Archives of Physical Medicine and Rehabilitation, May 1, 2021
The aims of the current study were to characterize veterans who used a complementary and integrat... more The aims of the current study were to characterize veterans who used a complementary and integrative health (CIH) service in the Veterans Health Administration (VHA) and to assess the extent to which using a CIH-related service was associated with receiving an opioid analgesic prescription following the initiation of specialty pain service, a time at which higher intensity care is needed for patients experiencing greater psychiatric and medical complexity. Design: This study utilized a retrospective cohort design of veterans using specialty pain services. The index visit was defined as the first specialty pain visit in Fiscal Years 2012-2015. Demographics, opioid analgesic prescriptions, psychiatric disorder diagnoses, medical comorbidity, pain severity scores, and pain conditions were extracted from VHA administrative data. Setting: The cohort was comprised of veterans who had at least one visit with a specialty pain service as identified by a billing code. Main outcome measures: The main outcome measures were use of a CIH-related service in the 365 days prior to the index visit and opioid analgesic prescription within 365 days after the index visit. Adjusted logistic regression analyses accounted for key covariate and potential confounding variables. Results: Use of CIH-related services was relatively low across the cohort (1.9%). Veterans who used a CIH-related service in the 365 days prior to the index visit were more likely to be female, be younger, have less medical comorbidity, have less severe pain, and were less likely to have received an opioid prescription in the 365 days prior to the index visit. After accounting for key covariates and potential confounders, veterans who used a CIHrelated service were less likely to receive an opioid analgesic prescription in the 365 days following the index visit. Conclusion: CIH-related services were not commonly used among Veterans initiating specialty pain services. Engaging in CIH-related services prior to specialty pain services is associated with decreased opioid analgesic and non-opioid analgesic prescriptions. risk of depression onset and recurrence. 9,10 Both the Centers of Disease Control and the joint Department of Veterans Affairs/Department of Defense (VA/DoD) released Clinical Practice Guidelines (CPGs) on opioid prescribing for pain. 3,4 The new CPGs recommend offering self-management and other nonpharmacologic approaches as frontline treatments for chronic pain. Additionally, if opioid therapy is provided, it should be offered in conjunction with these nonpharmacologic options. These recommendations are based on "strong" evidence indicating that there is the potential for long-term benefit with few adverse effects of
Background Few, if any estimates of cost-effectiveness for locomotor training strategies followin... more Background Few, if any estimates of cost-effectiveness for locomotor training strategies following spinal cord injury (SCI) are available. The purpose of this study was to estimate the cost-effectiveness of locomotor training strategies following spinal cord injury (overground robotic locomotor training versus conventional locomotor training) by injury status (complete versus incomplete) using a practice-based cohort. Methods A probabilistic cost-effectiveness analysis was conducted using a prospective, practice-based cohort from four participating Spinal Cord Injury Model System sites. Conventional locomotor training strategies (conventional training) were compared to overground robotic locomotor training (overground robotic training). Conventional locomotor training included treadmill-based training with body weight support, overground training, and stationary robotic systems. The outcome measures included the calculation of quality adjusted life years (QALYs) using the EQ-5D and ...
Archives of Physical Medicine and Rehabilitation, 2021
Predicting duration of outpatient physical therapy episodes for individuals with spinal cord inju... more Predicting duration of outpatient physical therapy episodes for individuals with spinal cord injury based on locomotor training strategy.
Journal of NeuroEngineering and Rehabilitation, 2020
BackgroundWe know little about the budget impact of integrating robotic exoskeleton over-ground t... more BackgroundWe know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury.MethodsA Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to u...
Archives of Physical Medicine and Rehabilitation, 2019
To investigate the association between insurance provider and reported assistive technology (AT) ... more To investigate the association between insurance provider and reported assistive technology (AT) use to access computers and electronic devices 1 year after sustaining tetraplegia. Design: Multicenter cross-sectional study. Setting: Participants enrolled in the Spinal Cord Injury Model Systems (SCIMS) National Database. Interventions: Not applicable. Participants: Men and women with tetraplegia (NZ498) enrolled in the SCIMS National Database were included in the analysis. Main Outcome Measures: The primary study outcome was the use of AT when operating a computer or other mobile electronic device. The primary predictor was the subject's principal health insurance provider, which was grouped into the 3 categories: government (Medicare, Medicaid, and other government), private (private insurance, private funds, and other), and workers' compensation. Results: Overall, 34.7% of participants reported using AT to access computers and electronic devices. Results of logistic regression analysis revealed sex, injury level, injury completeness, self-perceived health status, and 12-month history of pressure ulcer were all significantly associated with AT use. After adjusting for these factors, participants with workers' compensation were more likely to report AT use than individuals with either government or private insurance. Conclusions: Despite significant technological advances, AT is not readily available to the people who might benefit most from its use. Findings from the present study are the first to shed light on AT funding sources and reveal that individuals with workers' compensation are more likely use AT than individuals with either government or private insurance. Additional work focused on AT use and functional outcomes is needed to assess the effect of barriers to use. Collectively, this work may inform insurers of the importance of having AT available for this unique population to potentially improve quality of life and participation.
