developed for gait restoration, with considerable variation in actuator and sensing technologies, and control strategies. However, as with passive orthoses, exoskeletons for gait restoration are not yet a viable means of providing effective gait compensation because of the many limitations that are still to be overcome [20-23]. Although new promising exoskeletons are in clinical trials [24-25], further studies should be performed in the clinical setting to understand whether the limitations already identified in previous studies are addressed. …

Assessment of posttraumatic stress disorder-related functional impairment: a review.

Abstract: INTRODUCTION Research has consistently shown posttraumatic stress disorder (PTSD) to be associated with impairments in functioning across a number of psychosocial domains [1]. Specifically, PTSD is associated with impairments in occupational and academic functioning [2-6], marital and family functioning [5,7-8], parenting [9-10], and friendships and socializing [11]. Additional studies have shown associations between PTSD and objective indicators of quality of life (QOL) such as homelessness and unemployment [12-13]. Such impairments are common among populations at high risk for PTSD, such as military personnel deployed to combat [3,5-6,8-14]. Research suggests that these impairments are currently affecting many Veterans of the wars in Iraq and Afghanistan (Operations Iraqi Freedom and Enduring Freedom) and are therefore important to identify and treat [15]. In 2010, the Department of Veterans Affairs (VA) and the Department of Defense (DOD) jointly published the revised VA/DOD Clinical Practice Guideline for Management of Posttraumatic Stress [16]. This clinical practice guideline (CPG) provides evidence-based recommendations to clinicians for diagnosing and treating a spectrum of stress-related disorders including combat and operational stress reaction (COSR), acute stress reaction, acute stress disorder (ASD), acute PTSD, and chronic PTSD among servicemembers and Veterans. The VA/DOD CPG recommends a comprehensive assessment of all relevant domains of functioning. It stresses the importance of a thorough assessment of functional impairment for several reasons: (1) to identify individuals who may be at risk for endangering themselves or others during or after deployment as well as after military discharge, (2) to promote accurate diagnosis, (3) to guide treatment planning by clarifying the domains in which the individual is experiencing impairment, and (4) to monitor changes in functioning during and after treatment. This article is meant to complement the CPG recommendations for assessing stress disorder-related functional impairment and will provide information that may further guide clinicians in their assessment efforts. Although the VA/DOD CPG addresses several stress-related disorders, this article will focus mainly on the relation between PTSD and psychosocial functioning because the vast majority of prior research has examined this association. The information provided is based on these empirical findings from the extant literature as well as recent findings from an ongoing study of functional impairment among male and female Veterans. Specifically, we begin our article with a review of some of the recent empirical literature on the association between PTSD and impaired functioning across various psychosocial domains. We then provide specific recommendations on how to perform a comprehensive multimethod assessment of functional impairment and introduce a promising new assessment instrument. The article concludes with insights into several important issues related to assessing functional impairment that we encourage all clinicians to keep in mind when assessing functional impairment among Veterans and Active Duty servicemembers. METHODS We searched the U.S. National Library of Medicine's PubMed, PsycINFO, and PsycARTICLES databases for articles related to PTSD and functioning. We identified studies by searching the databases for references with the phrases "posttraumatic stress disorder" or "PTSD" (n = 10,109 English-language articles) or "functioning" in the title or abstract (n = 83).We reviewed the abstracts for the resulting articles to identify those relevant to our topic, and we also reviewed the references for the most relevant articles to identify additional studies of interest. Because we were unable to provide an exhaustive literature review in this article, we emphasized studies published since 2008 but also included a few earlier articles that were of particular relevance. …

The VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress (update 2010): development and methodology.

Abstract: CLINICAL PRACTICE GUIDELINES The Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) are recommendations that are made to VA/DOD healthcare providers regarding their approaches to treatment of a variety of medical conditions. They are based on the best available clinical evidence and are designed to achieve the most desirable outcomes based on a variety of clinical situations. In general, CPGs have been defined as "systematically developed statements to assist practitioner and patient in making decisions about appropriate healthcare for specific clinical circumstances" [1]. CPGs are being used throughout healthcare systems as a means of enhancing quality, reducing costs, and optimizing performance. Good CPGs can change the process of healthcare and improve outcomes by providing recommendations for the management of patients and supporting the development of standards to assess outcomes. A CPG should also assist in healthcare providers' education and training, likewise educating the patients; help in making informed decisions; and improve communication between the patient and provider. A CPG, when implemented, will influence practice patterns. GUIDELINE DEVELOPMENT There have been many recommended approaches to CPG development methodologies. The World Health Organization (WHO) assessed models of CPG development used internationally and identified the following best practices in CPG development [2]: * Developed by multidisciplinary CPG development working groups (WGs). * Explicit, transparent use of systematic reviews of evidence to develop recommendations. * Documentation of the CPG development process (including disclosure of interest declarations at all levels of involvement). * Include ratings of the evidence associated with key recommendations. * Defined and explicit process for consultation and peer review of the draft CPG. * Multiple level outputs, including versions (modules) for specialists, primary care professionals, and patients. The development and the underlying principles of the process used to develop the VA/DOD CPGs are very much consistent with the principles described by the WHO and those practiced by other healthcare organizations that have developed CPGs (e.g., National Institute for Health and Clinical Excellence and Institute for Clinical Systems Improvement). The VA/DOD process is also consistent with the proposed eight standards for developing trustworthy CPGs published recently by the Institute of Medicine [3]. CPGs are usually developed by groups of clinicians. Clinicians regularly make difficult choices about treatment options. Often, there is uncertainty about the value of different options, and practice can vary widely. CPGs can be seen as one way of assisting clinicians in decision-making. In an ideal world, CPGs would be based on evidence derived from rigorously conducted empirical studies. In practice, there are only few areas of care where sufficient research based evidence exists. In such situations, the development of comprehensive CPGs will inevitably have to be based partly on consensus of the opinions and experience of clinicians and others in the subject at hand. A technology assessment published in 1998, reviewed 177 primary research and review articles that studied the factors that affect the decisions that emerge from consensus development approaches and assessed the implications of the findings for the development of CPGs [4]. A group consensus process brings to bear a wider range of direct knowledge and experience. The interaction among the group members can stimulate consideration of a wider range of options, and debates can challenge old ideas and generate new ones. However, several issues need to be addressed and pitfalls need to be avoided when a group of experts is attempting to reach consensus. For example, the choice and mixture of participants, the bias and conflict of interest they may bring with them, and the cost of bringing people together. …

Prosthetic fitting, use, and satisfaction following lower-limb amputation: a prospective study.

