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OBJECTIVE The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines. DESIGN Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations. RESULTS All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53). CONCLUSIONS Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.

Objective To evaluate the quality of rehabilitation Clinical Practice Guidelines (CPG), specifically with respect to their applicability. Data Sources The Medline, Embase, Web of Science, CINAHL, PsycINFO, and Cochrane Library databases were searched for papers published between 2017 and 2019 that applied the Appraisal of Guidelines for Research & Evaluation II (AGREE II) CPG quality assessment tool to rehabilitation CPGs. Study Selection Deduplicated abstracts (N=449) were independently screened by 2 authors, resulting in 47 articles. Independent screening of 47 full texts by 2 authors resulted in a final selection of 40 papers appraising 544 CPGs. Data Extraction Data were extracted by 1 author using a pretested Excel form and were checked by a second author. Key data on the review papers included: purpose, methods used for finding and appraising CPGs, and observations and conclusions on CPG quality, specifically applicability. Key data on each CPG included the 6 AGREE II domain scores or 23 item scores, as well as 2 global evaluations. Data Synthesis The mean AGREE II domain scores for the 544 CPGs (all on a 0-100 scale) were: scope and purpose (72), stakeholder involvement (53), rigor of development (56), clarity of presentation (71), applicability (34), and editorial independence (50). Only 36% of CPGs were recommended without modification. The 40 review authors generally stated that all or most of the CPGs they appraised were poor or mediocre, especially with respect to applicability. They only infrequently pointed out what information, going beyond that specified in AGREE II, would enhance applicability. Conclusions CPGs in principle are an ideal means to move knowledge obtained from clinical research into practice. Our review of reviews of rehabilitation CPGs shows that they commonly have deficits, especially in terms of applicability. Much work needs to be done by guideline developers to make it easier for the average rehabilitation organization and clinician to implement CPGs in daily practice.

The ability to promote greater neuroplasticity through external influencers is an emerging field of study with potentially significant consequences on the treatment of neurologic injury. Several of these methods are reviewed in this paper. Through advances in neuroscience, a clearer understanding of the complexity of the brain’s interconnectedness and its ability to adapt to the environment is leading to neurorehabilitation treatments that augment the brain’s capacity towards neuroplastic change. An increased appreciation and recognition of neuroplasticity has led to novel approaches to promote neurorecovery that increase stimulation and the release of neutrophic factors. Some of these interventions include the use of pharmacologic agents, noninvasive stimulation, mirror therapy, aerobic and task-specific exercise, and the maximization of sleep. Future research will continue to build upon this foundation by continuing to pair therapeutic interventions with rehabilitation to enhance the brain’s natural healing power and improve functional outcomes.

Background: Spatial neglect is a neurocognitive syndrome. Affected individuals pay little or insufficient attention to the space contralateral to the injured cerebral hemisphere, often resulting in...

BACKGROUND Coaches, athletic trainers (ATCs), and parents/guardians (parents) are important contributors to the proper identification and management of concussions in student-athletes. However, there are limited studies on the identification of concussion knowledge gaps that will help inform educational efforts and improve concussion outcomes in these groups. OBJECTIVE To identify gaps and factors influencing concussion knowledge for high school athletics. DESIGN Survey. SETTING Public, private, and recreational leagues in New Jersey. PARTICIPANTS 41 coaches, 34 ATCs, and 65 parents of high school student-athletes. METHODS A 17-item online survey examining concussion knowledge was distributed to coaches, ATCs, and parents. Analyses included ANOVA for between-group comparisons of continuous variables and Pearson's correlations for categorical data. MAIN OUTCOME MEASUREMENTS Demographics, concussion knowledge, application of knowledge, access to educational materials, and confidence in the ability to identify concussions. RESULTS Significant between-group differences were found for overall knowledge (F[2137] = 11.0, P

