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Saurman JL, Nahab F, Barrett AM, Belagaje S, Henriquez L, Starnes D, Christopher H, Blanke D, Loring DW. A - 78 Characterization of Post-Stroke Cognitive and Mood Impairment within 1-Year Post-Stroke after Hospital Discharge. Arch Clin Neuropsychol 2023; 38:1243. [PMID: 37807220 DOI: 10.1093/arclin/acad067.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE To demonstrate the feasibility of cognitive and psychological characterization after stroke during post-discharge neurology visit as part of standard care. METHOD From January 1, to April 29, 2023, 33 patients were evaluated using the MoCA and screening tests for aphasia, spatial neglect, depression, and anxiety during their neurology outpatient visit. Neuropsychological measures evaluating attention, processing speed, language, visuospatial, memory, and executive function abilities were also administered. Patients were aged 30-87 years (Mage = 64.8, SDage = 14.2). The sample included 37.1% women and was primarily Black/African American (37.1%) and White (54.3%). The average level of education was some college (Medu = 14.7, SDedu = 32.7). Time between stroke and testing ranged from 0-11 months (Melapsed = 2.8, SDelapsed = 3.1 and 88.6% of patients experienced ischemic stroke. RESULTS Over 68% of patients examined demonstrated global cognitive impairment on the MoCA (MMoCA = 21.2, SDMoCA = 5.1). 5.7% of patients met criteria for spatial neglect and 5.7% met criteria for aphasia. A higher percentage demonstrated impairments within visuospatial or language domains (51.4% visuospatial and 34.3% language, respectively. Further, impairments were observed across all other domains assessed, including attention (22.9%), processing speed (31.4%), verbal memory (62.9%), visual memory (54.3%), and executive function (51.4%). Depression and anxiety were present in 42.9% and 37.1% of the sample, respectively. Elapsed time, type of stroke, lateralization of stroke, sex, or mood scores were not associated with lower performance on the MoCA. CONCLUSIONS Cognitive and behavioral deficits following stroke can be identified as part of standard neurologic care that may otherwise have been missed, providing an opportunity to intervene and maximize recovery in stroke patients.
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Crabtree RM, Barrett AM, Parsell DE, Ferguson WJ, Replogle WH, Barrett GR. Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction in Female Basketball Players: Does Race Play a Role? Am J Sports Med 2023; 51:3154-3162. [PMID: 37715518 DOI: 10.1177/03635465231195360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND Arthrofibrosis can limit function and return to sport after anterior cruciate ligament (ACL) reconstruction. Previously reported risk factors for developing arthrofibrosis after ACL reconstruction include female sex, age <18 years, time from injury to surgery <28 days, concomitant meniscal repair, prolonged immobilization, and genetic factors. There is a lack of evidence regarding whether race plays a significant role. HYPOTHESIS The risk of undergoing manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) after primary ACL reconstruction with bone-patellar tendon-bone (BTB) autograft in female basketball players is higher in African American players than in White players. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Using a computerized relational database, the authors identified competitive female basketball players who underwent primary ACL reconstruction with BTB autograft by the senior author over a 13-year period. Data previously entered from examinations and surgical findings were reviewed retrospectively. Univariate statistics and multivariable logistic regression were used to assess the relationship between undergoing subsequent MUA and/or LOA and study predictors. RESULTS A total of 186 knees (114 African American knees and 72 White knees) met inclusion criteria. The overall rate of MUA and/or LOA was 8.6%. Thirteen African American knees (11.4%) and 3 White knees (4.2%) underwent MUA and/or LOA for treatment of arthrofibrosis. No study predictor was found to have a statistically significant relationship with the rate of MUA and/or LOA on univariate analysis. However, when controlling for body mass index and previously described risk factors (age <18 years, time from injury to surgery ≤28 days, and concomitant meniscal repair) in the logistic regression model, the authors found that MUA and/or LOA was more likely in African American (odds ratio, 4.01 [95% CI, 1.01-15.92]; P = .049) than in White female players and in patients who underwent ACL reconstruction within 28 days of injury (odds ratio, 4.01 [95% CI, 1.18-13.57]; P = .026) compared with those with surgery delayed beyond 28 days. CONCLUSION In female basketball players, the present study found a statistically significantly increased risk for undergoing MUA and/or LOA after primary ACL reconstruction with BTB autograft in African American females compared with White females and in patients who underwent ACL reconstruction within 28 days of injury.
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Affiliation(s)
- Reaves M Crabtree
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Austin M Barrett
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
| | - Douglas E Parsell
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
| | - William J Ferguson
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
| | - William H Replogle
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Gene R Barrett
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Alabyad D, Lemuel-Clarke M, Antwan M, Henriquez L, Belagaje S, Rangaraju S, Mosley A, Cabral J, Walczak T, Ido M, Hashima P, Bayakly R, Collins K, Sutherly-Bhadsavle L, Brasher C, Danaie E, Victor P, Westover D, Webb M, Skukalek S, Barrett AM, Esper GJ, Nahab F. Telemedicine impact on post-stroke outpatient follow-up in an academic healthcare network during the COVID-19 pandemic. J Stroke Cerebrovasc Dis 2023; 32:107213. [PMID: 37384981 PMCID: PMC10284452 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND The expansion of telemedicine associated with the COVID-19 pandemic has influenced outpatient medical care. The objective of our study was to determine the impact of telemedicine on post-acute stroke clinic follow-up. METHODS We retrospectively evaluated the impact of telemedicine in Emory Healthcare, an academic healthcare system of comprehensive and primary stroke centers in Atlanta, Georgia, on post-hospital stroke clinic follow-up. We compared the frequency of 90-day follow-up in a centralized subspecialty stroke clinic among patients hospitalized before the local COVID-19 pandemic (January 1, 2019- February 28, 2020), during (March 1- April 30, 2020) and after telemedicine implementation (May 1- December 31, 2020). A comparison was made across hospitals less than 1 mile, 10 miles, and 25 miles from the stroke clinic. RESULTS Of 1096 ischemic stroke patients discharged home or to a rehab facility during the study period, 342 (31%) had follow-up in the Emory Stroke Clinic (comprehensive stroke center 46%, primary stroke center 10 miles away 18%, primary stroke center 25 miles away 14%). Overall, 90-day follow-up increased from 19% to 41% after telemedicine implementation (p<0.001) with telemedicine appointments amounting for up to 28% of all follow-up visits. In multivariable analysis, factors associated with teleneurology follow-up (vs no follow-up) included discharge from the comprehensive stroke center, thrombectomy treatment, private insurance, private transport to the hospital, NIHSS 0-5 and history of dyslipidemia. CONCLUSIONS Despite telemedicine implementation at an academic healthcare network successfully increasing post-stroke discharge follow-up in a centralized subspecialty stroke clinic, the majority of patients did not complete 90-day follow-up during the COVID-19 pandemic.
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Affiliation(s)
| | | | - Marlyn Antwan
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Laura Henriquez
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Samir Belagaje
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Srikant Rangaraju
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Ashlee Mosley
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Jacqueline Cabral
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Teri Walczak
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Moges Ido
- Georgia Department of Public Health, Atlanta, GA, United States
| | | | - Rana Bayakly
- Georgia Department of Public Health, Atlanta, GA, United States
| | | | | | | | | | | | | | - Mark Webb
- Emory Healthcare, Atlanta, GA, United States
| | - Susana Skukalek
- Department of Neurosurgery, Emory University, Atlanta, GA, United States
| | - A M Barrett
- Department of Neurology, University of Massachusetts, Worcester, MA, United States
| | - Gregory J Esper
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Fadi Nahab
- Department of Neurology, Emory University, Atlanta, GA, United States.
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Loetscher T, Barrett AM, Billinghurst M, Lange B. Immersive medical virtual reality: still a novelty or already a necessity? J Neurol Neurosurg Psychiatry 2023:jnnp-2022-330207. [PMID: 37055062 DOI: 10.1136/jnnp-2022-330207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/29/2023] [Indexed: 04/15/2023]
Affiliation(s)
- Tobias Loetscher
- Cognitive Ageing and Impairment Neurosciences, University of South Australia, Adelaide, South Australia, Australia
| | - A M Barrett
- UMass Chan Medical School, Worcester, Massachusetts, USA
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
| | - Mark Billinghurst
- Australian Research Centre for Interactive and Virtual Environments, University of South Australia, Adelaide, South Australia, Australia
- Empathic Computing Laboratory, The University of Auckland, Auckland, Auckland, New Zealand
| | - Belinda Lange
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
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Chen P, Hreha K, Gonzalez-Snyder C, Rich TJ, Gillen RW, Parrott D, Barrett AM. Impacts of Prism Adaptation Treatment on Spatial Neglect and Rehabilitation Outcome: Dosage Matters. Neurorehabil Neural Repair 2022; 36:500-513. [PMID: 35673990 DOI: 10.1177/15459683221107891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We examined whether number of prism adaptation treatment (PAT) sessions in regular clinical practice would predict spatial neglect (SN) improvement and rehabilitation outcomes. We reviewed clinical records from 16 U.S. rehabilitation hospitals where neurological patients were assessed for SN using the Catherine Bergego Scale (CBS) and if SN was detected, and may have received PAT. Multiple linear regression was used to predict CBS Change (indicating SN improvement) in 520 patients who received PAT while considering age, sex, diagnosis, time post diagnosis, CBS at baseline, neglected side of space, and length of stay. Another set of regression models including the same variables and adding Function Independent Measure (FIM®) at admission was used to predict FIM Gains (indicating rehabilitation outcomes) in 1720 patients receiving PAT or not. We found that greater number of PAT sessions predicted greater CBS Change, especially in patients with moderate-to-severe neglect. Number of PAT sessions also positively correlated with Total FIM, Motor FIM, and Cognitive FIM Gains regardless of SN severity classification at baseline. Furthermore, number of PAT sessions predicted CBS Change and FIM Gains among patients completing ≤8 PAT sessions but not among patients with ≥8 sessions, who however, showed greater CBS Change with increased PAT frequency (i.e., fewer days between two consecutive sessions). Receiving more once-daily PAT sessions predicted greater improvement in SN and rehabilitation outcomes. Receiving PAT at a higher frequency for 8 or more sessions predicted better SN improvement. Thus, dosage matters. The study provides practice-based evidence that PAT is appropriate for inpatient rehabilitation.
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Affiliation(s)
- Peii Chen
- Center for Stroke Rehabilitation Research, 158368Kessler Foundation, West Orange, NJ, USA
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Kimberly Hreha
- Division of Occupational Therapy Doctorate, Department of Orthopaedic Surgery, School of Medicine, 12277Duke University, Durham, NC, USA
| | | | - Timothy J Rich
- Center for Stroke Rehabilitation Research, 158368Kessler Foundation, West Orange, NJ, USA
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Robert W Gillen
- Neuropsychology Department, 21489Sunnyview Rehabilitation Hospital, Schenectady, NY, USA
| | - Devan Parrott
- Research, Training, and Outcome Center for Brain Injury, 24119Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - A M Barrett
- Department of Neurology, 1371Emory University School of Medicine, Atlanta, GA, USA
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, U.S. Department of Veterans Affairs, Decatur, GA, USA
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Barrett AM, Goedert KM, Carter AR, Chaudhari A. Spatial neglect treatment: The brain's spatial-motor Aiming systems. Neuropsychol Rehabil 2022; 32:662-688. [PMID: 33941021 PMCID: PMC9632633 DOI: 10.1080/09602011.2020.1862678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/29/2020] [Indexed: 10/21/2022]
Abstract
Animal and human literature supports spatial-motor "Aiming" bias, a frontal-subcortical syndrome, as a core deficit in spatial neglect. However, spatial neglect treatment studies rarely assess Aiming errors. Two knowledge gaps result: spatial neglect rehabilitation studies fail to capture the impact on motor-exploratory aspects of functional disability. Also, across spatial neglect treatment studies, discrepant treatment effects may also result from sampling different proportions of patients with Aiming bias. We review behavioural evidence for Aiming spatial neglect, and demonstrate the importance of measuring and targeting Aiming bias for treatment, by reviewing literature on Aiming spatial neglect and prism adaptation treatment, and presenting new preliminary data on bromocriptine treatment. Finally, we review neuroanatomical and network disruption that may give rise to Aiming spatial neglect. Because Aiming spatial neglect predicts prism adaptation treatment response, assessment may broaden the ability of rehabilitation research to capture functionally-relevant disability. Frontal brain lesions predict both the presence of Aiming spatial neglect, and a robust response to some spatial neglect interventions. Research is needed that co-stratifies spatial neglect patients by lesion location and Aiming spatial neglect, to personalize spatial neglect rehabilitation and perhaps even open a path to spatial retraining as a means of promoting better mobility after stroke.
