Predicting later categories of upper limb activity from earlier clinical assessments following stroke: An exploratory analysis

BACKGROUND: Accelerometers allow for direct measurement of upper limb (UL) activity. Recently, multi-dimensional categories of UL performance have been formed to provide a more complete measure of UL use in daily life. Prediction of motor outcomes after stroke have tremendous clinical utility and a next step is to explore what factors might predict someone\u27s subsequent UL performance category. PURPOSE: To explore how different machine learning techniques can be used to understand how clinical measures and participant demographics captured early after stroke are associated with the subsequent UL performance categories. METHODS: This study analyzed data from two time points from a previous cohort (n = 54). Data used was participant characteristics and clinical measures from early after stroke and a previously established category of UL performance at a later post stroke time point. Different machine learning techniques (a single decision tree, bagged trees, and random forests) were used to build predictive models with different input variables. Model performance was quantified with the explanatory power (in-sample accuracy), predictive power (out-of-bag estimate of error), and variable importance. RESULTS: A total of seven models were built, including one single decision tree, three bagged trees, and three random forests. Measures of UL impairment and capacity were the most important predictors of the subsequent UL performance category, regardless of the machine learning algorithm used. Other non-motor clinical measures emerged as key predictors, while participant demographics predictors (with the exception of age) were generally less important across the models. Models built with the bagging algorithms outperformed the single decision tree for in-sample accuracy (26-30% better classification) but had only modest cross-validation accuracy (48-55% out of bag classification). CONCLUSIONS: UL clinical measures were the most important predictors of the subsequent UL performance category in this exploratory analysis regardless of the machine learning algorithm used. Interestingly, cognitive and affective measures emerged as important predictors when the number of input variables was expanded. These results reinforce that UL performance, in vivo, is not a simple product of body functions nor the capacity for movement, instead being a complex phenomenon dependent on many physiological and psychological factors. Utilizing machine learning, this exploratory analysis is a productive step toward the prediction of UL performance. Trial registration NA

Implementation of wearable sensing technology for movement: Pushing forward into the routine physical rehabilitation care field

While the promise of wearable sensor technology to transform physical rehabilitation has been around for a number of years, the reality is that wearable sensor technology for the measurement of human movement has remained largely confined to rehabilitation research labs with limited ventures into clinical practice. The purposes of this paper are to: (1) discuss the major barriers in clinical practice and available wearable sensing technology; (2) propose benchmarks for wearable device systems that would make it feasible to implement them in clinical practice across the world and (3) evaluate a current wearable device system against the benchmarks as an example. If we can overcome the barriers and achieve the benchmarks collectively, the field of rehabilitation will move forward towards better movement interventions that produce improved function not just in the clinic or lab, but out in peoples\u27 homes and communities

A case-control study of the effectiveness of tissue plasminogen activator on 6 month patients -- reported outcomes and health care utilization

none5siWe examined the benefit of tissue plasminogen activator (tPA), delivered as part of usual stroke management, on patient-reported outcomes and health care utilization. Using a case control design, patients who received tPA as part of usual stroke management were compared with patients who would have received tPA had they arrived to the hospital within the therapeutic time window. Data were collected from surveys 6 months after stroke using standardized patient-reported outcome measures and questions about health care utilization. Demographic and medical data were acquired from hospital records. Patients were matched on stroke severity, age, race, and gender. Matching was done with 1:2 ratio of tPA to controls. Results were compared between groups with 1-tailed tests because of a directionally specific hypothesis in favor of the tPA group. The tPA (n = 78) and control (n = 156) groups were matched across variables, except for stroke severity, which was better in the control group; subsequent analyses controlled for this mismatch. The tPA group reported better physical function, communication, cognitive ability, depressive symptomatology, and quality of life/participation compared with the control group. Fewer people in the tPA group reported skilled nursing facility stays, emergency department visits, and rehospitalizations after their stroke compared with controls. Reports of other postacute services were not different between groups. Although it is known that tPA reduces disability, this is the first study to demonstrate the effectiveness of tPA in improving meaningful, patientreported outcomes. Thus, use of tPA provides a large benefit to the daily lives of people with ischemic stroke.mixedLang, Catherine E.; Bland, Marghuretta D.; Cheng, Nuo; Corbetta, Maurizio; Lee, Jin-MooLang, Catherine E.; Bland, Marghuretta D.; Cheng, Nuo; Corbetta, Maurizio; Lee, Jin Mo

Effects of remote limb ischemic conditioning on muscle strength in healthy young adults: A randomized controlled trial