Background and Purpose: Refinement of robotic exoskeletons for overground walking is progressing ... more Background and Purpose: Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility. Methods: We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions. Results: Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support. Discussion and Conclusions: Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.
Mixed methods were used in this study. The appropriateness of the levels of the Walking Index for... more Mixed methods were used in this study. The appropriateness of the levels of the Walking Index for Spinal Cord Injury II (WISCI-II) for application in children was critically reviewed by physical therapists using the Modified Delphi Technique, and the inter- and intra-rater reliability of the WISCI-II in children was evaluated. To examine the construct validity, and to establish reliability of the WISCI-II related to its use in children with spinal cord injury (SCI). United States of America. Using a Modified Delphi Technique, physical therapists critically reviewed the WISCI-II levels for pediatric utilization. Concurrently, ambulatory children under age 18 years with SCI were evaluated using the WISCI-II on two occasions by the same therapist to establish intra-rater reliability. One trial was photographed and de-identified. Each photograph was reviewed by four different physical therapists who gave WISCI-II scores to establish inter-rater reliability. Summary and descriptive stati...
Study design: In 2014, the adult spinal cord injury (SCI) common data element (CDE) recommendatio... more Study design: In 2014, the adult spinal cord injury (SCI) common data element (CDE) recommendations were made available. This project was a review of the adult SCI CDE for relevance to children and youth with SCI. Objectives: The objective of this study was to review the National Institute of Neurologic Disorders and Stroke (NINDS) adult SCI CDEs for relevance to children and youth with SCI. Setting: International. Methods: The pediatric working group consisted of international members with varied fields of expertise related to pediatric SCI. The group convened biweekly meetings for 6 months in 2015. All of the adult SCI CDEs were reviewed, evaluated and modified/created for four age groups: 0-5 years, 6-12 years, 13-15 years and 16-18 years. Whenever possible, results of published research studies were used to guide recommendations. In the absence of empirical support, grey literature and international content expert consensus were garnered. Existing pediatric NINDS CDEs and new CDEs were developed in areas where adult recommendations were not appropriate. After internal working group review of domain recommendations, these pediatric CDEs were vetted during a public review from November through December 2015. Results: Version 1.0 of the pediatric SCI CDEs was posted in February 2016. Conclusion: The pediatric SCI CDEs are incorporated directly into the NINDS SCI CDE sets and can be found at https:// commondataelements.ninds.nih.gov.
There is a significant need for kindergarten entry assessments (KEA) that meet state education ag... more There is a significant need for kindergarten entry assessments (KEA) that meet state education agency (SEA) requirements and are psychometrically sound measures of a broad range of school readiness domains such as language, literacy, math, science, executive function, and social-emotional skills. Research Findings: In this paper, we describe five phases of development, calibration, and launch of a new KEA for a large state. We developed and tested 14 English subtests. We describe how teacher input and SEA priorities and policies guided development of the test blueprint in phase one. We calibrated the measures across the state in phase two and established initial evidence of reliability and validity in phase three (n = 208). In phase four, we developed our technology platform, scoring, and student grouping tools to improve data utilization. Practice or Policy: We describe in phase five current delivery and implementation practices across the state and future work to improve and expand the measures along with a set of linked activities to help teachers use data to guide instruction. We discuss principles and methods the assessment developers utilized, as these perspectives may inform the development and usage of other KEAs.
The structure of executive function (EF), as it pertains to distinct "hot" (affectively salient) ... more The structure of executive function (EF), as it pertains to distinct "hot" (affectively salient) and "cool" (affectively neutral) dimensions, in early childhood is not well understood. Given that the neural circuitry underlying EF may become increasingly differentiated with development and enriched experiences, EF may become more dissociable into hot and cool factors with age and advantaged socioeconomic circumstances. We used confirmatory factor analysis (CFA) to compare a multidimensional hot and cool EF model with a unidimensional model in early childhood, and to investigate model invariance across age and maternal education. Participants were 1900 children (2-5 years of age) from socioeconomically diverse families in an urban area in the southern United States. We aggregated data from four previously collected studies that included EF tasks, thus this study includes secondary data analysis. We tested model fit across (1) children older and younger than 4 years of age and (2) higher (college experience) versus lower (no college) maternal education. Results indicated that a two-factor hot and cool EF model provided the best fit to the data across all groups. Although the number of factors was invariant, only partial metric invariance was met for age, suggesting that how certain tests represent EF changes with age. For maternal education, partial scalar invariance was met, with higher maternal education associated with higher scores on certain EF tasks. Findings with this large sample suggest that EF includes two factors characterized as hot and cool. However, the study raises questions about model invariance, particularly across age.
