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Objective: First, we describe the characteristics and functional outcomes of obese and bariatric patients in an inpatient rehabilitation facility (IRF). Second, we assessed differences in functional outcomes for bariatric, obese, and standard weight body mass index (BMI) groups. Third, we explored whether these characteristics differ between time periods and diagnostic groups., Design: A retrospective study comparing electronic medical record data collected in 2016 and 2018, using a repeated cross-sectional cohort design., Setting: IRF., Participants: Individuals ≥18 years of age diagnosed with brain injury, medical complexity, general neurology, orthopedic, spinal cord injury (SCI), and stroke. Participants grouped as standard (BMI <30 kg/m 2 ), obese (BMI 30-39 kg/m 2 ), and bariatric (BMI ≥40 kg/m 2 ) weights. (N = 2015 in 2016, N = 2768 in 2018.) INTERVENTIONS: Patients received standard inpatient rehabilitation. In 2018, clinicians had access to new weight-appropriate equipment., Main Outcome Measures: Discharge destination; length of stay (LOS) by BMI group and medical diagnoses; item-specific functional independence measure (FIM) change scores., Results: Sixty-four percent to 67% of all BMI groups achieved a home discharge. The bariatric BMI group had a longer LOS (21 days) than the standard or obese groups. There was a significant interaction in a linear regression analysis between diagnosis and LOS, where LOS was longer in medically complex patients with bariatric BMI (19.3 days compared to 16.1 days) but shorter in bariatric patients with SCI (20.6 days) compared to standard weight patients (26.2 days). In 2018, the bariatric BMI group had greater average FIM change scores for bathing, lower body dressing, toilet transfers, and bed transfers., Conclusions: Patient BMI is associated with LOS in the IRF, although affected by diagnosis. Patients with higher BMIs can make changes in specific individual motor FIM items. For patients with bariatric BMIs, FIM change scores were higher in 2018, possibly due to the use of equipment and facilities designed for higher weight capacities., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Motor and nonmotor symptoms occur in early Parkinson's disease (PD), or even in the prodromal stage. Many of these symptoms can be addressed by allied health therapies, including physical therapy, occupational therapy, speech therapy, and psychological therapies. However, referrals to these services early in the disease are low. We provide a review summarizing the efficacy of proactive allied health interventions on motor and nonmotor symptoms and daily function in prodromal and early disease. We also highlight areas for additional research and provide recommendations to improve care for individuals with early PD within each discipline. We recognize the overlapping roles of the allied health disciplines and support integrated or transdisciplinary care beginning soon after diagnosis to help stem the tide in the progression of PD symptoms and disability.

Abstract: Developing a culture of innovative thinking and one that emphasizes clinician-researcher interaction is critical for the future of rehabilitation. We designed and implemented a strategy to build a culture of interdisciplinary communication and collaboration that facilitates translational research across several disciplines in our inpatient rehabilitation hospital. We colocated clinicians and researchers in workspaces within a new hospital and created the Research Accelerator Program-a collection of team-focused initiatives that promote communication and collaboration among researchers, clinicians, and other staff. The purpose of this article is to disseminate this strategy, which has increased staff participation in research activities and increased scientific productivity of interdisciplinary research teams over the past 8 yrs., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. The authors declare salary from their organizations (see affiliations). RL reports travel support by the organization identified in the article, as well as being a scientific advisory board member of SpineX, Inc, and a Scientific Advisor of the KITE Research Institute of UHN, Toronto, Ontario, Canada, and has received in kind donations by Celgene, Inc, and Allergan, with no other relevant conflicts of interest. Work reported in this publication was supported, in part, for MB by philanthropy for the Research Accelerator Program and for RL by Research Career Scientist Award (number IK6 RX003351) from the US Department of Veterans Affairs Rehabilitation R&D (Rehab RD) Service. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the organizations., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Applying the knowledge gained through implementation science can support the uptake of research evidence into practice; however, those doing and supporting implementation (implementation practitioners) may face barriers to applying implementation science in their work. One strategy to enhance individuals' and teams' ability to apply implementation science in practice is through training and professional development opportunities (capacity-building initiatives). Although there is an increasing demand for and offerings of implementation practice capacity-building initiatives, there is no universal agreement on what content should be included. In this study we aimed to explore what capacity-building developers and deliverers identify as essential training content for teaching implementation practice., Methods: We conducted a convergent mixed-methods study with participants who had developed and/or delivered a capacity-building initiative focused on teaching implementation practice. Participants completed an online questionnaire to provide details on their capacity-building initiatives; took part in an interview or focus group to explore their questionnaire responses in depth; and offered course materials for review. We analyzed a subset of data that focused on the capacity-building initiatives' content and curriculum. We used descriptive statistics for quantitative data and conventional content analysis for qualitative data, with the data sets merged during the analytic phase. We presented frequency counts for each category to highlight commonalities and differences across capacity-building initiatives., Results: Thirty-three individuals representing 20 capacity-building initiatives participated. Study participants identified several core content areas included in their capacity-building initiatives: (1) taking a process approach to implementation; (2) identifying and applying implementation theories, models, frameworks, and approaches; (3) learning implementation steps and skills; (4) developing relational skills. In addition, study participants described offering applied and pragmatic content (e.g., tools and resources), and tailoring and evolving the capacity-building initiative content to address emerging trends in implementation science. Study participants highlighted some challenges learners face when acquiring and applying implementation practice knowledge and skills., Conclusions: This study synthesized what experienced capacity-building initiative developers and deliverers identify as essential content for teaching implementation practice. These findings can inform the development, refinement, and delivery of capacity-building initiatives, as well as future research directions, to enhance the translation of implementation science into practice., (© 2023. The Author(s).)