Remote limb ischemic conditioning (RLIC) is a clinically feasible method in which brief, sub-lethal bouts of ischemia protects remote organs or tissues from subsequent ischemic injury. A single session of RLIC can improve exercise performance and increase muscle activation. The purpose of this study, therefore, was to assess the effects of a brief, two-week protocol of repeated RLIC combined with strength training on strength gain and neural adaptation in healthy young adults. Participants age 18-40 years were randomized to receive either RLIC plus strength training (n = 15) or sham conditioning plus strength training (n = 15). Participants received RLIC or sham conditioning over 8 visits using a blood pressure cuff on the dominant arm with 5 cycles of 5 minutes each alternating inflation and deflation. Visits 3-8 paired conditioning with wrist extensors strength training on the non-dominant (non-conditioned) arm using standard guidelines. Changes in one repetition maximum (1 RM) and electromyography (EMG) amplitude were compared between groups. Both groups were trained at a similar workload. While both groups gained strength over time (P = 0.001), the RLIC group had greater strength gains (9.38 ± 1.01 lbs) than the sham group (6.3 ± 1.08 lbs, P = 0.035). There was not a significant group x time interaction in EMG amplitude (P = 0.231). The RLIC group had larger percent changes in 1 RM (43.8% vs. 26.1%, P = 0.003) and EMG amplitudes (31.0% vs. 8.6%, P = 0.023) compared to sham conditioning. RLIC holds promise for enhancing muscle strength in healthy young and older adults, as well as clinical populations that could benefit from strength training

Predictors of return to driving after stroke

OBJECTIVE: While returning to driving is a major concern for many stroke survivors, predicting who will return to driving after a stroke is often difficult for rehabilitation professionals. The primary aim of this study was to identify patient factors present at admission to an inpatient rehabilitation hospital that can be used to identify which patients with acute stroke will and will not return to driving. DESIGN: After comparing returners and non-returners on demographic and clinical characteristics, a logistic regression model with return to driving as the outcome variable was built using the backward stepwise method. RESULTS: Thirty-one percent (48/156) of patients who had been driving before their stroke had returned to driving six months post-stroke. The final regression model, using FIM cognition and lower extremity Motricity Index scores, predicted the driving outcome with an accuracy of 75% (107/143). CONCLUSIONS: Patients with lower FIM cognition and lower extremity Motricity Index scores at admission to inpatient rehabilitation are less likely to return to driving at six months. This model could be used by rehabilitation professionals to help counsel patients and their families and focus treatment goals

Prediction of discharge walking ability from initial assessment in a stroke inpatient rehabilitation facility population

Objectives: To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF. Design: Retrospective cohort study. Setting: IRF. Participants: Two samples of participants (n=110 and 159) admitted with stroke. Interventions: A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (= 0.4-0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants. Main Outcome Measure: Discharge 10-m walk speed. Results: Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6-63) for sample I and 32 (95% CI, 10-96) for sample 2 when the combination of having a Berg Balance Scale score of <= 20 and a FIM walk item score of 1 or 2 was present. Conclusions: A Berg Balance Scale score of <= 20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF

The brain recovery core: Building a system of organized stroke rehabilitation and outcomes assessment across the continuum of care

none10siThis Special Interest article describes a multidisciplinary, interinstitutional effort to build an organized system of stroke rehabilitation and outcomes measurement across the continuum of care. This system is focused on a cohort of patients who are admitted with the diagnosis of stroke to our acute facility, are discharged to inpatient and/or outpatient rehabilitation at our free-standing facility, and are then discharged to the community. This article first briefly explains the justification, goals, and purpose of the Brain Recovery Core system. The next sections describe its development and implementation, with details on the aspects related to physical therapy. The article concludes with an assessment of how the Brain Recovery Core system has changed and improved delivery of rehabilitation services. It is hoped that the contents of this article will be useful in initiating discussions and potentially facilitating similar efforts among other centers.mixedLang, Catherine E.; Bland, Marghuretta D.; Connor, Lisa Tabor; Fucetola, Robert; Whitson, Michelle; Edmiaston, Jeff; Karr, Clayton; Sturmoski, Audra; Baty, Jack; Corbetta, MaurizioLang, Catherine E.; Bland, Marghuretta D.; Connor, Lisa Tabor; Fucetola, Robert; Whitson, Michelle; Edmiaston, Jeff; Karr, Clayton; Sturmoski, Audra; Baty, Jack; Corbetta, Maurizi

Clinician adherence to a standardized assessment battery across settings and disciplines in a poststroke rehabilitation population

none12siObjectives: (1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence. Design: Retrospective cohort study. Setting: Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists). Participants: Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments. Interventions: Not applicable. Main Outcome Measures: Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence >= 5% and if so, how long the increase lasted. Results: Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P = 5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month. Conclusions: Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time. (C) 2013 by the American Congress of Rehabilitation MedicinemixedBland, Marghuretta D.; Sturmoski, Audra; Whitson, Michelle; Harris, Hilary; Connor, Lisa Tabor; Fucetola, Robert; Edmiaston, Jeff; Huskey, Thy; Carter, Alexandre; Kramper, Marian; Corbetta, Maurizio; Lang, Catherine E.Bland, Marghuretta D.; Sturmoski, Audra; Whitson, Michelle; Harris, Hilary; Connor, Lisa Tabor; Fucetola, Robert; Edmiaston, Jeff; Huskey, Thy; Carter, Alexandre; Kramper, Marian; Corbetta, Maurizio; Lang, Catherine E