We evaluate the cost‐effectiveness of two early childhood interventions that use instructional co... more We evaluate the cost‐effectiveness of two early childhood interventions that use instructional coaching and parent coaching as levers for improvement. The study design allows us to compare the individual effects of each intervention as well as their combined effect on student outcomes. We find that teachers receiving instructional coaching improve their use of evidence‐based instructional practices, while families receiving parent coaching show increases in numerous responsive parenting behaviors associated with positive child outcomes. Both interventions demonstrate positive impacts on students, but only parent coaching shows statistically significant effects across a range of student outcomes. Instructional coaching alone is substantially less costly and may therefore be the most cost‐effective of the three treatment conditions; however, small sample sizes limit our ability to reach definitive conclusions. Policy simulations suggest that implementing these interventions could rais...
This article looks closely at two types of errors children have been shown to make with universal... more This article looks closely at two types of errors children have been shown to make with universal quantification—Exhaustive Pairing (EP) errors and Underexhaustive errors—and asks whether they reflect the same underlying phenomenon. In a large-scale, longitudinal study, 140 children were tested 4 times from ages 4 to 7 on sentences involving the universal quantifier every. We find an interesting inverse relationship between EP errors and Underexhaustive errors over development: the point at which children stop making Underexhaustive errors is also when they begin making EP errors. Underexhaustive errors, common at early stages in our study, may be indicative of a non-adult, non-exhaustive semantics for every. EP errors, which emerge later, and remain frequent even at age 7, are progressive in nature and were also found with adults in a control study. Following recent developmental work (Drozd and van Loosbroek 2006; Smits 2010), we suggest that these errors do not signal lack of kno...
This study evaluated whether the combination of two proven interventions, one in Head Start class... more This study evaluated whether the combination of two proven interventions, one in Head Start classrooms (The Early Education Model, TEEM) and one in the home (Play and Learning Strategies, PALS) resulted in enhanced effects on at-risk 3-to 5-year-old children's school readiness skills when compared to either of these interventions alone. Teachers and parents were trained to use a responsive style and strategies that supported children's school readiness skills with the goal of providing children consistency in responsive practices across the school and home environments. The study was conducted in 77 classrooms with teachers randomized to either the TEEM (n = 39) or No TEEM (i.e., control or business as usual, n = 38) conditions. Six to eight children in each classroom were randomly assigned to either have their parents receive PALS (n = 314; 210 after attrition) or to a No PALS condition (n = 309; 221 after attrition) resulting in four conditions: TEEM/PALS, TEEM/No PALS, No TEEM/PALS, and No TEEM/No PALS. Results showed greater gains in the TEEM teachers' language and literacy instructional practices and sensitivity compared to control teachers, but there were few significant findings for child cognitive outcomes. Parents receiving PALS, as compared to those without PALS, showed greater increases across play and book reading contexts in numerous responsive behaviors linked to the attachment and socio-cultural theories. Children whose parents received PALS versus those whose parents did not showed greater gains in direct measures of print knowledge and self-regulation and in social and language skills observed during interactions with their parent. Interactive effects of TEEM plus PALS were seen for increased engagement in shared book reading but not for other cognitive or social outcomes.
Research studies have uncovered several metabolic abnormalities associated with autism spectrum d... more Research studies have uncovered several metabolic abnormalities associated with autism spectrum disorder (ASD), including mitochondrial disease (MD) and abnormal redox metabolism. Despite the close connection between mitochondrial dysfunction and oxidative stress, the relation between MD and oxidative stress in children with ASD has not been studied. Plasma markers of oxidative stress and measures of cognitive and language development and ASD behavior were obtained from 18 children diagnosed with ASD who met criteria for probable or definite MD per the Morava et al. criteria (ASD/MD) and 18 age and gender-matched ASD children without any biological markers or symptoms of MD (ASD/NoMD). Plasma measures of redox metabolism included reduced free glutathione (fGSH), oxidized glutathione (GSSG), the fGSH/GSSG ratio and 3-nitrotyrosine (3NT). In addition, a plasma measure of chronic immune activation, 3-chlorotyrosine (3CT), was also measured. Language was measured using the preschool language scale or the expressive one-word vocabulary test (depending on the age), adaptive behaviour was measured using the Vineland Adaptive Behavior Scale (VABS) and core autism symptoms were measured using the Autism Symptoms Questionnaire and the Social Responsiveness Scale. Children with ASD/MD were found to have lower scores on the communication and daily living skill subscales of the VABS despite having similar language and ASD symptoms. Children with ASD/MD demonstrated significantly higher levels of fGSH/GSSG and lower levels of GSSG as compared with children with ASD/NoMD, suggesting an overall more favourable glutathione redox status in the ASD/MD group. However, compare with controls, both ASD groups demonstrated lower fGSH