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To characterize transient and prolonged body position patterns in a large sample of nursing home (NH) residents and describe the variability in movement patterns based on time of occurrence.This study is a descriptive, exploratory analysis of up to 28 days of longitudinal accelerometer data for 1,100 NH residents from the TEAM-UP (Turn Everyone and Move for Ulcer Prevention) clinical trial. Investigators analyzed rates of transient events (TEs; less than 60 seconds) and prolonged events (PEs; 60 seconds or longer) and their interrelationships by nursing shift.Residents' positions changed for at least 1 minute (PEs) nearly three times per hour. Shorter-duration movements (TEs) occurred almost eight times per hour. Residents' PE rates were highest in shift 2 (3 pm to 11 pm ), when the median duration and maximum lengths of PEs were lowest; the least active time of day was shift 3 (11 pm to 7 am ). Three-quarters of all PEs lasted less than 15 minutes. The rate of TEs within PEs decreased significantly as the duration of PEs increased.The NH residents demonstrate complex patterns of movements of both short and prolonged duration while lying and sitting. Findings represent how NH residents naturally move in real-world conditions and provide a new set of metrics to study tissue offloading and its role in pressure injury prevention.

BACKGROUND An assessment tool is needed to measure clinical severity of nursing home residents to improve prediction of outcomes and provide guidance in treatment planning. OBJECTIVE To describe development of a Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. METHODS A retrospective, non-experimental design was used to develop and validate a Nursing Home Severity Index using secondary data from nine nursing homes participating in the 12-month pre-intervention period of the TEAM-UP pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury was accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident’s Worst-Braden score with/without severity dimensions generated propensity scores. Goodness-of-fit for overall models was assessed using C statistics; significance of improvement of fit after adding severity components to the model was determined using the Likelihood Ratio Chi Square test. Significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm reliability of the severity measure. Finally, discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. RESULTS Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C-statistics measuring predictive accuracy increased 19.3% (from 0.627 to 0.748, P CONCLUSIONS A clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This Index has the potential to significantly impact quality of care decisions aimed at improving individual pressure injury prevention plans. CLINICALTRIAL ClinicalTrials.gov NCT123456.

Nursing staff assessment to accurately identify pressure injury (PrI) risk is a hallmark in PrI prevention care. Risk scores from the Braden Scale for Predicting Pressure Sore Risk© (hereafter Braden), a commonly used tool for assessing PrI risk, signal the need for preventative care. Braden Mobility, Activity, and Sensory Perception subscale subgroups associated with repositioning movement features help identify preventative strategies that minimize pressure intensity and duration. Evidence confirming subscale rating accuracy is needed. This study compared assessment score accuracy with movement data collected via accelerometer sensor. Sample included 913 nursing home residents from the Turn Everyone and Move for Pressure Ulcer Prevention (TEAM-UP) cluster randomized trial. Movements and Braden Mobility and Activity subscale scores were evaluated for significant differences and associations. Mobility subgroups explained a small-medium amount of variance in mean lying and upright movement features (0.002 ≤ R2 ≤ 0.195). Activity subgroups explained a small-medium amount of variance in mean lying, upright, and ambulating movements (0.016 ≤ R2 ≤ 0.248). Significant associations occurred among subscale subgroups and most movements. Nursing assessment ratings using Braden scale’s Mobility and Activity subscale scores are accurate indicators of actual repositioning movements and can be relied upon for PrI prevention care planning for older adults.

Objective To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI). Setting Acute inpatient rehabilitation. Participants Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. Design Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data. Main measures Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9. Results When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment. Conclusions The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Obesity (body mass index [BMI] ≥30 kg/m2) can have a profound influence on the likelihood of developing a pressure injury (PrI); little is known about the movement behaviors (movement frequency, body position frequency, and position duration) of obese individuals. Purpose This report examines 2 cases of obese nursing home residents and their movement behaviors in relation to their potential influence on overall PrI risk. Methods Resident movements were monitored 24 hours/day using a wearable sensor, and repositioning events were observed as part of a larger study examining repositioning intervals. Braden Pressure Ulcer Risk Assessment was conducted weekly. Results Both residents (BMI 39 kg/m2 and 50 kg/m2) had limitations in movement with prolonged periods spent in a single body position. Each resident addressed movement challenges unique to their desire to remain mobile and level of dependency on nursing staff. Conclusion Presence of obesity is a factor affecting resident movement and creates environmental and psychosocial barriers to health. Nurses can play a key role in PrI prevention by addressing these barriers and encouraging positive, long-term behavior changes that mitigate risk. Future research should guide tailored PrI prevention protocols and national/ international guidelines for obese residents.