Abstract: Providing a satisfactory, functional prosthesis following lower-limb amputation is a primary goal of rehabilitation. The objectives of this study were to describe the rate of successful prosthetic fitting over a 12 mo period; describe prosthetic use after amputation; and determine factors associated with greater prosthetic fitting, function, and satisfaction. The study design was a multicenter prospective cohort study of individuals undergoing their first major lower-limb amputation because of vascular disease and/or diabetes. At 4 mo, unsuccessful prosthetic fitting was significantly associated with depression, prior arterial reconstruction, diabetes, and pain in the residual limb. At 12 mo, 92% of all subjects were fit with a prosthetic limb and individuals with transfemoral amputation were significantly less likely to have a prosthesis fit. Age older than 55 yr, diagnosis of a major depressive episode, and history of renal dialysis were associated with fewer hours of prosthetic walking. Subjects who were older, had experienced a major depressive episode, and/or were diagnosed with chronic obstructive pulmonary disease had greater functional restriction. Thus, while most individuals achieve successful prosthetic fitting by 1 yr following a first major nontraumatic lower-limb amputation, a number of medical variables and psychosocial factors are associated with prosthetic fitting, utilization, and function.

Dissemination and experience with cognitive processing therapy.

Abstract: Clinical practice guidelines suggest that cognitive behavioral therapies are recommended for the treatment of posttraumatic stress disorder (PTSD). One of these treatments, cognitive processing therapy (CPT), is an evidence-based treat- ment that has been shown to be effective at treating combat, assault, and interpersonal violence trauma in randomized con- trolled trials. The Department of Veterans Affairs (VA) Office of Mental Health Services has implemented an initiative to dis- seminate CPT as part of a broad effort to make evidence-based psychotherapies widely available throughout the VA healthcare system. This article provides an overview of CPT and reviews the efficacy and program evaluation data supporting its use in a variety of settings. In addition, we report on survey data from individuals who have participated in the VA initiative and on outcome data from patients treated by rollout-trained thera- pists. Our data suggest that many clinicians trained in the roll- out show good adoption of the CPT model and demonstrate solid improvements in their patients' PTSD and depressive symptomotology. Finally, we offer recommendations for using CPT in clinical settings.

Reliability of thermal quantitative sensory testing: a systematic review.

Abstract: The use of quantitative sensory testing (QST) has become more widespread, with increasing focus on describing somatosensory profiles and pain mechanisms. However, the reliability of thermal QST has yet to be established. We systematically searched the literature using key medical databases. Independent reviewers evaluated reliability data using the Quality Appraisal for Reliability Studies checklist. Of the 21 studies we included in this review, we deemed 5 to have high methodological quality. Narrative analysis revealed that estimates of reliability varied considerably, but overall, the reliability of cold and warm detection thresholds ranged from poor to excellent, while heat and cold pain thresholds ranged from fair to excellent. The methodological quality of research investigating the reliability of thermal QST warrants improvement, particularly in terms of appropriate blinding. The results from this review showed considerable variability in the reliability of each thermal QST parameter.

Review of VA/DOD Clinical Practice Guideline on Management of Acute Stress and Interventions to Prevent Posttraumatic Stress Disorder

Abstract: INTRODUCTION The newly revised Department of Veterans Affairs (VA)/Department of Defense (DOD) VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress, published October 2010 [1], draws greater attention than its predecessor to the challenge of promoting prevention of posttraumatic stress disorder (PTSD) and other adverse outcomes of exposure to traumatic stress in service-members, veterans, and their families. The entire Core Module of the CPG is now devoted to reviewing concepts and evidence-informed actions for prevention in three domains: promoting primary prevention through education and training (pre-exposure), identifying high-risk populations based on the nature of traumatic events and other stressors (peri-exposure), and implementing the secondary prevention action of screening for significant trauma-related symptoms so that appropriate early interventions can be undertaken (postexposure). Module A, which immediately follows the Core Module, now provides detailed guidance on specific evidence-informed early interventions to promote recovery from both preclinical acute stress reactions (ASRs) and acute stress disorder (ASD), a possible clinical precursor of PTSD. As we enter the second decade of war in Afghanistan and Iraq and the rolls of physical and psychological casualties continue to grow, the prevention of PTSD, suicide, violence, substance abuse, and other serious behavioral sequelae of war-zone stress have become a national mandate [2-3]. Over the past few years--since the first VA/ DOD Clinical Practice Guideline (CPG) for management of post-traumatic stress was released in 2004--countless new programs for prevention and resilience-building have been funded and launched in the VA, DOD, and military service branches, including their Active, Reserve, and National Guard components [4]. Besides being great in number, these new prevention programs for military personnel, veterans, and their families are highly diverse in their approaches. Some focus on pre-exposure education, training, and other interventions to promote resilience through multidomain fitness [5-6], while others provide tools for screening and early interventions to promote recovery postexposure [7]. Since the absolute and relative effectiveness of these diverse approaches to prevention have not yet been well studied, the value of expert, evidence-informed consensus recommendations such as those contained in the VA/DOD CPG can hardly be overstated. Like its predecessor, the revised CPG assigns confidence grades to each of its recommendations in three dimensions: level of evidence, quality of evidence, and strength of recommendation (see Appendix, available online only). In general, stronger recommendations in the CPG are based on higher levels and quality of evidence. Where existing literature is lacking, ambiguous, or conflicting, CPG recommendations are based on consensus of the expert working group tasked with writing the CPG. Particularly in the area of prevention, where the literature has not kept pace with the need for effective programs, the CPG at times makes strong recommendations in the absence of randomized controlled trials incorporating the most relevant outcome measures. METHODS We reviewed the sections of the Core Module and Module A of the CPG that specifically address postexposure screening and early interventions for the prevention of PTSD. Included are definitions of the spectrum of preclinical and clinical acute stress states; methods for recognizing them in servicemembers, veterans, and family members; and approaches for early intervention to prevent them from progressing to PTSD and other potentially chronic trauma-related disorders. We compared the approach taken to prevention and early intervention in the CPG to the current framework for classifying prevention interventions developed by the National Research Council (NRC)-Institute of Medicine (IOM) Committee for the Prevention of Mental Disorders. …

Issues in defining and measuring veteran community reintegration: proceedings of the Working Group on Community Reintegration, VA Rehabilitation Outcomes Conference, Miami, Florida.

