Early blood pressure management is central to neurologic resuscitation of spinal cord injury; however, the role of augmented blood pressure is unclear. To compare the efficacy and safety of augmented vs conventional blood pressure on 6-month neurologic outcomes after acute spinal cord injury. This multicenter randomized clinical trial took place from October 3, 2017, to July 26, 2023, and assessed patients 18 years or older with spinal cord injury followed up for 6 months at 13 large US trauma centers. Patients were equally randomized to augmented (>85-90 mm Hg) or conventional (>65-70 mm Hg) mean arterial pressure for 7 days or until intensive care unit discharge. Primary end points were change in motor and sensory American Spinal Injury Association Impairment Scale scores from baseline to 6 months. Safety end points included organ dysfunction and complications. The trial randomized 92 patients (mean [SD] age, 53.78 [18.74] years; 76 [83%] male). At 6 months, 38 patients had completed follow-up and 15 had died. Among survivors, there were no mean (SD) differences in change from baseline in upper extremity motor scores (34.95 [3.25] vs 32.95 [3.65]; difference, 2.48; 95% CI, −5.93 to 10.90; P = .55), lower extremity motor scores (18.53 [4.62] vs 19.95 [4.59]; difference, −4.56; 95% CI, −16.11 to 7.03; P = .43), or total sensory scores (108.47 [12.49] vs 130.89 [14.87]; difference, −32.00; 95% CI, −65.40 to 1.40; P = .06) comparing the augmented and conventional groups. The augmented group had higher mean (SD) modified Sequential Organ Failure Assessment scores (excluding cardiovascular components) at day 3 (1.65 [1.79] vs 0.80 [1.10]; difference, 0.85; 95% CI, 0.23-1.47; P = .008) and day 6 (1.55 [1.82] vs 0.80 [1.35]; difference, 0.74; 95% CI, 0.05-1.44; P = .04), longer mechanical ventilatory support (9.44 [15.27] vs 3.78 [8.42] days; difference, 5.67 days; 95% CI, 0.48-10.85 days; P = .03), and more respiratory complications (36 [78%] vs 18 [39%]; risk difference, 40%; 95% CI, 22%-58%; P < .001) than the conventional group. No differences in mortality or other secondary outcomes were observed. Although underpowered, this randomized clinical trial of patients with spinal cord injury did not demonstrate better neurologic recovery comparing early augmented and conventional blood pressure and calls this practice into question. Further study is needed to identify groups who may benefit from augmenting blood pressure and determine potential harm mechanisms. ClinicalTrials.gov Identifier: NCT02878850

Importance:Early blood pressure management is central to neurologic resuscitation of spinal cord injury; however, the role of augmented blood pressure is unclear. Objective:To compare the efficacy and safety of augmented vs conventional blood pressure on 6-month neurologic outcomes after acute spinal cord injury. Design, Setting, and Participants:This multicenter randomized clinical trial took place from October 3, 2017, to July 26, 2023, and assessed patients 18 years or older with spinal cord injury followed up for 6 months at 13 large US trauma centers. Interventions:Patients were equally randomized to augmented (>85-90 mm Hg) or conventional (>65-70 mm Hg) mean arterial pressure for 7 days or until intensive care unit discharge. Main Outcomes and Measures:Primary end points were change in motor and sensory American Spinal Injury Association Impairment Scale scores from baseline to 6 months. Safety end points included organ dysfunction and complications. Results:The trial randomized 92 patients (mean [SD] age, 53.78 [18.74] years; 76 [83%] male). At 6 months, 38 patients had completed follow-up and 15 had died. Among survivors, there were no mean (SD) differences in change from baseline in upper extremity motor scores (34.95 [3.25] vs 32.95 [3.65]; difference, 2.48; 95% CI, -5.93 to 10.90; P = .55), lower extremity motor scores (18.53 [4.62] vs 19.95 [4.59]; difference, -4.56; 95% CI, -16.11 to 7.03; P = .43), or total sensory scores (108.47 [12.49] vs 130.89 [14.87]; difference, -32.00; 95% CI, -65.40 to 1.40; P = .06) comparing the augmented and conventional groups. The augmented group had higher mean (SD) modified Sequential Organ Failure Assessment scores (excluding cardiovascular components) at day 3 (1.65 [1.79] vs 0.80 [1.10]; difference, 0.85; 95% CI, 0.23-1.47; P = .008) and day 6 (1.55 [1.82] vs 0.80 [1.35]; difference, 0.74; 95% CI, 0.05-1.44; P = .04), longer mechanical ventilatory support (9.44 [15.27] vs 3.78 [8.42] days; difference, 5.67 days; 95% CI, 0.48-10.85 days; P = .03), and more respiratory complications (36 [78%] vs 18 [39%]; risk difference, 40%; 95% CI, 22%-58%; P < .001) than the conventional group. No differences in mortality or other secondary outcomes were observed. Conclusions:Although underpowered, this randomized clinical trial of patients with spinal cord injury did not demonstrate better neurologic recovery comparing early augmented and conventional blood pressure and calls this practice into question. Further study is needed to identify groups who may benefit from augmenting blood pressure and determine potential harm mechanisms. Trial Registration:ClinicalTrials.gov Identifier: NCT02878850.