Objective: To develop a venous leg ulcer (VLU) risk stratification system for use in research and clinical practice. Approach: U.S. Wound Registry data were examined retrospectively and assigned an outcome. Bivariate analysis identified significant variables (p

Registries are a powerful tool for clinical research. Clinical registries for cerebral palsy can aid in comparative effectiveness research, especially using the practice-based evidence model. The Cerebral Palsy Research Network (CPRN) was initiated in 2014 as a patient-centered, multidisciplinary registry. The leadership group initiated a 4-stage participatory action research process: listen, reflect, plan/analyze, and take action. CPRN also joined with CP NOW, an advocacy group, to create a research agenda for cerebral palsy. With more than 20 centers and growing, CPRN hopes to generate evidence for developing best practices and measure their implementation and impact for individuals with cerebral palsy throughout North America.

Background An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning. Objective This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. Methods A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident’s Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. Results Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index–Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P Conclusions The clinical Nursing Home Severity Index–Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans. Trial Registration ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331

To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks.An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity.From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P.001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P.001).Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened.

Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD ( n = 62, 70%) and non-ADRD ( n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.

Background: Pressure injuries (PrIs) cause pain and infection, lengthen institutional care, raise healthcare costs, and hasten death in nursing home (NH) residents. Repositioning residents to offload pressure on tissues is the most common prevention strategy, yetthe optimal interval remains uncertain.Objective: Investigate clinical effectiveness of three nursing-home-wide repositioning intervals (2-,3-, or 4-hours) without compromising PrI incidence in four weeks in adult nursing home residents.Design, Setting, and Participants: Anembedded pragmatic cluster randomized controlled trial was conducted in 9 NHs from a large proprietary system located in 34 states. Each NH was randomly assigned to one of three NH-wide repositioning interval Arms (every 2, 3, or 4 hours). Data were provided for 12-month Baseline and 4-week Intervention during the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) study. Intervention residents were without current PrIs, had PrIrisk (Braden Score) ≥10 (low, mild, moderate, or high risk; not severe risk), and used viable 7” high-density foam mattresses.Methods: Each Arm included three NHs with assigned single repositioning interval as standard care during the 4-week Intervention. Mandatory staff education sessions were provided.A wireless patient monitoring system, using wearable single-use patient sensors, cued staff by displaying resident repositioning need on conveniently placed monitors.Primary outcome was PrI incidence; secondary outcome was staff repositioning compliance fidelity.Results: Eleven hundred residents from 9 NHs were fitted with sensors; 108 of these were ineligible for some analyses due to missing Baseline data. Effective sample size included 992 residents (mean age 78 years [SD13]; 63% female). Pressure injury incidence during the Intervention was 0.0% compared to 5.24% in Baseline, even though Intervention resident clinical risk scores were significantlyhigher (pConclusions: This study contributes to understanding alternativerepositioning intervalssuggestingcurrent 2-hour protocolscan be relaxed for many without compromising PrI development. Causal link was not established between three repositioning interval treatments and primary outcome—PrIs; however, no new PrIs developed. Cueing staff may benefit repositioningimplementation; compliance improved as repositioning interval lengthened.Trial Registration: (ClinicalTrials.gov Identifier: NCT02996331).Date: 16/05/2017

Objective To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge. Design Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data. Setting Nine inpatient rehabilitation centers in the United States. Participants Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI. Intervention Family attendance during therapy sessions. Main Outcome Measures Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Results Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance. Conclusions Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients' families in the rehabilitation process to maximize outcomes.