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Affiliation(s)
- A M Barrett
- Neurorehabilitation Division, Emory Brain Health Center, and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health System, Decatur, GA, USA
| | - Kelly M Goedert
- Department of Psychology, Seton Hall University, South Orange, NJ, USA
| | - Alexandre R Carter
- Neurorehabilitation Division, Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
- Program in Occupational Therapy, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Amit Chaudhari
- Department of Neurology, University of California Irvine, Irvine, CA, USA
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Barrett AM, Convoy-Hellmann J, Loring D, Saurman J, Benameur K, Goldstein FC, Krishnan S, Nahab FB. Abstract WP66: Acute Stroke Screening For Cognitive Disorders And Depression. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
As stroke survivors transition from acute to post-acute care, and finally to community settings, the Centers for Disease Control reports ~65% receive NO rehabilitation. Even more receive rehabilitation too late, after critical brain changes for recovery are complete. Stroke survivors with invisible disabilities of cognition and depression are especially vulnerable to experience poor recovery. We launched a dedicated process to identify invisible disabilities. Our long-term objective is to make acute and post-acute, evidence-based intervention accessible.
Hypothesis:
>50% of acute stroke patients have cognitive deficits, or depression.
Methods:
Our comprehensive stroke center completes bedside psychometric assessment with standardized instruments for aphasia (Language Screening Test, LAST), spatial neglect (Catherine Bergego Scale, CBS), memory/global cognition (Montreal Cognitive Assessment, MoCA), delirium (3-Minute Diagnostic Interview for the Confusion Assessment Method, 3D-CAM) and depression (Patient health questionnaire, PHQ-8). Patients unable to respond to questions are assessed for spatial neglect and delirium (standardized observations).
Results:
105 ischemic stroke survivors were assessed in the first quarter of program launch (April-July, 2021). Of that group, patients met screening criteria for spatial neglect (47%), aphasia (40%), delirium (19%) and depression (31%). Over 90% had memory / global cognitive impairment (MoCA<26/30).
Conclusions:
Our initiative, which includes systematic acute stroke unit spatial neglect screening, confirmed the previously reported high rate of cognitive disorders and depression (Champod, Eskes, Barrett, 2020). Our current step implements uniform recommendations for patients with deficits, and will examine post-acute outcomes, number receiving rehabilitation and medical follow-up, and treatment disparities (right/left stroke, under-represented groups).
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Reznik ME, Margolis SA, Mahta A, Wendell LC, Thompson BB, Stretz C, Rudolph JL, Boukrina O, Barrett AM, Daiello LA, Jones RN, Furie KL. Impact of Delirium on Outcomes After Intracerebral Hemorrhage. Stroke 2022; 53:505-513. [PMID: 34607468 PMCID: PMC8792195 DOI: 10.1161/strokeaha.120.034023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Delirium portends worse outcomes after intracerebral hemorrhage (ICH), but it is unclear if symptom resolution or postacute care intensity may mitigate its impact. We aimed to explore differences in outcome associated with delirium resolution before hospital discharge, as well as the potential mediating role of postacute discharge site. METHODS We performed a single-center cohort study on consecutive ICH patients over 2 years. Delirium was diagnosed according to DSM-5 criteria and further classified as persistent or resolved based on delirium status at hospital discharge. We determined the impact of delirium on unfavorable 3-month outcome (modified Rankin Scale score, 4-6) using logistic regression models adjusted for established ICH predictors, then used mediation analysis to examine the indirect effect of delirium via postacute discharge site. RESULTS Of 590 patients (mean age 70.5±15.5 years, 52% male, 83% White), 59% (n=348) developed delirium during hospitalization. Older age and higher ICH severity were delirium risk factors, but only younger age predicted delirium resolution, which occurred in 75% (161/215) of ICH survivors who had delirium. Delirium was strongly associated with unfavorable outcome, but patients with persistent delirium fared worse (adjusted odds ratio [OR], 7.3 [95% CI, 3.3-16.3]) than those whose delirium resolved (adjusted OR, 3.1 [95% CI, 1.8-5.5]). Patients with delirium were less likely to be discharged to inpatient rehabilitation than skilled nursing facilities (adjusted OR, 0.31 [95% CI, 0.17-0.59]), and postacute care site partially mediated the relationship between delirium and functional outcome in ICH survivors, leading to a 25% reduction in the effect of delirium (without mediator: adjusted OR, 3.0 [95% CI, 1.7-5.6]; with mediator: adjusted OR, 2.3 [95% CI, 1.2-4.3]). CONCLUSIONS Acute delirium resolves in most patients with ICH by hospital discharge, which was associated with better outcomes than in patients with persistent delirium. The impact of delirium on outcomes may be further mitigated by postacute rehabilitation.
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Affiliation(s)
- Michael E Reznik
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
- Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T.), Brown University, Alpert Medical School, Providence, RI
| | - Seth A Margolis
- Department of Psychiatry and Human Behavior (S.A.M., R.N.J.), Brown University, Alpert Medical School, Providence, RI
| | - Ali Mahta
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
- Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T.), Brown University, Alpert Medical School, Providence, RI
| | - Linda C Wendell
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
- Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T.), Brown University, Alpert Medical School, Providence, RI
- Section of Medical Education (L.C.W.), Brown University, Alpert Medical School, Providence, RI
| | - Bradford B Thompson
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
- Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T.), Brown University, Alpert Medical School, Providence, RI
| | - Christoph Stretz
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
| | - James L Rudolph
- Department of Medicine (J.L.R.), Brown University, Alpert Medical School, Providence, RI
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island (J.L.R.)
| | - Olga Boukrina
- Kessler Foundation and Kessler Institute for Rehabilitation, NJ (O.B.)
| | - A M Barrett
- Neurorehabilitation Program, Department of Neurology, Emory School of Medicine, Atlanta, GA (A.M.B.)
| | - Lori A Daiello
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
| | - Richard N Jones
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
- Department of Psychiatry and Human Behavior (S.A.M., R.N.J.), Brown University, Alpert Medical School, Providence, RI
| | - Karen L Furie
- Department of Neurology (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.), Brown University, Alpert Medical School, Providence, RI
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Lemuel-Clarke M, Antwan M, Henriquez L, Belagaje SR, RANGARAJU S, Mosley A, Cabral J, Walczak T, Ido M, Hashima P, Bayakly R, Jaffe J, Sutherly-Bhadsavle L, Brasher C, Danaie EI, Victor P, Westover D, Webb M, Skukalek SL, Barrett AM, Esper GJ, Nahab F. Abstract NS3: Telemedicine Impact On Post-stroke Outpatient Follow-up In An Academic Healthcare Network. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.ns3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The expansion of telemedicine associated with the COVID-19 pandemic has influenced outpatient medical care. The objective of our study was to determine the impact of telemedicine on post-acute stroke clinic follow-up.
Methods:
With this retrospective cohort study, we evaluated the impact of telemedicine in Emory Healthcare, an academic healthcare system of comprehensive (CSC) and primary stroke centers (PSC) in Atlanta, Georgia, on post-hospital stroke clinic follow-up. We compared the frequency of successful post-hospitalization follow-up in a centralized subspecialty stroke clinic among patients hospitalized before the local COVID-19 pandemic (January 1- February 28, 2020), during (March 1- April 30, 2020) and after telemedicine implementation (May 1- December 31, 2020). A comparison was made across network hospitals less than 1 mile (CSC) and 25 miles (PSC25) from the specialty stroke clinic.
Results:
Of the 553 ischemic stroke patients [median age 68 years (IQR 58-79), median NIHSS 4 (IQR 1-8)] discharged home or to a rehab facility during the study period, 241 (43.6%) had follow-up in the Emory Stroke Clinic (CSC=48%, PSC25=23%). Overall, 90-day follow-up increased from 31% before to 48% after telemedicine implementation. Similarly, telemedicine appointments increased from 19% to 72% of the follow-up visits. The increase in follow-up visits was modest among CSC patients, from 41% to 51% (p=0.16), relative to the increase among PSC25 patients (5.3% to 31%, p=0.002).
Conclusions:
Telemedicine implementation at an academic healthcare network successfully increased post-stroke discharge follow-up in a centralized subspecialty stroke clinic for hospitalized patients up to 25 miles from the clinic site. However, more work is required to facilitate follow up in the majority of patients.
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Hreha K, Barrett AM, Gillen RW, Gonzalez-Snyder C, Masmela J, Chen P. The Implementation Process of Two Evidence-Based Protocols: A Spatial Neglect Network Initiative. Front Health Serv 2022; 2:839517. [PMID: 36925858 PMCID: PMC10012810 DOI: 10.3389/frhs.2022.839517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/23/2022] [Indexed: 11/13/2022]
Abstract
Introduction Spatial neglect, a neurocognitive disorder of lateralized spatial attention, is prevalent among stroke survivors especially in inpatient rehabilitation facilities (IRFs). The ultimate goal of the project was to improve spatial neglect care in inpatient rehabilitation and trained as many OTs as possible using both tools in their regular practices as the means to achieve our overall objective. Therefore, we conducted a project aimed at implementing two evidence-based protocols, one for assessment (KF-NAP®) and the other for treatment (KF-PAT®), and share the implementation process, which included barriers and facilitators identified during and after the process, and implementation outcomes. Methods Sixteen IRFs were involved. The Knowledge-To-Action Cycle was used to describe the process of knowledge inquiry (training), translating knowledge (implementation) and evaluating the use of knowledge in clinical practice (outcomes). Barriers and strategies were reported using the Consolidated Framework for Implementation Research and identified through a survey, after the study concluded. Results Thirty-two therapists at the participating sites were trained to some level of the KF-NAP and KF-PAT. Throughout the project and also once after it finished, different barriers were identified by researchers and clinicians, who then determined together actions to eliminate or minimize the barriers. For example, multiple sites reported: "not having time to train other staff at their hospital due to high patient volume and other responsibilities." Discussion The project shared our implementation process which demonstrated the importance of using implementation methods and incorporating a researcher-clinician partnership, not only for knowledge generation but also knowledge translation. Frequent communications and exchanging information with stakeholders at different levels, may be determinant to the success of each implementation phase. Further research is needed.
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Affiliation(s)
- Kimberly Hreha
- Division of Occupational Therapy Doctorate, Department of Orthopaedic Surgery, School of Medicine, Duke University, Durham, NC, United States
| | - A M Barrett
- Atlanta VA Health Care System, U.S. Department of Veterans Affairs, Center for Visual and Neurocognitive Rehabilitation, Decatur, GA, United States.,Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Robert W Gillen
- Neuropsychology Department, Sunnyview Rehabilitation Hospital, Schenectady, NY, United States
| | - Chris Gonzalez-Snyder
- Division of In-Patient Rehabilitation, Select Medical, Mechanicsburg, PA, United States
| | - Jenny Masmela
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, United States
| | - Peii Chen
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, United States.,Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, NJ, United States
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Barrett AM. Spatial Neglect and Anosognosia After Right Brain Stroke. Continuum (Minneap Minn) 2021; 27:1624-1645. [PMID: 34881729 DOI: 10.1212/con.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Up to 80% of survivors of right brain stroke leave acute care without being diagnosed with a major invisible disability. Studies indicate that a generic cognitive neurologic evaluation does not reliably detect spatial neglect, nor does it identify unawareness of deficit after right brain stroke; this article reviews the symptoms, clinical presentation, and management of these two cognitive disorders occurring after right brain stroke. RECENT FINDINGS Stroke and occupational therapy practice guidelines stress a quality standard for spatial neglect assessment and treatment to reduce adverse outcomes for patients, their families, and society. Neurologists may attribute poor outcomes associated with spatial neglect to stroke severity. However, people with spatial neglect are half as likely to return to home and community, have one-third the community mobility, and require 3 times as much caregiver supervision compared with similar stroke survivors. Multiple randomized trials support a feasible first-line rehabilitation approach for spatial neglect: prism adaptation therapy; more than 20 studies reported that this treatment improves daily life independence. Evidence-based treatment of anosognosia is not as developed; however, treatment for this problem is also available. SUMMARY This article guides neurologists' assessment of right brain cognitive disorders and describes how to efficiently assemble and direct a treatment team to address spatial neglect and unawareness of deficit.