Research Objectives To capture the impressions of rehabilitation nurses working on the night shift with regard to factors that may be impacting sleep among inpatients with acquired brain injury. Design Cross-sectional. Setting Web-based survey of inpatient rehabilitation nurses. Participants Responses from 138 nurses across the United States were analyzed. Females comprised 88.4% of the sample. Years of experience as a nurse ranged from 1 to 35 years (M=8.9, SD=9.6). Interventions Not applicable. Main Outcome Measures A brief online survey was conducted to examine the frequency of encountering patients with a variety of sleep related issues. Two open-ended questions were included to capture additional qualitative information regarding sources of sleep disruption and nursing practices that can improve sleep quality. Results 83% of nurses said that they “often” or “always” encountered patients with at least one symptom of insomnia (trouble falling asleep at the beginning of the night, problems staying asleep throughout the night, or waking up too early and unable to go back to sleep). 77.1% of respondents endorsed noise as the most frequent source of sleep disruption, citing noise from staff, other patients, visitors, and electronics (monitors, call bells, intercom systems). With regard to potential solutions to improve sleep, over half of the sample identified practices that described the organization of care delivery, with 27% of the sample describing a practice of "clustering care." Other practices involved strategic timing of interventions and coordination with other staff members to avoid multiple disruptions. Conclusions Sleep is frequently disrupted in inpatients with brain injury due to both internal and external causes. Strategies to reduce noise and organizing the timing of night nursing care may help minimize environmental disturbances while providing necessary interventions. Author(s) Disclosures The authors have no conflicts of interest to disclose.

Research Objectives To obtain preliminary data on the usefulness of audiobooks to promote sleep using objective measures Design Within-subjects design with two experimental conditions, one with audiobook and the other without. Participants were randomized into one of two groups counterbalanced for order. Setting Inpatient rehabilitation hospital. Participants 6 adults (3 males,3 females) with acquired brain injury (5 from stroke and 1 from brain tumor). Ages ranged from 33 to 72 (M=58.5, SD=13.9). Interventions Participants were monitored for sleep activity for 4 consecutive nights. For 2 consecutive nights, participants listened to an audiobook of their choice prior to bed using headphones. Main Outcome Measures Actigraph data (wrist-worn accelerometer) was analyzed to derive total sleep time. Results The audiobooks were well-tolerated by the participants. Repeated measures ANOVA taking order into account showed a significant overall effect of condition, F(1,4)=33.7, p=0.004 with a significant condition x order interaction, F(1,4)=21.8, p=0.010. The effect was much more exaggerated among those who were assigned to the audiobook on days 3 and 4 (phase 2), showing an average increase in total sleep time of 45 minutes. Conclusions Non-pharmacological sleep interventions are needed for patients with acquired brain injury to avoid the potential detrimental effects of medications. These findings are preliminary with a very small sample. However, examination of the data showed that five out of six participants showed an increase in total sleep time after using the audiobook before bedtime with the remaining participant showing very little change between conditions. Further study is needed to understand how audiobooks may serve as a non-pharmacological tool to help patients achieve better sleep in a hospital setting. Author(s) Disclosures Fire Tablet and titles were provided by Audible

To examine the effect of cranioplasty on recovery.Retrospective cohort study.Retrospective chart review conducted in 2011 and 2012 on adult inpatients with craniectomy who completed a continuous episode of inpatient rehabilitation before and after receiving their cranioplasty. Patients were matched 1:1 or age, gender, functional level at admission, injury severity and length of stay with inpatients who completed rehabilitation before cranioplasty. Main outcome measures include FIMTwenty-six individuals (13 from the cranioplasty group and 13 from the comparison group) were analysed. FIMRate of recovery increased following cranioplasty and exceeded that of the comparison group suggesting that cranioplasty may contribute to improvement.

The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work.An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided.The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain.Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).

To test the feasibility and validity of an online version of an established interview designed to determine a lifetime history of traumatic brain injury (TBI).Cross-sectional.General community.A volunteer sample of individuals (N= 265) from the general population across the United States.Not applicable.Online version of the Ohio State University Traumatic Brain Injury Identification Method, Rivermead Postconcussion Symptoms Questionnaire (RPQ), Patient-Reported Outcomes Measurement Information System Cognitive Concerns Scale.The measure was completed by 89.4% of the sample with most participants completing the measure in8 minutes. After controlling for age, sex, psychiatric history, drug or alcohol history, and history of developmental disability, worst TBI severity was significantly associated with scores on the RPQ, F(2,230)=4.56, P=.011, and having a TBI within the past 2 years was associated with higher scores on the cognitive factor subscale of the RPQ, F(1,75)=7.7, P=.007.The online administration of the Ohio State University Traumatic Brain Injury Identification Method appears to be feasible in the general population. Preliminary validity was demonstrated for the indices of worst TBI severity and time since most recent TBI.