IntroductionMajor burns and the intensive care required induce numerous physiologic changes and stress responses that impact recovery for months after hospital discharge. Little is known about sleep quantity and quality after index hospitalization discharge. We report on actigraphy and sleep outcome data from subjects enrolled in a prospective trial of home-based virtual rehabilitation (HBVR) after burn injury.MethodsWe conducted a randomized controlled trial of a HBVR program over 12 weeks after index hospitalization. In both HBVR and control (usual care) groups, subjects were provided a wrist actigraphy accelerometer device (Garmin vívofit®) to wear. Sleep data were retrieved remotely and analyzed. Actigraphy data were defined a priori as complete if subjects had 5 out of 7 days of actigraphy wear in a week. Average weekly sleep was calculated and reported by group assignment. Sleep-relevant and fatigue outcomes were measured by PROMIS questionnaires at randomization (discharge + 0–30 days), 12-weeks, and 12-months. Descriptive statistics were used for comparisons and linear mixed effect model were used to evaluate trends in PROMIS T-scores between groups.ResultsFifty subjects were enrolled and 48 had complete sleep data. Mean age was 38 ± 14 years and mean burn size was 16 ± 13 % TBSA with a majority of subjects male (71 %). Average sleep duration was within general population norms, with little difference between subjects in the intervention and controls groups in the 12 weeks after study randomization (7.3 vs.7.2 h respectively, p = 0.25). Subjects in control group spent more time in light sleep (4.1 vs. 3.9 h, p < 0.01) and experienced a higher proportion of nights with sleep disturbances (0.75 vs. 0.70, p = 0.006). Thirty-two subjects (66 %) completed PROMIS questionnaires at both time of randomization and following the 12-week intervention period. Average PROMIS sleep disturbance T-scores were not significantly different at 3-months. The control group had significant improvement in average PROMIS T-scores at 3-months compared to the HBVR group (p = 0.015). PROMIS scores trended towards improvement over the 12-month study period for both groups.ConclusionsActigraphy data complement self-reported sleep data among burn-injured adults after hospital discharge. People with burn injury had mildly increased sleep disturbance, sleep impairment, and fatigue after hospital discharge but trended toward population norms over time.

Daily rehabilitation after burn injury is vital for the prevention of function-limiting contractures. However, adherence to prescribed therapy following acute burn hospitalization has historically been low and not well-studied. Studies involving virtual reality technology have demonstrated an association with improved functional outcomes in burn therapy. We conducted a 5-year randomized controlled trial comparing 12 weeks of a home-based virtual rehabilitation (HBVR) system with standard burn therapy. Our primary outcome was adherence to prescribed home therapy, measured by e-diary self-report. Secondary outcomes included steps walked daily and patient-reported outcomes regarding stiffness, upper extremity function, and mobility. We enrolled 50 subjects, of which 48 provided data for analysis (23 HBVR, 25 control). Overall adherence to prescribed home therapy was low, 37.2% in the HBVR group and 60.0% in the control group. Reasons for nonadherence in the HBVR group included lack of time, engagement, and replacement of therapy with other physical activity. However, some subjects enjoyed HBVR and believed it aided their recovery. There was no difference in daily steps walked between the 2 groups. Daily walking gradually improved from 3500 steps per day in the first week after baseline and plateaued at 6000 steps per day at week 5. There were no differences in stiffness, upper extremity function, and mobility between the 2 groups at baseline and 3-, 6-, and 12-month follow-up. Subjects demonstrated improved upper extremity function and mobility in the first year after discharge, which coincided with increasing stiffness.

