Rehabilitation Response to COVID-19: Optimizing Recovery and Social Reintegration for Military Beneficiaries.

COVID-19 is a novel disease with complex primary and secondary health effects that may significantly impact the functional independence and quality of life of patients and their families. While the term "rehabilitation" is often associated with exercise, the interventions employed by rehabilitation professionals in both the inpatient and outpatient setting are much more complex and very relevant in caring for individuals hospitalized with respiratory infections. Since the start of the pandemic, the Department of Rehabilitation at Walter Reed National Military Medical Center has cared for over 85% of the military beneficiaries admitted to the hospital for COVID-19. In addition to providing acute inpatient occupational, physical, and recreational therapy to help maximize each patient's functional independence, the rehabilitation team has also developed a novel program to help facilitate the safe discharge and successful recovery and social reintegration for all patients with COVID-19. Using a holistic approach, a team led by Occupational Therapy has applied a needs-based assessment of each patient and developed an individualized treatment plan, which employs home monitoring, virtual health interventions, peer support, and augmentation to case management and behavioral health care. The overall acceptance and satisfaction of this program by the patients and staff has been excellent, with early evidence to suggest improved quality of life and possible mitigation of long-term complications. This article describes the development and essential elements of this unique rehabilitation program so that other military treatment facilities may consider implementing.

Six-year clinical performance of etch-and-rinse and self-etch adhesives.

OBJECTIVE: To evaluate the 6-year clinical performance of Xeno IV, Xeno III, and XP Bond adhesives in the restoration of non-carious cervical lesions (NCCLs). METHODS: This was a randomized controlled clinical trial where 39 participants met the inclusion/exclusion criteria and were enrolled. Lesions restored were notch-shaped NCCLs. Prior to adhesive procedures, NCCLs were roughened. No enamel bevel was placed and no mechanical retention was created. Adhesive systems were applied following manufacturer's instructions and the NCCLs were restored with composite resin (TPH(3)). Restorations were finished immediately after placement and scored with regard to retention, marginal discoloration, marginal adaptation, sensitivity, and secondary caries using modified USPHS criteria. Descriptive statistics were performed. Logistic regression models were performed for each outcome separately with compound symmetry correlation structure where teeth were clustered by participants. All analyses were conducted using SAS 9.2. RESULTS: The 6-year recall rate was 77.5% of the restorations (76.9% of the participants). No statistical differences were found between adhesives for retention, marginal discoloration, and marginal adaptation. Restorations failed by loss of retention (16.7%, 27.6%, and 11.8% of Xeno IV, Xeno III, and XP Bond restorations, respectively) and marginal discoloration (7.4% of Xeno IV restorations). For every unit increase in restoration volume it was 1.31 (95%C.I. 1.05, 1.63, P=0.01) times more likely that the restoration retention would be maintained. SIGNIFICANCE: The tested adhesive systems presented similar clinical performance after six years of service, with annual failure rates of 2.8%, 4.6%, and 2.0% for Xeno IV, Xeno III, and XP Bond, respectively.

Chronic HPA axis response to stress in temporomandibular disorder.

PURPOSE: Perceived stress is associated with temporomandibular disorder (TMD), but whether cortisol levels are elevated in individuals with TMD is unknown. We hypothesized that cortisol concentration, a biomarker of hypothalamic-pituitary-adrenal (HPA) axis function, was elevated in TMD cases relative to controls, and that perceived stress was positively correlated with cortisol concentration. METHODS: In this case control study, TMD case status was determined by examiners using TMD Research Diagnostic Criteria. Participants (n=116) aged 18 to 59 years were recruited from within a 50 mile radius of the University of North Carolina at Chapel Hill. Following examination, cases (n=45) and controls (n=71) completed the 14-item Perceived Stress Scale using a reference interval of the past 3 months. Approximately 100 strands of hair were cut from the posterior vertex segment of their scalp. The 3 centimeters of hair most proximal to the scalp was analyzed with a commercially available salivary cortisol enzyme immunoassay adapted for hair cortisol. This length corresponds to the last 3 months of systemic HPA axis activity. RESULTS: TMD cases perceived higher stress than controls (p=0.001). However, hair cortisol concentration was lower in TMD cases than controls (p<0.001). The correlation coefficient revealed a weak negative relationship (r=-0.188) between perceived stress and hair cortisol concentration (p=0.044). In analysis stratified by case status, the relationship of perceived stress and hair cortisol concentration was non-significant for cases (p=0.169) and controls (p=0.498). CONCLUSION: Despite greater perceived stress, TMD cases had lower hair cortisol concentrations than controls and the 2 measures of stress were weakly and negatively correlated.

Chronic HPA axis response to stress in temporomandibular disorder.

