Publications by authors named "Behrman A"

160 Publications

White matter changes with age utilizing quantitative diffusion MRI.

Neurology 2014 Jul 13;83(3):247-52. Epub 2014 Jun 13.

From the University of Missouri-St. Louis (L.M.B., J.M.H., J.B., L.E.S., C.U., A.B., R.H.P.); Computer Science Department (D.H.L., R.C.) and Department for Biostatistics and Center for Statistical Sciences (J.H., Y.Z., X.L.), Brown University, Providence, RI; Washington University School of Medicine (T.E.C., E.A., A.R.M.), Mallinckrodt Institute of Radiology, St. Louis, MO; Division of Biology and Medicine (S.C.), Brown Medical School, Providence, RI; and Vanderbilt University Medical Center (E.M.L.), Nashville, TN.

Objective: To investigate the relationship between older age and mean cerebral white matter fiber bundle lengths (FBLs) in specific white matter tracts in the brain using quantified diffusion MRI.

Methods: Sixty-three healthy adults older than 50 years underwent diffusion tensor imaging. Tractography tracings of cerebral white matter fiber bundles were derived from the diffusion tensor imaging data.

Results: Results revealed significantly shorter FBLs in the anterior thalamic radiation for every 1-year increase over the age of 50 years.

Conclusions: We investigated the effects of age on FBL in specific white matter tracts in the brains of healthy older individuals utilizing quantified diffusion MRI. The results revealed a significant inverse relationship between age and FBL. Longitudinal studies of FBL across a lifespan are needed to examine the specific changes to the integrity of white matter.
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http://dx.doi.org/10.1212/WNL.0000000000000597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117364PMC
July 2014

Prediction of responders for outcome measures of locomotor Experience Applied Post Stroke trial.

J Rehabil Res Dev 2014 ;51(1):39-50

Department of Neurology, Geffen School of Medicine, UCLA, 710 Westwood Plaza, Los Angeles, CA 90095.

The Locomotor Experience Applied Post Stroke rehabilitation trial found equivalent walking outcomes for body weight-supported treadmill plus overground walking practice versus home-based exercise that did not emphasize walking. From this large database, we examined several clinically important questions that provide insights into recovery of walking that may affect future trial designs. Using logistic regression analyses, we examined predictors of response based on a variety of walking speed-related outcomes and measures that captured disability, physical impairment, and quality of life. The most robust predictor was being closer at baseline to the primary outcome measure, which was the functional walking speed thresholds of 0.4 m/s (household walking) and 0.8 m/s (community walking). Regardless of baseline walking speed, a younger age and higher Berg Balance Scale score were relative predictors of responding, whether operationally defined by transitioning beyond each speed boundary or by a continuous change or a greater than median increase in walking speed. Of note, the cutoff values of 0.4 and 0.8 m/s had no particular significance compared with other walking speed changes despite their general use as descriptors of functional levels of walking. No evidence was found for any difference in predictors based on treatment group.
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http://dx.doi.org/10.1682/JRRD.2013.04.0080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374620PMC
January 2015

Segmental and prosodic approaches to accent management.

Authors:
Alison Behrman

Am J Speech Lang Pathol 2014 Nov;23(4):546-61

Purpose: This study investigated the relative outcomes of segmental and prosodic training of nonnative speakers of American English.

Method: The study used a single-subject, alternating treatments, multiple baseline design with replication across participants and counterbalanced for order effect. Participants were 4 adult male native Hindi speakers proficient in English. Two participants received ABABCACA (A = baseline/withdrawal, B = segmental training, C = prosody training), and 2 participants received ACACBABA, with a minimum of 5 sessions per phase. Segmental accuracy and prosodic accuracy were probed at each session, as were perception of accentedness and ease of understanding.

Results: Visual assessment of data and effect size calculation demonstrated that segmental and prosody training resulted in increased accuracy of pronunciation and prosody patterns, respectively, and those improvements appeared to be maintained over the short term. Listeners perceived lesser accent and easier understanding as a result of the combination of segmental and prosody training. The findings are uncertain with respect to the relative contribution of segmental and prosody training, and they may be speaker dependent, but the data do suggest that both components are important.

Conclusion: Accent management, consisting of both segmental and prosody training, yielded positive outcomes. Further research with native language speakers of other languages is important to verify and expand on these findings.
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http://dx.doi.org/10.1044/2014_AJSLP-13-0074DOI Listing
November 2014

Phase dependent modulation of soleus H-reflex in healthy, non-injured individuals while walking with an ankle foot orthosis.

Gait Posture 2014 Apr 6;39(4):1086-91. Epub 2014 Feb 6.

Department of Physical Therapy, University of Florida, Gainesville, FL, USA; Brain Rehabilitation Research Center, Malcolm Randall VA Medical Center, Gainesville, FL, USA.