Introduction: Motor and nonmotor Parkinson's disease (PD) symptoms can negatively influence employment, which may contribute to financial hardship. This article explores the association between financial hardship, employment challenges, and quality of life in people with early PD., Methods: We measured financial hardship with a validated summary item (5-point scale, lower score - less hardship) and the Comprehensive Score for Financial Toxicity (0-44, lower score worse toxicity) in a cohort of 60 employed individuals with early PD (<5 years). We used Spearman's Correlations and nonparametric tests to identify associations between financial hardship, demographic characteristics, PD-related factors, employment factors, and quality of life (Neuro-QOL computer adapted measures)., Results: The sample was mostly white (93 %) and male (65 %). The plurality were highly-educated with graduate degrees (42 %). Of the 60 participants, 23 (38 %) reported a little bit and 14 (23 %) reported somewhat or more hardship. Comprehensive financial toxicity (22.0 ± 8.7) was correlated moderately ( ρ  = -0.56) with the single-item summary score. High financial hardship was associated with reduced confidence in job retention ( ρ  = -0.43, p = 0.001) and reduced perceived workplace success ( ρ  = -0.352, p = 0.006). Financial hardship was also associated with poorer quality of life in five Neuro-QOL domains: lower extremity function, satisfaction with social roles and activities, depression, anxiety, and stigma (p < 0.05)., Conclusion: Financial hardship was common and was associated with employment challenges and poor quality of life. Further work should explore the effects of medical and psychosocial interventions to alleviate financial and employment challenges in individuals with early PD., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Better information sharing in intensive care units has been associated with lower risk-adjusted mortality. This study explored how team characteristics and leadership are associated with information sharing in 4 intensive care units in a single large urban, academic medical center., Methods: A qualitative study was conducted to understand how team characteristics and leadership are associated with information sharing. Qualitative data were conducted through ethnographic observations. One postdoctoral research fellow and one PhD qualitative researcher conducted nonparticipant observations of a Medical, Surgical, Neurological, and Cardiothoracic intensive care unit morning and afternoon rounds, as well as nurse and resident handoffs from May to September 2021. Field notes of observations were thematically analyzed using deductive reasoning anchored to the Edmondson Team Learning Model. This study included nurses, physicians (ie, intensivists, surgeons, fellows, and residents), medical students, pharmacists, respiratory therapists, dieticians, physical therapists, physician assistants, and nurse practitioners., Results: We conducted 50 person-hours of observations involving 148 providers. Three themes emerged from the qualitative analysis: (1) team leaders used variable leadership techniques to involve team members in discussions for information sharing related to patient care, (2) predefined tasks for team members allowed them to prepare for effective information sharing during intensive care unit rounds, and (3) a psychologically safe environment allowed team members to participate in discussions for information sharing related to patient care., Conclusion: Inclusive team leadership is foundational in creating a psychologically safe environment for effective information sharing., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Stroke is a common cause of mortality and morbidity. Insufficient and untimely rehabilitation has been associated with inadequate recovery. Telerehabilitation provides an opportunity for timely and accessible services for individuals with stroke, especially in remote areas. Telerehabilitation is defined as a health care team's use of a communication mode (eg, videoconferencing) to remotely provide rehabilitation services. Telerehabilitation is as effective as facility-based rehabilitation; however, it is infrequently used due to implementation barriers., Objective: The aim of the study is to explore the interaction between the implementation strategies, context, and outcomes of telerehabilitation of patients with stroke., Methods: This review will follow four steps: (1) defining the review scope, (2) literature search and quality appraisal, (3) data extraction and evidence synthesis, and (4) narrative development. PubMed via MEDLINE, the PEDro database, and CINAHL will be queried till June 2023 and supplemented with citation tracking and a gray literature search. The relevance and rigor of papers will be appraised using the TAPUPAS (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity) and Weight of Evidence frameworks. The reviewers will extract and synthesize data iteratively and develop explanatory links between contexts, mechanisms, and outcomes. The results will be reported according to the Realist Synthesis publication standards set by Wong and colleagues in 2013., Results: The literature search and screening will be completed in July 2023. Data extraction and analysis will be completed in August 2023, and findings will be synthesized and reported in October 2023., Conclusions: This will be the first realist synthesis, uncovering the causal mechanisms to explain how, why, and to what extent implementation strategies impact telerehabilitation adoption and implementation., International Registered Report Identifier (irrid): PRR1-10.2196/47009., (©Mohamed Mosaad Hasan, Miriam R Rafferty, Sara Tawfik, Ahmed Tawfik, Molly Beestrum, Justin D Smith, Lisa R Hirschhorn, Elliot J Roth, Donna M Woods. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 11.07.2023.)