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Chen P, Diaz-Segarra N, Hreha K, Kaplan E, Barrett AM. Prism Adaptation Treatment Improves Inpatient Rehabilitation Outcome in Individuals With Spatial Neglect: A Retrospective Matched Control Study. Arch Rehabil Res Clin Transl 2021; 3:100130. [PMID: 34589681 PMCID: PMC8463461 DOI: 10.1016/j.arrct.2021.100130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To determine whether prism adaptation treatment (PAT) integrated into the standard of care improves rehabilitation outcome in patients with spatial neglect (SN). Design Retrospective matched control study based on information extracted from June 2017-September 2019. Setting Inpatient rehabilitation. Participants Patients from 14 rehabilitation hospitals scoring >0 on the Catherine Bergego Scale (N=312). The median age was 69.5 years, including 152 (49%) female patients and 275 (88%) patients with stroke. Interventions Patients were matched 1:1 by age (±5 years), FIM score at admission (±2 points), and SN severity using the Catherine Bergego Scale (±2 points) and classified into 2 groups: treated (8-12 daily sessions of PAT) vs untreated (no PAT). Main Outcome Measures FIM and its minimal clinically important difference (MCID) were the primary outcome variables. Secondary outcome was home discharge. Results Analysis included the 312 matched patients (156 per group). FIM scores at discharge were analyzed using repeated-measures analyses of variance. The treated group showed reliably higher scores than the untreated group in Total FIM, F=5.57, P=.020, partial η2=0.035, and Cognitive FIM, F=19.20, P<.001, partial η2=0.110, but not Motor FIM, F=0.35, P=.553, partial η2=0.002. We used conditional logistic regression to examine the odds ratio of reaching MCID in each FIM score and of returning home after discharge. No reliable difference was found between groups in reaching MCID or home discharge. Conclusions Patients with SN receiving PAT had better functional and cognitive outcomes, suggesting that integrating PAT into the standard of care is beneficial. However, receiving PAT may not determine home discharge.
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Key Words
- Brain injury
- CBS, Catherine Bergego Scale
- CMS, Centers for Medicare and Medicaid Services
- IRB, institutional review board
- KF-NAP, Kessler Foundation Neglect Assessment Process
- KF-PAT, Kessler Foundation Prism Adaptation Treatment
- LOS, length of stay
- List of abbreviations: ANOVA, analysis of variance
- MCID, minimal clinically important difference
- Neurorehabilitation
- OR, odds ratio
- OT, occupational therapist
- Outcome
- PAT, prism adaptation treatment
- RCT, randomized controlled trial
- Rehabilitation
- SN, spatial neglect
- Stroke rehabilitation
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Affiliation(s)
- Peii Chen
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ.,Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, NJ
| | - Nicole Diaz-Segarra
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, NJ.,Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, West Orange, NJ
| | - Kimberly Hreha
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Emma Kaplan
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ
| | - A M Barrett
- Department of Neurology, Emory University School of Medicine, Atlanta, GA.,Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, US Department of Veterans Affairs, Decatur, GA
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13
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Chen P, Zanca J, Esposito E, Barrett AM. Barriers and Facilitators to Rehabilitation Care of Individuals With Spatial Neglect: A Qualitative Study of Professional Views. Arch Rehabil Res Clin Transl 2021; 3:100122. [PMID: 34179758 PMCID: PMC8212009 DOI: 10.1016/j.arrct.2021.100122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To identify barriers and facilitators to achieving optimal inpatient rehabilitation outcome among individuals with spatial neglect (SN). Design Cross-sectional, semistructured focus group discussions. Setting Rehabilitation hospitals. Participants A total of 15 occupational therapists and 14 physical therapists treating patients with SN on 3 campuses of a rehabilitation hospital system (N=29). Six focus group sessions were conducted and audio-recorded for transcription. Interventions Not applicable. Main Outcome Measures Not applicable. Results Participants identified several patient-related characteristics that posed barriers to treatment, including the symptoms of SN itself, cognitive issues, physical weakness, comorbidities, and reduced therapy engagement. Supportive family members were considered a key facilitator, but lack of preparedness to assume caregiving roles, poor understanding of SN and rehabilitation goals, and inadequate levels of involvement were family-related barriers to successful treatment. Participants expressed that having resources and technologies available at their center to support SN treatment facilitated positive outcomes and perceived limited staff knowledge and skills and poor interclinician communication as barriers to treatment. At the health care system level, barriers included a lack of responsive measures of SN progress and insurer-related issues. Strong continuity of care between transitions was considered an important factor for enabling effective treatment. Conclusions Barriers and facilitators to the current practice of SN care were identified from occupational and physical therapists’ point of view. Opportunities exist to promote identified facilitators and minimize barriers to improve SN rehabilitation. The present study makes a unique contribution in identifying specific needs for innovative interventions that involve family support and training, promotion of interdisciplinary collaboration, development of interprofessional vocabulary, and continuous treatment and follow-up assessment for SN through care transitions.
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Affiliation(s)
- Peii Chen
- Kessler Foundation, West Orange, New Jersey, United States.,Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, New Jersey, United States
| | - Jeanne Zanca
- Kessler Foundation, West Orange, New Jersey, United States.,Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, New Jersey, United States
| | - Emily Esposito
- Department of Psychology, University of California, Riverside, California, United States
| | - A M Barrett
- Department of Neurology, Emory University, Atlanta, Georgia, United States.,Atlanta VA Health Care System, U.S. Department of Veterans Affairs, Decatur, Georgia, United States
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14
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Cramer SC, Le V, Saver JL, Dodakian L, See J, Augsburger R, McKenzie A, Zhou RJ, Chiu NL, Heckhausen J, Cassidy JM, Scacchi W, Smith MT, Barrett AM, Knutson J, Edwards D, Putrino D, Agrawal K, Ngo K, Roth EJ, Tirschwell DL, Woodbury ML, Zafonte R, Zhao W, Spilker J, Wolf SL, Broderick JP, Janis S. Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function. Neurology 2021; 96:e1812-e1822. [PMID: 33589538 DOI: 10.1212/wnl.0000000000011667] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/23/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains. METHODS Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains. RESULTS At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease. CONCLUSIONS Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations. CLINICAL TRIAL Clinicaltrials.gov identifier: NCT02360488. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.
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Affiliation(s)
- Steven C Cramer
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD.
| | - Vu Le
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Jeffrey L Saver
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Lucy Dodakian
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Jill See
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Renee Augsburger
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Alison McKenzie
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Robert J Zhou
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Nina L Chiu
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Jutta Heckhausen
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Jessica M Cassidy
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Walt Scacchi
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Megan Therese Smith
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - A M Barrett
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Jayme Knutson
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Dylan Edwards
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - David Putrino
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Kunal Agrawal
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Kenneth Ngo
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Elliot J Roth
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - David L Tirschwell
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Michelle L Woodbury
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Ross Zafonte
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Wenle Zhao
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Judith Spilker
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Steven L Wolf
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Joseph P Broderick
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
| | - Scott Janis
- From the Department of Neurology (S.C.C., J.L.S.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.), Los Angeles; Department of Neurology (S.C.C., V.L., L.D., J. See, R.A., A.M., R.J.Z., N.L.C., J.M.C.), Department of Psychological Science (J.H.), Institute for Software Research (W.S.), and Department of Statistics (M.T.S.), University of California, Irvine; Department of Physical Therapy (A.M.), Chapman University, Irvine, CA; Department of Allied Health Sciences (J.M.C.), University of North Carolina at Chapel Hill; Department of Stroke Rehabilitation Research (A.M.B.), Kessler Foundation; Department of Stroke Rehabilitation (A.M.B.), Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (J.K.), MetroHealth System, Case Western Reserve University, Cleveland, OH; Brain Stimulation and Robotics Laboratory (D.E.), Burke Neurological Institute; Department of Telemedicine and Virtual Rehabilitation (D.P.), Burke Medical Research Institute, White Plains, NY; Abilities Research Center (D.P.), Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Clinical Neurosciences (K.A.), University of California, San Diego, La Jolla; Brooks Rehabilitation Clinical Research Center (K.N.), Brooks Rehabilitation, Jacksonville, FL; Department of Physical Medicine and Rehabilitation (E.J.R.), Northwestern University, Chicago, IL; Department of Neurology (D.L.T.), University of Washington, Seattle; Departments of Health Science and Research (M.L.W.) and Public Health Sciences (W.Z.), Medical University of South Carolina, Charleston; Department of Physical Medicine and Rehabilitation (R.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; Department of Neurology (J. Spilker, J.P.B.), University of Cincinnati, OH; Department of Rehabilitation Medicine (S.L.W.), Division of Physical Therapy Education, Emory University, Atlanta, GA; Atlanta VA Health Care System (S.L.W.), Center for Visual and Neurocognitive Rehabilitation, Decatur, GA; and NINDS (S.J.), NIH, Bethesda, MD
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15
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Merians AS, Fluet GG, Qiu Q, Yarossi M, Patel J, Mont AJ, Saleh S, Nolan KJ, Barrett AM, Tunik E, Adamovich SV. Hand Focused Upper Extremity Rehabilitation in the Subacute Phase Post-stroke Using Interactive Virtual Environments. Front Neurol 2020; 11:573642. [PMID: 33324323 PMCID: PMC7726202 DOI: 10.3389/fneur.2020.573642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/14/2020] [Indexed: 01/14/2023] Open
Abstract
Introduction: Innovative motor therapies have attempted to reduce upper extremity impairment after stroke but have not made substantial improvement as over 50% of people post-stroke continue to have sensorimotor deficits affecting their self-care and participation in daily activities. Intervention studies have focused on the role of increased dosing, however recent studies have indicated that timing of rehabilitation interventions may be as important as dosing and importantly, that dosing and timing interact in mediating effectiveness. This study is designed to empirically test dosing and timing. Methods and Analysis: In this single-blinded, interventional study, subjects will be stratified on two dimensions, impairment level (Fugl-Meyer Upper Extremity Assessment (FM) and presence or absence of Motor Evoked Potentials (MEPs) as follows; (1) Severe, FM score 10–19, MEP+, (2) Severe, FM score 10–19, MEP–, (3) Moderate, FM score 20–49, MEP+, (4) Moderate, FM score 20–49, MEP–. Subjects not eligible for TMS will be assigned to either group 2 (if severe) or group 3 (if moderate). Stratified block randomization will then be used to achieve a balanced assignment. Early Robotic/VR Therapy (EVR) experimental group will receive in-patient usual care therapy plus an extra 10 h of intensive upper extremity therapy focusing on the hand using robotically facilitated rehabilitation interventions presented in virtual environments and initiated 5–30 days post-stroke. Delayed Robotic/VR Therapy (DVR) experimental group will receive the same intervention but initiated 30–60 days post-stroke. Dose-matched usual care group (DMUC) will receive an extra 10 h of usual care initiated 5–30 days post-stroke. Usual Care Group (UC) will receive the usual amount of physical/occupational therapy. Outcomes: There are clinical, neurophysiological, and kinematic/kinetic measures, plus measures of daily arm use and quality of life. Primary outcome is the Action Research Arm Test (ARAT) measured at 4 months post-stroke. Discussion: Outcome measures will be assessed to determine whether there is an early time period in which rehabilitation will be most effective, and whether there is a difference in the recapture of premorbid patterns of movement vs. the development of an efficient, but compensatory movement strategy. Ethical Considerations: The IRBs of New Jersey Institute of Technology, Rutgers University, Northeastern University, and Kessler Foundation reviewed and approved all study protocols. Study was registered in https://ClinicalTrials.gov (NCT03569059) prior to recruitment. Dissemination will include submission to peer-reviewed journals and professional presentations.