and fGSH/GSSG, demonstrating that both groups suffer from redox abnormalities. Younger ASD/MD children had higher levels of 3CT than younger ASD/NoMD children because of an agerelated effect in the ASD/MD group. Both ASD groups demonstrated significantly higher 3CT levels than control subjects, suggesting that chronic inflammation was present in both groups of children with ASD. Interestingly, 3NT was found to correlate positively with several measures of cognitive function, development and behavior for the ASD/MD group, but not the ASD/NoMD group, such that higher 3NT concentrations were associated with more favourable adaptive behaviour, language and ASDrelated behavior. To determine whether difference in receiving medications and/or supplements could account for the differences in redox and inflammatory biomarkers across ASD groups, we examined differences in medication and supplements across groups and their effect of redox and inflammatory biomarkers. Overall, significantly more participants in the ASD/MD group were receiving folate, vitamin B12, carnitine, co-enzyme Q10, B vitamins and antioxidants. We then determined whether folate, carnitine, co-enzyme Q10, B vitamins and/or antioxidants influenced redox or inflammatory biomarkers. Antioxidant supplementation was associated with a significantly lower GSSG, whereas antioxidants, co-enzyme Q10 and B vitamins were associated with a higher fGSH/GSSG ratio. There was no relation between folate, carnitine, co-enzyme Q10, B vitamins and antioxidants with 3NT, 3CT or fGSH. Overall, our findings suggest that ASD/MD children with a more chronic oxidized microenvironment have better development. We interpret this finding in light of the fact that more active mitochondrial can create a greater oxidized microenvironment especially when dysfunctional. Thus, compensatory upregulation of mitochondria which are dysfunctional may both increase activity and function at the expense of a more oxidized microenvironment. Although more ASD/MD children were receiving certain supplements, the use of such supplements were not found to be related to the redox biomarkers that were related to cognitive development or behavior in the ASD/MD group but could possibly account for the difference in glutathione metabolism noted between groups. This study suggests that different subgroups of children with ASD have different redox abnormalities, which may arise from different sources. A better understanding of the relationship between mitochondrial dysfunction in ASD and oxidative stress, along with other factors that may contribute to oxidative stress, will be critical to understanding how to guide treatment and management of ASD children. This study also suggests that it is important to identify ASD/MD children as they may respond differently to specific treatments because of their specific metabolic profile.
Sapropterin, a synthetic form of tetrahydrobiopterin (BH 4), has been reported to improve symptom... more Sapropterin, a synthetic form of tetrahydrobiopterin (BH 4), has been reported to improve symptoms in children with autism spectrum disorder (ASD). However, as BH 4 is involved in multiple metabolic pathway that have been found to be dysregulated in ASD, including redox, pterin, monoamine neurotransmitter, nitric oxide (NO) and immune metabolism, the metabolic pathway by which sapropterin exerts its therapeutic effect in ASD effect remains unclear. This study investigated which metabolic pathways were associated with symptomatic improvement during sapropterin treatment. Ten participants (ages 2-6 years old) with current social and/or language delays, ASD and a central BH 4 concentration p30 nM l À 1 were treated with a daily morning 20 mg kg À 1 dose of sapropterin for 16 weeks in an open-label fashion. At baseline, 8 weeks and 16 weeks after starting the treatment, measures of language, social function and behavior and biomarkers of redox, pterin, monoamine neurotransmitter, NO and immune metabolism were obtained. Two participants discontinued the study, one from mild adverse effects and another due to noncompliance. Overall, improvements in subscales of the Preschool Language Scale (PLS), Vineland Adaptive Behavior Scale (VABS), Aberrant Behavior Checklist (ABC) and autism symptoms questionnaire (ASQ) were seen. Significant changes in biomarkers of pterin, redox and NO were found. Improvement on several subscales of the PLS, VABS, ABC and ASQ were moderated by baseline and changes in biomarkers of NO and pterin metabolism, particularly baseline NO metabolism. These data suggest that behavioral improvement associated with daily 20 mg kg À 1 sapropterin treatment may involve NO metabolism, particularly the status of pretreatment NO metabolism.
Health Questionnaire (PHQ-9) assessed depression severity. These scales were administered in a re... more Health Questionnaire (PHQ-9) assessed depression severity. These scales were administered in a retrospective pre-test with a traditional post-test. At the conclusion of the 8-week interview, individual semistructured interviews with caregivers were conducted to illuminate the perceived impacts following a therapeutic yoga intervention for people with PD. Results: Following the 8-week intervention, the PHQ-9 revealed a 59% improvement in depressive symptoms and the PAC displayed a reduction of 4% over time. The qualitative data supports this finding, as the themes included enjoying the yoga intervention, increased motivation and patience, and decreased stress levels. All caregivers identified that they would like to continue with some type of yoga. Conclusions: Preliminary data from a therapeutic yoga intervention for PD indicated perceived benefits in depression levels for caregivers, and the qualitative data supported this finding as well. Although PAC scores minimally decreased during the intervention, caregivers reported feeling more patience and motivation in dealing with their care recipient.