Abstract Introduction Restoring cardiovascular fitness can be challenging during the first months after hospital discharge for adult burn patients. Furthermore, adherence to prescribed home therapy among people with burn injury has traditionally been low. We conducted a 5-year randomized controlled trial of 12-weeks of gamified virtual home therapy compared to prescribed home exercise (usual care). We hypothesized that those assigned to the virtual therapy would log more total daily walking during the intervention period. Methods All English-speaking adult patients hospitalized with burn injury were screened for participation. Eligibility criteria required discharge to home, personal smartphone, and access to a television with HDMI connectivity. Participants randomized to the virtual therapy group received access to a customized exercise software program with motion sensing hardware to use for twelve weeks in addition to usual home therapy instructions. All participants were instructed to continuously wear a provided actigraphy device during the 12-week period. Wilcoxon rank sum tests were used to compare median miles walked per day between groups. Adherence to the actigraphy device was defined a priori as having wear-data for 5 days in a calendar week. Results Actigraphy data from 44 participants (22 control, 22 experimental) were compared. Median miles walked per day increased from 1.5 miles/day (IQR 1.0-2.7) in Week 1 to 2.85 miles/day (IQR 1.8-4.5) in Week 12. Wilcoxon rank sum testing revealed no significant difference in median miles/day between groups during any week (Figure 1). Adherence to wearing the actigraphy device was equal or higher in control participants for all weeks. Conclusions Home-based virtual rehabilitation did not increase total daily walking during the first twelve weeks after discharge. At Week 12, daily walking is nearly twice that of Week 1 in both groups. Applicability of Research to Practice Post-discharge actigraphy data from people with burn injury can inform both patients and providers about activity after hospital discharge.

Disparities in socioeconomic status and minority status affect the risk of burn injury and the severity of that injury, thus affecting the subsequent cost of care. We aimed to characterize the demographic details surrounding receipt of financial assistance due to burn injury and its relationship with health-related quality of life scores. Participants ≥18 from Burn Model System National Longitudinal Database (BMS) with complete demographic data were included (n = 4330). Nonresponders to financial assistance questions were analyzed separately. The remaining sample (n = 1255) was divided into participants who received financial assistance because of burn injury, those who received no financial assistance, and those who received financial assistance before injury and as a result of injury. A demographic and injury-characteristic comparison was conducted. Health-related quality of life metrics (Satisfaction with Life, Short Form-12/Veterans RAND 12-Item Health Survey, Community Integration Questionnaire Social Component, and the Post-Traumatic Growth Inventory) were analyzed preinjury, then 6-months, 1-year, and 2-years postinjury. A matched cohort analysis compared these scores. When compared to their no financial assistance counterparts, participants receiving financial assistance due to burns were more likely to be minorities (19% vs 14%), have more severe injuries (%TBSA burn 21% vs 10%), and receive workers' compensation (24% vs 9%). They also had lower health-related quality of life scores on all metrics except the post-traumatic growth inventory. Financial assistance may aid in combating disparities in posttraumatic growth scores for participants at the greatest risk of financial toxicity but does not improve other health-related quality of life metrics.

