Baylor Scott and White Institute for Rehabilitation

Womble, M. N., Reynolds, E., Kissinger-Knox, A., Collins, M. W., Kontos, A. P., West, R. V., Eagle, S. and Elbin, R. J. (2022). “The Emerging Role of Telehealth for Concussion Clinical Care During the Coronavirus (COVID-19) Pandemic.” J Head Trauma Rehabil 37(2): E49-e54.

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The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.

Tondo, M., B. Wasek, J. C. Escola-Gil, D. de Gonzalo-Calvo, C. Harmon, E. Arning and T. Bottiglieri (2020). “Altered Brain Metabolome Is Associated with Memory Impairment in the rTg4510 Mouse Model of Tauopathy.” Metabolites Feb 14: 10(2) [Epub ahead of print.].

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Alzheimer’s disease (AD) is characterized, amongst other features, by the pathologic accumulation of abnormally phosphorylated tau filaments in neurons that lead to neurofibrillary tangles. However, the molecular mechanisms by which the abnormal processing of tau leads to neurodegeneration and cognitive impairment remain unknown. Metabolomic techniques can comprehensively assess disturbances in metabolic pathways that reflect changes downstream from genomic, transcriptomic and proteomic systems. In the present study, we undertook a targeted metabolomic approach to determine a total of 187 prenominated metabolites in brain cortex tissue from wild type and rTg4510 animals (a mice model of tauopathy), in order to establish the association of metabolic pathways with cognitive impairment. This targeted metabolomic approach revealed significant differences in metabolite concentrations of transgenic mice. Brain glutamine, serotonin and sphingomyelin C18:0 were found to be predictors of memory impairment. These findings provide informative data for future research on AD, since some of them agree with pathological alterations observed in diseased humans.

Swank, C., S. Almutairi, S. Wang-Price and F. Gao (2020). “Immediate kinematic and muscle activity changes after a single robotic exoskeleton walking session post-stroke.” Top Stroke Rehabil Feb 20:1-13. [Epub ahead of print].

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Background: Robotic Exoskeletons (EKSO) are novel technology for retraining common gait dysfunction in people post-stroke. EKSO’s capability to influence gait characteristics post-stroke is unknown.Objectives: To compare temporospatial, kinematic, and muscle activity gait characteristics before and after a single EKSO session and examine kinematic symmetry between involved and uninvolved limbs.Methods: Participants post-stroke walked under two conditions: pre-EKSO, and immediately post-EKSO. A 10-camera motion capture system synchronized with 6 force plates was used to obtain temporospatial and kinematic gait characteristics from 5 walking trials of 9 meters at a self-selected speed. Surface EMG activity was obtained from bilateral gluteus medius, rectus femoris, medial hamstrings, tibialis anterior, and soleus muscles. Wilcoxon Signed Rank tests were used to analyze differences pre- and post-EKSO. Single EKSO session consisted of 22.3+/-6.8 minutes total time (walk time=7.2+/-1.5 minutes) with 250+/-40 steps.Results: Six ambulatory (Functional Ambulation Category, range=4-5) adults (3 female; 44.7+/-14.6 years) with chronic stroke (4.5+/-1.9 years post-stroke) participated. No significant differences were observed for temporospatial gait characteristics. Muscle activity was significantly less post-EKSO in the involved leg rectus femoris during swing phase (p=0.028). Ankle dorsiflexion range of motion on the involved leg post-EKSO was significantly less during stance phase (p=0.046). Differences between involved and uninvolved joint range of motion symmetry were found pre-EKSO but not post-EKSO in swing phase hip flexion and stance phase knee flexion and knee extension.Conclusions: EKSO training appears capable of altering gait in people with chronic stroke and a viable intervention to reduce gait dysfunction post-stroke.

Swank, C., M. Trammell, L. Callender, M. Bennett, K. Patterson, J. Gillespie, P. Kapoor and S. Driver (2020). “The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation-a randomized controlled trial.” Clin Rehabil Jan 15. [Epub ahead of print].

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OBJECTIVE: Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge. DESIGN: Randomized control trial. SETTING: Inpatient rehabilitation facility. SUBJECTS: Patients admitted to inpatient rehabilitation post stroke. INTERVENTIONS: Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day. MAIN MEASURES: Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up. RESULTS: Seventy-three patients (PDAP (n = 37); control (n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 +/- 16.5 sessions (10.7 +/- 8.5 upper extremity; 12.4 +/- 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 +/- 655.82, control = 396.17 +/- 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 +/- 11.4, control = 80.8 +/- 16.7; P = 0.049), communication (PDAP = 93.6 +/- 8.3, control = 89.6 +/- 12.4; P = 0.042), mobility (PDAP = 62.2 +/- 22.5, control = 53.8 +/- 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 +/- 19.1, control = 52.2 +/- 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP (n = 11) completed significantly greater physical activity (P = 0.014; 3586.5 +/- 3468.5 steps/day) compared to control (n = 10; 1760.9 +/- 2346.3 steps/day). CONCLUSION: Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Sheehy, A. M., A. L. Masica and S. S. Shah (2020). “Next Steps for Next Steps: The Intersection of Health Policy with Clinical Decision-Making.” J Hosp Med 15(1): 5.

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The Journal of Hospital Medicine introduced the Choosing Wisely: Next Steps in Improving Healthcare Value series in 2015 as a companion to the popular Choosing Wisely: Things We Do for No Reason series that was introduced in October in the same year. Both series were created in partnership with the American Board of Internal Medicine Foundation and were designed in the spirit of the Choosing Wisely campaign’s mission to “promote conversations between clinicians and patients” in choosing care supported by evidence that minimizes harm, including avoidance of unnecessary treatments and tests. The Choosing Wisely: Next Steps in Improving Healthcare Value series extends these principles as a forum for manuscripts that focus on translating value-based concepts into daily operations, including systems-level care delivery redesign initiatives, payment model innovations, and analyses of relevant policies or practice trends. Since its inception, Choosing Wisely: Next Steps in Improving Healthcare Value manuscripts have been published, encompassing a wide range of topics such as post-acute care transitions,4 the role of hospital medicine practice within accountable care organizations (ACOs),5 and quality and value at end-of-life. Few physicians receive health policy training. Hospital medicine practitioners are a core component of the workforce, driving change and value-based improvements at almost every inpatient facility across the country. Regardless of their background or experience, hospital medicine practitioners must interface with legislation, regulation, and other policies every day while providing patient care. Intentional, value-based improvements are more likely to succeed if those providing direct patient care understand health policies, particularly the effects of those policies on transactional, point-of-care decisions. We are pleased to expand the Choosing Wisely: Next Steps in Improving Healthcare Value series to include articles exploring health policy implications at the bedside. (Excerpt from text, p. 5; no abstract available.)