Objective Given evidence that malnutrition and immobility increase the risk of pressure injuries (PIs) in nursing home (NH) residents and that body mass index guidelines related to undernutrition may differ between Asian and non-Asian populations, the purpose of this study was to describe differences in overall nutrition, dietary intake, and nonnutrition risk factors for PIs between Asian and non-Asian NH residents. Design and setting Secondary data analysis of a 3-week PI prevention randomized controlled trial in seven Canadian NHs. Patients Asian (n = 97) and non-Asian (n = 408) residents at moderate or high mobility-related risk of PI. Main outcome measure Incident PI by racial subgroups. Main results Asian residents (PI = 6) consumed significantly smaller meals and marginally different patterns of daily dietary consumption of protein types, liquid supplements, and snacks; took more frequent tub baths; and had marginally lower body mass index than non-Asian residents (PI = 4). Conclusions Findings are consistent with earlier research suggesting that nutrition consumption and care patterns may predispose Asian NH residents to develop more PIs than their non-Asian counterparts. Future research should focus on the threshold for and types of nutrition support sufficient to improve nutrition status and reduce PI risk.

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIMTM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Objectives To describe development and testing of a physical therapy treatment code documentation taxonomy. Design Clinician survey within a practice-based evidence study framework for patients with lymphedema. Setting Outpatient physical therapy clinics within a large public health care service using a central electronic medical record. Participants Certified lymphedema therapists (CLTs) (N=43). Intervention Treatment coding of 10 treatment vignettes representing real-life clinical scenarios. The CLTs were asked to accurately select 35 activity-intervention combination codes. Main Outcome Measures The CLT score represented percentage of treatment codes accurately selected by each therapist. The code score represented percentage of CLTs who accurately selected each treatment code. Results The mean CLT score was 91%, with 72% of CLTs meeting the 90% criterion. Personal feedback was provided to each CLT. The mean code score was also 91%; with 71% of treatment codes meeting the 90% criterion. We identified 9 low-score codes needing additional education or found to be redundant. These codes were either clarified or removed. Conclusions The proposed treatment code documentation system for lymphedema therapy was found to be clear and accurately used by most CLTs. Specific needs for improvement were identified. Follow-up testing is warranted to ensure ongoing accurate implementation of the treatment documentation system.

Objectives To explore the patterns of cognitive and motor recovery at 4 time points from admission to 9 months after discharge from inpatient rehabilitation (IR) and to investigate the association of therapeutic factors and conditions before and after discharge with long-term outcomes. Design Secondary analysis of traumatic brain injury (TBI) and practice-based evidence dataset. Setting IR in Ontario, Canada. Participants Patients with TBI consecutively admitted for IR between 2008 and 2011 who had data available from admission to 9 months after discharge (N=85). Interventions Not applicable. Main Outcome Measure FIM-Rasch cognitive and motor scores at admission, discharge, 3 months after discharge, and 9 months after discharge. Results Cognitive and motor recovery showed similar patterns of improvement with recovery up to 3 months but no significant change from 3 to 9 months. Having fewer postdischarge health conditions was associated with better long-term cognitive scores (95% confidence interval, -13.06 to -1.2) and added 9.9% to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% confidence interval, .02 to .09) and fewer postdischarge health conditions (95% confidence interval, -19.5 to -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively. Conclusion Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR.

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (

Magnetic state of exchanged biased CoO(20nm)/Co($d_F$) bilayer ($d_F$=5-20nm) was studied by means of polarized neutron reflectometry. By spacing of CoO/Co bilayer and Al$_2$O$_3$ substrate with Nb(20nm) layer we created waveguide structure which allowed us to significantly enhance intensity of spin-flip (SF) scattering in the position of optical resonances. For the trained sample with thinnest Co(5nm) we detected strong SF scattering at the resonance position (up to 30\% of incoming intensity) speaking about high non-collinearity of the system. As $d_F$ increases, the intensity of SF scattering linearly decreases. At the same time we observed asymmetry of up-down and down-up scattering channels at the resonance positions. We attribute this asymmetry to the Zeeman splitting of neutrons energies with different initial polarization taking place in high external field. Analysis, however, shows that the applied in the PNR experiment external field is not enough to quantitatively explain the observed asymmetry for the samples with $d_F > $ 5nm and we have to postulate presence of additional magnetic field produced by sample. We attribute this additional field to the stray field produced by chiral Bloch domain walls. The chirality of the domain walls can be explained by Dzyaloshinskii-Moriya interaction arising at the CoO/Co interface. Our results can be useful for designing of spintronic devices using exchange bias effect.