Archives of Physical Medicine and Rehabilitation, May 1, 2021
The aims of the current study were to characterize veterans who used a complementary and integrat... more The aims of the current study were to characterize veterans who used a complementary and integrative health (CIH) service in the Veterans Health Administration (VHA) and to assess the extent to which using a CIH-related service was associated with receiving an opioid analgesic prescription following the initiation of specialty pain service, a time at which higher intensity care is needed for patients experiencing greater psychiatric and medical complexity. Design: This study utilized a retrospective cohort design of veterans using specialty pain services. The index visit was defined as the first specialty pain visit in Fiscal Years 2012-2015. Demographics, opioid analgesic prescriptions, psychiatric disorder diagnoses, medical comorbidity, pain severity scores, and pain conditions were extracted from VHA administrative data. Setting: The cohort was comprised of veterans who had at least one visit with a specialty pain service as identified by a billing code. Main outcome measures: The main outcome measures were use of a CIH-related service in the 365 days prior to the index visit and opioid analgesic prescription within 365 days after the index visit. Adjusted logistic regression analyses accounted for key covariate and potential confounding variables. Results: Use of CIH-related services was relatively low across the cohort (1.9%). Veterans who used a CIH-related service in the 365 days prior to the index visit were more likely to be female, be younger, have less medical comorbidity, have less severe pain, and were less likely to have received an opioid prescription in the 365 days prior to the index visit. After accounting for key covariates and potential confounders, veterans who used a CIHrelated service were less likely to receive an opioid analgesic prescription in the 365 days following the index visit. Conclusion: CIH-related services were not commonly used among Veterans initiating specialty pain services. Engaging in CIH-related services prior to specialty pain services is associated with decreased opioid analgesic and non-opioid analgesic prescriptions. risk of depression onset and recurrence. 9,10 Both the Centers of Disease Control and the joint Department of Veterans Affairs/Department of Defense (VA/DoD) released Clinical Practice Guidelines (CPGs) on opioid prescribing for pain. 3,4 The new CPGs recommend offering self-management and other nonpharmacologic approaches as frontline treatments for chronic pain. Additionally, if opioid therapy is provided, it should be offered in conjunction with these nonpharmacologic options. These recommendations are based on "strong" evidence indicating that there is the potential for long-term benefit with few adverse effects of
Background Few, if any estimates of cost-effectiveness for locomotor training strategies followin... more Background Few, if any estimates of cost-effectiveness for locomotor training strategies following spinal cord injury (SCI) are available. The purpose of this study was to estimate the cost-effectiveness of locomotor training strategies following spinal cord injury (overground robotic locomotor training versus conventional locomotor training) by injury status (complete versus incomplete) using a practice-based cohort. Methods A probabilistic cost-effectiveness analysis was conducted using a prospective, practice-based cohort from four participating Spinal Cord Injury Model System sites. Conventional locomotor training strategies (conventional training) were compared to overground robotic locomotor training (overground robotic training). Conventional locomotor training included treadmill-based training with body weight support, overground training, and stationary robotic systems. The outcome measures included the calculation of quality adjusted life years (QALYs) using the EQ-5D and ...
Archives of Physical Medicine and Rehabilitation, 2021
Predicting duration of outpatient physical therapy episodes for individuals with spinal cord inju... more Predicting duration of outpatient physical therapy episodes for individuals with spinal cord injury based on locomotor training strategy.
Journal of NeuroEngineering and Rehabilitation, 2020
BackgroundWe know little about the budget impact of integrating robotic exoskeleton over-ground t... more BackgroundWe know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury.MethodsA Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to u...
Archives of Physical Medicine and Rehabilitation, 2019
To investigate the association between insurance provider and reported assistive technology (AT) ... more To investigate the association between insurance provider and reported assistive technology (AT) use to access computers and electronic devices 1 year after sustaining tetraplegia. Design: Multicenter cross-sectional study. Setting: Participants enrolled in the Spinal Cord Injury Model Systems (SCIMS) National Database. Interventions: Not applicable. Participants: Men and women with tetraplegia (NZ498) enrolled in the SCIMS National Database were included in the analysis. Main Outcome Measures: The primary study outcome was the use of AT when operating a computer or other mobile electronic device. The primary predictor was the subject's principal health insurance provider, which was grouped into the 3 categories: government (Medicare, Medicaid, and other government), private (private insurance, private funds, and other), and workers' compensation. Results: Overall, 34.7% of participants reported using AT to access computers and electronic devices. Results of logistic regression analysis revealed sex, injury level, injury completeness, self-perceived health status, and 12-month history of pressure ulcer were all significantly associated with AT use. After adjusting for these factors, participants with workers' compensation were more likely to report AT use than individuals with either government or private insurance. Conclusions: Despite significant technological advances, AT is not readily available to the people who might benefit most from its use. Findings from the present study are the first to shed light on AT funding sources and reveal that individuals with workers' compensation are more likely use AT than individuals with either government or private insurance. Additional work focused on AT use and functional outcomes is needed to assess the effect of barriers to use. Collectively, this work may inform insurers of the importance of having AT available for this unique population to potentially improve quality of life and participation.