Abstract Introduction Patients with major burns experience physiologic changes that can impact their recovery for months after hospital discharge. Little is known about sleep quantity and quality in the post-discharge period. Here, we report on actigraphy sleep data for participants enrolled in a prospective trial of home-based virtual rehabilitation. Methods We conducted a randomized controlled trial to evaluate the effect of home-based rehabilitation using Jintronix® modules and Kinect® motion sensor on adherence to therapy. In both intervention and control (usual care) groups, participants were provided a wrist actigraphy accelerometer device (Vivofit®) to wear for the 12-weeks intervention. Sleep data were retrieved remotely and analyzed. Actigraphy data were defined as complete and analyzable if participants had 5 out of 7 days of actigraphy wear and upload in a week. Average weekly sleep was calculated and reported by group assignment. Descriptive statistics were used for comparisons, with p< 0.05 deemed as significant. Results Forty-four participants were enrolled with a 1:1 group assignment. Mean age was 38.5 years (SD=14.8), mean TBSA was 15.6% and most were male (68%). Average sleep was well within healthy population norms, with little difference between intervention and controls (7.29 vs.7.20 hours respectively, p=0.25) in the 90 days after discharge. Participants in control group spent more time in light sleep (4.05 vs. 3.88 hours, p< 0.01). The percent deep sleep, however, was comparable to healthy population norms (2.92 and 2.75 respectively, p=0.25). Participants in the control group experienced a higher proportion of nights with sleep disturbances (0.75 vs. 0.70, p=0.006). Conclusions Remote wrist wearable-wearable actigraphy data provide an important glimpse into sleep duration and quality for burn injured individuals in the 12 weeks after hospital discharge. An encouraging finding was that total sleep and deep sleep proportion for this cohort were comparable to healthy population norms. Though intervention and control groups were similar in total sleep hours, there were important differences in sleep quality. Applicability of Research to Practice Remote data acquisition on post-discharge sleep is feasible.

The clinical burden of Long COVID, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and other post-infectious fatiguing illnesses (PIFI) is increasing. There is a critical need to advance understanding of the effectiveness and sustainability of innovative approaches to clinical care of patients having these conditions. We aim to assess the effectiveness of a Long COVID and Fatiguing Illness Recovery Program (LC FIRP) in a two-arm, single-blind, pragmatic, quality improvement, professional cluster, randomized controlled trial in which 20 consenting clinicians across primary care clinics in a Federally Qualified Health Center system in San Diego, CA, will be randomized at a ratio of 1:1 to either participate in (1) weekly multi-disciplinary team-based case consultation and peer-to-peer sharing of emerging best practices (i.e., teleECHO (Extension for Community Healthcare Outcomes)) with monthly interactive webinars and quarterly short courses or (2) monthly interactive webinars and quarterly short courses alone (a control group); 856 patients will be assigned to participating clinicians (42 patients per clinician). Patient outcomes will be evaluated according to the study arm of their respective clinicians. Quantitative and qualitative outcomes will be measured at 3- and 6-months post-baseline for clinicians and every 3-months post assignment to a participating clinician for patients. The primary patient outcome is change in physical function measured using the Patient-Reported Outcomes Measurement Information System (PROMIS)-29. Analyses of differences in outcomes at both the patient and clinician levels will include a linear mixed model to compare change in outcomes from baseline to each post-baseline assessment between the randomized study arms. A concurrent prospective cohort study will compare the LC FIRP patient population to the population enrolled in a university health system. Longitudinal data analysis approaches will allow us to examine differences in outcomes between cohorts. We hypothesize that weekly teleECHO sessions with monthly interactive webinars and quarterly short courses will significantly improve clinician- and patient-level outcomes compared to the control group. This study will provide much needed evidence on the effectiveness of a technology-enabled multi-disciplinary team-based care model for the management of Long COVID, ME/CFS, and other PIFI within a federally qualified health center. ClinicalTrials.gov, NCT05167227 . Registered on December 22, 2021.

BACKGROUND:Quantitative neuromuscular ultrasound is increasingly used to study muscle pathology and changes in muscle mass during critical illness. Advantages of ultrasound are high axial resolution, low procedural risks, no ionizing radiation, and ease of use early in the course of disease. However, ultrasound is known to be an operator dependent imaging modality and the intensive care unit setting poses additional challenges to obtaining reliable measurements. There is limited evidence validating the feasibility and reliability of its application in this setting.OBJECTIVE:To conduct a standardized protocol for measuring muscle linear depth and cross-sectional area in critically ill populations with a high degree of interrater agreement and feasibility.DESIGN:Prospective observational cohort study of interrater reliability.SETTING:Medical intensive care unit at an academic medical center and a level one trauma and burn center.PATIENTS:Fifteen critically ill patients were evaluated using a standardized ultrasound protocol measuring total elbow flexor, knee extensor, and tibialis anterior depth, as well as rectus femoris cross-sectional area. Each site was independently scanned by two investigators. Reliability of measurements between observers was determined by calculating intraclass correlation coefficients (ICCs) using a two-way random effects model and absolute agreement. An ICC > 0.75 was considered good and >0.90 was considered excellent.RESULTS:In critically ill patients, interrater reliability of linear depth measured at elbow flexor, knee extensor, tibialis anterior, and cross-sectional area of rectus femoris sites was good to excellent with ICC between 0.87 (0.54-0.97) and 0.99 (0.97-1.00). Interrater reliability was improved by creating a summary index of measures resulting in an ICC of 0.99 (0.98-1.00). Feasibility, as definite by the percentage of each measure that was obtainable, ranged from 75%-100%.CONCLUSIONS:Using a standardized protocol, ultrasound measures obtained in critically ill patients demonstrated high levels of interrater agreement with good to excellent feasibility.