Introduction: The Parkinson's Foundation sought to develop Parkinson's specific competencies for exercise professionals who work with people with Parkinson's (PwP). These competencies built upon exercise guidelines and professional competencies for healthy populations. The purpose of this article is to describe the development of the professional competencies, continuing education criteria, and a pilot accreditation process., Methods: Competency development included: (1) an expert panel conducting an environmental scan, within the USA, related to exercise professional education in Parkinson's and synthesizing Parkinson's-specific exercise guidelines, (2) surveying people with Parkinson's in the USA, and (3) developing the competencies and curriculum criteria with psychometricians. A pilot accreditation process for Parkinson's exercise educational programs and continuing education courses includes an application, baseline, 6- and 12-month assessments. Activities reported here did not require ethical review. The survey was approved by NORC at the University of Chicago's Institutional Review Board (IRB)., Results: The environmental scan, exercise guidelines, and survey (n = 627) informed competency development. The five key condition-specific domains were: (1) foundational information on the disease and role of exercise, (2) exercise screening, (3) group and individual exercise design, (4) behavior and counseling for exercise, and (5) interprofessional communication and program development. Seven applicants were accredited as certification programs (n = 3) or continuing education courses (n = 4)., Discussion: The competencies, curriculum criteria, and accreditation processes support exercise professionals working with PwP. Reducing variation in the knowledge and skills of exercise professionals can improve the safe implementation and effectiveness of exercise programs, which are a critical part of integrated plan for people with Parkinson's disease (PD)., Competing Interests: Declaration of competing interest The content is solely the responsibility of the authors and does not represent the official views of any funders., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: This investigation estimated the incremental cost-effectiveness of high-intensity training (HIT) compared with conventional physical therapy in individuals with subacute stroke, based on the additional personnel required to deliver the therapy., Design: Secondary analysis from a pilot study and subsequent randomized controlled trial., Setting: Outpatient laboratory setting., Participants: Data were collected from individuals with locomotor impairments 1-6 months poststroke (N=44) who participated in HIT (n=27) or conventional physical therapy (n=17)., Interventions: Individuals performing HIT practiced walking tasks in variable contexts (stairs, overground, treadmill) while targeting up to 80% maximum heart rate reserve. Individuals performing conventional therapy practiced impairment-based and functional tasks at lower intensities (<40% heart rate reserve)., Main Outcome Measures: Costs were assessed based on personnel use with availability of similar equipment. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves were calculated for quality-adjusted life years (QALYs) derived from the Medical Outcomes Short Form-36 questionnaire and gains in self-selected speeds (SSSs)., Results: Personnel costs were higher after HIT (mean, $1420±234) vs conventional therapy (mean, $1111±219), although between-group differences in QALYs (0.05 QALYs; 95% confidence interval [CI], 0.0-0.10 QALYs) and SSS (0.20 m/s; 95% CI, 0.05-0.35 m/s) favored HIT. ICERs were $6180 (95% CI, -$96,364 to $123,211) per QALY and $155 (95% CI, 38-242) for a 0.1 m/s gain in SSS., Conclusions: Additional personnel to support HIT are relatively inexpensive but can add substantial effectiveness to subacute rehabilitation. Future research should evaluate patient factors that increase the likelihood of improvement to maximize the cost-effectiveness of treatment post stroke., (Copyright © 2021 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Develop a screening battery for persons with Parkinson's Disease (PD) that is easily administered in a short amount of time by community exercise professionals and measures changes in function., Methods: An integrated, stakeholder-engaged, mixed methods approach included interviews and meetings with community exercise professionals on the development of a screening battery. Persons with PD ( n  = 57, age = 72.1 ± 8.1 years) who were already enrolled in fitness classes or individualized training at three locations participated in the screening battery twice over 8-16 weeks and provided feedback. Trends from interviews and meeting notes were identified using summative content analysis. Quantitative changes in performance were compared with paired t -tests. Cohen's d effect sizes were calculated for all significant differences., Results: Current barriers for functional screenings included time and space. Using this feedback, we developed a screening battery that took under 20 min, required little equipment, had been previously validated, could be performed in individual and group settings, and provided objective feedback that was motivating for persons with PD to continue exercising. Persons with PD demonstrated improved functional performance on sit-to-stand ( d  = -0.71), two-minute walk test ( d  = -3.83), and arm curls ( d  = -0.78)., Conclusion: Test results can be a motivator for persons with PD and lead to increased exercise adherence. Easily administered tests can show improvements in this population. Community exercise professionals are able to safely screen persons with PD to detect functional deficits and assist with programming.Implications for RehabilitationRegular exercise can slow declines in physical function and quality of life in people with Parkinson's disease.Use of physical assessments in community exercise programs can improve motivation to exercise for this population.Physical assessments such as sit-to-stand and arm curls can be used to demonstrate improvements in people with Parkinson's disease.

Background: Exercise and physical therapy (PT) can improve motor function and quality of life in individuals with Parkinson's disease (PD), but their role in hospitalization avoidance is not well-studied., Objectives: To determine the longitudinal and temporal association of exercise and PT use with hospital encounter., Methods: Longitudinal regression and χ 2 analyses were performed on Parkinson's Foundation Parkinson's Outcome Project exercise and PT use data from 4674 and 9259 persons with PD, respectively., Results: Greater exercise duration and intensity were associated with reduced odds of hospital encounter, whereas both PT and occupational therapy use were associated with increased odds. In the 2 years before a hospital encounter, there was an increased frequency of PT use, but not reductions in exercise., Conclusions: Consistent exercise may reduce hospitalization risk whereas PT referral may identify at-risk individuals without preventing this outcome. Further work to incentivize consistent exercise in PD may reduce healthcare use., (© 2022 International Parkinson and Movement Disorder Society.)

Background and Purpose: Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice., Summary of Key Points: Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care., Recommendations for Clinical Practice: Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364)., Competing Interests: All authors received honoraria and travel support related to this work from the Academy of Neurologic Physical Therapy as members of the Health Promotion and Wellness Task Force. Additionally, A.R. is a member of the World Health Organization Development Group for a Package of Rehabilitation Interventions for Traumatic Brain Injury. M.R.R. received additional concurrent funding from the National Institute of Disability, Independent Living, and Rehabilitation Research; Academy of Neurologic Physical Therapy; Parkinson's Foundation; and Davis Phinney Foundation. S.A.B. has a patent pending (18KU028M-02). E.C.H.B., S.F., K.J.H., and K.M. have no additional potential conflicts of interest to report., (Copyright © 2021 Academy of Neurologic Physical Therapy, APTA.)