Background and Purpose: Refinement of robotic exoskeletons for overground walking is progressing ... more Background and Purpose: Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility. Methods: We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions. Results: Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support. Discussion and Conclusions: Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.
Mixed methods were used in this study. The appropriateness of the levels of the Walking Index for... more Mixed methods were used in this study. The appropriateness of the levels of the Walking Index for Spinal Cord Injury II (WISCI-II) for application in children was critically reviewed by physical therapists using the Modified Delphi Technique, and the inter- and intra-rater reliability of the WISCI-II in children was evaluated. To examine the construct validity, and to establish reliability of the WISCI-II related to its use in children with spinal cord injury (SCI). United States of America. Using a Modified Delphi Technique, physical therapists critically reviewed the WISCI-II levels for pediatric utilization. Concurrently, ambulatory children under age 18 years with SCI were evaluated using the WISCI-II on two occasions by the same therapist to establish intra-rater reliability. One trial was photographed and de-identified. Each photograph was reviewed by four different physical therapists who gave WISCI-II scores to establish inter-rater reliability. Summary and descriptive stati...
Study design: In 2014, the adult spinal cord injury (SCI) common data element (CDE) recommendatio... more Study design: In 2014, the adult spinal cord injury (SCI) common data element (CDE) recommendations were made available. This project was a review of the adult SCI CDE for relevance to children and youth with SCI. Objectives: The objective of this study was to review the National Institute of Neurologic Disorders and Stroke (NINDS) adult SCI CDEs for relevance to children and youth with SCI. Setting: International. Methods: The pediatric working group consisted of international members with varied fields of expertise related to pediatric SCI. The group convened biweekly meetings for 6 months in 2015. All of the adult SCI CDEs were reviewed, evaluated and modified/created for four age groups: 0-5 years, 6-12 years, 13-15 years and 16-18 years. Whenever possible, results of published research studies were used to guide recommendations. In the absence of empirical support, grey literature and international content expert consensus were garnered. Existing pediatric NINDS CDEs and new CDEs were developed in areas where adult recommendations were not appropriate. After internal working group review of domain recommendations, these pediatric CDEs were vetted during a public review from November through December 2015. Results: Version 1.0 of the pediatric SCI CDEs was posted in February 2016. Conclusion: The pediatric SCI CDEs are incorporated directly into the NINDS SCI CDE sets and can be found at https:// commondataelements.ninds.nih.gov.
There is a significant need for kindergarten entry assessments (KEA) that meet state education ag... more There is a significant need for kindergarten entry assessments (KEA) that meet state education agency (SEA) requirements and are psychometrically sound measures of a broad range of school readiness domains such as language, literacy, math, science, executive function, and social-emotional skills. Research Findings: In this paper, we describe five phases of development, calibration, and launch of a new KEA for a large state. We developed and tested 14 English subtests. We describe how teacher input and SEA priorities and policies guided development of the test blueprint in phase one. We calibrated the measures across the state in phase two and established initial evidence of reliability and validity in phase three (n = 208). In phase four, we developed our technology platform, scoring, and student grouping tools to improve data utilization. Practice or Policy: We describe in phase five current delivery and implementation practices across the state and future work to improve and expand the measures along with a set of linked activities to help teachers use data to guide instruction. We discuss principles and methods the assessment developers utilized, as these perspectives may inform the development and usage of other KEAs.
The structure of executive function (EF), as it pertains to distinct "hot" (affectively salient) ... more The structure of executive function (EF), as it pertains to distinct "hot" (affectively salient) and "cool" (affectively neutral) dimensions, in early childhood is not well understood. Given that the neural circuitry underlying EF may become increasingly differentiated with development and enriched experiences, EF may become more dissociable into hot and cool factors with age and advantaged socioeconomic circumstances. We used confirmatory factor analysis (CFA) to compare a multidimensional hot and cool EF model with a unidimensional model in early childhood, and to investigate model invariance across age and maternal education. Participants were 1900 children (2-5 years of age) from socioeconomically diverse families in an urban area in the southern United States. We aggregated data from four previously collected studies that included EF tasks, thus this study includes secondary data analysis. We tested model fit across (1) children older and younger than 4 years of age and (2) higher (college experience) versus lower (no college) maternal education. Results indicated that a two-factor hot and cool EF model provided the best fit to the data across all groups. Although the number of factors was invariant, only partial metric invariance was met for age, suggesting that how certain tests represent EF changes with age. For maternal education, partial scalar invariance was met, with higher maternal education associated with higher scores on certain EF tasks. Findings with this large sample suggest that EF includes two factors characterized as hot and cool. However, the study raises questions about model invariance, particularly across age.