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Affiliation(s)
- Alma S Merians
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Gerard G Fluet
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Qinyin Qiu
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Mathew Yarossi
- Movement Neuroscience Laboratory, Department of Physical Therapy, Movement and Rehabilitation Science, Bouve College of Health Sciences, Northeastern University, Boston, MA, United States.,SPIRAL Group, Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, United States
| | - Jigna Patel
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Ashley J Mont
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, United States
| | - Soha Saleh
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Karen J Nolan
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - A M Barrett
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States.,Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, United States
| | - Eugene Tunik
- Movement Neuroscience Laboratory, Department of Physical Therapy, Movement and Rehabilitation Science, Bouve College of Health Sciences, Northeastern University, Boston, MA, United States.,Department of Bioengineering, College of Engineering, Northeastern University, Boston, MA, United States.,Department of Electrical and Computer Engineering, College of Engineering, Northeastern University, Boston, MA, United States
| | - Sergei V Adamovich
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States.,Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, United States
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16
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Zhong X, Lin JY, Li L, Barrett AM, Poeran J, Mazumdar M. Derivation and validation of a novel comorbidity-based delirium risk index to predict postoperative delirium using national administrative healthcare database. Health Serv Res 2020; 56:154-165. [PMID: 33020939 DOI: 10.1111/1475-6773.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To derive and validate a comorbidity-based delirium risk index (DRI) to predict postoperative delirium. DATA SOURCE/STUDY SETTING Data of 506 438 hip fracture repair surgeries from 2006 to 2016 were collected to derive DRI and perform internal validation from the Premier Healthcare Database, which provided billing information on 20-25 percent of hospitalizations in the USA. Additionally, data of 1 130 569 knee arthroplasty surgeries were retrieved for external validation. STUDY DESIGN Thirty-six commonly seen comorbidities were evaluated by logistic regression with the outcome of postoperative delirium. The hip fracture repair surgery cohort was separated into a training dataset (60 percent) and an internal validation (40 percent) dataset. The least absolute shrinkage and selection operator (LASSO) procedure was applied for variable selection, and weights were assigned to selected comorbidities to quantify corresponding risks. The newly developed DRI was then compared to the Charlson-Deyo Index for goodness-of-fit and predictive ability, using the Akaike information criterion (AIC), Bayesian information criterion (BIC), area under the ROC curve (AUC) for goodness-of-fit, and odds ratios for predictive performance. Additional internal validation was performed by splitting the data by four regions and in 4 randomly selected hospitals. External validation was conducted in patients with knee arthroplasty surgeries. DATA COLLECTION Hip fracture repair surgeries, knee arthroplasty surgeries, and comorbidities were identified by using ICD-9 codes. Postoperative delirium was defined by using ICD-9 codes and analyzing billing information for antipsychotics (specifically haloperidol, olanzapine, and quetiapine) typically recommended to treat delirium. PRINCIPAL FINDINGS The derived DRI includes 14 comorbidities and assigns comorbidities weights ranging from 1 to 6. The DRI outperformed the Charlson-Deyo Comorbidity Index with better goodness-of-fit and predictive performance. CONCLUSIONS Delirium risk index is a valid comorbidity index for covariate adjustment and risk prediction in the context of postoperative delirium. Future work is needed to test its performance in different patient populations and varying definitions of delirium.
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Affiliation(s)
- Xiaobo Zhong
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.,Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jung-Yi Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Lihua Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - A M Barrett
- Department of Neurology, Emory University of Medicine, Decatur, Georgia, USA.,Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, Decatur, Georgia, USA
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.,Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.,Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
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17
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Bushi S, Barrett AM, Oh-Park M. Inpatient Rehabilitation Delirium Screening: Impact on Acute Care Transfers and Functional Outcomes. PM R 2019; 12:766-774. [PMID: 31840935 DOI: 10.1002/pmrj.12304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/02/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Delirium is well studied in the acute care setting, but there is limited understanding of its impact in the postacute care setting, particularly in the inpatient rehabilitation facility (IRF). OBJECTIVE To investigate the prevalence and related outcomes of delirium in the IRF setting, particularly patients' transfers to acute care hospitals. DESIGN Retrospective cohort study. SETTING A freestanding IRF. PARTICIPANTS Patients discharged from an IRF between January 2016 and December 2016 (12 months). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Transfer to acute care hospitals, motor and cognitive Functional Independence Measures (FIM), length of stay, discharge disposition. RESULTS A total of 1567 patients (53.9% female, mean age 72.9 ± 13.9) were included in the analysis. Positive scores were found among 142 (9.1%) patients on a 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM), indicating delirium on admission. Fifty-nine (3.8%) were unscorable on 3D-CAM. Twice as many delirium patients were transferred to acute care hospitals compared to non-delirium patients (22.5% vs. 10.8%, P < .001). Multivariate logistic regression showed that, for patients with 3D-CAM positive scores, there was an increased risk of transfers to acute care hospitals at an odds ratio of 1.61 (1.03-2.53, P = .04) after adjusting for age, gender, neurological diagnosis, and motor FIM score. The delirium group also showed lower gains in motor function, increased lengths of stay, and reduced discharges to home when compared to the non-delirium group (P < .001). CONCLUSIONS This study finds that delirium on admission to an IRF is associated with worsened outcomes related to function, length of stay, discharge status, and transfer to acute care hospitals. Positive delirium screening is an independent predictor for transfer to acute care hospitals from an IRF. Early identification of delirium is recommended in order to mitigate preventable transfers.
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Affiliation(s)
- Sharon Bushi
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers - the State University of New Jersey, Newark, NJ.,Kessler Institute for Rehabilitation, West Orange, NJ
| | - A M Barrett
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health System, Atlanta, GA.,Neurorehabilitation Division, Emory University School of Medicine, Atlanta, GA
| | - Mooyeon Oh-Park
- Burke Rehabilitation Hospital, White Plains, NY.,Department of Rehabilitation Medicine, Albert Einstein College of Medicine, Montefiore Health System, New York, NY
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18
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Xue Y, Farhat FG, Boukrina O, Barrett AM, Binder JR, Roshan UW, Graves WW. A multi-path 2.5 dimensional convolutional neural network system for segmenting stroke lesions in brain MRI images. Neuroimage Clin 2019; 25:102118. [PMID: 31865021 PMCID: PMC6931186 DOI: 10.1016/j.nicl.2019.102118] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 12/06/2019] [Accepted: 12/08/2019] [Indexed: 11/23/2022]
Abstract
Automatic identification of brain lesions from magnetic resonance imaging (MRI) scans of stroke survivors would be a useful aid in patient diagnosis and treatment planning. It would also greatly facilitate the study of brain-behavior relationships by eliminating the laborious step of having a human expert manually segment the lesion on each brain scan. We propose a multi-modal multi-path convolutional neural network system for automating stroke lesion segmentation. Our system has nine end-to-end UNets that take as input 2-dimensional (2D) slices and examines all three planes with three different normalizations. Outputs from these nine total paths are concatenated into a 3D volume that is then passed to a 3D convolutional neural network to output a final lesion mask. We trained and tested our method on datasets from three sources: Medical College of Wisconsin (MCW), Kessler Foundation (KF), and the publicly available Anatomical Tracings of Lesions After Stroke (ATLAS) dataset. To promote wide applicability, lesions were included from both subacute (1 to 5 weeks) and chronic ( > 3 months) phases post stroke, and were of both hemorrhagic and ischemic etiology. Cross-study validation results (with independent training and validation datasets) were obtained to compare with previous methods based on naive Bayes, random forests, and three recently published convolutional neural networks. Model performance was quantified in terms of the Dice coefficient, a measure of spatial overlap between the model-identified lesion and the human expert-identified lesion, where 0 is no overlap and 1 is complete overlap. Training on the KF and MCW images and testing on the ATLAS images yielded a mean Dice coefficient of 0.54. This was reliably better than the next best previous model, UNet, at 0.47. Reversing the train and test datasets yields a mean Dice of 0.47 on KF and MCW images, whereas the next best UNet reaches 0.45. With all three datasets combined, the current system compared to previous methods also attained a reliably higher cross-validation accuracy. It also achieved high Dice values for many smaller lesions that existing methods have difficulty identifying. Overall, our system is a clear improvement over previous methods for automating stroke lesion segmentation, bringing us an important step closer to the inter-rater accuracy level of human experts.
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Affiliation(s)
- Yunzhe Xue
- Department of Computer Science, New Jersey Institute of Technology, Newark, NJ 07102, USA
| | - Fadi G Farhat
- Department of Computer Science, New Jersey Institute of Technology, Newark, NJ 07102, USA
| | - Olga Boukrina
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers - New Jersey Medical School, Newark, NJ, USA
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers - New Jersey Medical School, Newark, NJ, USA
| | - Jeffrey R Binder
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Usman W Roshan
- Department of Computer Science, New Jersey Institute of Technology, Newark, NJ 07102, USA.
| | - William W Graves
- Department of Psychology, Rutgers University - Newark, Newark, NJ, USA
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19
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Cramer SC, Dodakian L, Le V, See J, Augsburger R, McKenzie A, Zhou RJ, Chiu NL, Heckhausen J, Cassidy JM, Scacchi W, Smith MT, Barrett AM, Knutson J, Edwards D, Putrino D, Agrawal K, Ngo K, Roth EJ, Tirschwell DL, Woodbury ML, Zafonte R, Zhao W, Spilker J, Wolf SL, Broderick JP, Janis S. Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial. JAMA Neurol 2019; 76:1079-1087. [PMID: 31233135 DOI: 10.1001/jamaneurol.2019.1604] [Citation(s) in RCA: 172] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues. Objectives To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education. Design, Setting, and Participants In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population. Interventions Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups. Main Outcomes and Measures Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy. Results A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately. Conclusions and Relevance Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale. Trial Registration ClinicalTrials.gov identifier: NCT02360488.
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Affiliation(s)
| | - Lucy Dodakian
- Department of Neurology, University of California, Irvine
| | - Vu Le
- Department of Neurology, University of California, Irvine
| | - Jill See
- Department of Neurology, University of California, Irvine
| | - Renee Augsburger
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Alison McKenzie
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine.,Department of Physical Therapy, Chapman University, Irvine, California
| | - Robert J Zhou
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Nina L Chiu
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Jutta Heckhausen
- Department of Psychological Science, University of California, Irvine
| | - Jessica M Cassidy
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Walt Scacchi
- Institute for Software Research, University of California, Irvine
| | | | - A M Barrett
- Department of Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey.,Department of Stroke Rehabilitation, Kessler Institute for Rehabilitation, West Orange, New Jersey
| | - Jayme Knutson
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - Dylan Edwards
- Brain Stimulation and Robotics Laboratory, Burke Neurological Institute, White Plains, New York
| | - David Putrino
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
| | - Kunal Agrawal
- Department of Clinical Neurosciences, University of California, San Diego, La Jolla
| | - Kenneth Ngo
- Brooks Rehabilitation Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida
| | - Elliot J Roth
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
| | | | - Michelle L Woodbury
- Department of Health Science and Research, Medical University of South Carolina, Charleston
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts.,Massachusetts General Hospital, Boston.,Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Judith Spilker
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Steven L Wolf
- Division of Physical Therapy Education, Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| | | | - Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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20
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Boukrina O, Barrett AM, Graves WW. Cerebral perfusion of the left reading network predicts recovery of reading in subacute to chronic stroke. Hum Brain Mapp 2019; 40:5301-5314. [PMID: 31452284 PMCID: PMC6864894 DOI: 10.1002/hbm.24773] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/25/2019] [Accepted: 07/31/2019] [Indexed: 01/13/2023] Open
Abstract
Better understanding of cerebral blood flow (CBF) perfusion in stroke recovery can help inform decisions about optimal timing and targets of restorative treatments. In this study, we examined the relationship between cerebral perfusion and recovery from stroke‐induced reading deficits. Left stroke patients were tested with a noninvasive CBF measure (arterial spin labeling) <5 weeks post‐stroke, and a subset had follow up testing >3 months post‐stroke. We measured blood flow perfusion within the left and right sides of the brain, in areas surrounding the lesion, and areas belonging to the reading network. Two hypotheses were tested. The first was that recovery of reading function depends on increased perfusion around the stroke lesion. This hypothesis was not supported by our findings. The second hypothesis was that increased perfusion of intact areas within the reading circuit is tightly coupled with recovery. Our findings are consistent with this hypothesis. Specifically, higher perfusion in the left reading network measured during the subacute stroke period predicted better reading ability and phonology competence in the chronic period. In contrast, higher perfusion of the right homologous regions was associated with decreased reading accuracy and phonology competence in the subacute and chronic periods. These findings suggest that recovery of reading and language competence may rely on improved blood flow in the reading network of the language‐dominant hemisphere.
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Affiliation(s)
- Olga Boukrina
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey.,Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - A M Barrett
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey.,Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, New Jersey.,Kessler Institute for Rehabilitation, West Orange, New Jersey
| | - William W Graves
- Department of Psychology, Rutgers, The State University of New Jersey, Newark, New Jersey
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21
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Abstract
PURPOSE OF REVIEW Spatial neglect is asymmetric orienting and action after a brain lesion, causing functional disability. It is common after a stroke; however, it is vastly underdocumented and undertreated. This article addresses the implementation gap in identifying and treating spatial neglect, to reduce disability and improve healthcare costs and burden. RECENT FINDINGS Professional organizations published recommendations to implement spatial neglect care. Physicians can lead an interdisciplinary team: functionally relevant spatial neglect assessment, evidence-based spatial retraining, and integrated spatial and vision interventions can optimize outcomes. Research also strongly suggests spatial neglect adversely affects motor systems. Spatial neglect therapy might thus "kick-start" rehabilitation and improve paralysis recovery. Clinicians can implement new techniques to detect spatial neglect and lead interdisciplinary teams to promote better, integrated spatial neglect care. Future studies of brain imaging biomarkers to detect spatial neglect, and real-world applicability of prism adaptation treatment, are needed.