Abstract: In January 2010, the Department of Veterans Affairs (VA) Rehabilitation Research and Development Service convened a State of the Art (SOTA) conference to advance the field of outcome measurement for rehabilitation-related studies. This article reports on the proceedings of the SOTA Working Group on Community Reintegration. We explored the use of the International Classification of Health, Disability, and Functioning as a theoretical framework for measuring community reintegration; identified key dimensions of community reintegration that could and/or should be measured; discussed challenges in measuring community reintegration; suggested steps to enhance community reintegration measurement; proposed future research that focuses on outcomes measures for community reintegration and the study of community reintegration outcomes; and made policy recommendations that would facilitate community reintegration research within the VA.

Determining skill level in myoelectric prosthesis use with multiple outcome measures

Abstract: To obtain more insight into how the skill level of an upper-limb myoelectric prosthesis user is composed, the current study aimed to (1) portray prosthetic handling at different levels of description, (2) relate results of the clinical level to kinematic measures, and (3) identify specific parameters in these measures that characterize the skill level of a prosthesis user. Six experienced transradial myoelectric prosthesis users performed a clinical test (Southampton Hand Assessment Procedure [SHAP]) and two grasping tasks. Kinematic measures were end point kinematics, joint angles, grasp force control, and gaze behavior. The results of the clinical and kinematic measures were in broad agreement with each other. Participants who scored higher on the SHAP showed overall better performance on the kinematic measures. They had smaller movement times, had better grip force control, and needed less visual attention on the hand. The results showed that time was a key parameter in prosthesis use and should be one of the main focus aspects of rehabilitation. The insights from this study are useful in rehabilitation practice because they allow therapists to specifically focus on certain parameters that may result in a higher level of skill for the prosthesis user.

Performance on tests of central auditory processing by individuals exposed to high-intensity blasts.

Abstract: INTRODUCTION The recent conflicts in Afghanistan and Iraq (Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn [OIF/OEF/OND]) have resulted in unprecedented rates of exposure to high-intensity blasts, often resulting in traumatic brain injury (TBI) among members of the U.S. military. The Department of Veterans Affairs (VA) 2011 TBI Comprehensive Evaluation Summary [1] estimated the prevalence of TBI in the OIF/OEF/ OND Veteran population at 7.8 percent. While the typical focus of auditory evaluation is on damage to the peripheral auditory system, the prevalence of brain injury among those exposed to high-intensity blasts suggests that damage to the central auditory system is an equally important concern for blast-exposed persons. Discussions with clinical audiologists and OIF/OEF/OND Veterans Service Office personnel suggest that a common complaint voiced by blast-exposed Veterans is an inability to understand speech in noisy environments, even when peripheral hearing is within normal or near-normal limits. Such complaints are consistent with damage to neural networks responsible for higher-order auditory processing [2]. The auditory structures most vulnerable to axonal injury are the lower- and mid-brain stem nuclei, the thalamus, and the corpus callosum. Damage may include swelling, stretching, and shearing of neural connections, as well as inflammatory changes in response to tissue injury [3]. There also may be a loss of synaptic structures connecting nuclei in the central auditory system, resulting in distorted or missing information transmitted to cortical centers [4-5]. The interhemispheric pathways connecting auditory areas of the two cerebral hemispheres run through the posterior half of the corpus callosum [6]. The corpus callosum is a structure that may be particularly vulnerable, as it has been shown to be damaged even in non-blast-related head injury [7-8]. Axonal damage to this part of the corpus callosum would be expected to interfere with auditory and speech processing, as well as other bilaterally represented auditory cortical functions. Furthermore, recent modeling work has revealed that the blast wave itself can exert stress and strain forces on the brain that are likely to cause widespread axonal and blood vessel damage [9]. Such impacts would not necessarily create changes visible on a medical image, but could still impair function by reducing neural transduction time, efficiency, or precision of connectivity. This wide diversity of potential damage and sites of injury also suggests that the profile of central auditory damage is likely to vary considerably among patients. For this reason, the first step in the diagnosis and treatment of blast-related dysfunction is the identification of which brain functions have been impaired. TESTS OF CENTRAL AUDITORY FUNCTION Behavioral tests are mainstays of central auditory test batteries, and many have been shown to be both sensitive and specific to particular brain injuries. It may also be important, however, to include evoked potential (EP) measures (electrophysiological tests) of neural function [10] to complement the behavioral tests. The Auditory Brainstem Response (ABR) is a commonly used test that evaluates the integrity of the auditory nerve and brainstem structures, whereas measures from the auditory evoked late response reflect cortical processing [11]. Long latency responses (LLRs), which are sensitive to impaired neuronal firing and desynchronization of auditory information, are useful tools for the assessment of cognitive capability. Prolonged latencies in LLRs would suggest interruptions in neural transmission within or between cortical networks. This could be due to reduced cortical neuron availability or diminished neural firing intensity. In addition, longer neural refractory periods can result in reduced amplitudes of event-related potentials. The purpose of the current study was to determine whether performance on a battery of behavioral and electrophysiological tests of central auditory function differs between individuals who have recently experienced a high-explosive blast and those who have not. …

Review of group treatment for PTSD.

Abstract: The purpose of this article is to provide a brief review of group treatment for posttraumatic stress disorder (PTSD). This review includes a description of group-based treatments for PTSD and the available data on the efficacy of group treatment for PTSD. The literature review indicates that group treatment for PTSD is efficacious compared with no treatment. However, specific types of group treatment are not efficacious when compared with a nonspecific group treatment, such as psychoeducation or supportive counseling. Recommendations for practice and research are made in light of the available literature.