Objective: To examine the dynamic modulation of the soleus H-reflex while walking with a posterior leaf spring ankle foot orthosis (PAFO).

Methods: Soleus H-reflexes were evoked on randomly chosen lower limb of fourteen healthy individuals (age range of 22-36 years, 7 women) while walking on a treadmill with and without a PAFO. In order to capture excitability across the duration of the gait cycle, H-reflexes were evoked at heel strike (HS), HS+100ms, HS+200ms, HS+300ms, HS+400ms in the stance phase and at toe-off (TO), TO+100ms, TO+200ms, TO+300ms, TO+400ms in the swing phase respectively.

Results: H-reflex excitability was significantly higher in the form of greater slope of the rise in H-reflex amplitude across the swing phase (p=0.024) and greater mean H-reflex amplitude (p=0.014) in the swing phase of walking with a PAFO. There was no change in the slope (p=0.25) or the mean amplitude of H-reflexes (p=0.22) in the stance phase of walking with a PAFO. Mean background EMG activity between the two walking conditions was not significantly different for both the tibialis anterior (p=0.69) and soleus muscles (p=0.59).

Conclusion: PAFO increased reflex excitability in the swing phase of walking in healthy individuals. Altered sensory input originating from joint, muscle and cutaneous receptors may be the underlying mechanism for greater reflex excitability. The neurophysiological effect of PAFOs on reflex modulation during walking needs to be tested in persons with neurological injury. The relationship between the sensory input and the reflex output during walking may assist in determining if there exists a neurological disadvantage of using a compensatory device such as a PAFO.
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http://dx.doi.org/10.1016/j.gaitpost.2014.01.017DOI Listing
April 2014

Long-term facilitation of ventilation in humans with chronic spinal cord injury.

Am J Respir Crit Care Med 2014 Jan;189(1):57-65

1 Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.

Rationale: Intermittent stimulation of the respiratory system with hypoxia causes persistent increases in respiratory motor output (i.e., long-term facilitation) in animals with spinal cord injury. This paradigm, therefore, has been touted as a potential respiratory rehabilitation strategy.

Objectives: To determine whether acute (daily) exposure to intermittent hypoxia can also evoke long-term facilitation of ventilation after chronic spinal cord injury in humans, and whether repeated daily exposure to intermittent hypoxia enhances the magnitude of this response.

Methods: Eight individuals with incomplete spinal cord injury (>1 yr; cervical [n = 6], thoracic [n = 2]) were exposed to intermittent hypoxia (eight 2-min intervals of 8% oxygen) for 10 days. During all exposures, end-tidal carbon dioxide levels were maintained, on average, 2 mm Hg above resting values. Minute ventilation, tidal volume, and breathing frequency were measured before (baseline), during, and 30 minutes after intermittent hypoxia. Sham protocols consisted of exposure to room air and were administered to a subset of the participants (n = 4).

Measurements And Main Results: Minute ventilation increased significantly for 30 minutes after acute exposure to intermittent hypoxia (P < 0.001), but not after sham exposure. However, the magnitude of ventilatory long-term facilitation was not enhanced over 10 days of intermittent hypoxia exposures.

Conclusions: Ventilatory long-term facilitation can be evoked by brief periods of hypoxia in humans with chronic spinal cord injury. Thus, intermittent hypoxia may represent a strategy for inducing respiratory neuroplasticity after declines in respiratory function that are related to neurological impairment. Clinical trial registered with www.clinicaltrials.gov (NCT01272011).
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http://dx.doi.org/10.1164/rccm.201305-0848OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919124PMC
January 2014

Should influenza vaccination be mandatory for healthcare workers?

BMJ 2013 Nov 12;347:f6705. Epub 2013 Nov 12.

University of Pennsylvania Health System, 3400 Spruce St Philadelphia, PA 19104, USA.

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http://dx.doi.org/10.1136/bmj.f6705DOI Listing
November 2013

Adherence to accelerometry measurement of community ambulation poststroke.

Phys Ther 2014 Jan 12;94(1):101-10. Epub 2013 Sep 12.

S. Barak, PhD, Pediatric Rehabilitation Department, Edmond and Lily Safra Children's Hospital, Pediatric Rehabilitation Department, Sheba Medical Center, Ramat-Gan 52621, Israel, and Physical Education Department, Kaye Academic College of Education, Beer Sheva, Israel.

Background: The step activity monitor (SAM) quantifies steps taken in the home and community by patient populations. Although the SAM has been used to study individuals after stroke, adherence to the use of SAMs has not been addressed. Participants' adherence to wearing the monitor is critical for obtaining accurate assessments.

Objective: The purpose of this study was to determine the rate of and predictors for inferred adherence to the use of the SAM after stroke.

Design: A cross-sectional design was used.

