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The Behavioral Assessment Screening Tool (BAST) measures neurobehavioral symptoms in adults with traumatic brain injury (TBI). Exploratory Factor Analyses established five subscales: Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse. In the current study, we assessed all the subscales except Substance Abuse using Rasch analysis following the Rasch Reporting Guidelines in Rehabilitation Research (RULER) framework. RULER identifies unidimensionality and fit statistics, item hierarchies, targeting, and symptom severity strata as areas of interest for Rasch analysis. The BAST displayed good unidimensionality with only one item from the Impulsivity scale exhibiting potential item misfit (MnSQ 1.40). However, removing this item resulted in a lower average domain measure (1.42 to − 1.49) and higher standard error (0.34 to 0.43) so the item was retained. Items for each of the four subscales also ranged in difficulty (i.e. endorsement of symptom frequency) with more severe symptoms being endorsed in the Fatigue subscale and more mild symptoms being endorsed in the Impulsivity subscale. Though Negative Affect and Executive Function displayed appropriate targeting, the Fatigue and Impulsivity Subscales had larger average domain values (1.35 and − 1.42) meaning that more items may need to be added to these subscales to capture differences across a wider range of symptom severity. The BAST displayed excellent reliability via item and person separation indices and distinct strata for each of the four subscales. Future work should use Rasch analysis in a larger, more representative sample, include more items for the Fatigue and Impulsivity subscale, and include the Substance Abuse subscale.

Background and Objective: We aim to assess the cortical excitability under three montages with single session of transcranial direct current stimulation (tDCS) at 4 mA on ischemic stroke patients. Methods: Adult subjects with first-ever unilateral ischemic stroke ≥6 months and inducible motor evoked potentials (MEP) underwent 3 sessions (washed out ≥2 days apart) of 30 minutes 4 mA tDCS in anodal, cathodal or bihemispheric montage (in pseudorandom order) combined with t upper extremity repetitive task training administered by an Occupational Therapist. We collected MEP responses to transcranial magnetic stimulation (TMS) single pulse, short intracortical inhibition (SICI, 3 ms) and intracortical facilitation (ICF, 15 ms) on bilateral abductor pollicis brevis (APB) muscles at baseline and four post-stimulation timepoints 12 minutes apart. We also monitored safety by recording adverse events, surveying subjects with a questionnaire on tolerability issues and collecting biometric measures (body resistance, skin temperature under the tDCS electrode). Results: Eighteen subjects completed 54 tDCS sessions in total. We observed montage ( P P P >0.949) suggested sufficient washout interval across the visits. No subjects experienced any adverse events. Biometric measures and tolerability were comparable across the three montages. The most common tolerability issue was transient redness under the tDCS electrodes (70% at anode, 48% at cathode). Conclusions: The bihemispheric montage increased ipsilateral cortical excitability the most in a single session of 4 mA tDCS in chronic ischemic stroke patients. Additionally, a current level of 4 mA is safe and tolerable over multiple sessions.

Research Objectives To develop a short form assessment that combines items from the Fugl Meyer Assessment-Upper Extremity (FMA) and the Wolf Motor Function Test (WMFT) to provide a more comprehensive and precise measure of UE motor ability post stroke. Design We used a convenience sample of pre-intervention data from two upper extremity rehabilitation trials conducted with stroke survivors. Factor analysis and the Rasch rating scale model were applied to examine the properties of the full item bank prior to the development of the short form. Setting Outpatient, academic research center. Participants Data were pooled since the parent studies had similar eligibility criteria. Participants were included in the studies if they experienced a stroke ≥ 3 months prior and had UE hemiparesis. Participants were excluded if they had severe hemiparesis, severe spasticity (Modified Ashworth Scale >3 in elbow, wrist, or fingers), or reported UE pain. 167 individuals with stroke who completed both the WMFT and FMA were included. Interventions N/A. Main Outcome Measures Data from the 30-item FMA and the 15-item WMFT (rating scale score) were analyzed using factor analysis to ensure unidimensionality. Item response theory methodologies were used to develop the short form. The Rasch rating scale model was applied to examine the measurement properties. Results A 15-item short form was developed. Item infit statistics (Mnsq) ranged from 0.63-1.35 and point measure correlations ranged from 0.39-0.90. Person reliability was 0.93 and the person separation index was 3.7 indicating the measure can separate between 5 statistically different strata. Conclusions Items from the FMA and WMFT can be combined to provide a precise measure of UE motor ability. The short form demonstrated acceptable psychometric properties. Author(s) Disclosures The authors have no conflicts of interest to disclose.