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Affiliation(s)
- A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, East Hanover, NJ, USA.
| | - K E Houston
- Harvard Medical School, Department of Ophthalmology, Spaulding Rehabilitation Hospital, Boston, MA, USA
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22
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Barrett AM, Boukrina O, Saleh S. Ventral attention and motor network connectivity is relevant to functional impairment in spatial neglect after right brain stroke. Brain Cogn 2018; 129:16-24. [PMID: 30522777 DOI: 10.1016/j.bandc.2018.11.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 11/15/2022]
Abstract
Emerging research suggests spatial neglect after right stroke is linked to dysfunctional attention and motor networks. Advanced functional connectivity analysis clarified brain network recovery, however we need to know how networks participate in adaptive motor performance. We need to verify network changes associated with validated functional measures and spatial-motor performance in spatial neglect, especially in patients with large brain lesions and significant disability. This study tested whether disability-relevant spatial neglect associates with different patterns of resting state functional connectivity between motor, dorsal and ventral attention networks (MN, DAN and VAN). Right stroke patients had spatial neglect (n = 8) or not (n = 10) on the Behavioural Inattention Test-conventional. Spatial neglect patients had weaker intranetwork VAN connectivity, and reduced internetwork connectivity between VAN and left frontal eye field (DAN), and between VAN and the left primary motor area (MN). These network impairments might explain the co-occurrence of attention and motor deficits in spatial neglect, and open a path to assessing functional connectivity in clinical trials of combined spatial retraining and motor rehabilitation after stroke.
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Affiliation(s)
- A M Barrett
- Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA; Rutgers New Jersey Medical School, Newark, NJ 07102, USA; Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA.
| | - Olga Boukrina
- Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA; Rutgers New Jersey Medical School, Newark, NJ 07102, USA.
| | - Soha Saleh
- Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA; Rutgers New Jersey Medical School, Newark, NJ 07102, USA.
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23
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Pitteri M, Chen P, Passarini L, Albanese S, Meneghello F, Barrett AM. Conventional and functional assessment of spatial neglect: Clinical practice suggestions. Neuropsychology 2018; 32:835-842. [PMID: 29975073 PMCID: PMC6188804 DOI: 10.1037/neu0000469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Spatial neglect (SN) constitutes a substantial barrier to functional recovery after acquired brain injury. However, because of its multimodal nature, no single test can capture all the signs of SN. To provide a clinically feasible solution, we used conventional neuropsychological tests as well as the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP). The goal was to add evidence that a global approach should detect better even subtle signs of SN. METHOD Fourteen individuals with lesions located in the right cerebral hemisphere participated in the study. Participants were assessed with a comprehensive battery of neuropsychological tests, comprising a set of visuospatial tests to evaluate several spatial domains. In addition, patients underwent functional assessment with the Barthel Index, the Functional Independence Measure (FIM), and the CBS via KF-NAP. RESULTS The CBS via KF-NAP was associated with the visuospatial paper-based tests (p = .004) as well as the Motor FIM (p = .003), and was more sensitive than the Behavioral Inattention Test-Conventional in detecting SN (p = .014). CONCLUSIONS We showed that the CBS via KF-NAP was able: (a) to detect functional impairment, especially motor, related to SN; (b) to selectively measures spatial rather than nonspatial dysfunctions; and (c) to be highly sensitive in detecting SN signs especially in those patients with mild severity, covering several aspects of SN manifestations. The patient's SN diagnosis based on the CBS via KF-NAP is clinically important and directly relevant to care planning and goal setting. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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Affiliation(s)
- Marco Pitteri
- Neurology Section, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona
| | | | - Laura Passarini
- Laboratory of Neuropsychology, IRCCS San Camillo Hospital Foundation
| | - Silvia Albanese
- Laboratory of Neuropsychology, IRCCS San Camillo Hospital Foundation
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24
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Goedert KM, Chen P, Foundas AL, Barrett AM. Frontal lesions predict response to prism adaptation treatment in spatial neglect: A randomised controlled study. Neuropsychol Rehabil 2018; 30:32-53. [PMID: 29558241 DOI: 10.1080/09602011.2018.1448287] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Spatial neglect commonly follows right hemisphere stroke. It is defined as impaired contralesional stimulus detection, response, or action, causing functional disability. While prism adaptation treatment is highly promising to promote functional recovery of spatial neglect, not all individuals respond. Consistent with a primary effect of prism adaptation on spatial movements, we previously demonstrated that functional improvement after prism adaptation treatment is linked to frontal lobe lesions. However, that study was a treatment-only study with no randomised control group. The current study randomised individuals with spatial neglect to receive 10 days of prism adaptation treatment or to receive only standard care (control group). Replicating our earlier results, we found that the presence of frontal lesions moderated response to prism adaptation treatment: among prism-treated patients, only those with frontal lesions demonstrated functional improvements in their neglect symptoms. Conversely, among individuals in the standard care control group, the presence of frontal lesions did not modify recovery. These results suggest that further research is needed on how frontal lesions may predict response to prism adaptation treatment. Additionally, the results help elucidate the neural network involved in spatial movement and could be used to aid decisions about treatment.
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Affiliation(s)
- Kelly M Goedert
- Department of Psychology, Seton Hall University, South Orange, NJ, USA
| | - Peii Chen
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anne L Foundas
- Department of Psychology, Tulane University, New Orleans, LA, USA
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
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25
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Boukrina O, Barrett AM. Disruption of the ascending arousal system and cortical attention networks in post-stroke delirium and spatial neglect. Neurosci Biobehav Rev 2017; 83:1-10. [PMID: 28963037 DOI: 10.1016/j.neubiorev.2017.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 08/11/2017] [Accepted: 09/22/2017] [Indexed: 11/22/2022]
Abstract
Delirium is an acute attention and cognitive dysfunction, adversely affecting functional outcomes and mortality. As many as half of hospitalized right brain stroke survivors may develop delirium. Further, about 50% of right stroke patients experience spatial neglect, impairing safety and recovery. In this review we explore the brain mechanisms, which may explain the high incidence of delirium and spatial neglect after right-brain stroke. We suggest that brain networks for spatial attention and arousal, composed of ascending projections from the midbrain nuclei and integrating dorsal and ventral cortical and limbic components, may underlie impairments in delirium and spatial neglect. We propose that lateralized deficits in spatial neglect may arise because cortical and limbic components of these functional networks are disproportionally impaired by right-brain strokes, and that spatial neglect may lower the threshold for developing delirium. An improved understanding of the brain basis of delirium and spatial neglect could provide a critical biomarker for initiating preventive care in stroke patients at high risk of hospital morbidity and loss of independence.
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Affiliation(s)
- Olga Boukrina
- Stroke Rehabilitation Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA.
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA; Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, 185 S Orange Avenue, Newark, NJ, 07103, USA; Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ, USA.
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26
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Abstract
OBJECTIVE To characterize the mediation of attention and action in space following traumatic brain injury (TBI). METHOD Two exploratory analyses were performed to determine the influence of spatial 'Aiming' motor versus spatial 'Where' bias on line bisection in TBI participants. The first experiment compared performance according to severity and location of injury in TBI. The second experiment examined bisection performance in a larger TBI sample against a matched control group. In both experiments, participants bisected lines in near and far space using an apparatus that allowed for the fractionation of spatial Aiming versus Where error components. RESULTS In the first experiment, participants with severe injuries tended to incur rightward error when starting from the right in far space, compared with participants with mild injuries. In the second experiment, when performance was examined at the individual level, more participants with TBI tended to incur rightward motor error compared to controls. CONCLUSIONS TBI may cause frontal-subcortical cognitive dysfunction and asymmetric motor perseveration, affecting spatial Aiming bias on line bisection. Potential effects on real-world function need further investigation. (PsycINFO Database Record
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Affiliation(s)
- Daymond Wagner
- Department of Neurology, Milton S. Hershey Medical Center
| | - Paul J Eslinger
- Departments of Neurology, Neural & Behavioral Sciences, Pediatrics, and Radiology, Penn State College of Medicine
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, Departments of Physical Medicine and Rehabilitation/Neurology and Neurosciences, Rutgers/New Jersey Medical School
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27
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Hurt JA, Berry JH, Replogle W, Thibodeaux K, Hydrick JM, Barrett AM, Barrett GR. Efficacy of Two Techniques in Anterior Cruciate Ligament Reconstruction. J Knee Surg 2017; 30:606-611. [PMID: 27978587 DOI: 10.1055/s-0036-1593966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to compare failure rate and functional outcome in young, active patients (< 25 years) with two-incision (rear-entry) versus transtibial (all-endoscopic) anterior cruciate ligament (ACL) reconstructions.Utilizing a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA), 480 patients were identified that underwent ACL reconstruction, using a bone-patellar-tendon-bone autograft, by a single surgeon between January 2000 and December 2010 via a transtibial or two-incision technique. Totally, 377 (78.6%) of these patients were less than 25 years of age. Data for each patient were collected at their initial clinic visit, at the time of surgery, and at each follow-up clinic visit and entered into the computerized relational database. Overall, 274 patients (72.7%) underwent ACL reconstruction with a transtibial technique, and 103 patients (27.3%) underwent reconstruction with a two-incision technique. Failures were identified as a 2+ Lachman, 1+ or greater pivot shift, or a KT-1000 arthrometer difference of five or more.In patients < 25 years of age, there were 10 failures (9.7%) out of 103 patients undergoing a two-incision reconstruction and 28 failures (10.2%) out of 274 patients undergoing a transtibial reconstruction (p = 1.000). There was no statistical significance between the failure rate in the two different groups in regards to gender, meniscal tear, activity level, or any other factor that was analyzed.Our study showed no statistical difference between the two-incision technique and the transtibial technique for ACL reconstruction using bone-patellar-tendon-bone autograft with an overall 10.1% failure rate in young, active patients (< 25 years of age). The level of evidence is level IV.
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Affiliation(s)
- James A Hurt
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi
| | - John H Berry
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi
| | - William Replogle
- Department of Family Medicine, University of Mississippi Medical Center, Mississippi
| | - Kasey Thibodeaux
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi
| | - Josie M Hydrick
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi
| | - Austin M Barrett
- Department of Orthopaedic Surgery, Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi
| | - Gene R Barrett
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi
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28
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Caulfield MD, Chen P, Barry MM, Barrett AM. Which perseverative behaviors are symptoms of spatial neglect? Brain Cogn 2017; 113:93-101. [PMID: 28167411 DOI: 10.1016/j.bandc.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 10/31/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
Abstract
Spatial neglect is a characterized by a failure to attend or make movements towards left-sided stimuli. Common paper-and-pencil tasks to diagnose spatial neglect are sensitive to perseverative errors, including additional marks over already cancelled targets and "scribbling" out a target. Here, we examine whether functionally distinct perseverative behaviors are related to spatial neglect. Line cancellation tasks of 45 healthy controls and 220 right-hemisphere stroke survivors were examined for recurrent marks (RM) and continuous marks (CM) perseverations. We found that RM perseveration correlated with neglect severity, while CM perseveration did not. Examination of lesion profiles for the two groups indicated distinct anatomical correlates, with RM lesions overlapping regions implicated in spatial neglect including the rolandic operculum, superior temporal gyrus, and inferior parietal lobule.
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Affiliation(s)
- Meghan D Caulfield
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA; Department of Psychology, Lafayette College, Easton, PA, USA.
| | - Peii Chen
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Michele M Barry
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, USA; Kessler Institute for Rehabilitation, West Orange, NJ, USA
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29
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Rostanski SK, Pavol MA, Barbaro M, Kim M, Marshall RS, Barrett AM. Abstract WP160: Delirium in Right Hemisphere Stroke. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Delirium, a disorder of attention and arousal, poses a large public health burden. Inattention and fluctuating cognitive status, two primary delirium symptoms, also occur when specialized right brain systems are impaired. Although right hemisphere stroke may predispose to delirium, systematic assessment methods and management of these patients are not yet available. We sought to characterize the incidence of delirium in right hemisphere stroke patients and explore whether stroke localization was associated with delirium.