Patients with severe cases of coronavirus disease 2019 (COVID-19) often become critically ill requiring intensive care unit (ICU) management. These individuals are at risk for developing ICU-acquired weakness (ICUAW), a multifactorial condition in which polyneuropathy, myopathy, and/or disuse muscle atrophy result in motor weakness. This weakness is thought to contribute to the long-term functional disability frequently observed in survivors of critical illness. This review discusses the current evidence regarding the epidemiology, pathophysiology, evaluation, risk factors, and rehabilitation-specific management of ICUAW in patients with COVID-19. Because of the novelty of COVID-19, the exact prevalence of ICUAW is not well delineated among COVID-19 patients. However, ICUAW has been reported in this population with retrospective studies showing weakness occurring in up to 45.5% of patients with severe COVID-19. There are multiple risk factors for developing ICUAW among COVID-19 patients, including premorbid health status, sepsis, multiple organ failure, mechanical ventilation, immobilization, neuromuscular blockade, corticosteroid use, and glycemic control. ICUAW is more likely to occur after prolonged mechanical ventilation and long hospital stays and can be diagnosed with manual muscle and electrodiagnostic testing. Although the long-term sequela of COVID-19 after ICU stays is not fully studied, increasing evidence indicates significant risk for this population developing long-term functional impairments. Establishing postacute rehabilitation programs for COVID-19 survivors will be important for recovery of endurance, mobility, and function.

Summary: In patients with severe upper extremity weakness that may result from peripheral nerve injuries, stroke, and spinal cord injuries, standard therapy in the earliest stages of recovery consists primarily of passive rather than active exercises. Adherence to prescribed therapy may be poor, which may contribute to suboptimal functional outcomes. The authors have developed and integrated a custom surface electromyography device with a video game to create an interactive, biofeedback-based therapeutic gaming platform. Sensitivity of the authors’ custom surface electromyography device was evaluated with simultaneous needle electromyography recordings. Testing of this therapeutic gaming platform was conducted with a single 30-minute gameplay session in 19 patients with a history of peripheral nerve injury, stroke, spinal cord injury, and direct upper extremity trauma, including 11 patients who had undergone nerve and/or tendon transfers. The device was highly sensitive in detecting low levels of voluntary muscle activation and was used with 10 distinct muscles of the arm, forearm, and hand. Nerve and tendon transfer patients successfully activated the donor nerve/muscle and elicited the desired movement to engage in gameplay. On surveys of acceptability and usability, patients felt the system was enjoyable, motivating, fun, and easy to use, and their hand therapists expressed similar enthusiasm. Surface electromyography-based therapeutic gaming is a promising approach to rehabilitation that warrants further development and investigation to examine its potential efficacy, not only for building muscle strength and endurance but also for facilitating motor relearning after nerve and tendon transfer surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND:Intensive rehabilitation of adolescents occurs in general and pediatric inpatient rehabilitation facilities (IRFs), but differences in admission and outcomes by facility type have not been thoroughly investigated, particularly among persons with spinal cord injury (SCI).OBJECTIVES:To investigate factors related to admission to pediatric or adult IRFs among adolescents and compare the rehabilitation outcomes between facility types.METHODS:Using a single-center retrospective cohort study design, demographic information, medical data, and rehabilitation outcomes were obtained by chart review of patients aged 15 to 18 years who received a rehabilitation medicine consultation at an urban level 1 trauma center between 2017 and 2019 (N = 96). Analysis was performed using R statistical software.RESULTS:SCI was the second most common diagnosis (21% of patients) and accounted for 36% of inpatient rehabilitation admissions. SCI patients were more likely to undergo rehabilitation at the level 1 trauma versus pediatric facility (relative risk [RR] = 2.43; 95% confidence interval [CI] = 1.08-5.44) compared to traumatic brain injury patients. Admission to trauma versus pediatric IRF was also associated with Black compared to White race (RR = 2.5; CI = 1.12-5.56), violence compared to other etiologies of injury (RR = 2.0; CI = 1.10-3.77), and Medicaid compared to private insurance (RR = 2.15; CI = 1.01-4.59). Admission to pediatric IRF was associated with longer length of stay than admission to adult IRF when adjusted for diagnosis (30.86 ± 21.82 vs. 24.33 ± 18.17 days; p = .046), but Functional Independence Measures did not differ.CONCLUSION:Adolescents with SCI and those experiencing systemic disadvantages, including racism and poverty, were more likely to be admitted to trauma compared to pediatric IRF.