Introduction: Despite evidence of the benefits of exercise, people with Parkinson's disease (PD) often exercise less than recommended. We sought to identify exercise class-related factors associated with the amount of exercise in PD communities., Methods: We used Parkinson's Outcome Project (POP) data from 3146 people with PD at 19 participating Centers of Excellence (COEs). POP data included self-reported moderate-vigorous exercise (MVE) hours, light physical activity (PA) hours, demographic and disease severity variables. We also collected information about weekly exercise class availability, intensity, cost, and distance from class location to the COE. We examined differences between COE-based and community-based exercise classes using the Akritas test for paired and unpaired samples. We tested associations between class characteristics and exercise hours based on a two-part model: logistic regression on whether a participant does MVE or light PA and linear regression for log-transformed time of exercise., Results: Community-based exercise classes had a significantly higher weekly availability than COE-based classes (class hours per week: 47.5 ± 25.6 vs 6.5 ± 8.6, p < 0.001), a higher percentage of vigorous-intensity classes (24.2 ± 17.8 vs 11 ± 14.7, p < 0.001), and a broader geographic distribution (miles to COE: 12.8 ± 4.6 vs 6.2 ± 5.7, p < 0.001). Greater weekly hours of availability, intensity, and distance to COE were associated with increased MVE and light PA hours among participants who exercised (p < 0.01). Of these, higher weekly class availability explained the most variability in reported exercise hours., Conclusion: Parkinson's COEs may be able to increase exercise by facilitating a high weekly availability of exercise classes with higher intensity levels and broader geographical distribution., (© 2022 The Authors.)

Background: Implementation science frameworks aided the development of a new, evidence-based clinical physical therapy program. The purpose of this report is to describe the process of sustaining a clinical program in practice for over 4 years. We present a framework for integrating tools for sustainability with the Knowledge-to-Action model in the context of a proactive physical therapy (PAPT) program for individuals with early-stage Parkinson's disease., Methods: Sustainability of implementation strategies was addressed using the Dynamic Sustainability Framework and sustainability assessment tools. Repeated retrospective medical record reviews and phone interviews were used to evaluate the reach and adoption of the PAPT over 4 years. Characteristics of those who engaged with PAPT, implementation fidelity, and clinical effectiveness were assessed for year 1 and year 3. Sustainability was measured using RE-AIM, NHS Sustainability Model, and Clinical Sustainability Assessment Tool., Results: Reach increased from 28 to 110 total patients per year and spread occurred from one to three sites. PAPT user age, sex, Hoehn and Yahr rating, time since diagnosis, and type of insurance were similar in year 1 and year 3 (p > 0.05). The program sustained its effect to help participants increase or maintain self-reported exercise (Y1, 95%; Y3, 100%). However, upon evaluation PAPT users in year 3 had longer time since symptom onset and worse UPDRS motor scores compared to the PAPT users in year 1 (p < 0.05). All sites sustained the core intervention components, with sustainability scores of 71/100 (± 9.9) on the NHS Sustainability Model and 6.1/7 (± 0.9) on the Clinical Sustainability Assessment Tool., Conclusions: Integrating multiple sustainability models and assessments supported continued effectiveness, spread, and sustainment of PAPT for 4 years. Effective planning, anticipating common healthcare changes, and addressing sustainability determinants early in program implementation were essential aspects of long-term success., (© 2021. The Author(s).)

Background: Neurorehabilitation engineering faces numerous challenges to translating new technologies, but it is unclear which of these challenges are most limiting. Our aim is to improve understanding of rehabilitation therapists' real-time decision-making processes on the use of rehabilitation technology (RT) in clinical treatment., Methods: We used a phenomenological qualitative approach, in which three OTs and two PTs employed at a major, technology-encouraging rehabilitation hospital wrote vignettes from a written prompt describing their RT use decisions during treatment sessions with nine patients (4 with stroke, 2 traumatic brain injury, 1 spinal cord injury, 1 with multiple sclerosis). We then coded the vignettes using deductive qualitative analysis from 17 constructs derived from the RT literature and the Consolidated Framework for Implementation Research (CFIR). Data were synthesized using summative content analysis., Results: Of the constructs recorded, the five most prominent are from CFIR determinants of: (i) relative advantage, (ii) personal attributes of the patients, (iii) clinician knowledge and beliefs of the device/intervention, (iv) complexity of the devices including time and setup, and (v) organizational readiness to implement. Therapists characterized candidate RT as having a relative disadvantage compared to conventional treatment due to lack of relevance to functional training. RT design also often failed to consider the multi-faceted personal attributes of the patients, including diagnoses, goals, and physical and cognitive limitations. Clinicians' comfort with RT was increased by their previous training but was decreased by the perceived complexity of RT. Finally, therapists have limited time to gather, setup, and use RT., Conclusions: Despite decades of design work aimed at creating clinically useful RT, many lack compatibility with clinical translation needs in inpatient neurologic rehabilitation. New RT continue to impede the immediacy, versatility, and functionality of hands-on therapy mediated treatment with simple everyday objects., (© 2021. The Author(s).)