Robot-assisted practice of gait and stair climbing in nonambulatory stroke patients

Abstract: A novel gait robot enabled nonambulatory patients the repetitive practice of gait and stair climbing. Thirty nonambulatory patients with subacute stroke were allocated to two groups. During 60 min sessions every workday for 4 weeks, the experimental group received 30 min of robot training and 30 min of physiotherapy and the control group received 60 min of physiotherapy. The primary variable was gait and stair climbing ability (Functional Ambulation Categories [FAC] score 0-5); secondary variables were gait velocity, Rivermead Mobility Index (RMI), and leg strength and tone blindly assessed at onset, intervention end, and follow-up. Both groups were comparable at onset and functionally improved over time. The improvements were significantly larger in the experimental group with respect to the FAC, RMI, velocity, and leg strength during the intervention. The FAC gains (mean +/- standard deviation) were 2.4 +/- 1.2 (experimental group) and 1.2 +/- 1.5 (control group), p = 0.01. At the end of the intervention, seven experimental group patients and one control group patient had reached an FAC score of 5, indicating an ability to climb up and down one flight of stairs. At follow-up, this superior gait ability persisted. In conclusion, the therapy on the novel gait robot resulted in a superior gait and stair climbing ability in nonambulatory patients with subacute stroke; a higher training intensity was the most likely explanation. A large randomized controlled trial should follow.

Effect of prosthetic gel liner thickness on gait biomechanics and pressure distribution within the transtibial socket.

Abstract: Prosthetic gel liners are often prescribed for persons with lower-limb amputations to make the prosthetic socket more comfortable. However, their effects on residual limb pressures and gait characteristics have not been thoroughly explored. This study investigated the effects of gel liner thickness on peak socket pressures and gait patterns of persons with unilateral transtibial amputations. Pressure and quantitative gait data were acquired while subjects walked on liners of two different uniform thicknesses. Fibular head peak pressures were reduced (p = 0.04) with the thicker liner by an average of 26 +/- 21%, while the vertical ground reaction force (GRF) loading peak increased 3 +/- 3% (p = 0.02). Most subjects perceived increased comfort within the prosthetic socket with the thicker liner, which may be associated with the reduced fibular head peak pressures. Additionally, while the thicker liner presumably increased comfort by providing a more compliant limb-socket interface, the higher compliance may have reduced force and vibration feedback to the residual limb and contributed to the larger vertical GRF loading peaks. We conclude that determining optimal gel liner thickness for a particular individual will require further investigations to better identify and understand the compromises that occur between user perception, residual-limb pressure distribution, and gait biomechanics.

Pharmacotherapy for posttraumatic stress disorder: review with clinical applications.

Abstract: INTRODUCTION The prevalence of posttraumatic stress disorder (PTSD) has been estimated to be 7.8 percent in the general population [1]. A higher PTSD prevalence has been estimated in veterans. The prevalence of PTSD in Vietnam veterans is estimated to be 18.7 percent lifetime war-related and 9.1 percent current war-related. A prevalence of PTSD between 15 and 17 percent has been estimated in Iraq and Afghanistan veterans (Operation Iraqi Freedom/ Operation Enduring Freedom/Operation New Dawn [OIF/ OEF/OND]). The prevalence varies depending on the methods used and the time at which PTSD is assessed [2-3]. Although these rates are greater than the prevalence of PTSD in the general population, the prevalence of PTSD may be even higher in outpatient general medical settings, perhaps because PTSD is associated with comorbid medical problems and patients with PTSD are high utilizers of healthcare. Estimates of PTSD for veterans in medical settings have varied from 11.2 percent using stricter diagnostic criteria to as high as 20-30 percent using more liberal diagnostic criteria [3-9]. Experiencing combat wounds is recognized to further increase the risk of PTSD twofold [10]. Many of these patients will be seen initially by medical professionals in either primary care or general mental health settings, creating a need for physicians in all specialties to become familiar with the initial management steps, assessment, and diagnosis of PTSD. Questions and concerns have arisen about the current prescribing practices for PTSD among OIF/OEF/OND veterans as well as veterans from prior eras. We draw special attention to benzodiazepines and atypical antipsychotics, because these two classes of medication are prescribed for PTSD despite little evidence for their efficacy and considerable concern about their potential harm. Benzodiazepine prescribing within the Department of Veterans Affairs (VA) for veterans with PTSD has raised concerns about benzodiazepines' abuse potential given that studies have not found them effective in preventing or treating PTSD [11-14]. Further, because benzodiazepines reduce anxiety without addressing the underlying PTSD, clinicians may incorrectly believe the patient has improved, thus delaying definitive PTSD care. Atypical antipsychotics also are believed to be overprescribed for PTSD, causing both excessive medication costs and a risk of harmful side effects, including obesity and metabolic syndrome. An estimated 34 percent of veterans with PTSD on medications receive atypical antipsychotics, and 77 percent of these veterans do not have a comorbid diagnosis of schizophrenia or bipolar disorder (BP) [15-16]. The 2010 VADepartment of Defense (DOD) VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress ** recommends against atypical antipsychotic use as monotherapy for PTSD [17]. Furthermore, a recent large, multisite VA Cooperative Study concerning adjunctive use of risperidone demonstrated it to be no more effective than placebo at lowering PTSD symptoms after 24 weeks of treatment [18]. As a result, the clinical practice guideline (CPG) is being updated to recommend against prescribing risperidone as an adjunctive agent, concluding that evidence is insufficient to recommend any other atypical antipsychotic as adjunctive treatment for PTSD. We will review this evidence subsequently. While OIF/OEF/OND veterans access mental health services at a greater rate than combat veterans from prior conflicts, most patients with PTSD will be seen and possibly treated in primary care, medical specialty, or general mental health settings [19]. Physicians and midlevel practitioners in these settings should be familiar with the recommended pharmacologic management of PTSD and the appropriate indications for referral to specialty mental health care. Prescribers should remain aware that appropriate PTSD care involves not only providing the best initial evidence-based pharmacotherapy, but also ideally delivering it collaboratively with a psychotherapist who is trained in evidence-based, trauma-focused psychotherapy. …

Assessment and treatment of posttraumatic anger and aggression: A review

Abstract: The Department of Veterans Affairs (VA) and Department of Defense's (DOD) recently published and updated Department of Veterans Affairs/Department of Defense VA/ DOD Clinical Practice Guideline for Management of PostTraumatic Stress includes irritability, severe agitation, and anger as specific symptoms that frequently co-occur with PTSD. For the first time, the guideline includes nine specific recommendations for the assessment and treatment of PTSD-related anger, irritability, and agitation. This article will review the literature on PTSD and its association with anger and aggression. We highlight explanatory models for these associations, factors that contribute to the occurrence of anger and aggression in PTSD, assessment of anger and aggression, and effective anger management interventions and strategies.