Background Spatial neglect (SN) is a neuropsychological syndrome that impairs automatic attention orienting to stimuli in the contralesional visual space of stroke patients. SN is commonly assessed using paper and pencil tests. Recently, computerized tests have been proposed to provide a dynamic assessment of SN. However, both paper- and computer-based methods have limitations. New method Electroencephalography (EEG) shows promise for overcoming the limitations of current assessment methods. The aim of this work is to introduce an objective passive BCI system that records EEG signals in response to visual stimuli appearing in random locations on a screen with a dynamically changing background. Our preliminary experimental studies focused on validating the system using healthy participants with intact brains rather than employing it initially in more complex environments with patients having cortical lesions. Therefore, we designed a version of the test in which we simulated SN by hiding target stimuli appearing on the left side of the screen so that the subject’s attention is shifted to the right side. Results Results showed that there are statistically significant differences between EEG responses due to right and left side stimuli reflecting different processing and attention levels towards both sides of the screen. The system achieved average accuracy, sensitivity and specificity of 74.24%, 75.17% and 71.36% respectively. Comparison with existing methods The proposed test can examine both presence and severity of SN, unlike traditional paper and pencil tests and computer-based methods. Conclusions The proposed test is a promising objective SN evaluation method.

Research Objectives To perform a Rasch Analysis of the Behavioral Assessment Screening Tool (BAST) following the Rasch Reporting Guidelines in Rehabilitation Research (RULER) framework. Design Cross-sectional psychometric study. Setting Community. Participants A total of n=135 adult participants with a history of mild to severe TBI. Interventions Not Applicable. Main Outcome Measures The BAST is an established multidimensional measure of neurobehavioral symptoms with five subscales: Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse. We assessed all subscales, except substance abuse (due to need for further development of this subscale), using the RULER framework. Results The BAST subscales all met the assumption of unidimensionality, with only one item from the Impulsivity scale displaying item misfit (MnSQ=1.40). Upon removing this item, we found a lower average domain measure (1.42 to -1.49) and larger standard error (0.34 to 0.43) so we retained the item. Items for each of the four subscales ranged in difficulty (i.e. endorsement of symptom frequency) with more severe symptoms endorsed in the Fatigue subscale and milder symptoms endorsed in the Impulsivity subscale. Though Negative Affect and Executive Function displayed appropriate targeting, the Fatigue and Impulsivity Subscales had larger average domain values (1.35 and -1.42) meaning that more items may need to be added to these subscales to capture differences across a wider range of symptom severity. Conclusions Overall, the BAST displayed excellent item and person separation indices and distinct strata for each of the four subscales assessed. Future work should examine the BAST using Rasch analysis in a larger, more representative sample, include more items for the Fatigue and Impulsivity subscale, and include the Substance Abuse subscale. Author(s) Disclosures All authors report no conflicts.

Unilateral neglect (neglect) and anosognosia often co-occur post stroke. It is unknown whether anosognosia of neglect varies for different types of daily activities. The objective is to examine the frequency of anosognosia of neglect for items on the Catherine Bergego Scale (CBS) and to determine the level of agreement between participant/assessor item ratings and total scores. Secondary analysis of data was carried out. We conducted descriptive analyses and interrater reliability analyses (Cohen's kappa) to determine the level of agreement between assessor and participant item ratings. A paired t test was conducted to compare assessor and participant total scores. The frequency of anosognosia among items varied (29.2%-83.3%) and Kappa statistics ranged from -0.07 (no agreement) to 0.23 (fair agreement) for item ratings. There was a significant difference- t(36) = 3.02, p ≤ .01)-between assessor ( M = 8.0, SD = 5.2) and participant-rated ( M = 5.3, SD = 4.5) total CBS scores. Anosognosia is prevalent among those with neglect. Findings highlight the importance of assessing for anosognosia.