Objective The aim of the study was to compare the relative predictive value of Marshall Classification System and Rotterdam scores on long-term rehabilitation outcomes. This study hypothesized that Rotterdam would outperform Marshall Classification System. Design The study used an observational cohort design with a consecutive sample of 88 participants (25 females, mean age = 42.0 [SD = 21.3]) with moderate to severe traumatic brain injury who were admitted to trauma service with subsequent transfer to the rehabilitation unit between February 2009 and July 2011 and who had clearly readable computed tomography scans. Twenty-three participants did not return for the 9-mo postdischarge follow-up. Day-of-injury computed tomography images were scored using both Marshall Classification System and Rotterdam criteria by two independent raters, blind to outcomes. Functional outcomes were measured by length of stay in rehabilitation and the cognitive and motor subscales of the Functional Independence Measure at rehabilitation discharge and 9-mo postdischarge follow-up. Results Neither Marshall Classification System nor Rotterdam scales as a whole significantly predicted Functional Independence Measure motor or cognitive outcomes at discharge or 9-mo follow-up. Both scales, however, predicted length of stay in rehabilitation. Specific Marshall scores (3 and 6) and Rotterdam scores (5 and 6) significantly predicted subacute outcomes such as Functional Independence Measure cognitive at discharge from rehabilitation and length of stay. Conclusions Marshall Classification System and Rotterdam scales may have limited utility in predicting long-term functional outcome, but specific Marshall and Rotterdam scores, primarily linked to increased severity and intracranial pressure, may predict subacute outcomes.

Dementia contributes to the development of pressure injuries (PrIs).This study describes the real-time body positions of 2 nursing home (NH) residents, residing in the United States and living with dementia, to inform development of PrI prevention strategies tailored to individual risk profiles.As part of a larger study, eligible residents were fitted with a triaxial accelerometer sensor placed on the anterior chest to monitor body positions 24-hours daily through a 4-week monitoring period. The current study used an observational, prospective design during routine repositioning events for 2 residents. A convenience sample of 2 residents from a single NH wing who were considered moderately at risk for PrI development (Braden Scale score 13-14) with a Brief Interview for Mental Status score in the severely impaired range were selected based on nursing staff recommendation.Sensor data showed that both residents, although "chairfast" according to the Braden Scale, spent5% in an upright position and the great majority of time reclining at an angle50%. One (1) resident demonstrated a persistent side preference.Wearable sensors are not a long-term solution for protecting those with dementia from PrI formation but do provide a crude picture of overall body positions throughout the 24-hour day that may inform individualized PrI prevention strategies. Studies including large samples of NH residents living with dementia are warranted.

Obesity (body mass index [BMI] ≥30 kg/m2) can have a profound influence on the likelihood of developing a pressure injury (PrI); little is known about the movement behaviors (movement frequency, body position frequency, and position duration) of obese individuals.This report examines 2 cases of obese nursing home residents and their movement behaviors in relation to their potential influence on overall PrI risk.Resident movements were monitored 24 hours/day using a wearable sensor, and repositioning events were observed as part of a larger study examining repositioning intervals. Braden Pressure Ulcer Risk Assessment was conducted weekly.Both residents (BMI 39 kg/m2 and 50 kg/m2) had limitations in movement with prolonged periods spent in a single body position. Each resident addressed movement challenges unique to their desire to remain mobile and level of dependency on nursing staff.Presence of obesity is a factor affecting resident movement and creates environmental and psychosocial barriers to health. Nurses can play a key role in PrI prevention by addressing these barriers and encouraging positive, long-term behavior changes that mitigate risk. Future research should guide tailored PrI prevention protocols and national/ international guidelines for obese residents.

UNSTRUCTURED The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management. Perspective This report describes the results of the analyses of PROs and patient-related electronic health record data collected under standard of care from cancer patients at outpatient pain management clinics of Anesthesiology and Palliative Care at the Memorial Sloan Kettering Cancer Center. Consideration of sex and age as predictors of opioid use is critical in attempting to understand PROs and their relationship to pain management.

