Multidisciplinary collaborative consensus statement on the barriers and solutions to care access, patient and caregiver support, and clinical capacity and capability for patients with spasticity.

BACKGROUND: There is evidence that patients with spasticity are not receiving adequate care. Identifying the unmet needs of patients with spasticity is essential to develop services and treatment strategies to better support this population This is an effort to identify challenges related to treatment of spasticity and provide the springboard for the implementation of identified solutions. OBJECTIVE: To identify the main barriers to spasticity care and identify potential solutions. DESIGN: Delphi process. SETTING: Expert panel. PARTICIPANTS: A total of 35 participants with diverse experience and knowledge related to spasticity care were invited and 29 attended an in-person 2022 Spasticity Summit hosted by the American Academy of Physical Medicine and Rehabilitation. METHODS: The expert panel participated in a presummit survey to identify the main potential barriers to spasticity care. During the in-person meeting the panel initially worked in small groups and then as whole to reach consensus through the Delphi process. The panel also completed a postsummit survey. RESULTS: Several barriers to spasticity care and potentials solutions were identified. Consensus was reached for the top three barriers and potential solutions (>50% and >75%, respectively). Top barriers included the need for a document listing all the challenges related to access of care for spasticity, increased caregiver and community awareness of spasticity, and education of clinicians regarding patient needs. Top solutions to barriers included increasing the number of providers who treat spasticity, enhancing patient and caregiver education, and developing and publishing a consensus guidance statement. CONCLUSIONS: Consensus was achieved on the top three barriers to spasticity care and potential solutions. The purpose of this analysis is to pave the way for further development of solutions to improve the care of patients with spasticity.

Learning Post-Stroke Gait Training Strategies by Modeling Patient-Therapist Interaction.

For safe and effective robot-aided gait training, it is essential to incorporate the knowledge and expertise of physical therapists. Toward this goal, we directly learn from physical therapists' demonstrations of manual gait assistance in stroke rehabilitation. Lower-limb kinematics of patients and assistive force applied by therapists to the patient's leg are measured using a wearable sensing system which includes a custom-made force sensing array. The collected data is then used to characterize a therapist's strategies in response to unique gait behaviors found within a patient's gait. Preliminary analysis shows that knee extension and weight-shifting are the most important features that shape a therapist's assistance strategies. These key features are then integrated into a virtual impedance model to predict the therapist's assistive torque. This model benefits from a goal-directed attractor and representative features that allow intuitive characterization and estimation of a therapist's assistance strategies. The resulting model is able to accurately capture high-level therapist behaviors over the course of a full training session (r2=0.92, RMSE=0.23Nm) while still explaining some of the more nuanced behaviors contained in individual strides (r2=0.53, RMSE=0.61Nm). This work provides a new approach to control wearable robotics in the sense of directly encoding the decision-making process of physical therapists into a safe human-robot interaction framework for gait rehabilitation.

Congenital and acquired brain injury. 3. Spectrum of the acquired brain injury population.

UNLABELLED: This self-directed learning module highlights the subpopulations of traumatic brain injury (TBI) that are treated by the rehabilitation practitioner. It is part of the chapter on TBI in the self-directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Specifically, this article focuses on the management of patients with mild TBI, children, and individuals with acquired brain injury from other etiologies, such as anoxic events or neoplastic lesions. The clinical spectrum of TBI, from the most severe presentation to the mildest, requires similar clinical skills to evaluate and manage. OVERALL ARTICLE OBJECTIVE: To describe the spectrum of brain injury populations based on age, severity, and etiology.

Congenital and acquired brain injury. 5. Emerging concepts in prognostication, evaluation, and treatment.

UNLABELLED: This self-directed learning module describes recent developments in the field of traumatic brain injury (TBI) rehabilitation. In particular, it focuses on the implications of recent technological advances for evaluation, prognostication, and treatment. It is part of the chapter on TBI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on neuroplasticity and its implications for rehabilitation interventions, the role of innovative neuroimaging modalities, improvements in our ability to prognosticate made possible by newer technologies, technologically based enhancement of motor rehabilitation, and the role of alternative and complementary medicine in TBI rehabilitation. OVERALL ARTICLE OBJECTIVE: To describe recent advances in our ability to evaluate, prognosticate, and treat traumatic brain injury.