BACKGROUND Maximizing long-term recovery following traumatic brain injury (TBI) is an important end point. We hypothesized that the addition of a dedicated physiatrist specializing in brain injury medicine to the trauma team would lead to improved functional outcomes. METHODS Data from the Northern NJ TBI Model Systems were queried for all patients admitted to rehabilitation from four regional trauma centers, one with a full-time TBI physiatrist (PHYS) and three without (NO-PHYS). Patient demographics, mechanism of injury, Glasgow Coma Scale (GCS) score, length of posttraumatic amnesia, length of stay, and Functional Independence Measure (FIM) were abstracted. TBI severity was determined by GCS score and length of posttraumatic amnesia. FIM motor and cognitive scores at rehabilitation admission and discharge were the primary outcome measure. TBI medications (stimulants, sleep, and neurodepressants) administered in acute care were reviewed to evaluate prescription patterns. RESULTS A total of 148 patients treated at four trauma centers and discharged to a single acute inpatient rehabilitation center between 2005 to 2013 were divided into two groups, PHYS with 44 patients and NO-PHYS with 104 patients. Compared with those in the NO-PHYS group, patients from the PHYS group had significant improvement in FIM motor and cognitive scores (p < 0.05). Prescription patterns differed. Patients from the PHYS group received significantly more neurostimulants (p < 0.001) and sleep medications (p = 0.02) compared with the NO-PHYS group. Analysis of covariance was conducted to examine FIM (motor and cognitive) changes from rehabilitation admission to discharge based on medications initiated in acute care. Those who received neither a neurostimulant nor a sleep medication had significantly lower FIM motor scores compared with those who received at least one of these medications (p = 0.047) and compared with those who received both types of medication (p = 0.17). No significant differences were found in FIM cognitive scores. CONCLUSION The addition of a dedicated physiatrist providing early specialized care to patients who sustained a moderate or severe TBI was associated with improved functional outcomes upon discharge from rehabilitation. The presence of a dedicated trauma center physiatrist, trained in TBI rehabilitation, was also associated with a change in neuroprotective medication management in the acute care setting. LEVEL OF EVIDENCE Therapeutic study, level IV.

Background. Current knowledge about spatial neglect and its impact on rehabilitation mostly originates from stroke studies. Objective. To examine the impact of spatial neglect on rehabilitation outcome in individuals with traumatic brain injury (TBI). Methods. The retrospective study included 156 consecutive patients with TBI (73 women; median age = 69.5 years; interquartile range = 50-81 years) at an inpatient rehabilitation facility (IRF). We examined whether the presence of spatial neglect affected the Functional Independence Measure (FIM) scores, length of stay, or discharge disposition. Based on the available medical records, we also explored whether spatial neglect was associated with tactile sensation or muscle strength asymmetry in the extremities and whether specific brain injuries or lesions predicted spatial neglect. Results. In all, 30.1% (47 of 156) of the sample had spatial neglect. Sex, age, severity of TBI, or time postinjury did not differ between patients with and without spatial neglect. In comparison to patients without spatial neglect, patients with the disorder stayed in IRF 5 days longer, had lower FIM scores at discharge, improved slower in both Cognitive and Motor FIM scores, and might have less likelihood of return home. In addition, left-sided neglect was associated with asymmetric strength in the lower extremities, specifically left weaker than the right. Finally, brain injury–induced mass effect predicted left-sided neglect. Conclusions. Spatial neglect is common following TBI, impedes rehabilitation progress in both motor and cognitive domains, and prolongs length of stay. Future research is needed for linking specific traumatic injuries and lesioned networks to spatial neglect and related impairment.