The Weill Cornell Medical College Pain Registry database contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,159 chronic pain patients who were seen at the Weill Cornell Medical College Pain Medicine outpatient clinic from July 8, 2011 to December 10, 2014. Patients aged 45 to 64 years comprised 43% followed by age ≥ 65 years at 37%. Fifty-eight percent were female. Average pain intensity (Brief Pain Inventory) was reported as mild by 22.3% of patients, moderate by 34.7%, and severe by 43.0%. For each pain intensity category, patient's report of average percent pain relief and health state (EuroQOL 5 Dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Seventy-seven percent of patients received an opioid at 1 or more clinic encounters. Median daily opioid dose in morphine equivalents was 55 with a range from 2 to 1,145 morphine equivalents. Regression analysis revealed that being male was associated with greater likelihood of an opioid ordered and higher average dosage than being female. The registry can identify patient characteristics and treatments that provide new insights into chronic pain management. Perspective This article describes results of analyses of patient-reported outcomes and patient–related electronic health record data collected under standard of care from a prospective cohort of chronic pain outpatients at a New York City pain management clinic. The registry provides an opportunity to learn how to improve individualized chronic pain management.

Registries are a powerful tool for clinical research. Clinical registries for cerebral palsy can aid in comparative effectiveness research, especially using the practice-based evidence model. The Cerebral Palsy Research Network (CPRN) was initiated in 2014 as a patient-centered, multidisciplinary registry. The leadership group initiated a 4-stage participatory action research process: listen, reflect, plan/analyze, and take action. CPRN also joined with CP NOW, an advocacy group, to create a research agenda for cerebral palsy. With more than 20 centers and growing, CPRN hopes to generate evidence for developing best practices and measure their implementation and impact for individuals with cerebral palsy throughout North America.

Adding intravenous (IV) acetaminophen to an opioid-based regimen as multimodal pain management for perioperative pain control in adults undergoing spine surgery can lead to effective pain control, reduce the risk of opioid-related adverse effects, and facilitate postoperative neurologic evaluation for surgical outcomes. This descriptive pilot study investigated the analgesic effect of a single dose of IV acetaminophen administered intraoperatively as routine practice for perioperative pain management for adults undergoing elective spine surgery. A retrospective comparative cohort study compared an IV acetaminophen group with a group not receiving IV acetaminophen for primary outcomes measured by visual analog scale (VAS) and associated secondary outcomes. The IV acet-aminophen group had lower mean VAS scores than the group not receiving IV acetaminophen (4.33 vs 6.22, P = .01, at 60 minutes after entry into the postanesthesia care unit [PACU] for procedure level 4; 2.43 vs 3.11, P = .002, at PACU discharge for procedure level 3). The study did not show consistently lower VAS scores for the IV acetaminophen group vs the group not receiving IV acetaminophen. No difference was found for other secondary outcomes between groups. Future prospective studies are needed to assess the analgesic effects of IV acetaminophen for spine surgery cases.

OBJECTIVE To determine the relationship between comorbid health conditions and the trajectory of functional recovery 5 years following traumatic brain injury (TBI) rehabilitation. SETTING Two acute rehabilitation facilities. PARTICIPANTS A total of 407 patients with primary diagnosis of TBI. DESIGN Prospective, observational. MAIN MEASURES Functional Independence Measure Cognitive and Motor scores. RESULTS Female gender was negatively associated with the trajectory of motor recovery (P < .001). TBI severity was negatively associated with both motor and cognitive recovery and interacted with time after injury (both Ps < .0001). Hypertension was negatively associated with both motor (P < .0001) and cognitive (P = .0121) recovery, although this relationship diminished over time for motor function (P = .0447). Cardiac conditions were negatively associated with motor recovery (P = .0204), and rate of cognitive recovery was more rapid for patients with cardiac conditions (P = .0088). Depressed patients recovered cognitive function more quickly than those who were not depressed (P = .0196). Diabetes was negatively associated with motor function (P = .0088). Drug/alcohol use was positively associated with motor function (P = .0036). CONCLUSIONS Injury severity remains an important predictor of long-term recovery; however, certain comorbid medical conditions are negatively associated with functional abilities over the first 5 years after injury. Patients being discharged from TBI rehabilitation with comorbid cardiac, hypertensive, diabetic, and/or depressive conditions may benefit from early and ongoing clinical surveillance.