We evaluate the cost‐effectiveness of two early childhood interventions that use instructional co... more We evaluate the cost‐effectiveness of two early childhood interventions that use instructional coaching and parent coaching as levers for improvement. The study design allows us to compare the individual effects of each intervention as well as their combined effect on student outcomes. We find that teachers receiving instructional coaching improve their use of evidence‐based instructional practices, while families receiving parent coaching show increases in numerous responsive parenting behaviors associated with positive child outcomes. Both interventions demonstrate positive impacts on students, but only parent coaching shows statistically significant effects across a range of student outcomes. Instructional coaching alone is substantially less costly and may therefore be the most cost‐effective of the three treatment conditions; however, small sample sizes limit our ability to reach definitive conclusions. Policy simulations suggest that implementing these interventions could rais...
This article looks closely at two types of errors children have been shown to make with universal... more This article looks closely at two types of errors children have been shown to make with universal quantification—Exhaustive Pairing (EP) errors and Underexhaustive errors—and asks whether they reflect the same underlying phenomenon. In a large-scale, longitudinal study, 140 children were tested 4 times from ages 4 to 7 on sentences involving the universal quantifier every. We find an interesting inverse relationship between EP errors and Underexhaustive errors over development: the point at which children stop making Underexhaustive errors is also when they begin making EP errors. Underexhaustive errors, common at early stages in our study, may be indicative of a non-adult, non-exhaustive semantics for every. EP errors, which emerge later, and remain frequent even at age 7, are progressive in nature and were also found with adults in a control study. Following recent developmental work (Drozd and van Loosbroek 2006; Smits 2010), we suggest that these errors do not signal lack of kno...
This study evaluated whether the combination of two proven interventions, one in Head Start class... more This study evaluated whether the combination of two proven interventions, one in Head Start classrooms (The Early Education Model, TEEM) and one in the home (Play and Learning Strategies, PALS) resulted in enhanced effects on at-risk 3-to 5-year-old children's school readiness skills when compared to either of these interventions alone. Teachers and parents were trained to use a responsive style and strategies that supported children's school readiness skills with the goal of providing children consistency in responsive practices across the school and home environments. The study was conducted in 77 classrooms with teachers randomized to either the TEEM (n = 39) or No TEEM (i.e., control or business as usual, n = 38) conditions. Six to eight children in each classroom were randomly assigned to either have their parents receive PALS (n = 314; 210 after attrition) or to a No PALS condition (n = 309; 221 after attrition) resulting in four conditions: TEEM/PALS, TEEM/No PALS, No TEEM/PALS, and No TEEM/No PALS. Results showed greater gains in the TEEM teachers' language and literacy instructional practices and sensitivity compared to control teachers, but there were few significant findings for child cognitive outcomes. Parents receiving PALS, as compared to those without PALS, showed greater increases across play and book reading contexts in numerous responsive behaviors linked to the attachment and socio-cultural theories. Children whose parents received PALS versus those whose parents did not showed greater gains in direct measures of print knowledge and self-regulation and in social and language skills observed during interactions with their parent. Interactive effects of TEEM plus PALS were seen for increased engagement in shared book reading but not for other cognitive or social outcomes.
Research studies have uncovered several metabolic abnormalities associated with autism spectrum d... more Research studies have uncovered several metabolic abnormalities associated with autism spectrum disorder (ASD), including mitochondrial disease (MD) and abnormal redox metabolism. Despite the close connection between mitochondrial dysfunction and oxidative stress, the relation between MD and oxidative stress in children with ASD has not been studied. Plasma markers of oxidative stress and measures of cognitive and language development and ASD behavior were obtained from 18 children diagnosed with ASD who met criteria for probable or definite MD per the Morava et al. criteria (ASD/MD) and 18 age and gender-matched ASD children without any biological markers or symptoms of MD (ASD/NoMD). Plasma measures of redox metabolism included reduced free glutathione (fGSH), oxidized glutathione (GSSG), the fGSH/GSSG ratio and 3-nitrotyrosine (3NT). In addition, a plasma measure of chronic immune activation, 3-chlorotyrosine (3CT), was also measured. Language was measured using the preschool language scale or the expressive one-word vocabulary test (depending on the age), adaptive behaviour was measured using the Vineland Adaptive Behavior Scale (VABS) and core autism symptoms were measured using the Autism Symptoms Questionnaire and the Social Responsiveness Scale. Children with ASD/MD were found to have lower scores on the communication and daily living skill subscales of the VABS despite having similar language and ASD symptoms. Children with ASD/MD demonstrated significantly higher levels of fGSH/GSSG and lower levels of GSSG as compared with children with ASD/NoMD, suggesting an overall more favourable glutathione redox status in the ASD/MD group. However, compare with controls, both ASD groups demonstrated lower fGSH and fGSH/GSSG, demonstrating that both