Lessons Learned: The Difficulties of Incorporating Intensity Principles Into Inpatient Stroke Rehabilitation.

OBJECTIVE: The objective of this study was to determine the feasibility of a rehabilitation approach focusing on cardiovascular, strength, and gait training intensity in the inpatient rehabilitation setting after a new onset of stroke. We additionally aimed to determine the efficacy of this intensity-based program on rehabilitation outcomes compared with usual care. DESIGN: Participants were pseudo-randomized to an intensity-based program focusing on gait, cardiovascular, and strength training or to usual care. Outcomes included FIM, 10-meter walk, 2-minute walk, timed Up and Go test, 5-time sit-to-stand test, and Tinetti balance assessment. INTERVENTION: The intervention consisted of 6 20-minute sessions per week dedicated to intensity of activity: 2 each for walking, cardiovascular training, and strength training. PARTICIPANTS: Patients (N=49) with new onset stroke admitted to inpatient rehabilitation over the course of 1 year. SETTING: Four inpatient rehabilitation facilities with comprehensive neurologic rehabilitation teams. RESULTS: Thirty-five individuals (16 intervention, 19 controls) completed all testing. Subject compliance to the intensity intervention demonstrated completion of approximately half the prescribed sessions. All outcomes improved significantly from admission to discharge, and a significant interaction between treatment group and time was observed for the 2-minute walk and the Tinetti balance assessment. The 2-minute walk, Tinetti balance assessment, 10-meter walk, and FIM demonstrated between-group effect sizes greater than 0.60 in favor of the intervention group. CONCLUSIONS: The intensity-based protocol was safe, and several measures demonstrated efficacy when compared with usual care. Results may have been limited by poor program compliance, showing a need to identify and ameliorate obstacles to integration of comprehensive intensity-based programs addressing endurance, strength, and gait training. Applying physiological principles of exercise to acute stroke rehabilitation demonstrates great promise for improving independent physical function.

The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic.

This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p = 0.03) and perceptions of clinical reasoning skills when compared to the control group (p = 0.002). This study is novel as it examined students' perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.

Risk of Fall-Related Injuries among Ambulatory Participants with Spinal Cord Injury.

BACKGROUND: With medical and rehabilitation advances, many people are able to regain or maintain ambulation after spinal cord injury (SCI). However, those who are ambulatory may be at increased risk for falls. OBJECTIVE: To assess the relationships between walking devices and behaviors, including alcohol use, prescription medication use, and exercise, with falls among persons with SCI who are ambulatory. METHODS: A total of 515 adults with chronic SCI who were able to ambulate provided self-report of their use of assistive devices for ambulation, prescription medication use, alcohol use, exercise, and falls resulting in injury (FRI). RESULTS: At least 1 FRI was reported by 20.3% of participants in the past year. Ambulatory participants who reported using a wheelchair as their primary mode of mobility were less likely to have an FRI than those who reported walking more than using a wheelchair. Those with perceived poor balance were 2.41 times more likely to have an FRI than those without poor balance. Those who reported less exercise than other persons with a comparable SCI severity were 2.77 times more likely to have an FRI than those reporting the same or more amount of exercise. Pain medication misuse also was associated with higher odds of an FRI. CONCLUSIONS: Health care providers should be aware of the risk for FRI among those who are ambulatory. They should assess and consider not only ambulatory ability, but also behaviors, including prescription medication use and exercise, when recommending ambulation techniques.

Ambulation and complications related to assistive devices after spinal cord injury.

OBJECTIVE: To evaluate long-term health outcomes including pain intensity, pain interference, and fatigue among ambulatory persons with spinal cord injury (SCI). DESIGN: Prospective cohort study. SETTING: Data were analyzed at a major medical university in the southeast USA. PARTICIPANTS: Participants included 783 ambulatory adults with SCI of traumatic origin, who were at least 1-year post-injury. Participants were identified through three sources of records at a large specialty hospital in the southeastern USA. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Pain intensity and interference (Brief Pain Inventory) and fatigue (Modified Fatigue Impact Scale Abbreviated Version 5). RESULTS: Examining assistive devices used for ambulation, 66% of the population used at least one device. In the logistic model, wheelchair and cane usage were significantly related to the outcomes after controlling for age, gender, and race. Wheelchair usage 50% of the time or less was significantly related to pain intensity (odds ratio (OR) 2.05, 95% confidence interval (CI) = 1.39-3.03), pain interference (OR 2.11, 95% CI = 1.43-3.12), and fatigue (OR 1.99, 95% CI = 1.12-1.43). Additionally, unilateral cane use was significantly related to the outcomes; pain intensity (OR 1.86, 95% CI = 1.35-2.56), pain interference (OR 2.11, 95% CI = 1.52-2.93), and fatigue (OR 2.49, 95% CI = 1.52-4.08). CONCLUSIONS: Among ambulatory persons with SCI, increased pain intensity, pain interference, and fatigue are associated with minimal wheelchair usage (50% or less) and less supportive assistive device (unilateral cane) usage.

Discharge planning simulation: training the interprofessional team for the future workplace.

PURPOSE: The integration of interprofessional education (IPE) into health professions curricula offers a possible way to increase collaboration among health professionals. In this paper we introduce an innovative IPE model of a team-based discharge planning case scenario. METHODS: Occupational therapy, physician assistant, and physical therapy students (n=173) participated in a discharge planning simulation (DPS) focused on a patient with a stroke and subsequent hip fracture. A discharge-planning meeting DVD was developed and disseminated to the students. Pre and post surveys were sent to the students. OUTCOMES: Eighty-nine percent (n=153) of the students responded to the pre-DPS survey and 77% (n=132) responded to the post-DPS survey. There was no significant difference when comparing pre-DPS or post-DPS by program of study, but significant differences were found in three of the four questions when comparing individual answers. CONCLUSION: Participation in the DPS model resulted in significant changes in perception of a student's individual role as well as the role of their interprofessional team members in discharge planning for the complex patient. Preliminary results indicate that this model can be a useful tool to effectively teach the interprofessional team.