BACKGROUND Although some attention has been given to the association of functional outcomes with rehabilitation intensity, the evidence is still sparse in this field. OBJECTIVE To investigate the effect of inpatient rehabilitation (IR) on discharge cognitive and motor function and the association of time spent in occupational and physical therapy and level of effort with cognitive and motor function in patients with traumatic brain injury (TBI). DESIGN Secondary analysis of TBI-Practice Based Evidence dataset. SETTINGS Inpatient rehabilitation. PARTICIPANTS One hundred forty-nine patients with TBI who were consecutively admitted for IR between 2008 and 2011 in Ontario, Canada. INTERVENTIONS Not applicable. MAIN OUTCOME MEASUREMENTS Admission and discharge Functional Independence Measure-Rasch Cognitive and Motor Scores. RESULTS Patients showed significant improvement in cognitive and motor function from admission to discharge (P

The Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury (TBI-CER) project used causal inference methods as an alternative to randomized controlled trials to evaluate rehabilitation practices. The TBI practice-based evidence dataset afforded the opportunity to compare the outcomes of different rehabilitation approaches while controlling for a large set of potential confounders using propensity score methods (PSMs). PSMs rely on 4 assumptions: positivity, exchangeability, consistency, and correct specification of the propensity score model. When these assumptions are met, PSMs provide a transparent means for evaluating potential causal relations between interventions and outcomes using observational data. In combination, the series of studies resulting from the TBI-CER project suggested that the content and approach used in treatment have a stronger effect on outcomes than the amount of time spent in treatment. Further, engagement of the patient and family in treatment is key to optimizing outcomes up to 9 months postdischarge from rehabilitation.

Standardization of care that is derived from analysis of outcomes data can lead to improvements in quality and efficiency of care. The outcomes data should be validated, standardized, and integrated into ongoing patient care with minimal burden on the patient and health care team. This article describes the organization and workflow of a chronic pain clinic registry designed to collect and analyze patient data for quality improvement and dissemination. Future efforts in using mobile technology and integrating patient-reported outcome data in the electronic health records have the potential to offer new and improved models of comprehensive pain management.

Background and Purpose— Mexican Americans (MAs) have worse neurological, functional, and cognitive outcomes after stroke. Stroke rehabilitation is important for good outcome. In a population-based study, we sought to determine whether allocation of stroke rehabilitation services differed by ethnicity. Methods— Patients with stroke were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, TX, USA. Cases were validated by physicians using source documentation. Patients were followed prospectively for 3 months after stroke to determine rehabilitation services and transitions. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t tests or Wilcoxon rank-sum tests by ethnicity. Categorical baseline variables were compared using χ 2 tests. Ethnic comparisons of rehabilitation services were compared using χ 2 tests, Fisher’s exact tests, and logistic regression. Results— Seventy-two subjects (50 MA and 22 non-Hispanic white [NHW]) were followed. Mean age, NHW-69 (SD 13), MA-66 (SD 11) years, sex (NHW 55% male, MA 50% male) and median presenting National Institutes of Health Stroke Scale did not differ significantly. There were no ethnic differences among the proportion of patients who were sent home without any rehabilitation services ( P =0.9). Among those who received rehabilitation, NHWs were more likely to get inpatient rehabilitation (73%) compared with MAs (30%), P =0.016. MAs (51%) were much more likely to receive home rehabilitation services compared with NHWs (0%) ( P =0.0017). Conclusions— In this population-based study, MAs were more likely to receive home-based rehabilitation, whereas NHWs were more likely to get inpatient rehabilitation. This disparity may, in part, explain the worse stroke outcome in MAs.

The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.

Objective To evaluate the effect of providing a greater percentage of therapy as contextualized treatment on acute traumatic brain injury (TBI) rehabilitation outcomes. Design Propensity score methods are applied to the TBI Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data. Setting Acute inpatient rehabilitation. Participants Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received their first inpatient rehabilitation facility admission in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation. Interventions Not applicable. Main Outcome Measures Participation Assessment with Recombined Tools-Objective (PART-O)-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Results Increasing the percentage of contextualized treatment during inpatient TBI rehabilitation leads to better outcomes, specifically in regard to community participation. Conclusions Increasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used.