Methods: Community-dwelling individuals (n=408) 2 months after stroke with moderate-to-severe gait impairment (gait speed of ≤0.8 m/s) were studied. Step activity was assessed for 2 days with the SAM. Inferred adherence was established in 3 periods: 6:00 am to 12:00 pm, 12:01 pm to 6:00 pm, and 6:01 pm to 12:00 am. Adherence was defined as activity recorded in all 3 periods. The percentage of participant adherence for the first day, second day, both days, and either day was calculated. Demographic and clinical characteristics of adherers and nonadherers were compared. Independent adherence predictors were identified by means of stepwise logistic regression.

Results: Inferred adherence rates for the first day, second day, both days, and either day were 68%, 61%, 53%, and 76%, respectively. Upper and lower extremity impairment, balance control, and endurance were significantly different between adherers and nonadherers. On the other hand, older age, greater balance self-efficacy, and better walking endurance were significant predictors of adherence.

Limitations: Participants were individuals with subacute stroke. Therefore, the findings of this study may not be generalized to individuals during the acute and chronic phases of stroke recovery.

Conclusions: Strategies to improve adherence are needed when collecting data for more than 1 day and in samples with younger individuals and those with low levels of balance self-efficacy and walking endurance.
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http://dx.doi.org/10.2522/ptj.20120473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3892677PMC
January 2014

The influence of semantic context on the perception of Spanish-accented American English.

J Speech Lang Hear Res 2013 Oct 23;56(5):1567-78. Epub 2013 Jul 23.

Correspondence to Alison Behrman:

Purpose: In this article, the authors examine (a) the effect of semantic context on accentedness, comprehensibility, and intelligibility of Spanish-accented American English (AE) as judged by monolingual AE listeners and (b) the interaction of semantic context and accentedness on comprehensibility and intelligibility.

Method: Twenty adult native (L1) Spanish speakers proficient in AE and 4 L1 AE speakers (controls) read 48 statements consisting of true-false, semantically meaningful, and semantically anomalous sentences. Eighty monolingual AE listeners assessed accentedness, comprehensibility, and intelligibility of the statements.

Results: A significant main effect was found for semantic category on all 3 dependent variables. Accents were perceived to be stronger, and both comprehensibility and intelligibility were worse, in semantically anomalous contexts. Speaker data were grouped into strong, mid-level, and mild accents. The interaction between semantic category and accent was significant for both comprehensibility and intelligibility. The effect of semantic context was strongest for strong accents. Intelligibility was excellent for speakers with mid-level accents in true-false and semantically meaningful contexts, and it was excellent for mild accents in all contexts.

Conclusions: Listeners access semantic information, in addition to phonetic and phonotactic features, in the perception of nonnative speech. Both accent level and semantic context are important in research on foreign-accented speech.
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http://dx.doi.org/10.1044/1092-4388(2013/12-0192)DOI Listing
October 2013

Thinking through every step: how people with spinal cord injuries relearn to walk.

Qual Health Res 2013 Aug 17;23(8):1027-41. Epub 2013 Jun 17.

University of Florida, Department of Sociology, Criminology, and Law, 3219 Turlington Hall, PO Box 117330, Gainesville, FL 32611, USA.

In this article we explore how people with incomplete spinal cord injury (iSCI) create meaning out of their changing bodies as they undergo a therapeutic intervention called locomotor training (LT). Therapeutic interventions like LT are used to promote the recovery of walking ability among individuals with iSCI. The chronological nature of this study--interviews at three points throughout the 12-week intervention--enhances understanding of the recovering self after spinal cord injury. Drawing on a constructivist theoretical framework, we organize data according to three narrative frames. Participants interpreted LT as (a) a physical change that was meaningful because of its social significance, (b) a coping strategy for dealing with the uncertainty of long-term recovery, and (c) a moral strategy to reconstitute the self. We offer findings that lay the conceptual groundwork for generating new knowledge about what is important to people with iSCI as they relearn how to walk.
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http://dx.doi.org/10.1177/1049732313494119DOI Listing
August 2013

Modular control of varied locomotor tasks in children with incomplete spinal cord injuries.

J Neurophysiol 2013 Sep 12;110(6):1415-25. Epub 2013 Jun 12.

Department of Physical Therapy, University of Florida, Gainesville, Florida;

A module is a functional unit of the nervous system that specifies functionally relevant patterns of muscle activation. In adults, four to five modules account for muscle activation during walking. Neurological injury alters modular control and is associated with walking impairments. The effect of neurological injury on modular control in children is unknown and may differ from adults due to their immature and developing nervous systems. We examined modular control of locomotor tasks in children with incomplete spinal cord injuries (ISCIs) and control children. Five controls (8.6 ± 2.7 yr of age) and five children with ISCIs (8.6 ± 3.7 yr of age performed treadmill walking, overground walking, pedaling, supine lower extremity flexion/extension, stair climbing, and crawling. Electromyograms (EMGs) were recorded in bilateral leg muscles. Nonnegative matrix factorization was applied, and the minimum number of modules required to achieve 90% of the "variance accounted for" (VAF) was calculated. On average, 3.5 modules explained muscle activation in the controls, whereas 2.4 modules were required in the children with ISCIs. To determine if control is similar across tasks, the module weightings identified from treadmill walking were used to reconstruct the EMGs from each of the other tasks. This resulted in VAF values exceeding 86% for each child and each locomotor task. Our results suggest that 1) modularity is constrained in children with ISCIs and 2) for each child, similar neural control mechanisms are used across locomotor tasks. These findings suggest that interventions that activate the neuromuscular system to enhance walking also may influence the control of other locomotor tasks.
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http://dx.doi.org/10.1152/jn.00676.2012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763159PMC
September 2013

