Pairing Rehabilitation Interventions to Maximize Efficiency and Recovery (PRIMER)
T. George Hornby, PT, PhD
Approximately 70% of patients post-stroke experience persistent lower extremity deficits in strength and coordination; these impairments contribute to limitations in the ability to perform many functional activities in the home and community, including walking, rising from a chair, and maintaining balance. These activity limitations severely restrict mobility in the home and community, which in turn leads to secondary health complications and decreased participation. Over the past 2 decades, converging data from animal models and individuals with neurological injury suggests that the amount and specificity of motor practice are important training parameters that facilitate improvements in walking performance. Providing substantial stepping practice on a treadmill or overground can improve gait speed and endurance as compared to traditional approaches. Such training appears to strengthen synaptic circuits underlying the practiced behaviors, with more recent data suggesting that the amount of stepping practice is associated with improved locomotor performance.
The overall goal of this project is to evaluate the individual and paired contributions of intensity and variability of stepping training on lower extremity function, health and community participation in patients with chronic hemiparesis post-stroke. We will use a randomized controlled clinical trial design to investigate the independent and combined (paired) contributions of intensity and variability of stepping training on locomotor function, with secondary measures of health and community mobility.
We also will evaluate the independent and combined effects of intensity and variability of stepping training on non-walking lower extremity tasks and we will evaluate the cost effectiveness of providing these interventions. Our central hypothesis is that results of this study will provide a theoretical foundation for implementation of physical therapy interventions which can facilitate short-term gains in locomotor function, and contribute to long-term improvements in health, function and participation through increased community mobility.
Implementation of Evidenced Based-Interventions during Inpatient Rehabilitation to Improve Mobility, Health and Participation
T. George Hornby, PT, PhD
Jennifer Moore, PT, NCS, DHS
Recovery of walking early following stroke, spinal cord injury (SCI) or acquired brain injury (ABI) is a primary goal of patients and their families, although return of independent locomotion depends largely on the magnitude and location of the injury. Most patients with stroke or ABI can recover some gait function (80-95%), but only 25% of those with SCI (50% motor incomplete) walk independently. For those who do recover, most walk at slow speeds and for limited distances. The extent of walking ability is often a primary predictor of discharge destination following rehabilitation, subsequent health status and community participation status. Studies suggest that even small decreases in gait speed from baseline are associated with significant increases in health care utilization.
Converging data over the past 2 decades indicate that substantial amounts of stepping practice can improve walking function in these patient populations. Repeated stepping training is often performed at moderate to high aerobic capacities with data suggesting greater improvements than conventional physical therapy (PT) interventions. However, PT strategies utilized during inpatient rehabilitation unfortunately provided very limited walking practice. Reasons that patients do not achieve greater stepping practice include the magnitude of patient’s impairments, lack of adequate equipment, and therapists’ adherence to traditional interventions. Few studies have attempted to implement focused stepping interventions during inpatient rehabilitation to examine its feasibility and effectiveness on long-term outcomes.
The objective of this project is to evaluate the impact of Focused, Repeated Stepping Training (FIRST) applied during clinical inpatient rehabilitation on short- and long-term mobility outcomes, health, and community participation in adults with acute neurological injury. Our central hypotheses are that the FIRST program provided to patients early following acute-onset neurological injury will augment recovery of short and long-term mobility, health and community participation. Using a two-step implementation process with our partnering rehabilitation hospital (Mary Free Bed Rehabilitation Hospital), we will evaluate the contemporaneous (Years 1-2) and historical (Years 3-5) effectiveness of the FIRST program as compared to conventional strategies.
The Intensive Comprehensive Aphasia Program (ICAP): A Randomized Clinical Trial
Leora Cherney, PhD
Recent research has emphasized the need for intensive aphasia treatment to consolidate long-term neuroplastic changes associated with recovery following a stroke. Furthermore, studies have indicated that intensive aphasia treatment is more efficacious than less intensive treatment. Despite such evidence, the reality is that public and private payers are drastically reducing services to persons with aphasia (PWA). Legislation has seriously curtailed the amount of treatment a PWA may receive after hospitalization. Often patients receive only a limited number of treatment sessions over an abbreviated duration, and in some cases, receive no treatment for their communication disorders following acute hospitalization. Reduced resources (e.g. transportation difficulties, therapist shortages in rural areas) also may limit services.
The Intensive Comprehensive Aphasia Program (ICAP) is a novel service delivery model for aphasia developed to bridge the gap between the treatment that people with aphasia require to live successfully, and the limited services typically available to them. Cohorts of participants who start and end the program at the same time receive intensive treatment targeting a broad range of impairments and activity/participation limitations. Although several studies have shown that the ICAP model is feasible and can improve communication skills, community participation, and communication-related quality of life, the ICAP model has not yet been rigorously evaluated using a random controlled trial study design. This study will be the first to assess the efficacy and cost-effectiveness of the ICAP. For this study, we focus primarily on the variable of intensity.
Peer Health Navigation for Medicaid Beneficiaries with Physical Disabilities: A Community-Based Participatory Research Development Study
Susan Magasi, PhD
Christina Papadimitriou, PhD
Americans with disabilities comprise 15% of Medicaid beneficiaries and account for a disproportionate amount of Medicaid spending. Access to healthcare by Medicaid beneficiaries is complicated by Medicaid expansion under the Affordable Care Act. Medicaid beneficiaries with physical disabilities experience structural, financial, cognitive/knowledge, attitudinal, and physical barriers to healthcare that put them at a high risk for health disparities. The present intervention development investigation will develop, implement, and evaluate a Peer Health Navigator (PHN) Program, Our Peers - Empowerment and Navigational Support (OP-ENS), embedded in the Community Care Alliance of Illinois (CCAI), a Medicaid managed care organization created to provide comprehensive coordinated healthcare to Medicaid beneficiaries with disabilities. PHNs are persons from the local community who share the same demographic and/or clinical background as those they serve. PHNs empower individuals to take control of their healthcare by providing individualized supports and structured problem solving skill building to help overcome healthcare barriers.
The goals of this project are to develop a PHN program tailored to the needs of Medicaid beneficiaries with physical disabilities; evaluate the effectiveness of the program; and to develop knowledge translation products to promote the implementation of program for Medicaid beneficiaries with physical disabilities in diverse settings, including 1) training protocols for PHN; 2) standard operating procedures and resource materials for PHN implementation; and 3) a customizable budget impact worksheet.
Health Economics Core
Neil Jordan, PhD
The purpose of the Health Economics Core is two-fold: to provide economic evaluation expertise to each of the four research studies within the Center, and to develop and disseminate training and educational activities related to the value and cost-effectiveness themes of our proposed Center.
Core members will direct the economic value objectives described in each study, work with study collaborators on manuscript development, present key findings at national conferences and forums, and provide focused dissemination and educational activities through cyber-seminars. We envision the development and delivery of a cyber-seminar entitled “Methods for Assessing Value and Cost-Effectiveness of Rehabilitation Interventions” during Year 3, and a second cyber-seminar entitled “Applications of Value and Cost-Effectiveness Methods within Rehabilitation Interventions” during Year 5.