Multisensory impairment reported by veterans with and without mild traumatic brain injury history.

Abstract: INTRODUCTION Since 2001, more than 2 million troops have deployed to the Global War on Terrorism (GWOT) in Afghanistan and Iraq [1]. Those serving in Operation Iraqi Freedom/ Operation Enduring Freedom (OIF/OEF) face combat conditions and are vulnerable to injury from roadside bombs and explosive devices [2], as well as nonblast events like gunshots, vehicle accidents, assaults, and falls. Despite improvements that reduce injury and risks of long-term effects from casualties [3-5], up to 19 percent of returning servicemembers are thought to have experienced traumatic brain injury (TBI), the "signature injury" of GWOT [6-9]. A recent study of combat wounds treated at U.S. military medical facilities showed that the proportion of head and neck injuries was higher for OIF/OEF than for prior wars and more than 75 percent of wounds were due to blasts [10]. Almost 50 percent of head and neck injuries were attributable to improvised explosive devices and more than half of combat injuries requiring medical evacuation were due to blasts [11]. Following mild TBI (mTBI), also called concussion, troops may report physical, sensory, cognitive, and behavioral/emotional changes (e.g., headaches, sleep disturbance, impaired vision, memory problems, and irritability) [12-13]. Symptoms typically resolve within days or weeks and significant improvement is often seen in 3 months [14-15]. The most visible injuries (e.g., penetrating wounds) understandably receive the most attention in theater, but other symptoms may emerge or be reported later [16], after even a mild injury [17-18]. Scott et al. identified 12 blast-related conditions typically overlooked in patients with polytrauma, including sensory impairments such as hearing loss, tinnitus, vision changes, and vestibular problems [16]. Interviewing patients who have sustained a concussion about current symptoms, which are often underreported, and performing high-yield screening evaluations (e.g., hearing test, office-based balance testing) are recommended [16,19-20]. Dual sensory impairment (DSI) has been documented in OIF/OEF veterans with blast-related TBI who were inpatients at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center [7]. Audiologic and visual evaluations indicated that 19 percent had auditory impairment, 34 percent visual impairment, and 32 percent DSI. The largest study to date examining DSI in OIF/OEF veterans documented rates of self-reported impairment in more than 21,000 veterans evaluated for TBI in VA outpatient clinics [8]. In this sample, 9.9 percent reported visual impairment, 31.3 percent auditory impairment, and 34.6 percent DSI. Veterans exposed to blast and evaluated as having a history of TBI made up nearly half the sample and reported the highest rates of DSI (35.4%). These results suggest a moderate rate of self-reported sensory disturbance among these OIF/OEF veterans. The auditory system is particularly vulnerable to blasts [21-22]. Primary blast waves involve a high-pressure shock wave followed by a blast wind [2]. Over- or underpressurization of the auditory canal have been major sources of injury that manifest as hearing loss, tinnitus, or vertigo, among other impairments [2,17-18,21,23]. In one study, damage to the ears was the most common single injury type, accounting for approximately 1 in 4 injuries [24]. Hearing impairment associated with combat injury can result in peripheral or central dysfunction [25-29]. Damage to the eyes and visual system has been documented at rates higher than those reported from previous wars [30-32]. Damage can range anywhere from the end organ to the visual cortex, resulting in vision loss or more subtle symptoms of eye fatigue, binocular vision dysfunction, decreased visual acuity, spatial deficits, or decreased levels of reading speed [33-34]. Battle-related eye injuries accounted for 15.8 percent of the in-theater medical evacuations in one study of OIF/OEF soldiers [32]. …

Can vibratory feedback be used to improve postural stability in persons with transtibial limb loss

Abstract: The use of vibration as a feedback modality to convey motion of the body has been shown to improve measures of postural stability in some groups of patients. Because individuals using transtibial prostheses lack sensation distal to the amputation, vibratory feedback could possibly be used to improve their postural stability. The current investigation provided transtibial prosthesis users (n = 24, mean age 48 yr) with vibratory feedback proportional to the signal received from force transducers located under the prosthetic foot. Postural stability was evaluated by measuring center of pressure (CoP) movement, limits of stability, and rhythmic weight shift while participants stood on a force platform capable of rotations in the pitch plane (toes up/toes down). The results showed that the vibratory feedback increased the mediolateral displacement amplitude of CoP in standing balance and reduced the response time to rapid voluntary movements of the center of gravity. The results suggest that the use of vibratory feedback in an experimental setting leads to improvements in fast open-loop mechanisms of postural control in transtibial prosthesis users.

Audiological issues and hearing loss among Veterans with mild traumatic brain injury.

Abstract: INTRODUCTION A dramatic increase in the use of explosive devices in Operation Enduring Freedom and Operation Iraqi Freedom is responsible for a significant shift in the types of injuries experienced among soldiers. Between 2003 and 2005, 68 percent of combat injuries were blast related [1]. Head and neck injuries have increased in proportion relative to previous conflicts, and 78 percent of these injuries were consequential to explosions caused by devices such as improvised explosive devices (IEDs), land mines, mortars, bombs, or grenades [2]. Mild traumatic brain injury (TBI) can result from these types of blast-related injuries [3], and their prevalence in modern combat has increased dramatically. An estimated 20 percent, or 300,000 of the 1.6 million soldiers deployed to Iraq and Afghanistan, have mild TBI [4]. Individuals with mild TBI can present clinically with cognitive, physical, or behavioral problems [5]. Individuals also often present with complaints of anxiety, depression, apathy, and mood swings [5]. In conjunction with the increase in mild TBI, blast-related injuries also result in auditory and vestibular issues. Because the human ear is designed to be sensitive to changes in pressure, it is the most susceptible organ to damage from the pressure created by a blast wave [6]. Previous studies have found that 62 percent of blast-related TBI patients admitted after the onset of Operation Iraqi Freedom complained of hearing loss and 38 percent reported tinnitus [7]. Hearing problems were also found to be present in TBI patients who had not experienced a blast, with 44 percent complaining of hearing loss and 18 percent reporting tinnitus [7]. A study of 12,521 Veterans with TBI found that 34.6 percent of the cohort self-reported auditory impairment and an additional 9.9 percent reported both auditory and visual impairment. Of these, Veterans who experienced blast-related injuries were found to have the highest rate of self-reporting both auditory and visual impairment [8]. Ear and hearing injuries may significantly affect the daily lives of soldiers, both in and out of combat. Permanent hearing loss has been reported to contribute to psychosocial and physical health problems, such as depression, decreased social and emotional function, personal relationships, and decreased cognitive function [9-11]. While studies have examined the link between TBI and hearing loss, the mild TBI population specifically has not been widely studied. A previous study of 36 American adults with a history of mild TBI found that when compared with the normative values, these individuals performed significantly worse on the Dichotic Word Listening Task [12]. Additionally, more than one-third of individuals with a mild TBI were found to fail at least one condition of a dichotic word recall task [13]. However, these studies do not include information about clinical testing and results. METHODS A retrospective chart review of 250 Veterans with mild TBI was performed at a single, midwestern Department of Veterans Affairs (VA) medical center. Individuals with a confirmed diagnosis of mild TBI between June 15, 2007, and July 15, 2009, were identified by local physicians based on TBI reports to the Veterans Health Administration (VHA) Support Service Center and considered for inclusion. Patients with moderate/severe TBI, a prior history of ear disease or hearing loss, or non-VA care for hearing loss were excluded. Veterans with mild TBI and hearing problems were identified using the VA's comprehensive second-level TBI evaluation. Veterans are referred for a comprehensive second-level evaluation after receiving an initial positive mild TBI screening. The initial screening is administered by a healthcare provider and consists of four questions regarding exposure to a mild TBI event(s), immediate symptoms, and current symptoms. Further information regarding the VHA's mild TBI screening process is described by Donnelly et al. …