Does exercise tolerance testing at 60 days poststroke predict rehabilitation performance?

Arch Phys Med Rehabil 2013 Jul 30;94(7):1223-9. Epub 2013 Mar 30.

Department of Physical Therapy, University of Florida, Gainesville, FL, USA.

Objective: To assess the relationship between exercise tolerance test (ETT) performance at 6 weeks poststroke and subsequent performance in a treadmill and overground locomotor training program (LTP).

Design: Prospective cohort study.

Setting: Exercise testing laboratory in either a primary care hospital or outpatient clinic.

Participants: Community-dwelling individuals (N=469), 54.9±19.0 days poststroke, enrolled in the Locomotor Experience Applied Post-Stroke randomized controlled trial.

Interventions: Not applicable.

Main Outcome Measures: For participants randomly assigned to LTP, the number of sessions needed to attain the training goal of 20 minutes of treadmill stepping was determined. Regression analyses determined the contribution of ETT performance (cycling duration), age, and 6-minute walk test (6MWT) distance to attainment of the stepping duration goal.

Results: Age, 6MWT, and ETT performance individually accounted for 10.74%, 10.82%, and 10.76%, respectively, of the variance in the number of sessions needed to attain 20 minutes of stepping. When age and 6MWT were included in the model, the additional contribution of ETT performance was rendered nonsignificant (P=.150).

Conclusions: To the extent that ETT performance can be viewed as a measure of cardiovascular fitness rather than neurologic impairment, cardiovascular fitness at the time of the ETT did not make a significant unique contribution to the number of sessions needed to achieve 20 minutes of stepping. The 6MWT, which involves less intensive exercise than the ETT and therefore is likely to be predominantly affected by neurologic impairment and muscular condition, appeared to account for as much variance as the ETT.
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http://dx.doi.org/10.1016/j.apmr.2013.01.031DOI Listing
July 2013

Minimal detectable change for spatial and temporal measurements of gait after incomplete spinal cord injury.

Top Spinal Cord Inj Rehabil 2012 ;18(3):273-81

School of Health and Medical Sciences, Seton Hall University , South Orange, New Jersey.

Background And Purpose: Gait deviations in individuals after incomplete spinal cord injury (ISCI) that are quantified using spatiotemporal (ST) parameters are often targeted during therapeutic interventions. The purpose of our study was to establish reliability and responsiveness of ST parameters of gait after ISCI using an instrumented walkway (GaitMat II).

Methods: Sixteen individuals with ISCI participated in the study. Each subject completed at least 2 walking trials at self-selected (SS) walking speed. Intraclass correlation coefficients model 2, 1 (ICC2,1) with 95% confidence intervals (CIs), standard error of measurement (SEM), SEM percent change (SEM%), the minimal detectable change (MDC), and the MDC percent change (MDC%) were determined for 8 ST parameters including step length, single limb support, and double limb support time for the more and less impaired limb, cadence, and speed.

Results: Excellent test-retest agreement (0.84-0.99) was observed in all ST parameters. SEM% ranged from 8% to 29%, while MDC% ranged from 21% (cadence) to 80% (double limb support time). MDC% values were relatively higher (5-12 MDC%) for the more versus less impaired limb.

Discussion: SEM% results indicate that small to moderate changes were needed to indicate a real change in walking performance. Differences in MDC% values between limbs indicated that variability in parameters might be sensitive to level of motor impairment.

Conclusion: In individuals with ISCI, different gait, balance, or strength training programs can be compared and contrasted based on a quantifiable and meaningful change in the ST parameter of interest.
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http://dx.doi.org/10.1310/sci1803-273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584781PMC
July 2013

Varicella immunity in vaccinated healthcare workers.

J Clin Virol 2013 Jun 20;57(2):109-14. Epub 2013 Feb 20.

Hospital of the University of Pennsylvania Division of Occupational Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: Nosocomial spread of varicella-zoster virus (VZV) infection can cause severe disease among vulnerable patient-populations and healthcare personnel (HCP). Limited data are available on duration of varicella vaccine-induced protection among adults and to what extent cell-mediated immunity (CMI) and antibody avidity contribute to protection.