Objective To determine if patients’ level of effort (LOE) in therapy sessions during traumatic brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour Rule of the Centers for Medicare & Medicaid Services. Design Propensity score methodology applied to the TBI Practice-Based Evidence database, consisting of multisite, prospective, longitudinal observational data. Setting Acute inpatient rehabilitation facilities (IRF). Participants Patients (N=1820) who received their first IRF admission for TBI in the United States and were enrolled for 3- and 9-month follow-up. Main Outcome Measures Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Results When the full cohort was examined, no strong main effect of compliance with the 3-Hour Rule was identified and LOE did not modify the effect of compliance with the 3-Hour Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression. When the sample was stratified by level of disability, LOE modified the effect of compliance, particularly on the outcomes of participants with less severe disability. For these patients, providing 3 hours of therapy for 50% or more of therapy days in the context of low effort resulted in poorer performance on select outcome measures at discharge and up to 9 months postdischarge compared to patients with Conclusions LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with the 3-Hour Rule was not found to have a substantive effect on the outcomes. The results support matching time in therapy during acute TBI rehabilitation to patients’ LOE in order to optimize long-term benefits on outcomes.

Objective To use causal inference methods to determine if receipt of a greater proportion of inpatient rehabilitation treatment focused on higher level functions, for example, executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results in better rehabilitation outcomes. Design A cohort study using propensity score methods applied to the traumatic brain injury practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective, longitudinal observational data. Setting Acute inpatient rehabilitation facilities. Participants Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation facility admission to 1 of 9 sites in the United States, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. Interventions Not applicable. Main Outcome Measures Participation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Results Controlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year after discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities. Conclusions Increasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient’s recovery trajectory to influence therapists’ decisions to provide a greater amount of AdvTx.

AIM To determine caregiver knowledge and preferences for gross motor information and examine differences across Gross Motor Function Classification System (GMFCS) levels. METHOD A questionnaire was developed. Respondents reported GMFCS knowledge, preference for knowledge, and experience with GMFCS and motor curve information. RESULTS In total, 303 caregivers of children with cerebral palsy (CP) (GMFCS level I: 22%; GMFCS level II: 16%; GMFCS level III: 15%; GMFCS level IV: 23%; GMFCS level V: 24%) completed the questionnaire. Forty-five per cent of caregivers knew the GMFCS level at survey, and only 31% knew how their child's motor development compared with others of similar age and level. Caregiver education level was associated with knowledge (p

Aim To establish a patient-centered research agenda for cerebral palsy (CP). Method We engaged a large cross-section of the extended community of people living with CP and those providing healthcare to people with CP ('the community') in an educational series and collaborative survey platform to establish an initial list of prioritized research ideas. After online workshops, a facilitated Delphi process was used to select the 20 highest priorities. Select participants attended an in-person workshop to provide comment and work toward consensus of research priorities. Results A research agenda for CP was developed by the community, which included consumers, clinicians, and researchers interested in advancing the established research agenda. The results included the top 16 research concepts produced by the process to shape and steward the research agenda, and an engaged cross-section of the community. Interpretation It has been shown that proactively engaging consumers with clinical researchers may provide more meaningful research for the community. This study suggests that future research should have more focus on interventions and outcomes across the lifespan with increased emphasis on the following outcome measures: function, quality of life, and participation. What this paper adds A patient-centered research agenda for cerebral palsy was established. Comparative effectiveness of interventions, physical activity, and understanding ageing were leading themes. Longitudinal studies across the lifespan, clinical spectrum, and ages were highly ranked. Participants reported high value for participation outcomes. Participants reported great appreciation for the engagement between consumers and clinician researchers.

Recent evidence suggests that less frequent repositioning of long-term care residents at moderate/high risk of developing pressure ulcers (PrUs) is non-inferior to current repositioning standards in preventing PrUs. However, the long-term health and economic consequences of less frequent repositioning have not been adequately estimated. Our objective is to estimate the cost-effectiveness of different repositioning strategies (2-, 3-, or 4-hour intervals). We conducted a cost-utility analysis using a lifetime horizon based on data from a randomized clinical trial and from the literature. We updated a published PrU decision model with resource utilization, unit costs, and epidemiological estimates from the literature and from a small observational study. The Ontario Ministry of Health and Long-Term Care perspective was taken. We estimated the reduction in costs at 3-hour vs 2- or 4-hour repositioning at CAN$5,425 (95% Credible Interval (CrI): $922 – $12,166), or CAN$3,296 (95%CrI: −$483 – $9,738) per resident across their lifetime respectively. The gain in the expected Quality Adjusted Life Years (QALYs) between 3-hour and 2- or 4-hour repositioning strategies were 0.008, (95% CrI: 0.005 – 0.016) and 0.009 (95%CrI: 0.007 – 0.018) respectively. Repositioning at 3-hour intervals was the dominant strategy with respect to the incremental cost-effectiveness ratio against both 2- and 4-hour strategies. Sensitivity analysis showed a 99% probability that the 3-hourly repositioning was a dominant strategy. We concluded that repositioning at 3-hour intervals for residents at moderate or high risk of PrUs and who were cared for on high-density foam mattresses appeared to be the most cost-effective strategy.