Introduction: By the proof of concept, a phase I tDCS current escalation safety study established the safety and tolerability of up to 4 mA with single session application in ischemic stroke patients; however, the sample size is relatively small with only 3 subjects received 4 mA dose in the 3+3 design. We aim to further investigate the safety and tolerability of tDCS at 4 mA currents with multiple sessions. Hypothesis: tDCS in 4 mA strength is safe and tolerable in three montage conditions (anodal, cathodal and bihemispheric) Methods: Eighteen aging stroke patients underwent 3 sessions of 4 mA tDCS that are at least 2 days apart: anodal (Anode: lesional C3/C4, Cathode: non-lesional FP1/FP2), cathodal (Anode: lesional FP1/FP2, Cathode: non-lesional C3/C4), or bihemispheric (Anode: lesional C3/C4, Cathode: non-lesional C3/C4). We monitored safety by looking for any adverse event (AE) or serious adverse event (SAE). We measured tolerability using questionnaire/examination. We implemented biometric monitoring (body resistance, skin temperature at tDCS application sites) to ensure the patient safety. Results: All 18 patients completed all 54 sessions of tDCS (3 sessions per subject) without any adverse event or serious adverse event. Per Questionnaire, the most common tolerability issue was transient redness at tDCS application sites (70% at anode, 48% at cathode, see A). Body resistance was comparable across montages and skin temperature was below body temperature in all tDCS sessions (see B). Conclusion: Our findings provide further evidence that tDCS at 4 mA is safe and tolerable. The efficacy of 4 mA tDCS is being investigated by NIH StrokeNet-funded study called TRANSPORT2.

Introduction: The differential brain modulatory effects across hemispheres from different montages in stroke patients is not well established. We aimed to investigate the cortical excitability on lesional and contra-lesional hemisphere modulated by anodal, cathodal and bihemispheric montage at 4 mA tDCS strengths. Hypothesis: Bihemispheric tDCS montage induces more cortical excitability on the lesional hemisphere. Methods: Eighteen aging stroke patients with unilateral ischemic stroke of 6 or more months and inducible motor evoked potentials (MEP) underwent 3 sessions of 30 minutes 4 mA tDCS combined with occupational therapy. Each session was at least 2 days apart and consisted of one of the 3 different montages: anodal (Anode: lesional C3/C4, Cathode: non-lesional FP1/FP2), cathodal (Anode: lesional FP1/FP2, Cathode: non-lesional C3/C4), or bihemispheric (Anode: lesional C3/C4, Cathode: non-lesional C3/C4). We collected MEP size, short intracortical inhibition (SICI, 3 ms) and intracortical facilitation (ICF, 15 ms) on bilateral abductor pollicis brevis (APB) muscles using single or paired pulse TMS at 5 timepoints (baseline and four post-tDCS 12 minutes apart sessions). Results: All 18 subjects had comparable resting motor threshold (rMT) across 3 montages (see A). Bihemispheric tDCS montage offered significantly larger peak-to-peak MEP responses on the lesioned cortex (ANOVA, F=8.97, P Conclusion: Our findings support that bihemispheric montage is better suited in post-stroke motor recovery tDCS applications.

Objective To test the feasibility of the Fugl-Meyer Assessment of the Upper Extremity "keyform," derived from Rasch analysis, as a method for systematically planning and progressing rehabilitation. Design Feasibility study, single group design. Setting University rehabilitation research laboratory. Participants Participants (N=10; mean age, 59.70±9.96y; 24.1±30.54mo poststroke) with ischemic or hemorrhagic stroke >3 months prior, voluntarily shoulder flexion ≥30°, and simultaneous elbow extension ≥20°. Interventions The keyform method defined initial rehabilitation targets (goals) and progressed the rehabilitation program after every third session. Targets were repetitively practiced within the context of client-selected functional tasks not in isolation. Main Outcome Measures Feasibility was defined by subject's pain or fatigue, upper extremity motor function (Wolf Motor Function Test), and movement patterns (kinematics). Assessments were administered pre- and posttreatment and compared using paired t tests. Task-difficulty and patient-ability measures were calculated using Rasch analysis and compared using paired t tests ( P Results Ten participants completed 9 sessions, 200 movement repetitions per session in P =.01), improved shoulder-elbow coordination (index of curvature: pretreatment, 1.30±0.15; posttreatment, 1.21±0.11; P =.01), and exhibited reduced trunk compensatory movement (trunk displacement: pretreatment, 133.97±74.15mm; posttreatment, 108.08±64.73mm; P =.02). Task-difficulty and patient-ability measures were not statistically different throughout the program (person-ability measures of 1.01±0.05, 1.64±0.45, and 2.22±0.65 logits and item-difficulty measures of 0.93±0.37, 1.70±0.20, and 2.06±0.24 logits at the 3 testing time points, respectively; P >.05). Conclusions The Fugl-Meyer Assessment of the Upper Extremity keyform is a feasible method to ensure that the difficulty of tasks practiced were well matched to initial and evolving levels of upper extremity motor ability.