PURPOSE: Perceived stress is associated with temporomandibular disorder (TMD), but whether cortisol levels are elevated in individuals with TMD is unknown. We hypothesized that cortisol concentration, a biomarker of hypothalamic-pituitary-adrenal (HPA) axis function, was elevated in TMD cases relative to controls, and that perceived stress was positively correlated with cortisol concentration. METHODS: In this case control study, TMD case status was determined by examiners using TMD Research Diagnostic Criteria. Participants (n=116) aged 18 to 59 years were recruited from within a 50 mile radius of the University of North Carolina at Chapel Hill. Following examination, cases (n=45) and controls (n=71) completed the 14-item Perceived Stress Scale using a reference interval of the past 3 months. Approximately 100 strands of hair were cut from the posterior vertex segment of their scalp. The 3 centimeters of hair most proximal to the scalp was analyzed with a commercially available salivary cortisol enzyme immunoassay adapted for hair cortisol. This length corresponds to the last 3 months of systemic HPA axis activity. RESULTS: TMD cases perceived higher stress than controls (p=0.001). However, hair cortisol concentration was lower in TMD cases than controls (p<0.001). The correlation coefficient revealed a weak negative relationship (r=-0.188) between perceived stress and hair cortisol concentration (p=0.044). In analysis stratified by case status, the relationship of perceived stress and hair cortisol concentration was non-significant for cases (p=0.169) and controls (p=0.498). CONCLUSION: Despite greater perceived stress, TMD cases had lower hair cortisol concentrations than controls and the 2 measures of stress were weakly and negatively correlated.

Results of clinicians using a therapeutic robotic system in an inpatient stroke rehabilitation unit.

BACKGROUND: Physical rehabilitation is an area where robotics could contribute significantly to improved motor return for individuals following a stroke. This paper presents the results of a preliminary randomized controlled trial (RCT) of a robot system used in the rehabilitation of the paretic arm following a stroke. METHODS: The study's objectives were to explore the efficacy of this new type of robotic therapy as compared to standard physiotherapy treatment in treating the post-stroke arm; to evaluate client satisfaction with the proposed robotic system; and to provide data for sample size calculations for a proposed larger multicenter RCT. Twenty clients admitted to an inpatient stroke rehabilitation unit were randomly allocated to one of two groups, an experimental (robotic arm therapy) group or a control group (conventional therapy). An occupational therapist blinded to patient allocation administered two reliable measures, the Chedoke Arm and Hand Activity Inventory (CAHAI-7) and the Chedoke McMaster Stroke Assessment of the Arm and Hand (CMSA) at admission and discharge. For both groups, at admission, the CMSA motor impairment stage of the affected arm was between 1 and 3. RESULTS: Data were compared to determine the effectiveness of robot-assisted versus conventional therapy treatments. At the functional level, both groups performed well, with improvement in scores on the CAHAI-7 showing clinical and statistical significance. The CAHAI-7 (range7-49) is a measure of motor performance using functional items. Individuals in the robotic therapy group, on average, improved by 62% (95% CI: 26% to 107%) while those in the conventional therapy group changed by 30% (95% CI: 4% to 61%). Although performance on this measure is influenced by hand recovery, our results showed that both groups had similar stages of motor impairment in the hand. Furthermore, the degree of shoulder pain, as measured by the CMSA pain inventory scale, did not worsen for either group over the course of treatment. CONCLUSION: Our findings indicated that robotic arm therapy alone, without additional physical therapy interventions tailored to the paretic arm, was as effective as standard physiotherapy treatment for all responses and more effective than conventional treatment for the CMSA Arm (p = 0.04) and Hand (p = 0.04). At the functional level, both groups performed equally well.

Dental hygiene students' attitudes toward ethical dilemmas in practice.

This article reports the findings of a survey-based study conducted in 2006 to determine graduating dental hygiene students' attitudes toward ethical dilemmas in eight areas of practice: substandard care, overtreatment of patients, scope of practice, fraud, confidentiality, impaired professionals, sexual harassment, abuse, and health status. The findings, based on responses from 1,165 students at 141 U.S. dental hygiene programs, indicate that many dental hygiene students do not understand what behaviors in the patient care environment are consistent with ethical practice and which are not. Responding students believed that hygienists have a strong duty to report, intercede, or educate in areas of abuse, sexual harassment, detection of cancer, and smoking cessation. However, they were less likely to report concerns about ethical transgressions such as fraud, inadequate infection control, exceeding practice scope, and failure to diagnose disease when such disclosures could potentially threaten their employment status. Based on the results, we recommend that dental hygiene programs explore curriculum enhancements to improve students' comprehension of what constitutes fraud and other ethical transgressions and the proper reporting mechanisms.

Documentation of daily sit-to-stands performed by community-dwelling adults.

No information exists about how many sit-to-stands (STSs) are performed daily by community-dwelling adults. We, therefore, examined the feasibility of using a tally counter to document daily STSs, documented the number of daily STSs performed, and determined if the number of STSs was influenced by demographic or health variables. Ninety-eight community-dwelling adults (19-84 years) agreed to participate. After providing demographic and health information, subjects used a tally counter to document the number of STSs performed daily for 7 consecutive days. All but two subjects judged their counter-documented STS number to be accurate. Excluding data from these and two other subjects, the mean number of STSs for subjects was 42.8 to 49.3, depending on the day. The number was significantly higher on weekdays than weekends. No demographic or health variable was significantly related to the number of STSs in univariate or multivariate analysis. In conclusion, this study suggests that a tally counter may be a practical aid to documenting STS activity. The STS repetitions recorded by the counter in this study provide an estimate of the number of STSs that community-dwelling adults perform daily.