Background Growing attention in the past few decades has focused on improving care quality and quality of life for nursing home residents. Many traditional nursing homes have attempted to transform themselves to become more homelike emphasizing individualized care. This trend is referred to as nursing home culture change in the U.S. A promising culture change nursing home model, the Green House nursing home model, has shown positive psychological outcomes. However, little is known about whether the Green House nursing home model has positive effects on physical function compared to traditional nursing homes. Objectives To examine the longitudinal effects of the Green House nursing home model by comparing change patterns of activities of daily living function over time between Green House home residents and traditional nursing home residents. Design A retrospective longitudinal study. Settings Four Green House organizations (nine Green House units and four traditional units). Participants A total of 242 residents (93 Green House residents and 149 traditional home residents) who had stayed in the nursing home at least 6 months from admission. Methods The outcome was activities of daily living function, and the main independent variable was the facility type in which the resident stayed: a Green House or traditional unit. Age, gender, comorbidity score, cognitive function, and depressive symptoms at baseline were controlled. All of these measures were from a minimum dataset. Growth curve modeling and growth mixture modeling were employed in this study for longitudinal analyses. Results The mean activities of daily living function showed deterioration over time, and the rates of deterioration between Green House and traditional home residents were not different over time. Four different activities of daily living function trajectories were identified for 18 months, but there was no statistical difference in the likelihood of being in one of the four trajectory classes between the two groups. Conclusions Although Green House nursing homes are considered to represent an innovative model changing the nursing home environment into more person-centered, this study did not demonstrate significant differences in activities of daily living function changes for residents in the Green House nursing homes compared to traditional nursing homes. Given that the Green House model continues to evolve as it is being implemented and variations within and across Green House homes are identified, large-scale longitudinal studies are needed to provide further relevant information on the effects of the Green House model.

Objective: To develop a healing index for patients with diabetic foot ulcers (DFUs) for use in clinical practice, research analysis, and clinical trials. Approach: U.S. Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, etc.). Significant variables were identified with bivariate analyses. A multivariable logistic regression model was created based on significant factors (p

Objective To determine the association of enteral nutrition (EN) with patient preinjury and injury characteristics and outcomes for patients receiving inpatient rehabilitation after traumatic brain injury (TBI). Design Prospective observational study. Setting Nine rehabilitation centers. Participants Patients (N=1701) admitted for first full inpatient rehabilitation after TBI. Interventions Not applicable. Main Outcome Measures FIM at rehabilitation discharge, length of stay, weight loss, and various infections. Results There were many significant differences in preinjury and injury characteristics between patients who received EN and patients who did not. After matching patients with a propensity score of >40% for the likely use of EN, patients receiving EN with either a standard or a high-protein formula (>20% of calories coming from protein) for >25% of their rehabilitation stay had higher FIM motor and cognitive scores at rehabilitation discharge and less weight loss than did patients with similar characteristics not receiving EN. Conclusions For patients receiving inpatient rehabilitation after TBI and matched on a propensity score of >40% for the likely use of EN, clinicians should strongly consider, when possible, EN for ≥25% of the rehabilitation stay and especially with a formula that contains at least 20% protein rather than a standard formula.

This supplement of the Archives of Physical Medicine and Rehabilitation is devoted to the Traumatic Brain Injury–Practice Based Evidence study, the first practice-based evidence study, to our knowledge, of traumatic brain injury rehabilitation. The purpose of this preface is to place this study in the broader context of comparative effectiveness research and introduce the articles in the supplement.