Parkinson disease (PD) and other related diseases with α-synuclein pathology are associated with a long prodromal or preclinical stage of disease. Predictive models based on diagnosis of idiopathic rapid eye movement (REM) sleep behavior disorder (iRBD) make it possible to identify people in the prodromal stage of synucleinopathy who have a high probability of future disease and provide an opportunity to implement neuroprotective therapies. However, rehabilitation providers may be unaware of iRBD and the motor abnormalities that indicate early motor system dysfunction related to α-synuclein pathology. Furthermore, there is no existing rehabilitation framework to guide early interventions for people with iRBD. The purpose of this work is to (1) review extrapyramidal signs of motor system dysfunction in people with iRBD and (2) propose a framework for early protective or preventive therapies in prodromal synucleinopathy using iRBD as a predictive marker. Longitudinal and cross-sectional studies indicate that the earliest emerging motor deficits in iRBD are bradykinesia, deficits performing activities of daily living, and abnormalities in speech, gait, and posture. These deficits may emerge up to 12 years before a diagnosis of synucleinopathy. The proposed rehabilitation framework for iRBD includes early exercise-based interventions of aerobic exercise, progressive resistance training, and multimodal exercise with rehabilitation consultations to address exercise prescription, progression, and monitoring. This rehabilitation framework may be used to implement neuroprotective, multidisciplinary, and proactive clinical care in people with a high likelihood of conversion to PD, dementia with Lewy bodies, or multiple systems atrophy.

Purpose of Review: This review summarizes the evidence on rehabilitation for people with Parkinson's disease, including when to refer, what rehabilitation professionals should address, and how to deliver rehabilitation care., Recent Findings: Clinical practice guidelines support physical therapy, occupational therapy, and speech-language pathology for Parkinson's disease. However, integrating guidelines into practice may be difficult. Implementation studies take into account patient and clinician perspectives. Synthesizing guidelines with implementation research can improve local delivery. There is moderate to strong evidence supporting physical therapy, occupational therapy, and speech-language pathology soon after diagnosis and in response to functional deficits. We propose a framework of three pathways for rehabilitation care: (1) consultative proactive rehabilitation soon after diagnosis for assessment, treatment of early deficits, and promotion meaningful activities; (2) restorative rehabilitation to promote functional improvements; and (3) skilled maintenance rehabilitation for long-term monitoring of exercise, meaningful activities, safety, contractures, skin integrity, positioning, swallowing, and communication.

Introduction: Rehabilitation therapies are critical for optimizing quality-of-life and daily functions for individuals living with Parkinson's disease (PD). Thus, understanding the patterns of and under what conditions physicians make rehabilitation referrals is important for optimizing care., Method: We analyzed data from 5020 participants (4 countries) collected from 1/3/2016 to 4/20/2018 as part of the Parkinson's Foundation Quality Improvement Initiative (PF QII). Data were analyzed for single discipline and multidiscipline referrals to speech language pathology (SLP), physical therapy (PT), and occupational therapy (OT). Group comparisons (referred vs. not-referred) and regression procedures were implemented to determine demographic and clinical variables that were associated with an increased likelihood of rehabilitation referral., Results: 35.3% of participants were referred to rehabilitation services. Of these, 25.1% received a multidiscipline referral. There was a statistically significant effect of disease stage on both single discipline (χ 2 (2) = 45.1, p < 0.0001) and multidiscipline (χ 2 (2) = 74.2, p < 0.0001) referrals, with higher rates in later stages. Referred vs. not-referred participants differed significantly on a number of variables; however, only falls in the 6-months prior, advanced- and moderate-stage disease, older age, hospital admissions, and higher caregiver burden were associated with an increased likelihood of rehabilitation referral (adjusted odds ratios ≥ 1, Range = 1.08 to 1.62)., Conclusions: Despite evidence supporting multidiscipline and proactive rehabilitation in PD, the majority of referrals were made to a single service and may be reactions to falls or advancing disease. Data suggest there may be missed opportunities for optimizing care through proactive rehabilitation interventions., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Numerous models, frameworks, and theories exist for specific aspects of implementation research, including for determinants, strategies, and outcomes. However, implementation research projects often fail to provide a coherent rationale or justification for how these aspects are selected and tested in relation to one another. Despite this need to better specify the conceptual linkages between the core elements involved in projects, few tools or methods have been developed to aid in this task. The Implementation Research Logic Model (IRLM) was created for this purpose and to enhance the rigor and transparency of describing the often-complex processes of improving the adoption of evidence-based interventions in healthcare delivery systems., Methods: The IRLM structure and guiding principles were developed through a series of preliminary activities with multiple investigators representing diverse implementation research projects in terms of contexts, research designs, and implementation strategies being evaluated. The utility of the IRLM was evaluated in the course of a 2-day training to over 130 implementation researchers and healthcare delivery system partners., Results: Preliminary work with the IRLM produced a core structure and multiple variations for common implementation research designs and situations, as well as guiding principles and suggestions for use. Results of the survey indicated a high utility of the IRLM for multiple purposes, such as improving rigor and reproducibility of projects; serving as a "roadmap" for how the project is to be carried out; clearly reporting and specifying how the project is to be conducted; and understanding the connections between determinants, strategies, mechanisms, and outcomes for their project., Conclusions: The IRLM is a semi-structured, principle-guided tool designed to improve the specification, rigor, reproducibility, and testable causal pathways involved in implementation research projects. The IRLM can also aid implementation researchers and implementation partners in the planning and execution of practice change initiatives. Adaptation and refinement of the IRLM are ongoing, as is the development of resources for use and applications to diverse projects, to address the challenges of this complex scientific field.