Methods:
We identified consecutive patients admitted to our stroke service with acute right hemisphere stroke over a 6-month period from our prospective stroke registry. We reviewed the medical record for core delirium symptoms: inattention, cognitive fluctuation, and either disorganized thinking, or altered level of consciousness. Delirium was assessed by systematically screening for trigger words. We compared baseline characteristics with Fisher’s exact and t-tests and assessed relation of stroke localization to delirium with logistic regression.
Results:
Of 105 patients with acute right hemisphere stroke, 27 (26%) had delirium. Delirium patients were older (mean age 78 vs. 68, p<0.01), more likely to have dementia (30% vs. 5%, p<0.01) and prior stroke (52% vs. 28%, p=0.03). Median length of stay was longer (5 vs. 3 days, p<0.01), and discharge home less likely (37% vs. 64%, p=0.01) in those with delirium. Delirium patients more often had strokes involving the parietal lobe (44% vs. 17%, p<0.01). In a multivariable model, parietal localization strongly predicted incident delirium (OR 3.6 95%CI 1.1-11.3, p=0.03) adjusting for age, baseline NIHSS, and premorbid dementia.
Conclusion:
The high delirium incidence we found supports routine delirium screening in acute stroke patients. Stroke localization may be one factor to incorporate into screening tools. Studies to prospectively identify and treat delirium in both right and left hemisphere stroke patients are warranted.
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Affiliation(s)
| | | | | | - Minji Kim
- Neurology, Columbia Univ, New York, NY
| | | | - A M Barrett
- Stroke Rehabilitation, Kessler Foundation, West Orange, NJ
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30
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Hendrix ST, Barrett AM, Chrea B, Replogle WH, Hydrick JM, Barrett GR. Relationship Between Posterior-Inferior Tibial Slope and Bilateral Noncontact ACL Injury. Orthopedics 2017; 40:e136-e140. [PMID: 27755640 DOI: 10.3928/01477447-20161013-06] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/06/2016] [Indexed: 02/03/2023]
Abstract
Is there a correlation between increased posterior-inferior tibial slope angle and noncontact anterior cruciate ligament (ACL) injury? Does increasing the posterior-inferior tibial slope angle increase the risk of bilateral ACL injury? A computerized relational database (Access 2007; Microsoft Inc, Redmond, Washington) was used to conduct a retrospective review of patients undergoing bilateral or unilateral ACL reconstruction surgery or treatment by a single surgeon between 1995 and 2013. Included in the study were patients with bilateral and unilateral ACL injuries and patellofemoral pain syndrome with no associated ACL deficiency. Exclusion criteria included concomitant ligament injury, previous ACL reconstruction, and previous knee surgery. Also excluded were patients who did not have plain lateral radiographs. Fifty patients were randomly selected from each group. After controlling for age and Tegner activity level, the authors found that the posterior-inferior tibial slope angle was a significant predictor (P=.002) of noncontact ACL injury. Mean posterior-inferior tibial slope angle for the bilateral, unilateral, and control groups was 11.8°±2.3°, 9.3°±2.4°, and 7.5°±2.3°, respectively. In the group with unilateral ACL injury vs the group without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle (P=.03) was associated with a 20% increase in unilateral ACL injury. In those with bilateral ACL injury vs those without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle (P=.001) increased bilateral knee injury by 34%. The difference between the mean angles of the control group without ACL deficiency and both the bilateral injury and unilateral injury cohorts was statistically significant (P=.003). Increased posterior-inferior tibial slope angle is associated with an increased risk of noncontact bilateral and unilateral ACL injury. [Orthopedics. 2017; 40(1):e136-e140.].
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31
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Hreha K, Mulry C, Gross M, Jedziniak T, Gramas N, Ohevshalom L, Sheridan A, Szabo G, Davison C, Barrett AM. Assessing chronic stroke survivors with aphasia sheds light on prevalence of spatial neglect. Top Stroke Rehabil 2016; 24:91-98. [PMID: 27322860 DOI: 10.1080/10749357.2016.1196906] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke is a chronic disease. Standardized assessment is essential in order to determine areas for treatment. Individuals with aphasia are often excluded from research, because it is believed that their language impairments may impact their ability to provide informed consent. Thus, right spatial neglect could be under-diagnosed. OBJECTIVE This study was developed to (1) determine the frequency of spatial neglect in chronic left-brain stroke survivors with aphasia, (2) determine the clinical utility of an aphasia-friendly consent form, and (3) determine any differences between neglect and no-neglect groups regarding activities of daily living (ADL) performance and community independence. METHODS Forty-six people were consented at community center. Three were screen failures secondary to the exclusion criteria. A novel, aphasia-friendly consent form was developed to facilitate participation of individuals with aphasia. This enabled 93% or 40 out of the 43 recruited participants to be included in this study. The Behavioral Inattention Test-conventional and the Catherine Bergego Scale via Kessler Foundation Neglect Assessment Process (CBS via KF-NAP) were utilized to determine neglect. The Life Space Questionnaire was used to determine community mobility and independence. The Barthel Index (BI) was used for objective clarification of performance in ADL. RESULTS Successful use of the consent form resulted in determination that five out of 40 (12.5%) met criteria for spatial neglect; (on the CBS via KF-NAP). The neglect group had lower scores on the Life Space, suggesting less community mobility and independence, however, it was not statistically significant (p = 0.16). Differences in BI scores were also not significant (p = .013) but the neglect group did have reduced independence. CONCLUSIONS This study demonstrates the need to administer functional neglect assessments in left-brain stroke and to include individuals with aphasia in research.
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Affiliation(s)
- Kimberly Hreha
- a Department of Medicine , Kessler Institute for Rehabilitation , Saddle Brook , NJ , USA.,b Stroke Lab, Kessler Foundation , West Orange , NJ , USA.,d Biobehavioral Sciences, Teachers College , Columbia University , New York , NY , USA
| | - Claire Mulry
- e Occupational Therapy Department , Kean University , Union , NJ , USA
| | - Melissa Gross
- e Occupational Therapy Department , Kean University , Union , NJ , USA
| | - Tarah Jedziniak
- e Occupational Therapy Department , Kean University , Union , NJ , USA
| | - Natanya Gramas
- e Occupational Therapy Department , Kean University , Union , NJ , USA
| | - Leora Ohevshalom
- e Occupational Therapy Department , Kean University , Union , NJ , USA
| | - Alisha Sheridan
- e Occupational Therapy Department , Kean University , Union , NJ , USA
| | - Gretchen Szabo
- f Speech Therapy Department , Adler Aphasia Center , Maywood , NJ , USA
| | - Christina Davison
- g Occupational Therapy Department , Genesis Rehab Services: Brandywine Senior Living at Middlebrook Crossing , Bridgewater , NJ , USA
| | - A M Barrett
- b Stroke Lab, Kessler Foundation , West Orange , NJ , USA.,c Rutgers - New Jersey Medical School , Newark , NJ , USA
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Affiliation(s)
- A M Barrett
- From Stroke Rehabilitation Research (A.M.B.), Kessler Foundation, Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark; and Departments of Neurology and Physical Medicine and Rehabilitation (R.H.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia.
| | - Roy H Hamilton
- From Stroke Rehabilitation Research (A.M.B.), Kessler Foundation, Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark; and Departments of Neurology and Physical Medicine and Rehabilitation (R.H.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Daffner KR, Gale SA, Barrett AM, Boeve BF, Chatterjee A, Coslett HB, D'Esposito M, Finney GR, Gitelman DR, Hart JJ, Lerner AJ, Meador KJ, Pietras AC, Voeller KS, Kaufer DI. Improving clinical cognitive testing: report of the AAN Behavioral Neurology Section Workgroup. Neurology 2015; 85:910-8. [PMID: 26163433 DOI: 10.1212/wnl.0000000000001763] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/07/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the evidence basis of single-domain cognitive tests frequently used by behavioral neurologists in an effort to improve the quality of clinical cognitive assessment. METHODS Behavioral Neurology Section members of the American Academy of Neurology were surveyed about how they conduct clinical cognitive testing, with a particular focus on the Neurobehavioral Status Exam (NBSE). In contrast to general screening cognitive tests, an NBSE consists of tests of individual cognitive domains (e.g., memory or language) that provide a more comprehensive diagnostic assessment. Workgroups for each of 5 cognitive domains (attention, executive function, memory, language, and spatial cognition) conducted evidence-based reviews of frequently used tests. Reviews focused on suitability for office-based clinical practice, including test administration time, accessibility of normative data, disease populations studied, and availability in the public domain. RESULTS Demographic and clinical practice data were obtained from 200 respondents who reported using a wide range of cognitive tests. Based on survey data and ancillary information, between 5 and 15 tests in each cognitive domain were reviewed. Within each domain, several tests are highlighted as being well-suited for an NBSE. CONCLUSIONS We identified frequently used single-domain cognitive tests that are suitable for an NBSE to help make informed choices about clinical cognitive assessment. Some frequently used tests have limited normative data or have not been well-studied in common neurologic disorders. Utilizing standardized cognitive tests, particularly those with normative data based on the individual's age and educational level, can enhance the rigor and utility of clinical cognitive assessment.
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Affiliation(s)
- Kirk R Daffner
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill.
| | - Seth A Gale
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - A M Barrett
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Bradley F Boeve
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Anjan Chatterjee
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - H Branch Coslett
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Mark D'Esposito
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Glen R Finney
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Darren R Gitelman
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - John J Hart
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Alan J Lerner
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Kimford J Meador
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Alison C Pietras
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Kytja S Voeller
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
| | - Daniel I Kaufer
- From the Center for Brain/Mind Medicine (K.R.D., S.A.G., A.C.P.), Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Kessler Foundation Research Center (A.M.B.), West Orange, NJ; Department of Neurology (B.F.B.), Mayo Clinic, Rochester, MN; Department of Neurology and Center for Cognitive Neuroscience (A.C., H.B.C.), University of Pennsylvania, Philadelphia; Helen Wills Neuroscience Institute (M.D.), University of California, Berkeley; Department of Neurology (G.R.F.), University of Florida College of Medicine, Gainesville; Department of Neurology (D.R.G.), Northwestern University, Feinberg School of Medicine, Chicago, IL; Center for Brain Health (J.J.H.), School of Behavioral & Brain Sciences, University of Texas at Dallas; Department of Neurology (A.J.L.), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Neurology and Neurological Sciences (K.J.M.), Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, CA; Western Institute for Neurodevelopmental Studies and Interventions (K.S.V.), Boulder, CO; and Memory Disorders Program (D.I.K.), UNC Department of Neurology, University of North Carolina at Chapel Hill
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Abstract
Spatial motor–intentional “Aiming” bias is a dysfunction in initiation/execution of motor–intentional behavior, resulting in hypokinetic and hypometric leftward movements. Aiming bias may contribute to posture, balance, and movement problems and uniquely account for disability in post-stroke spatial neglect. Body movement may modify and even worsen Aiming errors, but therapy techniques, such as visual scanning training, do not take this into account. Here, we evaluated (1) whether instructing neglect patients to move midline body parts improves their ability to explore left space and (2) whether this has a different impact on different patients. A 68-year-old woman with spatial neglect after a right basal ganglia infarct had difficulty orienting to and identifying left-sided objects. She was prompted with four instructions: “look to the left,” “point with your nose to the left,” “point with your [right] hand to the left,” and “stick out your tongue and point it to the left.” She oriented leftward dramatically better when pointing with the tongue/nose, than she did when pointing with the hand. We then tested nine more consecutive patients with spatial neglect using the same instructions. Only four of them made any orienting errors. Only one patient made >50% errors when pointing with the hand, and she did not benefit from pointing with the tongue/nose. We observed that pointing with the tongue could facilitate left-sided orientation in a stroke survivor with spatial neglect. If midline structures are represented more bilaterally, they may be less affected by Aiming bias. Alternatively, moving the body midline may be more permissive for leftward orienting than moving right body parts. We were not able to replicate this effect in another patient; we suspect that the magnitude of this effect may depend upon the degree to which patients have directional akinesia, spatial Where deficits, or cerebellar/frontal cortical lesions. Future research could examine these hypotheses.