Objective: Evaluate humoral and cell-mediated immune responses of HCP who received a 2-dose regimen of varicella vaccine, and observe the responses to a 3rd vaccine dose among HCP who were seronegative after vaccination.

Study Design: A convenience sample of HCP with documented 2 doses of varicella vaccine was used to assess acquired VZV immune parameters (cytokine production, IgG avidity). HCP seronegative after 2 doses of vaccine were offered a third dose and evaluated further. Vaccine recipients' immune responses were compared with responses from persons with history of wild-type VZV infection.

Results: The convenience sample consisted of 101 HCP with documented 2 doses of varicella vaccine; 12 (11.9%) were seronegative post-vaccination. 11.5% of 61 seropositive 2-dose recipients produced low avidity antibody, suggesting suboptimal response to vaccine. Seven 2-dose vaccinees who were VZV seronegative seroconverted after a third dose; however, 3/7 (42.9%) produced low avidity IgG. 142 persons with a history of varicella were all VZV IgG seropositive, and all had moderate to high avidity IgG.

Conclusions: Measurements of serum IgG titers alone may not accurately reflect vaccine protection. Varicella vaccination of HCP remains important but further studies are needed to evaluate CMI and antibody avidity responses in HCP vaccinated with two doses of varicella vaccine.
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http://dx.doi.org/10.1016/j.jcv.2013.01.015DOI Listing
June 2013

Restorative rehabilitation entails a paradigm shift in pediatric incomplete spinal cord injury in adolescence: an illustrative case series.

J Pediatr Rehabil Med 2012 ;5(4):245-59

Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, University of Louisville, Kentucky, Louisville, KY, USA.

Physical rehabilitation after spinal cord injury (SCI) in adult and pediatric populations has traditionally compensated for paralysis and weakness using wheelchairs, assistive devices, and braces to achieve seated mobility, upright standing, or bracewalking. Recent evidence indicates efficacy of activity-based therapies in adults with SCI, specifically locomotor training (LT), to activate the neuromuscular system below the injury level and improve walking and postural control by restoring pre-morbid movements. The purpose of this paper is to demonstrate the feasibility of LT, using repetitive stepping practice on a treadmill and translated to over ground and the community, to meet the unique needs and demands of pediatric, adolescent rehabilitation. Three outpatient adolescents, T5 AIS D, age 15 (primary wheelchair user), T5 AIS C, age 14 (primary wheelchair user), and C2, AIS D, 14 years (primary ambulator), received a standardized protocol of LT 4-5 times per week for 75, 293, and 40 total sessions, respectively, across 1-3 episodes of care. Two adolescents became full-time ambulators, and one adolescent improved locomotor skills, kinematics, and endurance with two individuals lacking significant increases in strength to account for the benefits. Motivational strategies were developmentally specific, parental involvement critical for carryover, and musculoskeletal considerations paramount with growth and maturation. In comparison to adults, adolescents' continued musculoskeletal, cognitive, and social growth and maturation necessitate repeated episodes of therapy and bi-annual re-evaluations to identify needs and address new goals. The use of activity-based therapies, i.e. LT, represents a paradigm shift in pediatric rehabilitation towards activation of the neuromuscular system below the lesion via task-specific training and experience, minimizing compensation strategies, and targeting recovery of function achieved via use of pre-morbid movement patterns.
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http://dx.doi.org/10.3233/PRM-2012-00225DOI Listing
July 2013

Clinical trials in neurorehabilitation.

Handb Clin Neurol 2013 ;110:61-6

Department of Physical Therapy, University of Florida and Brain Rehabilitation Research Center, Gainesville, FL, USA.

The clinical trial is essential to testing efficacy and effectiveness of therapeutic interventions. Neurorehabilitation presents unique challenges in the execution of clinical trials due to the complexity of both human interface with complex interventions and clinical/research staff interaction. Attention to key elements, recruitment, retention, treatment fidelity, and control intervention selection, contributes to successful conduct of a trial. Alternatives to the randomized controlled trial and outcome measure selection are important considerations contributing to the merit of the trial. While clinical trial outcomes contribute to the scientific evidence, their true value and impact comes in the next step, translation to clinical practice and the improvement of patient outcomes and qualify of life. Translation of evidence into practice may best be achieved via partnerships of scientists, clinicians, and administrators resulting in a dynamic interface between science and practice, the laboratory, and the clinic.
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http://dx.doi.org/10.1016/B978-0-444-52901-5.00005-8DOI Listing
August 2013

Locomotor rehabilitation of individuals with chronic stroke: difference between responders and nonresponders.

Arch Phys Med Rehabil 2013 May 5;94(5):856-62. Epub 2012 Dec 5.

Ralph H. Johnson VA Medical Center, Charleston, SC, USA.

Objectives: To identify the clinical measures associated with improved walking speed after locomotor rehabilitation in individuals poststroke and how those who respond with clinically meaningful changes in walking speed differ from those with smaller speed increases.