Assessment of upper-body dynamic stability during walking in patients with subacute stroke.

Abstract: The analysis of upper-body acceleration is a promising and simple technique to quantitatively assess dynamic gait stability. However, this method has rarely been used for people with stroke, probably because of some technical issues still not addressed. We evaluated the root-mean-square (RMS) and harmonic ratio of trunk accelerations for a group of 15 inpatients with subacute stroke who were able to walk (61.4 +/- 14.9 yr) and compared them with those of an age-matched group of nondisabled subjects (65.1 +/- 8.8 yr) and those of a highly functional group of young nondisabled subjects (29.0 +/- 5.0 yr). Small (<2%) but significant (p < 0.03) differences were found in RMS values obtained by applying the two most common computational approaches: (1) averaging among individual-stride RMS values and (2) computing the RMS value over the entire walking trial without stride partitioning. We found that the intersubject dependency of acceleration RMS values by selected walking speed was specific for each group and for each of the three body axes. The analysis of ratios between these three accelerations provided informative outcomes correlated with clinical scores and not affected by walking speed. Our findings are an important step toward transferring accelerometry from human movement analysis laboratories to clinical settings.

Review of posttraumatic stress disorder and chronic pain: the path to integrated care.

Abstract: INTRODUCTION As of November 17, 2011, 6,320 U.S. servicemembers have been killed in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) [1]. An estimated 50,000 to 100,000 servicemembers have experienced nonmortal wounds and injuries during military deployments in OIF/OEF. The number of those injured is staggering, with an unprecedented number of injured U.S. servicemembers returning home compared with previous historical military actions. OIF/OEF have resulted in the highest wounded to fatality ratio compared with past conflicts involving U.S. servicemembers. The wounded to fatality ratio for our current military actions is 16 servicemembers wounded per every fatality. During World War I and World War II, there were two servicemembers wounded per every fatality. For the conflicts in Korea and Vietnam, the wounded to fatality ratio was close to three wounded per every fatality [2]. Our nation's wars prior to OIF/OEF resulted in a far greater loss of American lives, with not only fewer servicemembers surviving war injuries, but also a greater number being called to serve in combat. With a significantly greater number of servicemembers surviving devastating combat injuries today, it is clear that much credit is due to the incredible advances in military medicine. More servicemembers are surviving major combat injuries with the resulting medical, psychological, and social costs to servicemembers, their families, and the Department of Defense (DOD) and Department of Veterans Affairs (VA) medical systems to provide care for those with combat-related injuries. This has resulted in the emergence of multimodal pain management with the identification of proactive, not reactive, pain management to contribute to early rehabilitation and recovery [3]. These Veterans and servicemembers require complex medical care and our medical systems are constantly challenged to address their physical as well as psychological injuries, such as posttraumatic stress disorder (PTSD), as Veterans take steps forward in their lives following military discharge. In response to the comorbid presentations of both PTSD and chronic pain, the VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress was revised in 2010 with a special section devoted to the management and treatment of pain in patients who have PTSD. This article will highlight the clinical practice guideline with the primary purpose of helping clinicians gain a deeper understanding of these conditions as we continue to or begin to develop models of care to best meet the treatment needs of these patients. We must work in collaboration to integrate the care provided in our medical centers for all Veterans with both PTSD and chronic pain. METHODS A search of Medline (Medical Literature Analysis and Retrieval System Online), CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine Database), and PsycINFO (Psychological Information Database) was performed. No start date limit on the search criteria of the databases was set, but the end date was the first week of August 2011. The search was performed using the following combinations of terms: * "PTSD and Chronic Pain" within title and abstract. * "Posttraumatic Stress Disorder and Chronic Pain" within title and abstract. * "(Posttraumatic Stress Disorder or Chronic Pain) AND therapy" within title and abstract. * "(Posttraumatic Stress Disorder or Chronic Pain) AND medications" within title and abstract. * "(Posttraumatic Stress Disorder or Chronic Pain) AND depression." * "(PTSD or Chronic Pain)) and Substance Abuse" within title and abstract. * "Chronic Pain and Opioids" within title and abstract. * "Chronic Pain and Buprenorphine" within title and abstract. * "Chronic Pain and Headaches" within title and abstract. …

Efficiency of voluntary opening hand and hook prosthetic devices : 24 years of development?