Congenital and acquired brain injury. 4. Outpatient and community reintegration.

UNLABELLED: This self-directed learning module highlights the rehabilitation aspects of care for people with traumatic brain injury (TBI) after the acute phase. It focuses on issues important to community reentry, outpatient care, and return to work. It is part of the chapter on TBI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the formulation of rehabilitation plans to address the issues of cognitive dysfunction, behavioral disturbances, and community reintegration. Topics covered include pharmacologic and nonpharmacologic approaches to cognitive and affective disorders, intimacy, social isolation, mobility, and return to work. Finally, the critical issues of legal competency and obtaining informed consent in the population with cognitive impairment are discussed. OVERALL ARTICLE OBJECTIVE: To summarize the issues that affect outpatient care, independence, and community reentry after traumatic brain injury.

Congenital and acquired brain injury. 1. Epidemiology, pathophysiology, prognostication, innovative treatments, and prevention.

UNLABELLED: This self-directed learning module reviews the current epidemiology of traumatic brain injury (TBI), its pathophysiology, prognostication after injury, currently available innovative early approaches to diagnosis and treatment, and effective methods of prevention. It is intended to provide the rehabilitation clinician with current knowledge to accurately inform patients, families, significant others, referring physicians, and payers and to aid in clinical decision making while caring for patients after TBI. OVERALL ARTICLE OBJECTIVE: To describe current knowledge in traumatic brain injury epidemiology, pathophysiology, prognostication, acute treatment, and prevention.

Congenital and acquired brain injury. 2. Medical rehabilitation in acute and subacute settings.

UNLABELLED: This self-directed learning module reviews common clinical problems and issues pertaining to early management of persons with traumatic brain injury (TBI). It is part of the study guide on brain injury medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Acute TBI is frequently complicated by agitation, dystonia, and numerous orthopedic and neurologic comorbidities, often causing a decrement in function, which requires careful assessment and treatment. Individuals with acute brain injury typically receive rehabilitation in a setting determined by numerous factors, including medical stability and tolerance to rehabilitation interventions. OVERALL ARTICLE OBJECTIVES: To describe (a) common traumatic brain injury-related comorbidities and treatment strategies, (b) potential causes of declining patient performance, and (c) appropriate settings for rehabilitation interventions.

Subjective reports of fatigue during early recovery from traumatic brain injury.

OBJECTIVE: To determine whether patients with traumatic brain injury (TBI) report higher levels of fatigue than do normal controls and to identify demographic and cognitive correlates of self-reported fatigue. DESIGN: Prospective study. SETTING: Inpatient neurorehabilitation unit in a medical center and neurological institute. PARTICIPANTS: Forty-seven neurorehabilitation inpatients with TBI. MAIN OUTCOME MEASURES: Barrow Neurological Institute (BNI) Fatigue Scale and BNI Screen for Higher Cerebral Functions. RESULTS: Patients reported significantly greater levels of fatigue compared to the levels reported by normal controls, although fatigue was found to be unrelated to injury severity, number of days from injury to assessment, cognitive impairment, and gender. Inspection of individual items revealed no significant differences between severe versus moderate versus mild TBI groups. However, being able to last the day without taking a nap (ie, item 10) was found to be the most sensitive item associated with fatigue in the TBI group. CONCLUSIONS: Results of this study suggest the need to integrate activities and interventions to increase endurance in patients with TBI during early rehabilitation. Accommodating regular rest breaks and increasing restful sleep should be a focus of inpatient neurorehabilitation units.

Fatigue after brain injury: initial reliability study of the BNI Fatigue Scale.

OBJECTIVE: Fatigue is a common problem of many neurological disorders. Yet, few measures have been developed to adequately assess fatigue, particularly during the early stages following a brain injury. The purpose of this study was to document the psychometric properties of the BNI Fatigue Scale for use on an acute, inpatient neurorehabilitation unit. RESEARCH DESIGN: A prospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: The BNI Fatigue Scale was administered to an heterogeneous sample of 84 neurologic patients upon admission to the Neurorehabilitation unit within 20 days of their injury. RESULTS: Principle components factor analysis yielded a one-factor solution. Acceptable internal consistency was calculated for the scale items. Overall index of fatigue correlated significantly with the total scale score. CONCLUSIONS: This initial study on the BNI Fatigue Scale supports its reliability and clinical utility for use with acute neurological patients. Information obtained by this scale may help to guide the rehabilitation process and provide direction for intervention and treatment.