Comparing 2 versions of the Chedoke Arm and Hand Activity Inventory with the Action Research Arm Test.

BACKGROUND AND PURPOSE: The Chedoke Arm and Hand Activity Inventory (CAHAI) is a new, validated upper-limb measure that uses a 7-point quantitative scale in order to assess functional recovery of the arm and hand after a stroke. The purposes of this study were: (1) to determine whether the longitudinal validity of scores on 2 versions of a new upper-limb measure, the CAHAI (CAHAI-9 and CAHAI-13), was greater than that of scores on the Action Research Arm Test (ARAT) and (2) to determine whether the cross-sectional and longitudinal validity of the CAHAI-13 scores was greater than that of the CAHAI-9 scores. SUBJECTS: One hundred five people with upper-limb dysfunction following a stroke were stratified into 2 impairment groups (mild to moderate and severe), which were expected to change by different amounts. METHODS: The CAHAI-13 and ARAT were administered twice (time between assessments varied from 2 to 6 weeks). Receiver operating characteristic curves, Pearson product moment coefficient of correlation, and regression analyses were used. RESULTS: Receiver operating characteristic curve areas (CAHAI-13=0.86, CAHAI-9=0.82, ARAT=0.72) were significantly greater for the CAHAI versions. Scores on both CAHAI versions had identical levels of cross-sectional validity. DISCUSSION AND CONCLUSION: Both CAHAI versions demonstrated more sensitivity to change than the ARAT. It remains unclear whether the CAHAI-9 provides precise estimates of CAHAI-13 scores at the individual level.

Test-retest reliability, validity, and sensitivity of the Chedoke arm and hand activity inventory: a new measure of upper-limb function for survivors of stroke.

OBJECTIVES: To estimate the test-retest reliability and validity of the Chedoke Arm and Hand Activity Inventory (CAHAI) and to test whether the CAHAI was more sensitive to change in upper-limb function than the Impairment Inventory of the Chedoke-McMaster Stroke Assessment (CMSA) and the Action Research Arm Test (ARAT). DESIGN: Construct validation process. SETTING: Inpatient/outpatient rehabilitation facilities. PARTICIPANTS: Stratified sample of 39 survivors of stroke: 24 early (mean age, 71.4 y; mean days poststroke, 27.3) and 15 chronic (mean age, 64.0 y; mean days poststroke, 101.7). INTERVENTION: Regular therapy. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs), receiver operating characteristic (ROC), standard error of measurement, and correlation coefficients. RESULTS: High interrater reliability was established with an ICC of .98 (95% confidence interval [CI], .96-.99). The minimal detectable change score was 6.3 CAHAI points. Higher correlations were obtained between the CAHAI and the ARAT and CMSA scores compared with the CMSA shoulder pain scores (1-sided, P=.001). Areas under the ROC curves were as follows: CAHAI, .95 (95% CI, 0.87-1.00); CMSA, .76 (95% CI, .61-.92); and ARAT, .88 (95% CI, 0.76-1.00). CONCLUSIONS: High interrater reliability and convergent and discriminant cross-sectional validity were established for the CAHAI. The CAHAI is more sensitive to clinically important change than the ARAT.

Prevalence of protein malnutrition in children maintained on peritoneal dialysis.

A paucity of outcome measures exist for children, making evidence-based treatment guidelines difficult to establish. Serum albumin has been identified as a surrogate marker for nutritional status and morbidity/mortality in patients with end-stage renal disease (ESRD). We hypothesized that the prevalence of low serum albumin (<2.9 g/dl) in children on peritoneal dialysis (PD) may be greater, making this population at risk. Patient data were collected prospectively over 24 months (1999-2000) from all children (1-18 years) maintained on either hemodialysis (HD) or PD within the six-state New England area; 64 observations were made on 39 children on PD over the 2-year period. The mean age was 11.7+/-4.7 years (mean+/-SD). The prevalence of low serum albumin in children was 35.9% (23/64 observations) compared with 19.5% (712/3,719 observations) in adult Network ESRD patients on PD ( P<0.004). None of the 32 children (47 observations) maintained on HD exhibited low serum albumin during the data collection period. The prevalence of low serum albumin in adult HD patients was 5.5%. Dietary protein intake was estimated from a calculated protein catabolic rate (PCR). PCRs in children treated with both PD and HD were similar, averaging 1.1+/-0.4 g/kg per day (mean+/-SD). Thus, children maintained on PD are at greater risk of protein malnutrition compared with peers treated with HD and adults on PD or HD. A PCR of approximately 1 g/kg per day may not be adequate to maintain nutrition.