Advancements in critical care medicine have improved survival rates for patients experiencing critical illness in intensive care units (ICUs). Although mortality has declined, more than half of ICU survivors experience functional impairments that persist beyond discharge. Of particular concern is ICU-related cognitive impairment, which can extend across the care continuum, ranging from acute and transient presentations in the ICU (eg, delirium) to long-term impairments years after discharge. ICU-related cognitive impairment has received increased attention in the literature, particularly as it relates to ICU survivors who have received and survived critical care in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and are now experiencing postacute sequelae of SARS-CoV-2 infection. The medical complexity and heterogeneity of ICU survivors, coupled with the multifactorial etiology of ICU-related cognitive impairments, lead to challenges in how to optimize care for ICU survivors at various stages of recovery. This review aims to provide an overview of cognitive outcomes associated with critical illness by integrating recent literature focused on etiology, assessment, and interventions in the context of ICU-related cognitive impairments. The narrative review employs a biopsychosocial framework to comprehensively evaluate the multifactorial nature of ICU-related cognitive outcomes. Authors also highlight that multidisciplinary teams composed of key rehabilitation providers are likely best suited for optimizing recovery trajectories of ICU survivors.

There are an increasing number of individuals with long‐term symptoms of coronavirus‐19 disease (COVID‐19); however, the prognosis for recovery of physical function and fatigue after COVID‐19 is uncertain.

Abstract Introduction Financial toxicity negatively impacts recovery after injury. Financial assistance (FA; e.g., disability income, food stamps, low-income housing voucher) may mitigate the impacts of financial toxicity. We aimed to describe FA after burn injury and its association with health-related quality of life (HRQL) and return to work. Methods Data from adult participants participating in a multicenter longitudinal database from 2015 to 2021 were used for complete-case analysis. Participants were separated into two groups: those who received any form of financial assistance due to their burn injury, and those who did not. The cohort and FA were described. Multi-level, mixed-effects, linear regression was performed to assess the associations of FA with VR-12 Physical and Mental Health Component Summary scores (PCS, MCS) and return to work. Lastly, a propensity score analysis matched 3:1 on age, gender, pre-injury PCS and MCS, burn size, length of hospital stay, and the number of operations as a result of burn injury was used to maximally reduce potential confounding. Results The analysis included 1,237 participants [725 who received FA, 512 who did not receive FA (NFA)]. Participants who received FA due to their burn injury were more likely to be younger (median 42 FA vs 48 NFA, p-value < 0.001), racially minoritized (19.2% FA vs 14.3% NFA, p-value < 0.001), have larger injuries (21% FA vs. 10% TBSA NFA, p-value < 0.001), longer hospital stays (median 29.5 days FA vs. 17 days NFA, p-value < 0.001), more days before returning to work (median 220 days FA vs 79 days NFA, p-value < 0.001), and have a workers compensation insurance payer (23.6% FA vs. 9.38% NFA, p-value < 0.001) compared to peers who did not receive FA. The number of participants who received new FA decreased after the 6-month time point: 11% at discharge, 33% at 6 months, and 15% at 12 months. Propensity score analysis demonstrated that receiving FA was associated with lower PCS and MCS scores at all time points and longer time to return to work (Table 1). Conclusions Given that financial toxicity is associated with unsatisfactory recovery after injury, efforts to reduce financial stressors are needed. FA seems somewhat matched to patients with greater recovery challenges (e.g., larger injuries, more complex hospitalizations). Additionally, most patients do not receive FA for a prolonged period (e.g., >6 months). While FA is associated with lower HRQL and longer return to work, these data may represent improvement compared to what people living with burn injury might have experienced without FA and represent unmeasured confounding.