Disturbances in affective communication following brain injury.

PRIMARY OBJECTIVE: Disturbances in affect expression and perception are often clinically observed in brain injured patients during the acute stages of recovery. This study examined whether such disturbances are related to the acute nature of the injury or specific type of injury in patients with stroke (CVA) versus traumatic brain injury (TBI). RESEARCH DESIGN: Retrospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: Participants were 27 CVA and 27 TBI patients. Their performance was compared to 27 normal controls on the BNI Screen for Higher Cerebral Functions. OUTCOMES AND RESULTS: While both patient groups performed significantly worse than the control group on affect expression, perception and spontaneity (p<0.01), the CVA group performed significantly worse than the TBI group (p<0.01) on affect perception. Results of this study document disturbances in affect in brain injured patients and highlight the importance of assessing affect during early recovery.

The use of the BNI screen for higher cerebral functions in assessing disorientation after traumatic brain injury.

OBJECTIVE: To examine the use of the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) in assessing disorientation in patients with traumatic brain injury (TBI) during the acute phases of rehabilitation. DESIGN: Persons with TBI (n = 65) were compared with patients with spinal cord injury (SCI; n = 18) and to controls (n = 35). SETTING: Inpatient neurorehabilitation unit. OUTCOME MEASURES: Orientation items from the BNIS measuring time (day, month, date of month, year) and place (city and hospital). RESULTS: TBI patients showed a significantly greater proportion of incorrect responses to time and place compared with the SCI and normal control groups. There was a greater accuracy on orientation to place compared with orientation to time, and date of month produced the lowest rate of accuracy in all three groups. The single best predictor of disorientation to time was increasing age, and increasing age was most associated with disorientation to date of month. CONCLUSIONS: The BNIS was shown to be a sensitive measure of disorientation in TBI patients and yielded similar patterns of performance as documented by other measures.

The Patient Distress Scale questionnaire: factor structure and internal consistency.

PRIMARY OBJECTIVE: This study examined the factor structure and internal consistency of the Patient Distress Scale (PDS). The PDS is an 11-item questionnaire that was developed to assess acute neurological patients' awareness of emotional disturbances during early rehabilitation. RESEARCH DESIGN: A retrospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: The PDS was administered to patients and family members upon admission to the neurorehabilitation unit as part of their neuropsychological evaluation. OUTCOMES AND RESULTS: Subjects were heterogeneous sample of acute neurological inpatients (n = 84) and their relatives (n = 64). A principle components factor analysis with varimax rotation yielded a three factor solution, which together accounted for 62% of the variance. The factor solution provided partial support for the initial structure of the PDS. Analyses revealed relatively strong reliability coefficients for patients (r = 0.82) and relatives (r = 0.86) on the PDS total score. Acceptable reliability coefficients were also found for patients and relatives on each of the factor scores. CONCLUSIONS: Preliminary findings support the utility of the PDS as a measure of awareness in acute neurological patients.

Cognitive and affective sequelae in complicated and uncomplicated mild traumatic brain injury.

This study examined cognitive and affective disturbances in patients with complicated (presence of space occupying lesion) vs uncomplicated (absence of space occupying lesion) mild traumatic brain injury (TBI). It was predicted that the complicated group would perform worse in both domains compared to the uncomplicated group. Participants were 28 patients admitted to an inpatient neurorehabilitation unit with mild TBI and assessed within 40 days of their injury. The complicated group (n = 14) was matched to the uncomplicated group (n = 14) on Glasgow Coma Scale score and compared to 14 normal controls on the BNI Screen for Higher Cerebral Functions (BNIS). The complicated group showed greater cognitive disturbances than the uncomplicated and control groups, while both TBI groups performed worse on affective measures. These findings document the role of affective disturbances in mild TBI. They also highlight the importance of early intervention strategies for improving affective communication in patients with mild TBI.