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Affiliation(s)
- Amit Chaudhari
- Stroke Rehabilitation Research, Kessler Foundation , West Orange, NJ , USA ; Department of Neurology and Neurosciences, Rutgers-New Jersey Medical School , Newark, NJ , USA
| | - Kara Pigott
- Department of Neurology, University of Pennsylvania Health System , Philadelphia, PA , USA
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation , West Orange, NJ , USA ; Department of Neurology and Neurosciences, Rutgers-New Jersey Medical School , Newark, NJ , USA
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Chen P, Goedert KM, Shah P, Foundas AL, Barrett AM. Integrity of medial temporal structures may predict better improvement of spatial neglect with prism adaptation treatment. Brain Imaging Behav 2015; 8:346-58. [PMID: 22941243 DOI: 10.1007/s11682-012-9200-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Prism adaptation treatment (PAT) is a promising rehabilitative method for functional recovery in persons with spatial neglect. Previous research suggests that PAT improves motor-intentional "aiming" deficits that frequently occur with frontal lesions. To test whether presence of frontal lesions predicted better improvement of spatial neglect after PAT, the current study evaluated neglect-specific improvement in functional activities (assessment with the Catherine Bergego Scale) over time in 21 right-brain-damaged stroke survivors with left-sided spatial neglect. The results demonstrated that neglect patients' functional activities improved after two weeks of PAT and continued improving for four weeks. Such functional improvement did not occur equally in all of the participants: Neglect patients with lesions involving the frontal cortex (n = 13) experienced significantly better functional improvement than did those without frontal lesions (n = 8). More importantly, voxel-based lesion-behavior mapping (VLBM) revealed that in comparison to the group of patients without frontal lesions, the frontal-lesioned neglect patients had intact regions in the medial temporal areas, the superior temporal areas, and the inferior longitudinal fasciculus. The medial cortical and subcortical areas in the temporal lobe were especially distinguished in the "frontal lesion" group. The findings suggest that the integrity of medial temporal structures may play an important role in supporting functional improvement after PAT.
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Affiliation(s)
- Peii Chen
- Kessler Foundation Research Center, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA,
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Goedert KM, Zhang JY, Barrett AM. Prism adaptation and spatial neglect: the need for dose-finding studies. Front Hum Neurosci 2015; 9:243. [PMID: 25983688 PMCID: PMC4415396 DOI: 10.3389/fnhum.2015.00243] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/14/2015] [Indexed: 12/29/2022] Open
Abstract
Spatial neglect is a devastating disorder in 50–70% of right-brain stroke survivors, who have problems attending to, or making movements towards, left-sided stimuli, and experience a high risk of chronic dependence. Prism adaptation is a promising treatment for neglect that involves brief, daily visuo-motor training sessions while wearing optical prisms. Its benefits extend to functional behaviors such as dressing, with effects lasting 6 months or longer. Because one to two sessions of prism adaptation induce adaptive changes in both spatial-motor behavior (Fortis et al., 2011) and brain function (Saj et al., 2013), it is possible stroke patients may benefit from treatment periods shorter than the standard, intensive protocol of ten sessions over two weeks—a protocol that is impractical for either US inpatient or outpatient rehabilitation. Demonstrating the effectiveness of a lower dose will maximize the availability of neglect treatment. We present preliminary data suggesting that four to six sessions of prism treatment may induce a large treatment effect, maintained three to four weeks post-treatment. We call for a systematic, randomized clinical trial to establish the minimal effective dose suitable for stroke intervention.
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Affiliation(s)
- Kelly M Goedert
- Department of Psychology, Seton Hall University South Orange, NJ, USA
| | | | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation West Orange, NJ, USA ; Department of Neurology and Neurosciences, Rutgers-New Jersey Medical School Newark, NJ, USA ; Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School Newark, NJ, USA
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Dugas JR, Barrett AM, Beason DP, Plymale MF, Fleisig GS. Tibiofemoral contact biomechanics following meniscocapsular separation and repair. Int J Sports Med 2015; 36:498-502. [PMID: 25734910 DOI: 10.1055/s-0034-1398656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Meniscocapsular separations are often seen in knees with other intra-articular pathology. The consequences of these tears with regard to knee contact mechanics are currently unknown, and the biomechanical advantages of repair have not been measured. We hypothesize that tears to the meniscocapsular junction will cause an increase in tibiofemoral contact pressure and a decrease in contact area, with a return to more normal conditions after repair. 10 fresh-frozen cadaver knees each underwent 10 cycles of axial compressive loading in full extension under three different testing conditions: intact, meniscocapsular separation, and repair. A pressure sensor matrix was inserted into the medial joint space and used to measure magnitude and location of contact pressure and area. Mean contact pressure increased from 0.80±0.17 MPa in the intact knee to 0.88±0.19 MPa with separation, with a decrease to 0.78±0.14 MPa following repair. Peak pressures followed a similar trend with 2.59±0.41, 3.03±0.48, and 2.84±0.40 MPa for the same three groups, respectively. While none of the changes seen was statistically significant, even these small changes would potentially create degenerative changes at the articular surface over prolonged (i. e., months or years) standing, walking, and activity in the unrepaired state.
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Affiliation(s)
- J R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, United States
| | - A M Barrett
- American Sports Medicine Institute, Birmingham, Alabama, United States
| | - D P Beason
- American Sports Medicine Institute, Birmingham, Alabama, United States
| | - M F Plymale
- American Sports Medicine Institute, Birmingham, Alabama, United States
| | - G S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, United States
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Abstract
UNLABELLED [Correction Notice: An Erratum for this article was reported in Vol 29(2) of Neuropsychology (see record 2014-42242-001). The funding source information was missing from the author note, and A. M. Barrett's institutional affiliation was incorrect. The funding source information and Barrett's correct institutional affiliation are provided in the erratum.] OBJECTIVE The sparse existing research on ipsilesional neglect supports an association of this disorder with damage to the right frontal and subcortical brain networks. It is believed that dysfunction in these networks may result in primarily "aiming" motor-intentional spatial errors. The purpose of this study was to confirm whether frontal-subcortical circuits are indeed commonly affected in ipsilesional neglect and to determine the relative presence of "aiming" motor-intentional versus "where" perceptual-attentional spatial errors in these individuals. METHODS We identified 12 participants with ipsilesional neglect based on a computerized line bisection task and used the line bisection data to quantify participants' perceptual-attentional and motor-intentional errors. We were able to discriminate between these 2 biases using the algebraic solutions for 2 separate equations, one for "aiming" and one for "where" biases. Lesion mapping was conducted for all participants using MRIcron software; lesion checklist and overlap analysis were created from these images. RESULTS A greater percentage of participants with ipsilesional neglect had frontal/subcortical damage (83%) compared with the expected percentage (27%) observed in published patient samples with contralesional neglect. We observed the greatest area of lesion overlap in frontal lobe white matter pathways. Nevertheless, participants with ipsilesional neglect made primarily "where" rather than "aiming" spatial errors. CONCLUSION Our data confirm previous research suggesting that ipsilesional neglect may result from lesions to the right frontal-subcortical networks. Furthermore, in our group, ipsilesional neglect was also strongly associated with primarily "where" perceptual-attentional bias, and less so with "aiming" motor-intentional spatial bias.
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Abstract
Given the increasing rates of stroke and our aging population, it is critical that we continue to foster innovation in stroke rehabilitation. Although there is evidence supporting cognitive rehabilitation in stroke, the set of cognitive domains effectively addressed to date represents only a small subset of the problems experienced by stroke survivors. Further, a gap remains between investigational treatments and our evolving theories of brain function. These limitations present opportunities for improving the functional impact of stroke rehabilitation. The authors use a case example to encourage the reader to consider the evidence base for cognitive rehabilitation in stroke, focusing on four domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. Ultimately, they attempt to draw neuroscience and practice closer together by using translational reasoning to suggest possible new avenues for treating these disorders.
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Affiliation(s)
- Cheryl L Shigaki
- Department of Health Psychology, University of Missouri, Columbia, Missouri
| | - Scott H Frey
- Department of Psychological Sciences and Brain Imaging Center, University of Missouri, Columbia, Missouri
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey
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Chen P, Chen CC, Hreha K, Goedert KM, Barrett AM. Kessler Foundation Neglect Assessment Process uniquely measures spatial neglect during activities of daily living. Arch Phys Med Rehabil 2014; 96:869-876.e1. [PMID: 25461827 DOI: 10.1016/j.apmr.2014.10.023] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/30/2014] [Accepted: 10/31/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To explore the factor structure of the Kessler Foundation Neglect Assessment Process (KF-NAP), and evaluate the prevalence and clinical significance of spatial neglect among stroke survivors. DESIGN Inception cohort. SETTING Inpatient rehabilitation facility (IRF). PARTICIPANTS Participants (N=121) with unilateral brain damage from their first stroke were assessed within 72 hours of admission to an IRF, and 108 were assessed again within 72 hours before IRF discharge. INTERVENTIONS Usual and standard IRF care. MAIN OUTCOME MEASURES During each assessment session, occupational therapists measured patients' functions with the KF-NAP, FIM, and Barthel Index (BI). RESULTS The KF-NAP showed excellent internal consistency with a single-factor structure. The exploratory factor analysis revealed the KF-NAP to be unique from both the FIM and BI even though all 3 scales were correlated. Symptoms of spatial neglect (KF-NAP>0) were present in 67.8% of the participants at admission and 47.2% at discharge. Participants showing the disorder at IRF admission were hospitalized longer than those showing no symptoms. Among those presenting with symptoms, the regression analysis showed that the KF-NAP scores at admission negatively predicted FIM scores at discharge, after controlling for age, FIM at admission, and length of stay. CONCLUSIONS The KF-NAP uniquely quantifies symptoms of spatial neglect by measuring functional difficulties that are not captured by the FIM or BI. Using the KF-NAP to measure spatial neglect, we found the disorder persistent after inpatient rehabilitation, and replicated previous findings showing that spatial neglect adversely affects rehabilitation outcome even after prolonged IRF care.
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Affiliation(s)
- Peii Chen
- Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ.
| | - Christine C Chen
- Department of Rehabilitation Sciences, University of Texas, El Paso, TX
| | - Kimberly Hreha
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY; Kessler Institute for Rehabilitation, West Orange, NJ
| | - Kelly M Goedert
- Department of Psychology, Seton Hall University, South Orange, NJ
| | - A M Barrett
- Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Institute for Rehabilitation, West Orange, NJ
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Barrett AM, Harris NI, DeMuro C, Kachroo S, Phatak H. Literature Review Of Pro Measures Assessing Anticoagulant Therapy. Value Health 2014; 17:A495-A496. [PMID: 27201485 DOI: 10.1016/j.jval.2014.08.1477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | - N I Harris
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - C DeMuro
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - S Kachroo
- Bristol-Myers Squibb Company, Princeton, NJ, USA
| | - H Phatak
- Bristol-Myers Squibb Company, Princeton, NJ, USA
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Barrett AM, Galletta EE, Zhang J, Masmela JR, Adler US. Stroke survivors over-estimate their medication self-administration (MSA) ability, predicting memory loss. Brain Inj 2014; 28:1328-33. [PMID: 24884398 DOI: 10.3109/02699052.2014.915984] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Medication self-administration (MSA) may be cognitively challenging after stroke, but guidelines are currently lacking for identifying high-functioning stroke survivors who may have difficulty with this task. Complicating this matter, stroke survivors may not be aware of their cognitive problems (cognitive anosognosia) and may over-estimate their MSA competence. The authors wished to evaluate medication self-administration and MSA self-awareness in 24 consecutive acute stroke survivors undergoing inpatient rehabilitation, to determine if they would over-estimate their medication self-administration and if this predicted memory disorder. METHODS Stroke survivors were tested on the Hopkins Medication Schedule and also their memory, naming mood and dexterity were evaluated, comparing their performance to 17 matched controls. RESULTS The anosognosia ratio indicated MSA over-estimation in stroke survivors compared with controls--no other over-estimation errors were noted relative to controls. A strong correlation was observed between over-estimation of MSA ability and verbal memory deficit, suggesting that formally assessing MSA and MSA self-awareness may help detect cognitive deficits. CONCLUSIONS Assessing medication self-administration and MSA self-awareness may be useful in rehabilitation and successful community-return after stroke.