Background: Although some advances have been made in recent years, the lack of measures remains a major challenge in the field of implementation research. This results in frequent adaptation of implementation measures for different contexts-including different types of respondents or professional roles-than those for which they were originally developed and validated. The psychometric properties of these adapted measures are often not rigorously evaluated or reported. In this study, we examined the internal consistency, factor structure, and structural invariance of four well-validated measures of inner setting factors across four groups of respondents. The items in these measures were adapted as part of an evaluation of a large-scale organizational change in a rehabilitation hospital, which involved transitioning to a new building and a new model of patient care, facilitated by a significant redesign of patient care and research spaces., Methods: Items were tailored for the context and perspective of different respondent groups and shortened for pragmatism. Confirmatory factor analysis was then used to test study hypotheses related to fit, internal consistency, and invariance across groups., Results: The survey was administered to approximately 1208 employees; 785 responded (65% response rate) across the roles of clinician, researcher, leader, support staff, or dual clinician and researcher. For each of the four scales, confirmatory factor analysis demonstrated adequate fit that largely replicated the original measure. However, a few items loaded poorly and were removed from the final models. Internal consistencies of the final scales were acceptable. For scales that were administered to multiple professional roles, factor structures were not statistically different across groups, indicating structural invariance., Conclusions: The four inner setting measures were robust for use in this new context and across the multiple stakeholder groups surveyed. Shortening these measures did not significantly impair their measurement properties; however, as this study was cross sectional, future studies are required to evaluate the predictive validity and test-retest reliability of these measures. The successful use of adapted measures across contexts, across and between respondent groups, and with fewer items is encouraging, given the current emphasis on designing pragmatic implementation measures.

Background and Purpose: European clinical practice guidelines recommend physical therapy for people with Parkinson disease (PD) soon after diagnosis to provide education, physical activity advice, and individualized interventions when needed. However, therapy is frequently not used until after gait and balance problems occur. The purpose of this administrative case study is to present the application of a proactive physical therapy (PAPT) approach at 1 rehabilitation center using implementation frameworks to support the (1) implementation process, (2) determinants of implementation success, and (3) implementation evaluation., Case Description: The PAPT program targeted people with PD before the onset of significant mobility dysfunction. It was initiated in 1 outpatient neurological rehabilitation center. The program used shared decision-making to promote long-term maintenance of independent exercise. The Knowledge-to-Action Framework was used by champions to plan implementation processes. Implementation barriers were addressed using the Consolidated Framework for Implementation Research. The program was evaluated using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework with mixed methods., Outcomes: In the program's first year, 38 people were referred, 28 were evaluated, and 20 participated in the 6-month program evaluation. Following PAPT, the number of participants reporting regular participation in aerobic, strengthening, and flexibility exercise approximately doubled, while those engaging in balance activities increased from 1 to 8. They reported a median of 140 minutes of aerobic exercise per week. Implementation barriers included location, insurance coverage, and difficulty scheduling long-term follow-up visits. Participants reported physical and emotional benefits of the program., Discussion: Implementation frameworks assisted with the implementation and evaluation of a PAPT delivery model that helped people with PD to increase and maintain independent exercise participation., (© 2019 American Physical Therapy Association.)

Objective: To examine rehabilitation therapy utilization for Parkinson disease (PD)., Methods: We identified 174,643 Medicare beneficiaries with a diagnosis of PD in 2007 and followed them through 2009. The main outcome measures were annual receipt of physical therapy (PT), occupational therapy (OT), or speech therapy (ST)., Results: Outpatient rehabilitation fee-for-service use was low. In 2007, only 14.2% of individuals with PD had claims for PT or OT, and 14.6% for ST. Asian Americans were the highest users of PT/OT (18.4%) and ST (18.4%), followed by Caucasians (PT/OT 14.4%, ST 14.8%). African Americans had the lowest utilization (PT/OT 7.8%, ST 8.2%). Using logistic regression models that accounted for repeated measures, we found that African American patients (adjusted odds ratio [AOR] 0.63 for PT/OT, AOR 0.63 for ST) and Hispanic patients (AOR 0.97 for PT/OT, AOR 0.91 for ST) were less likely to have received therapies compared to Caucasian patients. Patients with PD with at least one neurologist visit per year were 43% more likely to have a claim for PT evaluation as compared to patients without neurologist care (AOR 1.43, 1.30-1.48), and this relationship was similar for OT evaluation, PT/OT treatment, and ST. Geographically, Western states had the greatest use of rehabilitation therapies, but provider supply did not correlate with utilization., Conclusions: This claims-based analysis suggests that rehabilitation therapy utilization among older patients with PD in the United States is lower than reported for countries with comparable health care infrastructure. Neurologist care is associated with rehabilitation therapy use; provider supply is not., (© 2017 American Academy of Neurology.)

Background and Purpose: This study presents a secondary analysis from the Progressive Resistance Exercise Training in Parkinson Disease (PRET-PD) trial investigating the effects of progressive resistance exercise (PRE) and a Parkinson disease (PD)-specific multimodal exercise program, modified Fitness Counts (mFC), on spatial, temporal, and stability-related gait impairments in people with PD., Methods: Forty-eight people with PD were randomized to participate in PRE or mFC 2 times a week for 24 months; 38 completed the study. Gait velocity, stride length, cadence, and double-support time were measured under 4 walking conditions (off-/on-medication, comfortable/fast speed). Ankle strength was also measured off- and on-medication. Twenty-four healthy controls provided comparison data at one time point., Results: At 24 months, there were no significant differences between exercise groups. Both groups improved fast gait velocity off-medication, cadence in all conditions, and plantarflexion strength off-/on-medication. Both groups with PD had more gait measures that approximated the healthy controls at 24 months than at baseline. Plantarflexion strength was significantly associated with gait velocity and stride length in people with PD at baseline and 24 months, but changes in strength were not associated with changes in gait., Discussion and Conclusions: Twenty-four months of PRE and mFC were associated with improved off-medication fast gait velocity and improved cadence in all conditions, which is important because temporal gait measures can be resistant to medications. Spatial and stability-related measures were resistant to long-term improvements, but did not decline over 24 months. Strength gains did not appear to transfer to gait.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A161)., Competing Interests: No other conflicts of interest related to this project are reported by other authors.