Design: A single group pre-post intervention study. Participants were stratified on the basis of a walking speed change of greater than (responders) or less than (nonresponders) .16m/s. Paired sample t tests were run to assess changes in each group, and correlations were run between the change in each variable and change in walking speed.

Setting: Outpatient interdisciplinary rehabilitation research center.

Participants: Hemiparetic subjects (N=27) (17 left hemiparesis; 19 men; age: 58.74±12.97y; 22.70±16.38mo poststroke).

Intervention: A 12-week locomotor intervention incorporating training on a treadmill with body weight support and manual trainers accompanied by training overground walking.

Main Outcome Measures: Measures of motor control, balance, functional walking ability, and endurance were collected at pre- and postintervention assessments.

Results: Eighteen responders and 9 nonresponders differed by age (responders=63.6y, nonresponders=49.0y, P=.001) and the lower extremity Fugl-Meyer Assessment score (responders=24.7, nonresponders=19.9, P=.003). Responders demonstrated an average improvement of .27m/s in walking speed as well as significant gains in all variables except daily step activity and paretic step ratio. Conversely, nonresponders demonstrated statistically significant improvements only in walking speed and endurance. However, the walking speed increase of .10m/s was not clinically meaningful. Change in walking speed was negatively correlated with changes in motor control in the nonresponder group, implying that walking speed gains may have been accomplished via compensatory mechanisms.

Conclusions: This study is a step toward discerning the underlying factors contributing to improved walking performance.
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http://dx.doi.org/10.1016/j.apmr.2012.11.032DOI Listing
May 2013

Current approach to latent tuberculosis diagnosis and treatment among medical center occupational health physicians.

Infect Control Hosp Epidemiol 2012 Dec 23;33(12):1262-5. Epub 2012 Oct 23.

Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania 19102, USA.

We surveyed physicians in a national occupational medicine society regarding diagnosis of latent tuberculosis infection in healthcare workers. Most respondents used a combination of skin testing and interferon gamma release assays. Respondents integrating interferon gamma release assays into screening placed greater importance on employee acceptability and convenience.
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http://dx.doi.org/10.1086/668437DOI Listing
December 2012

Evidence-based therapy for recovery of function after spinal cord injury.

Handb Clin Neurol 2012 ;109:259-74

Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.

Physical rehabilitation for individuals coping with neurological deficits is evolving in response to a paradigm shift in thinking about the injured nervous system and using evidence as a basis for clinical decisions. Functional recovery from paralysis was generally believed to be nearly impossible, based on traditional expert opinion, and the priority was to develop compensation strategies to achieve functional goals in the home and community. Research, which began in animal models of neurological insult and is currently being translated to the clinic, has challenged these assumptions. The nervous system, whether intact or injured, has enormous potential for adaptation and modification, which can be harnessed to facilitate recovery. In this chapter we will briefly outline the history of physical rehabilitation as it concerns the development of strategies aimed at compensation, rather than functional recovery. Then we will discuss how new activity-based therapies are being developed, based on evidence from basic science and clinical evidence. One of these activity-based therapies is locomotor training, a program which relies on the intrinsic, automatic, control of locomotion by "lower" neural centers. A brief description of the program, including the four foundational principles, will be followed by an introduction to the use of robotics in these programs. Finally, we will discuss a second activity-based therapy, functional electrical stimulation (FES), and the future of physical rehabilitation for spinal cord injury and other neurological disorders.
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http://dx.doi.org/10.1016/B978-0-444-52137-8.00016-4DOI Listing
August 2013

Outcomes of spinal cord injuries in young children.

Dev Med Child Neurol 2012 Dec 16;54(12):1078. Epub 2012 Oct 16.

Department of Physical Therapy, University of Florida, Gainsville, FL, USA.

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http://dx.doi.org/10.1111/j.1469-8749.2012.04440.xDOI Listing
December 2012

Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation.

Arch Phys Med Rehabil 2012 Sep;93(9):1588-97

Department of Neurological Surgery, Kentucky Spinal Cord Research Center, University of Louisville, Louisville, KY, USA.

Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a "paradigm shift." Not only do we recognize the potential of the damaged nervous system, but we also see that "recovery" can and should be valued and defined broadly. Quality-of-life measures and the individual's sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation's NeuroRecovery Network.
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http://dx.doi.org/10.1016/j.apmr.2012.04.032DOI Listing
September 2012

Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury.

Arch Phys Med Rehabil 2012 Sep;93(9):1518-29

Department of Physical Therapy, University of Florida, Gainesville, FL, USA.

Objective: To develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations' level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations' level of function and the insensitivity to change within the available outcome measures.

Design: Prospective observational cohort with longitudinal follow-up.

Setting: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).

Participants: Individuals (N=95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN.

Interventions: Intensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities.