Date Presented 03/26/20 Driving is an occupation that is highly dependent on the interaction between the person and the environment. Mobile EEG is a tool that can overcome limitations to brain imaging methods that restrict measuring occupational performance in natural contexts. This study describes a case example using mobile EEG in a driving assessment with an individual following a right hemispheric stroke with mild residual hemispatial neglect. Primary Author and Speaker: Amanda Frias Contributing Authors: Josephine Chan, Theresa Smith, Emily Grattan

Date Presented 03/26/20 Neglect is a common impairment following stroke. Currently, there is a lack of evidence regarding the impact of neglect on performance of instrumental activities of daily living, participation, safety, perceived quality of life, and caregiver burden. This study examined the experience of living with poststroke neglect. These findings can help clinicians better understand the long-term needs of stroke survivors with neglect and the daily challenges they face. Primary Author and Speaker: Emily Grattan Additional Authors and Speakers: Emerson Hart Contributing Authors: Nicholas Dean, Brianna Eberl, Hannah Hooks, Lindsay Manning, Katie Schafer, Stacie McLamb

Date Presented 03/26/20 Neglect is a common impairment following stroke. It is important that clinicians assess stroke survivors for neglect, but comprehensive assessment guidelines do not exist. This study provides evidence regarding the concurrent validity of behavioral and virtual reality neglect assessments. These findings can help clinicians select a valid, sensitive, and feasible assessment that can be used in clinical practice. Primary Author and Speaker: Emily Grattan Additional Authors and Speakers: Emerson Hart

Rasch keyforms can help interpret clinical assessment scores. The Action Research Arm Test (ARAT) is a commonly used assessment, yet no keyform currently exists. The aim is to provide a keyform for the ARAT and demonstrate how a clinician can use the keyform to design optimally challenging rehabilitation sessions. Secondary analysis of ARAT data ( n = 122) using confirmatory factor and Rasch analyses were used to examine the measurement properties and generate a keyform. The item standardized factor loadings were >0.40 (range = 0.82-0.96) and R2 values were >.60 (range = .65-.96). All items exhibited adequate infit statistics with point measure correlations >.60 (range = .72-.97). Person reliability was .98, and person separation was 7.07. Item-difficulty measures ranged from −2.78 logits to 2.64 logits. The ARAT has strong measurement properties, and a keyform was provided. We showed how the keyform can be utilized by clinicians to interpret scores, set goals, and plan treatment.

Date Presented 04/05/19 Nonuse of the paretic arm is highly prevalent after stroke. In the chronic stage of stroke, individuals with neglect have similar patterns of paretic arm use as individuals without neglect when matched for paretic arm motor impairment. These findings highlight how critical it is that stroke rehabilitation therapists address paretic arm nonuse in therapy. Primary Author and Speaker: Emily Grattan Additional Authors and Speakers: Michelle Woodbury

Date Presented 04/05/19 Primary Author and Speaker: Gabrielle Burns Additional Authors and Speakers: Emily Grattan