Objective To demonstrate sensitivity to change of the Stroke Rehabilitation Assessment of Movement (STREAM) as well as the concurrent and predictive validity of the STREAM in an acute rehabilitation setting. Design Prospective cohort study. Setting Acute, in-patient rehabilitation department within a tertiary-care teaching hospital in the United States. Participants Thirty adults with a newly diagnosed, first ischemic stroke. Methods Clinical assessments were conducted on admission and then again on discharge from the rehabilitation hospital with the STREAM (total STREAM and upper extremity, lower extremity, and mobility subscales), Functional Independence Measure (FIM), and Stroke Impact Scale-16 (SIS-16). Sensitivity to change was determined with the Wilcoxon signed rank test and by the calculation of standardized response means. Spearman correlations were used to assess concurrent validity of the total STREAM and STREAM subscales with the FIM and SIS-16 on admission and discharge. We determined predictive validity for all instruments by correlating admission scores with actual and predicted length of stay and by testing associations between admission scores and discharge destination (home vs subacute facility). Main Outcomes Not applicable. Results For all instruments, there was statistically significant improvement from admission to discharge. The standardized response means for the total STREAM and STREAM subscales were large. Spearman correlations between the total STREAM and STREAM subscales and the FIM and SIS-16 were moderate to excellent, both on admission and discharge. Among change scores, only the SIS-16 correlated with the total STREAM. All 3 instruments were significantly associated with discharge destination; however, the associations were strongest for the total STREAM and STREAM subscales. All instruments showed moderate-to-excellent correlations with predicted and actual length of stay. Conclusions The STREAM is sensitive to change and demonstrates good concurrent and predictive validity as compared with the FIM and SIS-16 in the acute inpatient rehabilitation population.

the reinforcer being sought. DRO provided positive reinforcement for desired behaviors. Main Outcome Measure(s): Primary outcome measures include the number of perseverations per day, number of other challenging behaviors per day, positive statements per day and social contacts per week. Staff attitudes toward the subject were also measured at baseline and at every 3 months during treatment phase. Results: Results of study indicated that the intervention RIRD/DRO significantly reduced daily perseverative episodes, reducing incidents from an average of 5.33 episodes per day to .74 episodes per day after one year. There was also a significant reduction in other challenging behaviors that were identified as attention-seeking in nature. Results also demonstrated a significant increase in daily positive statements, weekly social contacts, and improved staff attitudes. Conclusions: In this case, the RIRD/DRO intervention was successful in reducing perseverative episodes. Simultaneously, other maladaptive behaviors were also reduced and replaced with more positive statements and social behaviors. As the subject became less perseverative, staff attitudes toward the subject improved which likely contributed to more successful interactions. This study is limited in its generalizability due to single-case design, but suggests that further investigation is warranted to determine if results can be replicated.

The Dizziness Handicap Inventory (DHI) by Jacobson and Newman is a 25-item self-assessment measuring the functional, emotional, and physical effects of dizziness and unsteadiness in individuals 19 years of age. The test can be completed in 5 to 10 minutes. Total scores range from 0 to 100 with increasing scores signifying greater perception of handicap because of dizziness. A total score of 16 indicates a handicap for patients with peripheral or central pathology, whereas scores >10 necessitate an examination by a balance specialist. The DHI can also be broken down into 3 subscales: physical (28 points), emotional (36 points), and functional (36 points). The DHI is reliable and valid for adults with peripheral and central vestibular pathology, multiple sclerosis, posttraumatic brain injury, whiplash-associated disorders, and benign paroxysmal positional vertigo. This Rehabilitation Measures Database summary provides a review of the psychometric properties of the DHI in individuals with vestibular dysfunction. For a full review of the DHI, along with nearly 200 other instruments, please go to www.rehabmeasures.org. Please address correspondence to rehabmeasures@ric.org.

The ability to sense DNA damage and activate response pathways that coordinate cell cycle progression and DNA repair is essential for the maintenance of genomic integrity and the viability of organisms. During the last couple of years, several proteins have been identified that participate very early in the DNA damage response. Here we review the current understanding of the mechanisms by which mammalian cells detect DNA lesions, especially double-strand breaks, and mediate the signal to downstream transducers.