Main Outcome Measures: Berg Balance Scale, six-minute walk test, and ten-meter walk test.

Results: Individuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups.

Conclusions: Assessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.
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http://dx.doi.org/10.1016/j.apmr.2011.04.027DOI Listing
September 2012

Life care planning projections for individuals with motor incomplete spinal cord injury before and after locomotor training intervention: a case series.

J Neurol Phys Ther 2012 Sep;36(3):144-53

Shepherd Center, 2020 Peachtree Rd, NW, Atlanta, GA 30309, USA.

Background/purpose: We present a retrospective case series of 2 individuals with motor-incomplete spinal cord injury (SCI) to examine differences in lifetime cost estimates before and after participation in an intensive locomotor training (LT) program. Sections of a life care plan (LCP) were used to determine the financial implications associated with equipment, home renovations, and transportation for patients who receive LT. An LCP is a viable method of quantifying outcomes following any therapeutic intervention.

Case Description: The LCP cases analyzed were a 61-year-old woman and a 4½-year-old boy with motor-incomplete SCI and impairments classified by the American Spinal Injury Association Impairment Scale (AIS) as AIS D and AIS C, respectively.

Interventions: Each patient received an intensive outpatient LT program 3 to 5 days per week. The 61-year-old woman received 198 sessions over 57 weeks and the 4½-year-old boy received 76 sessions over 16 weeks.

Outcomes: The equipment, home renovation, and transportation costs of an LCP were calculated before and after LT. Prior to the implementation of LT, the 61-year-old woman had estimated lifetime costs between $150,247.00 and $199,654.00. Following LT, the estimated costs decreased to between $2010.00 and $2446.00 (a decrease of $148,237.00 and $197,208.00). Similarly, the 4-year-old boy had estimated lifetime costs for equipment, home renovation, and transportation between $535,050.00 and $771,665.00 prior to LT. However, the estimated costs decreased to between $97,260.00 and $200,047.00 (a decrease of $437,790.00 and $571,618.00) following LT.

Discussion: The lifetime financial costs associated with equipment, home renovations, and transportation following a motor-incomplete SCI were decreased following an intensive LT program for the 2 cases presented in this article. The LCP, including costs of rehabilitation and long-term medical and personal care costs, may be an effective tool to discern cost benefit of rehabilitation interventions.
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http://dx.doi.org/10.1097/NPT.0b013e318262e5abDOI Listing
September 2012

Unexpected recovery after robotic locomotor training at physiologic stepping speed: a single-case design.

Arch Phys Med Rehabil 2012 Aug 23;93(8):1476-84. Epub 2012 Mar 23.

Brain Rehabilitation Research Center, Malcom Randall VAMC, Gainesville, FL 32608, USA.

Objectives: To investigate the effect of walking speed on the emergence of locomotor electromyogram (EMG) patterns in an individual with chronic incomplete spinal cord injury (SCI), and to determine whether central pattern generator activity during robotic locomotor training (RLT) transfers to volitional EMG activity during overground walking.

Design: Single-case (B-A-B; experimental treatment-withdrawal-experimental treatment) design.

Setting: Freestanding rehabilitation research center.

Participant: A 50-year-old man who was nonambulatory for 16 months after incomplete SCI (sub-T11).

Interventions: The participant completed two 6-week blocks of RLT, training 4 times per week for 30 minutes per session at walking speeds up to 5km/h (1.4m/s) over continuous bouts lasting up to 17 minutes.

Main Outcome Measures: Surface EMG was recorded weekly during RLT and overground walking. The Walking Index for Spinal Cord Injury (WISCI-II) was assessed daily during training blocks.

Results: During week 4, reciprocal, patterned EMG emerged during RLT. EMG amplitude modulation revealed a curvilinear relationship over the range of walking speeds from 1.5 to 5km/h (1.4m/s). Functionally, the participant improved from being nonambulatory (WISCI-II 1/20), to walking overground with reciprocal stepping using knee-ankle-foot orthoses and a walker (WISCI-II 9/20). EMG was also observed during overground walking. These functional gains were maintained greater than 4 years after locomotor training (LT).

Conclusions: Here we report an unexpected course of locomotor recovery in an individual with chronic incomplete SCI. Through RLT at physiologic walking speeds, it was possible to activate the central pattern generator even 16 months postinjury. Further, to a certain degree, improvements from RLT transferred to overground walking. Our results suggest that LT-induced changes affect the central pattern generator and allow supraspinal inputs to engage residual spinal pathways.
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http://dx.doi.org/10.1016/j.apmr.2012.02.030DOI Listing
August 2012

Arm and leg coordination during treadmill walking in individuals with motor incomplete spinal cord injury: a preliminary study.

Gait Posture 2012 May 14;36(1):49-55. Epub 2012 Feb 14.

Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States; Department of Physical Therapy, University of Florida, Gainesville, FL 32608, USA.