Background: Research-based exercise interventions improve health-related quality of life (HRQL) and mobility in people with Parkinson's disease (PD)., Objective: To examine whether exercise habits were associated with changes in HRQL and mobility over two years., Methods: We identified a cohort of National Parkinson Foundation Quality Improvement Initiative (NPF-QII) participants with three visits. HRQL and mobility were measured with the Parkinson's Disease Questionnaire (PDQ-39) and Timed Up and Go (TUG). We compared self-reported regular exercisers (≥2.5 hours/week) with people who did not exercise 2.5 hours/week. Then we quantified changes in HRQL and mobility associated with 30-minute increases in exercise, across PD severity, using mixed effects regression models., Results: Participants with three observational study visits (n = 3408) were younger, with milder PD, than participants with fewer visits. After 2 years, consistent exercisers and people who started to exercise regularly after their baseline visit had smaller declines in HRQL and mobility than non-exercisers (p < 0.05). Non-exercisers worsened by 1.37 points on the PDQ-39 and a 0.47 seconds on the TUG per year. Increasing exercise by 30 minutes/week was associated with slower declines in HRQL (-0.16 points) and mobility (-0.04 sec). The benefit of exercise on HRQL was greater in advanced PD (-0.41 points) than mild PD (-0.14 points; p < 0.02)., Conclusions: Consistently exercising and starting regular exercise after baseline were associated with small but significant positive effects on HRQL and mobility changes over two years. The greater association of exercise with HRQL in advanced PD supports improving encouragement and facilitation of exercise in advanced PD.

Background. The progressive resistance exercise (PRE) in Parkinson's disease trial (PRET-PD) showed that PRE improved the motor signs of PD compared to a modified Fitness Counts (mFC) program. It is unclear how long-term exercise affects physical function in these individuals. Objective. To examine the effects of long-term PRE and mFC on physical function outcome measures in individuals with PD. Methods. A preplanned secondary analysis was conducted using data from the 38 patients with idiopathic PD who completed the PRET-PD trial. Participants were randomized into PRE or mFC groups and exercised 2 days/week up to 24 months. Blinded assessors obtained functional outcomes on and off medication at baseline, 6 and 24 months with the Modified Physical Performance Test, 5 times sit to stand test, Functional Reach Test, Timed Up and Go, Berg Balance Scale, 6 minute walk test (6MWT), and 50-ft walking speed (walk speed). Results. The groups did not differ on any physical function measure at 6 or 24 months (Ps > .1). Across time, all physical function measures improved from baseline to 24 months when tested on medication (Ps < .0001), except for 6MWT (P = .068). Off medication results were similar except that the 6MWT was now significant. Conclusions. Twenty-four months of supervised and structured exercise (either PRE or mFC) is effective at improving functional performance outcomes in individuals with moderate PD. Clinicians should strive to include structured and supervised exercise in the long-term plan of care for individuals with PD., (© The Author(s) 2014.)

Background: Despite the benefits of medications and surgical interventions for Parkinson's disease (PD), these treatments are not without complications and neuroprotective strategies are still lacking. Therefore, there is a need for effective alternative approaches to treat motor and non-motor symptoms in PD. During the last decade, several studies have investigated endurance exercise training as a potential treatment for individuals with PD., Objective: This paper reviews the therapeutically beneficial effects of endurance exercise training on motor and non-motor symptoms in PD., Methods: First, we performed a systematic review of the literature on the effects of endurance exercise training on motor and non-motor signs of parkinsonism, functional outcomes including gait, balance and mobility, depression and fatigue, quality of life and perceived patient improvement, cardiorespiratory function, neurophysiological measures, and motor control measures in PD. Second we performed a meta-analysis on the motor section of the UPDRS. Then, we focused on several important factors to consider when prescribing endurance exercise training in PD such as intensity, duration, frequency, specificity and type of exercise. In addition, we identified current knowledge gaps regarding endurance exercise training in PD and made suggestions for future research., Results: A total of eight randomized controlled trials met the inclusion criteria and were reviewed. This systematic review synthesizes evidence that endurance exercise training at a sufficiently high level enhances cardiorespiratory capacity and endurance by improving VO2 max and gait in moderately to mildly affected individuals with PD. However, there is not yet a proven effect of endurance exercise training on specific features of PD such as motor signs of parkinsonism., Conclusion: Endurance exercise training improves physical conditioning in PD patients; however, to date, there is insufficient evidence to include endurance exercise training as a specific treatment for PD. There is a need for well-designed large-scale randomized controlled trials to confirm benefits and safety of endurance exercise training in PD and to explore potential benefits on the motor and non-motor signs of PD.

The effects of progressive resistance exercise (PRE) on the motor signs of Parkinson's disease have not been studied in controlled trials. The objective of the current trial was to compare 6-, 12-, 18-, and 24-month outcomes of patients with Parkinson's disease who received PRE with a stretching, balance, and strengthening exercise program. The authors conducted a randomized controlled trial between September 2007 and July 2011. Pairs of patients matched by sex and off-medication scores on the Unified Parkinson's Disease Rating Scale, motor subscale (UPDRS-III), were randomly assigned to the interventions with a 1:1 allocation ratio. The PRE group performed a weight-lifting program. The modified fitness counts (mFC) group performed a stretching, balance, and strengthening exercise program. Patients exercised 2 days per week for 24 months at a gym. A personal trainer directed both weekly sessions for the first 6 months and 1 weekly session after 6 months. The primary outcome was the off-medication UPDRS-III score. Patients were followed for 24 months at 6-month intervals. Of 51 patients, 20 in the PRE group and 18 in the mFC group completed the trial. At 24 months, the mean off-medication UPDRS-III score decreased more with PRE than with mFC (mean difference, -7.3 points; 95% confidence interval, -11.3 to -3.6; P<0.001). The PRE group had 10 adverse events, and the mFC group had 7 adverse events. PRE demonstrated a statistically and clinically significant reduction in UPDRS-III scores compared with mFC and is recommended as a useful adjunct therapy to improve Parkinsonian motor signs. © 2013 Movement Disorder Society., (Copyright © 2013 Movement Disorder Society.)