To test the feasibility of the Fugl-Meyer Assessment of the Upper Extremity "keyform," derived from Rasch analysis, as a method for systematically planning and progressing rehabilitation.Feasibility study, single group design.University rehabilitation research laboratory.Participants (N=10; mean age, 59.70±9.96y; 24.1±30.54mo poststroke) with ischemic or hemorrhagic stroke3 months prior, voluntarily shoulder flexion ≥30°, and simultaneous elbow extension ≥20°.The keyform method defined initial rehabilitation targets (goals) and progressed the rehabilitation program after every third session. Targets were repetitively practiced within the context of client-selected functional tasks not in isolation.Feasibility was defined by subject's pain or fatigue, upper extremity motor function (Wolf Motor Function Test), and movement patterns (kinematics). Assessments were administered pre- and posttreatment and compared using paired t tests. Task-difficulty and patient-ability measures were calculated using Rasch analysis and compared using paired t tests (P.05).Ten participants completed 9 sessions, 200 movement repetitions per session in2 hours without pain or fatigue. Participants gained upper extremity motor function (Wolf Motor Function Test: pretreatment, 22.23±24.26s; posttreatment, 15.46±22.12s; P=.01), improved shoulder-elbow coordination (index of curvature: pretreatment, 1.30±0.15; posttreatment, 1.21±0.11; P=.01), and exhibited reduced trunk compensatory movement (trunk displacement: pretreatment, 133.97±74.15mm; posttreatment, 108.08±64.73mm; P=.02). Task-difficulty and patient-ability measures were not statistically different throughout the program (person-ability measures of 1.01±0.05, 1.64±0.45, and 2.22±0.65 logits and item-difficulty measures of 0.93±0.37, 1.70±0.20, and 2.06±0.24 logits at the 3 testing time points, respectively; P.05).The Fugl-Meyer Assessment of the Upper Extremity keyform is a feasible method to ensure that the difficulty of tasks practiced were well matched to initial and evolving levels of upper extremity motor ability.

Date Presented 3/30/2017 This poster highlights how common anosognosia is among clients after stroke and how important it is for practitioners to assess for anosognosia and plan treatment to address it in this client population. Primary Author and Speaker: Emily Grattan Contributing Authors: Elizabeth Skidmore, Michelle Woodbury

OBJECTIVE. We determined whether various assessment tools detect neglect differently by administering a battery of assessments to people with stroke. METHOD. We conducted a case series study and administered five neglect assessments (paper-and-pencil, functional, virtual reality) to participants poststroke. RESULTS. Twelve participants (6 men, 6 women) with stroke completed the assessment battery, which required approximately 2 hr to administer (over one to two sessions). All participants demonstrated neglect on three or more assessments. Functional assessments and the virtual reality assessment detected neglect more frequently than the paper-and-pencil assessments. Participants performed differently on the paper-and-pencil assessments and functional assessments. CONCLUSION. Because neglect is complex, detection may depend largely on the assessment administered.

OBJECTIVE. We examined the feasibility, tolerability, and preliminary efficacy of repetitive task-specific practice for people with unilateral spatial neglect (USN). METHOD. People with USN ≥6 mo poststroke participated in a single-group, repeated-measures study. Attendance, total repetitions, and satisfaction indicated feasibility and pain indicated tolerability. Paired t tests and effect sizes were used to estimate changes in upper-extremity use (Motor Activity Log), function (Action Research Arm Test), and attention (Catherine Bergego Scale). RESULTS. Twenty participants attended 99.4% of sessions and completed a high number of repetitions. Participants reported high satisfaction and low pain, and they demonstrated small, significant improvements in upper-extremity use (before Bonferroni corrections; t = –2.1, p = .04, d = .30), function (t = –3.0, p < .01, d = .20), and attention (t = –3.4, p < .01, d = –.44). CONCLUSION. Repetitive task-specific practice is feasible and tolerable for people with USN. Improvements in upper-extremity use, function, and attention may be attainable.

While repetitive task practice programs improve upper extremity use and function after stroke,1–2 there remains some debate among clinicians as to whether clients with comorbid cognitive impairments or depressive symptoms attain benefit from these programs. Repetitive task practice programs facilitate intense task-oriented practice with the affected upper extremity, and frequently include supervised clinic-based practice, as well as prescribed home-based practice components. For these reasons, one may argue that individuals with cognitive impairments or depressive symptoms may not remember to or have the ability to initiate and complete home-based practice, thereby limiting opportunities for practice-based improvements. However, cognitive impairments and depressive symptoms frequently co-occur with upper extremity impairment after stroke,3–4 and therefore it is important to empirically examine whether cognitive impairments and depressive symptoms influence treatment response attributed to repetitive task practice programs. Repetitive task practice studies usually exclude individuals with severe cognitive impairments (typically defined by Mini-Mental State Examination