Introduction: As of December 19th 2020, Coronavirus Disease 2019 (COVID-19) has resulted in approximately 17.6 million cases and 315,000 deaths in the United States. The hospitalization rate for COVID-19 in the US continues to rise and is currently around 295.8 hospitalizations per 100,000 population. Despite the increasing number of individuals who are contracting and recovering from this disease, little is known about their functional recovery. Understanding functional outcomes in these patients is critical to address their rehabilitation needs. The purpose of this study is to characterize the 30-day patient-reported functional outcomes of older and younger adults following acute hospitalization for COVID-19. Methods: A single-center prospective cohort study was performed from April to October 2020 of adult survivors of hospitalization for COVID-19 (n=28). A standardized telephone questionnaire was administered 30-days after hospital discharge to participants addressing their ability to perform basic activities of daily living (ADLs), instrumental ADLs, mobility, fatigue symptoms (Patient-Reported Outcomes Measurement Information Systems-PROMIS) and general disability (Health Assessment Questionnaire Disability Index - HAQ-DI). Results: Participants' were 23-95 years old. Twenty-one (75%) were less than 65 years old. Fifteen (54%) were female and 19 (68%) were white. Mean hospital length of stay was 11.3 days and 10 (36%) participants required ICU admission. Among adults aged 65 years developed new impairments and 29% new dependence. The most common new impairments in both age groups were transferring for basic ADLs and preparing meals and grocery shopping for instrumental ADLs. Seventy-one percent of older and 76% of younger adults experienced a decline in at least one mobility task (getting up from a chair, walking up 10 stairs, or walking mile). Seventy-six percent of younger adults and 43% of older adults experienced a clinically significant worsening (> 5 points) in their PROMIS fatigue scores. Sixty-two percent of younger adults and 43% of older adults experienced a clinically significant worsening (> 0.22 points) in their HAQ-DI scores. Conclusions: Among adults hospitalized with COVID-19, the majority experienced a decline in ≥1 functional task 30 days after discharge compared to pre-hospitalization. Younger adults had similar to worse impairment in physical functional outcomes than older adults. These results indicate all adults, regardless of age, are at risk for prolonged, clinically significant functional impairment following hospitalization for COVID-19.

BACKGROUND:Many coronavirus disease 2019 (COVID-19) survivors experience persistent symptoms, such as fatigue, dyspnea, and musculoskeletal pain. However, less is known about the impact of COVID-19 on longer term functional outcomes. OBJECTIVE:To evaluate patient-reported activity of daily living (ADL) function and fatigue symptoms 30 days after hospitalization for COVID-19. DESIGN:Cross-sectional study. SETTING:Tertiary care university hospital. PARTICIPANTS:Adults 18 years or older hospitalized for COVID-19 and survived to 30 days after discharge. METHODS:A standardized telephone questionnaire was administered 30 days after hospital discharge. MAIN OUTCOME MEASURES:Ability to perform basic and instrumental ADLs and fatigue symptoms severity (Patient-Reported Outcome Measurement Information System [PROMIS] Fatigue Short Form 7a) were assessed by self-report. RESULTS:Participants (n = 55) were 22-95 years old. Compared to pre-COVID hospitalization, 52% developed new difficulty and 6% new dependence with performing basic ADLs (bADLs), 48% developed new difficulty and 11% new dependence with instrumental ADLs (iADLs), and 69% experienced a clinically significant worsening in their fatigue symptom severity. The average fatigue symptom severity T-score before hospitalization was 44.2 ± 7.4 and after hospitalization was 54.5 ± 9.8. In exploratory multivariate analyses, each additional COVID symptom at presentation was associated with a predicted increase of 1.43 units (95% confidence interval [CI], 0.45-2.42) in the 30-day fatigue symptom severity T-score, each additional day of hospitalization was associated with an 1.2 times increased odds of worsening fatigue (95% CI, 0.98-1.5; p = .08), and each unit increase in baseline body mass index was associated with 0.8 times decreased odds of new bADL or iADL dependence at 30 days (95% CI, 0.65-0.99). CONCLUSIONS:New functional impairments are common at 30 days after discharge among survivors of hospitalization for COVID-19. Early rehabilitation, advance care planning, and referrals to appropriate therapies should be considered in postacute COVID-19 care to maximize patients' functional outcomes. However, ongoing research is still needed regarding management of these patients.