Abstract: Quantitative data on the mechanical performance of upper-limb prostheses are very important in prostheses development and selection. The primary goal of this study was to objectively evaluate the mechanical performance of adult-size voluntary opening (VO) prosthetic terminal devices and select the best tested device. A second goal was to see whether VO devices have improved in the last two decades. Nine devices (four hooks and five hands) were quantitatively tested (Hosmer model 5XA hook, Hosmer Sierra 2 Load VO hook, RSL Steeper Carbon Gripper, Otto Bock model 10A60 hook, Becker Imperial hand, Hosmer Sierra VO hand, Hosmer Soft VO hand, RSL Steeper VO hand, Otto Bock VO hand). We measured the pinch forces, activation forces, cable displacements, mass, and opening span and calculated the work and hysteresis. We compared the results with data from 1987. Hooks required lower activation forces and delivered higher pinch forces than hands. The activation forces of several devices were very high. The pinch forces of all tested hands were too low. The Hosmer model 5XA hook with three bands was the best tested hook. The Hosmer Sierra VO hand was the best tested hand. We found no improvements in VO devices compared with the data from 1987.

Case report of modified Box and Blocks test with motion capture to measure prosthetic function.

Abstract: This case study report demonstrates the use of motion analysis with a modification of the Box and Blocks test. The goal was to quantify observed improvements in compensatory movements and simultaneous control in a subject using different prostheses before and after targeted muscle reinnervation (TMR) surgery. This is a single case study with data collection using a body-powered prosthesis pre-TMR surgery and 6 mo postfitting with a TMR myoelectric prosthesis. The Box and Blocks test was modified for cyclical motion within a motion capture laboratory. With the TMR myoelectric prosthesis, the subject was able to simultaneously activate the hand and elbow. Task performance was slower, but there was improved elbow flexion and less trunk compensatory motion than with the body-powered prosthesis. There are several limitations to the case study because there is no direct comparison of myoelectric performance before and after TMR surgery; however, the current report presents a potential method to quantify quality of motion and compensatory movements of prosthetic users. With further study, this test procedure has the potential to be a useful outcome measure for future standardized assessments of upper-limb prosthetic function.

Assessment of transfemoral amputees using C-Leg and Power Knee for ascending and descending inclines and steps.

Abstract: INTRODUCTION Over 840 U.S. military servicemembers have sustained a major lower-limb amputation as a result of the current conflicts, Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) [1]. These servicemembers are almost always extremely motivated to reach their highest level of function. Whether remaining on Active Duty or eventually separating to civilian life, each individual will continue to have many physical obstacles to negotiate, including stairs and slopes. The loss of a limb, and the respective anatomical joints, has been shown to cause a deviation from "normalized" mobility and can result in asymmetries during gait [2-8]. These asymmetries have been reported to contribute to secondary injuries such as osteoarthritis, joint degeneration, and low-back pain [7,9-15]. Servicemembers with trauma, including amputation, to one or both lower limbs may be at a greater risk for secondary injuries because of additional physical compensations during ambulation. Ascending and descending slopes and stairs present a greater biomechanical challenge than overground walking. The additional difficulties associated with slopes and stairs may translate into additional degeneration of the remaining joints caused by increased forces and moments compared with overground walking. Research has shown that for young nondisabled individuals, joint forces and moments at the knees and hips are greater during stair ascent than descent or level walking. This implies a greater demand on those joints [1617]. Minimal research has been conducted on ambulation of those with major limb loss during stair and ramp ascent and descent. One study examined stair descent for persons with transfemoral amputation (TFA) and transtibial amputation and stair ascent for those with transtibial amputation only [18]. They concluded that during stair descent, people with TFA respond more similarly to controls than people with transtibial amputation. This result occurs because people with TFA who use a microprocessor knee are better able to control knee hydraulics during the descent than those with mechanical knees. Better knee hydraulics allow a person using a microprocessor knee to control their descent. During ascent, functional compensations are made primarily by the contralateral limb [18]. The compensations and resulting forces on the nondisabled limb may be even greater for those with TFA because of loss of a functional knee on the involved side. For people who have TFA, stair climbing is a challenging functional task. One study reports that only 7.2 percent of people with TFA are able to ascend stairs without handrail assistance and only 3 percent descend stairs step-over-step [19]. This result differs from previously mentioned research [18], which reports people with TFA descending predominantly step-over-step. These differing results may have occurred because of the prosthetic technologies used for the studies cited and when the studies occurred (1984 vs 2007). These data highlight the difficulty of this task and the importance of identifying solutions that will ease the burden of stair ambulation, particularly for people with TFA. Compared with stair ambulation, ramp ambulation was easier for these individuals because 99 percent required no assistance to ascend or descend ramps while 1 percent needed assistance [19]. This does not imply that sloped gait is not difficult for persons with TFA. One study shows that kinematic adjustment strategies are employed while negotiating slopes [20]. Efforts to replace knee function with mechanical devices have been met with varying degrees of success. The literature contains an ample number of biomechanical studies that, through the years, can be shown to correlate improved gait dynamics with technological advances in prosthetic knee design [21-23]. Decreased frequency of falls and stumbles and increased user satisfaction have also been demonstrated with the use of microprocessor-controlled prosthetic knee units compared with mechanical devices [24-25]. …

Vergence in mild traumatic brain injury: a pilot study.

Abstract: Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life, functional abilities, and rehabilitative progress. In this study, we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms. The results were compared with 10 control adult subjects. With respect to dynamic parameters, responses in those with mTBI were slowed, variable, and delayed. With respect to static parameters, reduced near point of convergence and restricted near vergence ranges were found in those with mTBI. The present results provide evidence for the substantial adverse effect of mTBI on vergence function.

Initial developmental process of a VA semistructured clinical interview for TBI identification.