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Affiliation(s)
- A M Barrett
- Kessler Foundation Research Center , West Orange, NJ , USA
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Bagherpour R, Dykstra DD, Barrett AM, Luft AR, Divani AA. A Comprehensive Neurorehabilitation Program Should be an Integral Part of a Comprehensive Stroke Center. Front Neurol 2014; 5:57. [PMID: 24795694 PMCID: PMC4001043 DOI: 10.3389/fneur.2014.00057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 04/07/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Reza Bagherpour
- Department of Physical Medicine and Rehabilitation, University of Minnesota , Minneapolis, MN , USA ; Department of Neurology, University of Minnesota , Minneapolis, MN , USA
| | - Dennis D Dykstra
- Department of Physical Medicine and Rehabilitation, University of Minnesota , Minneapolis, MN , USA
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation , West Orange, NJ , USA
| | - Andreas R Luft
- Clinical Neurorehabilitation, Department of Neurology, University of Zurich , Zurich , Switzerland
| | - Afshin A Divani
- Department of Neurology, University of Minnesota , Minneapolis, MN , USA ; Department of Neurosurgery, University of Minnesota , Minneapolis, MN , USA
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Abstract
BACKGROUND Spatial neglect is a neurocognitive disorder that affects perception, representation, and/or motor planning. Neglect dyslexia in spatial neglect after right hemisphere damage may co-occur with, or be dissociated from, other spatial neglect signs. Previous neglect dyslexia research focused on word-level stimuli and reading errors. Using single words for assessment may leave some people with neglect dyslexia undiagnosed, and assessment materials that are closer to texts read in real life may better capture neglect dyslexia. METHOD The authors tested reading in 67 right hemisphere stroke survivors with 4 types of text materials: words, phrases, an article, and a menu. RESULTS Accuracy on reading the menu and article texts was significantly poorer than reading the words and phrases. The hypothesis that assessment materials with ecological validity such as reading a menu and reading an article may be more challenging than reading single words and phrases was supported. CONCLUSION Results suggest that neglect dyslexia assessment after stroke should include text materials comparable to those read in everyday life. Increasing the spatial extent of training materials in future research might also yield better functional generalization after right brain stroke.
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Affiliation(s)
- Elizabeth E Galletta
- Hunter College, The City University of New York, New York, New York The Graduate School and University Center, The City University of New York, New York, New York Kessler Foundation Research Center, West Orange, New Jersey
| | - Luca Campanelli
- The Graduate School and University Center, The City University of New York, New York, New York
| | - Kristen K Maul
- Kessler Foundation Research Center, West Orange, New Jersey
| | - A M Barrett
- Kessler Foundation Research Center, West Orange, New Jersey New Jersey Medical School, Newark, New Jersey
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Oh-Park M, Hung C, Chen P, Barrett AM. Severity of spatial neglect during acute inpatient rehabilitation predicts community mobility after stroke. PM R 2014; 6:716-22. [PMID: 24412266 DOI: 10.1016/j.pmrj.2014.01.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 12/25/2013] [Accepted: 01/06/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine whether stroke survivors with more severe spatial neglect during their acute inpatient rehabilitation had poorer mobility after returning to their communities. DESIGN A prospective observational study. SETTING Acute inpatient rehabilitation and follow-up in the community. PARTICIPANTS Thirty-one consecutive stroke survivors with right-brain damage (women, n = 15 [48.4%]), with the mean (standard deviation) age of 60 ± 11.5 years, were included in the study if they demonstrated spatial neglect within 2 months after stroke. METHODS Spatial neglect was assessed with the Behavioral Inattention Test (BIT) (range, 0-146 [a lower score indicates more severity]) and the Catherine Bergego Scale (range, 0-30 [a higher score indicates more severity]). A score of the Behavioral Inattention Test <129 or of the Catherine Bergego Scale >0 defined the presence of spatial neglect. MAIN OUTCOME MEASUREMENTS The outcome measure is community mobility, defined by the extent and frequency of traveling within the home and in the community, and is assessed with the University of Alabama at Birmingham Study of Aging Life-Space Assessment (range, 0-120 [a lower score indicates less mobile]). This measure was assessed after participants returned home ≥6 months after stroke. The covariates were age, gender, functional independence at baseline; follow-up interval; and depressed mood, which may affect the relationship between spatial neglect and community mobility. RESULTS A lower Behavioral Inattention Test score was a significant predictor of a lower Life-Space Assessment score after controlling for all the covariates (β = 0.009 [95% confidence interval, 0.008-0.017]); P = .020). The proportion of participants unable to travel independently beyond their homes was 0%, 27.3%, and 72.7% for those with mild, moderate, and severe acute neglect, respectively (Catherine Bergego Scale range, 1-10, 11-20, and 21-30, respectively). CONCLUSIONS Our result indicates that acute spatial neglect has a negative impact on regaining of functional mobility in the community. Specific screening and treatment of spatial neglect during acute stroke care may be necessary to improve long-term mobility recovery.
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Affiliation(s)
- Mooyeon Oh-Park
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ; Kessler Institute for Rehabilitation, West Orange, NJ; Stroke Rehabilitation Research Laboratory, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ 07052(∗).
| | - Cynthia Hung
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ(†)
| | - Peii Chen
- Stroke Rehabilitation Research Laboratory, Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ(‡)
| | - A M Barrett
- Stroke Rehabilitation Research Laboratory, Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ; Kessler Institute for Rehabilitation, West Orange, NJ(§)
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Goedert KM, Chen P, Boston RC, Foundas AL, Barrett AM. Presence of Motor-Intentional Aiming Deficit Predicts Functional Improvement of Spatial Neglect With Prism Adaptation. Neurorehabil Neural Repair 2013; 28:483-93. [PMID: 24376064 DOI: 10.1177/1545968313516872] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED Background Spatial neglect is a debilitating disorder for which there is no agreed on course of rehabilitation. The lack of consensus on treatment may result from systematic differences in the syndrome's characteristics, with spatial cognitive deficits potentially affecting perceptual-attentional "Where" or motor-intentional "Aiming" spatial processing. Heterogeneity of response to treatment might be explained by different treatment impacts on these dissociated deficits: prism adaptation, for example, might reduce Aiming deficits without affecting Where spatial deficits. OBJECTIVE Here, we tested the hypothesis that classifying patients by their profile of Where-versus-Aiming spatial deficit would predict response to prism adaptation and specifically that patients with Aiming bias would have better recovery than those with isolated Where bias. Methods We classified the spatial errors of 24 subacute right stroke survivors with left spatial neglect as (1) isolated Where bias, (2) isolated Aiming bias, or (3) both. Participants then completed 2 weeks of prism adaptation treatment. They also completed the Behavioral Inattention Test and Catherine Bergego Scale (CBS) tests of neglect recovery weekly for 6 weeks. Results As hypothesized, participants with only Aiming deficits improved on the CBS, whereas those with only Where deficits did not improve. Participants with both deficits demonstrated intermediate improvement. Conclusion These results support behavioral classification of spatial neglect patients as a potential valuable tool for assigning targeted, effective early rehabilitation.
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Affiliation(s)
| | - Peii Chen
- Kessler Foundation, West Orange, NJ, USA Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | | | - A M Barrett
- Kessler Foundation, West Orange, NJ, USA Rutgers New Jersey Medical School, Newark, NJ, USA Kessler Institute for Rehabilitation, West Orange, NJ, USA
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47
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Abstract
Neurologists have a new toolbox of options for neurorehabilitation of disabling brain disorders such as stroke and traumatic brain injury. An emerging intellectual paradigm for neurologic recovery that includes neural regeneration, repair, and dynamic reorganization of functional neural systems, as well as increasing awareness of behavioral principles that may support best return to function and freedom, brought forward treatments based on experience-dependent learning, neurophysiologic stimulation, and a combination of these concepts. In this article, we summarize five rehabilitative approaches to watch: constraint therapy for motor and language recovery, synergy of motor-language rehabilitation, prism adaptation training and other virtual feedback approaches, and noninvasive magnetic and electrical brain stimulation.
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Affiliation(s)
- A M Barrett
- Stroke Rehabilitation Research (AMB, MO-P, PC), Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (AMB, MO-P, PC), Rutgers-New Jersey Medical School, Newark, NJ; and Departments of Neurology and Physical Medicine and Rehabilitation (NLI), the University of Texas Medical School at Houston, Houston, TX
| | - Mooyeon Oh-Park
- Stroke Rehabilitation Research (AMB, MO-P, PC), Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (AMB, MO-P, PC), Rutgers-New Jersey Medical School, Newark, NJ; and Departments of Neurology and Physical Medicine and Rehabilitation (NLI), the University of Texas Medical School at Houston, Houston, TX
| | - Peii Chen
- Stroke Rehabilitation Research (AMB, MO-P, PC), Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (AMB, MO-P, PC), Rutgers-New Jersey Medical School, Newark, NJ; and Departments of Neurology and Physical Medicine and Rehabilitation (NLI), the University of Texas Medical School at Houston, Houston, TX
| | - Nneka L Ifejika
- Stroke Rehabilitation Research (AMB, MO-P, PC), Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation (AMB, MO-P, PC), Rutgers-New Jersey Medical School, Newark, NJ; and Departments of Neurology and Physical Medicine and Rehabilitation (NLI), the University of Texas Medical School at Houston, Houston, TX
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Abstract
Spatial neglect-a syndrome in which there is asymmetric perception, orienting, or response associated with functional disability(1)-has a potentially devastating effect on self-care and safety after stroke. Still, it frequently goes unrecognized.(2) How is this possible? A tremendously disabling disorder should be easy to detect. In this issue of Neurology(®), Rousseaux et al.(3) present a study that may give us an inkling of the problem: we may be assessing the eyes, but not the body.
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Affiliation(s)
- A M Barrett
- From Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ
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Goedert KM, Boston RC, Barrett AM. Advancing the science of spatial neglect rehabilitation: an improved statistical approach with mixed linear modeling. Front Hum Neurosci 2013; 7:211. [PMID: 23730283 PMCID: PMC3657689 DOI: 10.3389/fnhum.2013.00211] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 05/02/2013] [Indexed: 11/13/2022] Open
Abstract
Valid research on neglect rehabilitation demands a statistical approach commensurate with the characteristics of neglect rehabilitation data: neglect arises from impairment in distinct brain networks leading to large between-subject variability in baseline symptoms and recovery trajectories. Studies enrolling medically ill, disabled patients, may suffer from missing, unbalanced data, and small sample sizes. Finally, assessment of rehabilitation requires a description of continuous recovery trajectories. Unfortunately, the statistical method currently employed in most studies of neglect treatment [repeated measures analysis of variance (ANOVA), rANOVA] does not well-address these issues. Here we review an alternative, mixed linear modeling (MLM), that is more appropriate for assessing change over time. MLM better accounts for between-subject heterogeneity in baseline neglect severity and in recovery trajectory. MLM does not require complete or balanced data, nor does it make strict assumptions regarding the data structure. Furthermore, because MLM better models between-subject heterogeneity it often results in increased power to observe treatment effects with smaller samples. After reviewing current practices in the field, and the assumptions of rANOVA, we provide an introduction to MLM. We review its assumptions, uses, advantages, and disadvantages. Using real and simulated data, we illustrate how MLM may improve the ability to detect effects of treatment over ANOVA, particularly with the small samples typical of neglect research. Furthermore, our simulation analyses result in recommendations for the design of future rehabilitation studies. Because between-subject heterogeneity is one important reason why studies of neglect treatments often yield conflicting results, employing statistical procedures that model this heterogeneity more accurately will increase the efficiency of our efforts to find treatments to improve the lives of individuals with neglect.
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Affiliation(s)
- Kelly M Goedert
- Department of Psychology, Seton Hall University South Orange, NJ, USA
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50
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Abstract
SR suffered a right hemispheric stroke more than 3 years ago, and now lives with left-sided hemiparesis and chronic spatial neglect due to damaged white matter pathways connecting the frontal, temporal and parietal regions. We report here that SR suffers from both viewer-centered (i.e., egocentric) and object-centered (i.e., allocentric) spatial neglect. Notably, unlike most neuropsychological and functional assessments that focus on egocentric deficits, a specialized neuropsychological figurative discrimination test (the Apples test) revealed SR's allocentric neglect. Further, using assessments sensitive to detect functional deficits related to allocentric neglect, we observed SR's difficulty in reading and using clocks, reflecting his object-centered errors in these everyday activities. SR's case suggests that allocentric-specific assessments, both neuropsychological and functional, are valuable in standard neglect examinations, particularly to predict daily function after stroke. We recommend that neglect-related functional disability be distinguished further with respect to allocentric spatial deficits, and functional assessments for allocentric neglect should be validated in future large sample studies. Identifying allocentric neglect early, and learning about its influence on daily function, may enhance care quality and facilitate effective rehabilitation planning for stroke recovery.
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Affiliation(s)
- Priyanka P Shah
- Department of Neurology, Center for Cognitive Neuroscience, University of Pennsylvania, Philadelphia, PA 19104-6241, USA.
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