Arm and leg coordination naturally emerges during walking, but can be affected by stroke or Parkinson's disease. The purpose of this preliminary study was to characterize arm and leg coordination during treadmill walking at self-selected comfortable walking speeds (CWSs) in individuals using arm swing with motor incomplete spinal cord injury (iSCI). Hip and shoulder angle cycle durations and amplitudes, strength of peak correlations between contralateral hip and shoulder joint angle time series, the time shifts at which these peak correlations occur, and associated variability were quantified. Outcomes in individuals with iSCI selecting fast CWSs (range, 1.0-1.3m/s) and speed-matched individuals without neurological injuries are similar. Differences, however, are detected in individuals with iSCI selecting slow CWSs (range, 0.25-0.65 m/s) and may represent compensatory strategies to improve walking balance or forward propulsion. These individuals elicit a 1:1, arm:leg frequency ratio versus the 2:1 ratio observed in non-injured individuals. Shoulder and hip movement patterns, however, are highly reproducible (coordinated) in participants with iSCI, regardless of CWS. This high degree of inter-extremity coordination could reflect an inability to modify a single movement pattern post-iSCI. Combined, these data suggest inter-extremity walking coordination may be altered, but is present after iSCI, and therefore may be regulated, in part, by neural control.
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http://dx.doi.org/10.1016/j.gaitpost.2012.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362672PMC
May 2012

Advancing measurement of locomotor rehabilitation outcomes to optimize interventions and differentiate between recovery versus compensation.

J Neurol Phys Ther 2012 Mar;36(1):38-44

Ralph H. Johnson VA Medical Center, Charleston, SC 29425, USA.

Progress in locomotor rehabilitation has created an increasing need to understand the factors that contribute to motor behavior, to determine whether these factors are modifiable, and if so, to determine how best to modify them in a way that promotes improved function. Currently available clinical measures do not have the capacity to distinguish between neuromotor recovery and compensation for impaired underlying body structure/functions. This Special Interest article examines the state of outcomes measurement in physical therapy in regard to locomotor rehabilitation, and suggests approaches that may improve assessment of recovery and clinical decision-making capabilities. We examine historical approaches to measurement of locomotor rehabilitation outcomes, including rating scales, timed movement tasks, and laboratory-based outcome measures, and we discuss the emerging use of portable technology to assess walking in a free-living environment. The ability to accurately measure outcomes of rehabilitation, both in and away from the clinical/laboratory setting, allows assessment of skill acquisition, retention, and long-term carryover in a variety of environments. Accurate measurement allows behavioral changes to be observed, and assessments to be made, regarding an individual's ability to adapt during interventions and to incorporate new skills into real-world behaviors. The result of such an approach to assessment may be that interventions truly translate from clinical/laboratory to real-world environments. Future locomotor measurement tools must be based on a theoretical framework that can guide their use to accurately quantify treatment effects and provide a basis upon which to develop and refine therapeutic interventions.
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http://dx.doi.org/10.1097/NPT.0b013e3182472cf6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426854PMC
March 2012

Characterizing and identifying risk for falls in the LEAPS study: a randomized clinical trial of interventions to improve walking poststroke.

Stroke 2012 Feb 12;43(2):446-52. Epub 2012 Jan 12.

Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90033, USA.

Background And Purpose: Better understanding of fall risk poststroke is required for developing screening and prevention programs. This study characterizes falls in the Locomotor Experience Applied Post-Stroke (LEAPS) randomized clinical trial, describes the impact of 2 walking recovery interventions on falls, and examines the value of clinical assessments for predicting falls.

Methods: Community-dwelling ambulatory stroke survivors enrolled in LEAPS were assessed 2 months poststroke. Falls were monitored until 12 months poststroke and participants were characterized as multiple or injurious (M/I); single, noninjurious; or nonfallers. Incidence and time to M/I falls were compared across interventions (home exercise and locomotor training initiated 2 months [early-LTP] or 6 months [late-LTP] poststroke). Predictive value of 2-month clinical assessments for falls outcome was assessed.

Results: Among the 408 participants, 36.0% were M/I, 21.6% were single, noninjurious, and 42.4% were nonfallers. Most falls occurred at home in the first 3 months after assessment. Falls incidence was highest for those with severe walking impairment who received early-LTP (P=0.025). Berg Balance Scale score ≤ 42/56 was the single best predictor of M/I falls.

Conclusions: As individuals with stroke improve in walking capacity, risk for M/I falls remains high. Individuals walking <0.4 m/s are at higher risk for M/I falls if they receive early-LTP training. Berg Balance Scale score at 2 months poststroke is useful for informing falls risk, but it cannot account for the multifactorial nature of the problem. Falls prevention in stroke will require multifactorial risk assessment and management provided concomitantly with exercise interventions to improve mobility.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00243919.
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http://dx.doi.org/10.1161/STROKEAHA.111.636258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265675PMC
February 2012
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