groups suffer from redox abnormalities. Younger ASD/MD children had higher levels of 3CT than younger ASD/NoMD children because of an agerelated effect in the ASD/MD group. Both ASD groups demonstrated significantly higher 3CT levels than control subjects, suggesting that chronic inflammation was present in both groups of children with ASD. Interestingly, 3NT was found to correlate positively with several measures of cognitive function, development and behavior for the ASD/MD group, but not the ASD/NoMD group, such that higher 3NT concentrations were associated with more favourable adaptive behaviour, language and ASDrelated behavior. To determine whether difference in receiving medications and/or supplements could account for the differences in redox and inflammatory biomarkers across ASD groups, we examined differences in medication and supplements across groups and their effect of redox and inflammatory biomarkers. Overall, significantly more participants in the ASD/MD group were receiving folate, vitamin B12, carnitine, co-enzyme Q10, B vitamins and antioxidants. We then determined whether folate, carnitine, co-enzyme Q10, B vitamins and/or antioxidants influenced redox or inflammatory biomarkers. Antioxidant supplementation was associated with a significantly lower GSSG, whereas antioxidants, co-enzyme Q10 and B vitamins were associated with a higher fGSH/GSSG ratio. There was no relation between folate, carnitine, co-enzyme Q10, B vitamins and antioxidants with 3NT, 3CT or fGSH. Overall, our findings suggest that ASD/MD children with a more chronic oxidized microenvironment have better development. We interpret this finding in light of the fact that more active mitochondrial can create a greater oxidized microenvironment especially when dysfunctional. Thus, compensatory upregulation of mitochondria which are dysfunctional may both increase activity and function at the expense of a more oxidized microenvironment. Although more ASD/MD children were receiving certain supplements, the use of such supplements were not found to be related to the redox biomarkers that were related to cognitive development or behavior in the ASD/MD group but could possibly account for the difference in glutathione metabolism noted between groups. This study suggests that different subgroups of children with ASD have different redox abnormalities, which may arise from different sources. A better understanding of the relationship between mitochondrial dysfunction in ASD and oxidative stress, along with other factors that may contribute to oxidative stress, will be critical to understanding how to guide treatment and management of ASD children. This study also suggests that it is important to identify ASD/MD children as they may respond differently to specific treatments because of their specific metabolic profile.
Sapropterin, a synthetic form of tetrahydrobiopterin (BH 4), has been reported to improve symptom... more Sapropterin, a synthetic form of tetrahydrobiopterin (BH 4), has been reported to improve symptoms in children with autism spectrum disorder (ASD). However, as BH 4 is involved in multiple metabolic pathway that have been found to be dysregulated in ASD, including redox, pterin, monoamine neurotransmitter, nitric oxide (NO) and immune metabolism, the metabolic pathway by which sapropterin exerts its therapeutic effect in ASD effect remains unclear. This study investigated which metabolic pathways were associated with symptomatic improvement during sapropterin treatment. Ten participants (ages 2-6 years old) with current social and/or language delays, ASD and a central BH 4 concentration p30 nM l À 1 were treated with a daily morning 20 mg kg À 1 dose of sapropterin for 16 weeks in an open-label fashion. At baseline, 8 weeks and 16 weeks after starting the treatment, measures of language, social function and behavior and biomarkers of redox, pterin, monoamine neurotransmitter, NO and immune metabolism were obtained. Two participants discontinued the study, one from mild adverse effects and another due to noncompliance. Overall, improvements in subscales of the Preschool Language Scale (PLS), Vineland Adaptive Behavior Scale (VABS), Aberrant Behavior Checklist (ABC) and autism symptoms questionnaire (ASQ) were seen. Significant changes in biomarkers of pterin, redox and NO were found. Improvement on several subscales of the PLS, VABS, ABC and ASQ were moderated by baseline and changes in biomarkers of NO and pterin metabolism, particularly baseline NO metabolism. These data suggest that behavioral improvement associated with daily 20 mg kg À 1 sapropterin treatment may involve NO metabolism, particularly the status of pretreatment NO metabolism.
Health Questionnaire (PHQ-9) assessed depression severity. These scales were administered in a re... more Health Questionnaire (PHQ-9) assessed depression severity. These scales were administered in a retrospective pre-test with a traditional post-test. At the conclusion of the 8-week interview, individual semistructured interviews with caregivers were conducted to illuminate the perceived impacts following a therapeutic yoga intervention for people with PD. Results: Following the 8-week intervention, the PHQ-9 revealed a 59% improvement in depressive symptoms and the PAC displayed a reduction of 4% over time. The qualitative data supports this finding, as the themes included enjoying the yoga intervention, increased motivation and patience, and decreased stress levels. All caregivers identified that they would like to continue with some type of yoga. Conclusions: Preliminary data from a therapeutic yoga intervention for PD indicated perceived benefits in depression levels for caregivers, and the qualitative data supported this finding as well. Although PAC scores minimally decreased during the intervention, caregivers reported feeling more patience and motivation in dealing with their care recipient.
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Papers by Heather Taylor