Background: Robotic-assisted locomotor training has demonstrated some efficacy in individuals with neurological injury and is slowly gaining clinical acceptance. Both exoskeletal devices, which control individual joint movements, and elliptical devices, which control endpoint trajectories, have been utilized with specific patient populations and are available commercially. No studies have directly compared training efficacy or patient performance during stepping between devices., Objective: The purpose of this study was to evaluate kinematic, electromyographic (EMG), and metabolic responses during elliptical- and exoskeletal-assisted stepping in individuals with incomplete spinal cord injury (SCI) compared with therapist-assisted stepping. Design A prospective, cross-sectional, repeated-measures design was used., Methods: Participants with incomplete SCI (n=11) performed 3 separate bouts of exoskeletal-, elliptical-, or therapist-assisted stepping. Unilateral hip and knee sagittal-plane kinematics, lower-limb EMG recordings, and oxygen consumption were compared across stepping conditions and with control participants (n=10) during treadmill stepping., Results: Exoskeletal stepping kinematics closely approximated normal gait patterns, whereas significantly greater hip and knee flexion postures were observed during elliptical-assisted stepping. Measures of kinematic variability indicated consistent patterns in control participants and during exoskeletal-assisted stepping, whereas therapist- and elliptical-assisted stepping kinematics were more variable. Despite specific differences, EMG patterns generally were similar across stepping conditions in the participants with SCI. In contrast, oxygen consumption was consistently greater during therapist-assisted stepping. Limitations Limitations included a small sample size, lack of ability to evaluate kinetics during stepping, unilateral EMG recordings, and sagittal-plane kinematics., Conclusions: Despite specific differences in kinematics and EMG activity, metabolic activity was similar during stepping in each robotic device. Understanding potential differences and similarities in stepping performance with robotic assistance may be important in delivery of repeated locomotor training using robotic or therapist assistance and for consumers of robotic devices.

This paper reviews the therapeutically beneficial effects of progressive resistance exercise (PRE) on Parkinson's disease (PD). First, this paper discusses the rationale for PRE in PD. Within the first section, the review discusses the central mechanisms that underlie bradykinesia and muscle weakness, highlights findings related to the central changes that accompany PRE in healthy individuals, and extends these findings to individuals with PD. It then illustrates the hypothesized positive effects of PRE on nigro-striatal-thalamo-cortical activation and connectivity. Second, it reviews recent findings of the use of PRE in individuals with PD. Finally, knowledge gaps of using PRE on individuals with PD are discussed along with suggestions for future research.

Background: In individuals with motor incomplete spinal cord injury (SCI), ambulatory function determined in the clinical setting is related to specific measures of body structure and function and activity limitations, although few studies have quantified the relationship of these variables with daily stepping (steps/day)., Objective: The aim of this study was to quantify daily stepping in ambulatory individuals with SCI and its relationship with clinical walking performance measures and specific demographics, impairments, and activity limitations., Design: A cross-sectional study was performed to estimate relationships among clinical variables to daily stepping in self-identified community versus non-community (household) walkers., Methods: Average daily stepping was determined in 50 people with chronic, motor incomplete SCI. Data for clinical and self-report measures of walking performance also were collected, and their associations with daily stepping were analyzed using correlation and receiver operating characteristic (ROC) analyses. Relationships between daily stepping and the measures of demographics, impairments, and activity limitations were identified using correlation and regression analyses., Results: The ROC analyses revealed a significant discriminative ability between self-reported community and non-community walkers using clinical gait measures and daily stepping. Stepping activity generally was low throughout the sample tested, however, with an average of approximately 2,600 steps/day. Knee extension strength (force-generating capacity) and static balance were the primary variables related to daily stepping, with metabolic efficiency and capacity and balance confidence contributing to a lesser extent., Limitations: The small sample size and use of specific impairment-related measures were potential limitations of the study., Conclusions: Daily stepping is extremely limited in individuals with incomplete SCI, with a potentially substantial contribution of impairments in knee extension strength and balance.

Quantification of the effects of management programs on water quality is critical to agencies responsible for water resource protection. This research documents reductions in stream water phosphorus (P) loads resulting from agricultural best management practices (BMPs) implemented as part of an effort to control eutrophication of Cannonsville Reservoir, a drinking water supply for New York City. Dairy farms in the upstate New York reservoir basin were the target of BMPs designed to reduce P losses. A paired watershed study was established on one of these farms in 1993 to evaluate changes in P loading attributable to implementation of BMPs that included manure management, rotational grazing, and improved infrastructure. Intensive stream water monitoring provided data to calculate P loads from the 160-ha farm watershed for all runoff events during a two-year pre-treatment period and a four-year post-treatment period. Statistical control for inter-annual climatic variability was provided by matched P loads from a nearby 86-ha forested watershed, and by several event flow variables measured at the farm. A sophisticated multivariate analysis of covariance (ANCOVA) provided estimates of both seasonal and overall load reductions. Statistical power and the minimum detectable treatment effect (MDTE) were also calculated. The results demonstrated overall event load reductions of 43% for total dissolved phosphorus (TDP) and 29% for particulate phosphorus (PP). Changes in farm management practices and physical infrastructure clearly produced decreases in event P losses measurable at the small watershed scale.