Purpose: Upper extremity weakness may be debilitating and results from a variety of causes, including peripheral nerve and cervical spinal cord injury, stroke, and disuse atrophy. Therapy is critical for regaining function but patients are unable to engage with traditional methods of therapy until evidence of motor recovery is seen on clinical exam. In this study, we have developed an innovative system of gamified therapy that uses signals detected by surface electromyography (EMG), a well-established, noninvasive technique that measures electrical activity generated by muscle contractions from electrodes placed on the overlying skin. Methods: We constructed a highly sensitive custom surface EMG device and integrated it with multiple gaming platforms. In our system, adhesive electrodes are placed over a muscle of interest, and muscle activation greater than a set threshold triggers a single action in the virtual gaming environment. Patients with upper extremity weakness from any cause were recruited to use the surface EMG device to play games. Acceptability surveys were administered after each gaming session, and additional metrics to assess feasibility were examined, including task learning speed, length of gameplay session, high scores achieved, and technical problems encountered. Results: The sensitivity of our custom surface EMG device was assessed through simultaneous needle EMG recordings. Our device is capable of detecting muscle activation even during recruitment of a single motor unit, and signals recorded represent activity from the specific muscle of interest and not of opposing muscle groups nearby. Patients quickly learned how to activate their muscles to interact with the virtual gaming environment. Interestingly, patients lacking antigravity muscle strength, scoring as low as 2/5 on manual muscle testing, were still able to engage in reliable gameplay. Responses from acceptability surveys showed that the majority of patients found the surface EMG-based gaming platform to be motivating, enjoyable, easy to understand, and safe. Conclusion: Gamified therapy represents a novel approach to rehabilitation that promotes patient engagement, motivation, and compliance. The use of surface EMG signals as input for therapeutic gaming has tremendous potential for severe muscle weakness in the earliest stages of recovery, as nascent signals from underlying affected muscles are detectable on EMG before significant movement is observed on clinical exam. This creates the opportunity for earlier initiation of therapy in many patients with upper extremity weakness. In patients with brachial plexus injuries who have undergone nerve transfer surgeries, surface EMG-based therapy may have the added benefit of facilitating cortical retraining by helping patients learn the association between donor nerve activation and recipient muscle movement. Future studies are needed to assess the clinical efficacy of surface EMG-based gamification therapy in these distinct patient populations.

BACKGROUND Upper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients. OBJECTIVE The goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss. METHODS Patients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game’s acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative. RESULTS Patients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04). CONCLUSIONS Based on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke.

BackgroundEarly mobilization in critically ill patients has been documented to reduce neuromuscular complications, but access to rehabilitation services is often limited in the intensive care unit (ICU). Virtual platforms that deliver therapy may increase access to rehabilitation services and improve patient motivation to participate. Xbox Kinect Jintronix software delivers interventions using games and activities designed for therapy.ObjectiveTo determine the feasibility of the Jintronix virtual therapy system in an ICU setting by observing outcomes related to patient satisfaction, adverse events, and technical applicability.DesignProspective observational feasibility study.SettingMedical ICU at a Level 1 Trauma Center within an academic medical center.ParticipantsTwenty adults admitted to ICU.InterventionParticipants engaged in one therapy session with a maximum of 14 Jintronix modules targeting arm, leg, and/or trunk strength, range of motion, and endurance.Outcome MeasuresA trained physician‐observer recorded events related to adverse events and technical applicability. Participants completed a survey to determine patient satisfaction.ResultsA total of 188 modules were completed. Participants completed a median of nine modules each. Five participants completed the maximum of 14 modules. Fatigue was the most common reason for cessation. Mean intervention time was 29 minutes. There were no falls, lines dislodged, or medical events. Participants required physical assistance or verbal cues in 36% of modules. Technical errors affected 25% of modules and led to activity cessation in one case. Nearly all participants reported the activity was enjoyable, comfortable, safe, easy to understand, would improve range of motion and strength, and would motivate them to continue.ConclusionsUse of a virtual therapy environment in an intensive care setting is feasible.