Abstract: INTRODUCTION Evaluating military servicemembers and veterans for possible undetected injuries or conditions of war has been a high priority for the Department of Defense (DOD) and Department of Veterans Affairs (VA). One such condition is traumatic brain injury (TBI), particularly mild TBI. In the context of returning Active Duty servicemembers or veterans presenting for healthcare months or years after a possible mild TBI, the identification of mild TBI is a challenge because of the necessary reliance on subjective report of a relatively remote historical event. The need to identify and appropriately treat individuals with TBI led the Veterans Health Administration (VHA) to establish a task force to develop clinically appropriate screening and evaluation tools for TBI. Lacking an existing and validated screening instrument, the task force reviewed the literature on the natural history of TBI and existing screening tools and collaborated with the Defense and Veterans Brain Injury Center to develop a TBI screening instrument. In April 2007, the four-section TBI screening instrument was mandated for all individuals returning from deployment in the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) theaters of operation (VHA Directive 2007-013). The screening process is initiated through an automated computerized patient record system (CPRS) that triggers a four-section TBI screen, the TBI Clinical Reminder. Patients who respond affirmatively to each of the four TBI screening sections are considered to have a positive screen and are referred for further evaluation. The TBI Clinical Reminder screen was designed to be sensitive to symptomatic individuals who likely sustained a TBI during OIF/OEF deployment. Hoge et al. [1] and Tanielian and Jaycox [2] have noted high levels of comorbidity and overlap in symptoms across diagnostic conditions in this patient population (e.g., TBI, posttraumatic stress disorder [PTSD], and depression) that may trigger false-positive responses to the TBI screen. Hoge et al. suggested that implementation of such a TBI screening process could have unintended iatrogenic consequences [1]. Although the VHA screening process has been in effect since April 2007, the overall validity (false positives and false negatives) and reliability of the TBI Clinical Reminder are just beginning to be evaluated. However, a recent prospective study of 500 veterans across six VA facilities in one Veterans Integrated Service Network found that the TBI Clinical Reminder had high internal consistency (0.77), test-retest reliability (0.80), and sensitivity (0.94), but only moderate specificity (0.59) [3], consistent with the concerns about excessive false-positive responses. The study utilized research assistants specifically trained to identify TBI by using a comprehensive structured interview. As a result, these reliability estimates are likely inflated compared with the VHA national average. Another test-retest reliability study found relatively poor stability coefficients for individual subitems within the TBI Clinical Reminder (kappa values generally less than 0.50) but did not report on the overall test-retest reliability for the screener as a whole (i.e., positive vs negative screen across test-retest) or attempt to address issues of sensitivity and specificity [4]. Following a positive TBI Clinical Reminder screen, VHA clinical programs complete a Second Level TBI Evaluation by using a defined protocol that includes a clinical history, review of systems, targeted neurological evaluation, the Neurobehavioral Symptom Inventory [5], and an individualized plan of care. A CPRS template was released to the field on October 1, 2007, to facilitate and standardize this evaluation and treatment plan development. However, the template does not provide a structured format for completing a history or determining whether or not a TBI occurred during deployment. …

Application of self-report and performance-based outcome measures to determine functional differences between four categories of prosthetic feet.

Abstract: We examined the application of outcome measures to determine changes in function caused by standardized functional prosthetic gait training and the use of four different prosthetic feet in people with unilateral transtibial limb loss. Two self-report measures (Prosthetic Evaluation Questionnaire-Mobility Scale [PEQ-13] and Locomotor Capabilities Index [LCI]), and three performance-based measures (Amputee Mobility Predictor with a prosthesis [AMPPRO], 6-minute walk test [6MWT] and step activity monitor [SAM]) were used. Ten people with unilateral transtibial limb loss, five with peripheral vascular disease (PVD) and five without PVD, completed testing. Subjects were tested at baseline and after receiving training with their existing prosthesis and with the study socket and four prosthetic feet, i.e., SACH (solid ankle cushion heel), SAFE (stationary attachment flexible endoskeletal), Talux, and Proprio feet, over 8 to 10 weeks. Training was administered between testing sessions. No differences were detected by the PEQ-13, LCI, 6MWT, or SAM following training and after fitting with test feet. The AMPPRO demonstrated differences following training with the existing prosthesis in the PVD group and between selected feet from baseline testing ( p

Small N designs for rehabilitation research

Abstract: INTRODUCTION Rehabilitation research implements studies in which the long-term goals are to improve health and promote wellness for persons with physical disabilities. Rehabilitation presents a growing area of research within society as a whole and, more specifically, within the Veterans Health Administration (VHA) and Department of Defense. The recent Operation Iraqi Freedom/Operation Enduring Freedom conflicts have resulted in an unprecedented number of wounded warriors presenting for rehabilitation because of traumatic brain injury (TBI), blast injuries, amputation, and other conditions, which frequently include polytrauma characterized by lung, bowel, and inner ear injuries; traumatic-limb or partial-limb amputation; soft tissue trauma from fragments and other missiles; and posttraumatic stress injuries [1-3]. As a result, the VHA has targeted rehabilitation research as a primary focus of the overall research portfolio. The randomized clinical trial (RCT) is the gold standard of research designs, providing the best evidence of effect [4]. The RCT is regarded as the most rigorous design because of the prospective nature, randomization of subjects to independent study arms, and blinding process. Ideally, the randomization process balances potential confounding factors equally across study groups, and blinding reduces potential bias by blocking investigators and subjects from the hypothesis under investigation. However, RCTs are generally narrow in scope and thus lack generalizability [5-7]; they are costly and time-consuming. The RCT design may not be applicable to assistive technologies and environmental modifications--vital components of disability and rehabilitation research. In many clinical scenarios, a meaningful control group experience is difficult--if not impossible--to design or implement. For example, many interventions in the rehabilitation setting are highly individualized (e.g., modifying assistive equipment to individual needs or abilities) and a control-group comparison is unreasonable [8]. RCTs are typically contingent on participants consenting to the randomization process, which raises concerns about the degree to which consenting participants are representative of the larger number of those who are unable or unwilling to consent. Rehabilitation research often involves specific behavioral and performance outcomes among persons who have low-incidence conditions or who have multiple and complex co-occurring conditions (e.g., polytrauma with behavioral disturbance among returning veterans). The effectiveness of randomization depends on large samples, representative of the population of concern, to distribute unmeasured factors that might otherwise influence results. Issues of underpowered studies, sample size requirements, and recruitment goals often plague rehabilitation research. Statistical issues regarding sample size requirements for an adequately powered RCT may be in direct conflict with realistic recruitment and subject retention goals. There is simply no margin for error given the number of available subjects with infrequent or co-occurring conditions. Rehabilitation researchers are hard-pressed to balance scientific rigor with clinical feasibility. Consequently, the narrow scope and stringent requirements of the RCT may be theoretically premature, clinically time-consuming, and of questionable generalizability for many research problems encountered in clinical rehabilitation. In January 2010, the Department of Veteran Affairs (VA), Rehabilitation Research and Development Service convened a State-of-the-Art conference in Miami, Florida, to discuss current and future seminal issues pertinent to rehabilitation research both within and without VA. In this article, we summarize the strategy discussion about situations typically encountered by rehabilitation researchers in which small samples sizes are an issue. Quasi-experimental and experimental small N designs are ideal methods for clinical research in which understanding and changing maladaptive patterns in a patient's behavior and functional status are primary goals [9-10]. …