Children with disabilities (CWD) participate in community settings less often than their nondisabled peers, often due to a lack of support. Occupational performance coaching (OPC) is an intervention that coaches adults to facilitate participation of CWD. This study examined if an OPC intervention provided to adult volunteers increased inclusion for CWD within a church setting. A mixed methods approach to using a cohort of Sunday school children with and without disabilities in a faith-setting was used. Improvements by 3 points in Goal Attainment Scale scores, by 3.2 points in total performance and 3.6 points in total satisfaction on the Canadian Occupational Performance Measure scores and improvements in the social networks were noted. This study suggests OPC used with community partners to be a feasible approach for increasing community inclusion for CWD.

ImportanceCoaching is an effective intervention strategy in occupational therapy but there lacks consensus in the literature about terms, definitions, and approaches used which can be barriers to the clinical use of this method.ObjectiveThe purpose of this review is to understand how coaching adults is used as an intervention to support children with disabilities.MethodsGuidelines from foundational scoping review articles and PRISMA-ScR were followed. Studies using adult coaching as an intervention to support children with disabilities were reviewed. A total of 20 articles met inclusion criteria and were included in the review.FindingsThe use of coaching terms and definitions vary. There are commonalities with coaching structures, "key ingredients," and use of outcome measures among studies which can provide a starting framework for occupational therapists wanting to use coaching as an intervention in their practice.Conclusions and RelevanceCoaching adults to support children with disabilities is already known to be an effective occupational therapy intervention strategy. Developing structured protocols with clearer and more unified terminology may improve the fidelity of this intervention approach.What This Article AddsThis article presents current practices in adult coaching to support children with disabilities in Occupational Therapy. The authors discuss commonalities across coaching practices for therapists who wish to use coaching protocols in their clinical practice.

The aim of this perspective is to describe the theory and practical steps of using principles of social network analysis to help measure the social inclusion of individuals with intellectual and developmental disabilities (IDD). Social inclusion for those with disabilities has become an important area of focus of rehabilitative professionals in the past decade. Social inclusion is comprised of the domains participation and social interaction. Decreased social inclusion can negatively impact quality of life and health. Individuals with IDD continue to experience barriers to social inclusion such as limited opportunities to socialize and participate in community groups, physical barriers, and the lack of available valued social roles. There are limited methods for measuring social inclusion for individuals with IDD. Social network analysis is one way to analyze and understand social relationships to better understand the social inclusion of individuals with IDD. Providing a way to measure social inclusion may help answer questions about the effectiveness of interventions, ultimately leading to increased social inclusion for individuals with IDD.

CONTEXT:Exercise has been shown to improve gait in individuals with Parkinson's disease (PD). Stepping practice at higher intensity levels has been suggested as a beneficial treatment option to improve gait in the neurological population. Unfortunately, this mode is poorly understood and underutilized within the PD population. Information on what individuals with PD are doing for exercise would be beneficial to help tailor exercise programs to improve gait and provide exercise options in the community for intensity-based exercise.OBJECTIVE:To investigate the current exercise habits of individuals living with PD in the community aimed at improving walking and to understand the impact of perceived intensity on daily exercise practices.DESIGN SETTING PARTICIPANTS:One hundred thirty-eight individuals with PD living in the community were surveyed online regarding their current exercise habits.MAIN OUTCOME MEASURE:A total of 22 questions aimed to understand exercise selection, focus, and perceived intensity. Questions asked basic demographic, symptom presentation and management of disease related symptoms that were present while living with PD. Exercise questions focused understanding participants current function level, practice exercise habits and perceived levels of exercise intensity during daily routines.RESULTS:Of the 138 individuals surveyed for this preliminary study, eighty-seven percent of individuals with PD participated in exercise with seventy-five percent choosing walking as a mode for exercise. Sixty-five percent of the respondents noted that despite exercise, their walking speed and endurance has worsened since diagnosis. Eighty-one percent perceived exercising at moderate intensity levels, however little provocation of intensity symptoms was noted.CONCLUSION:Our preliminary study survey results suggest that individuals with PD are exercising but not at high enough intensity levels to promote improvements in gait performance. Individuals with PD may need to be pushed at higher intensity levels, beyond their voluntary limits, to induce gait performance changes. These findings can provide a foundation for future fitness interventions within this population to target improving gait.

Background and Purpose: Individuals after stroke often have multiple chronic conditions, such as hypertension, diabetes, dyslipidemia, obesity, and tobacco use. These comorbidities not only are commonly found in individuals with stroke, but also negatively affect functional outcomes and increase risk for hospital readmission and overall mortality. It is important for physical therapists to address the whole person during treatment after stroke, including comorbidities, not just the problems resulting from the stroke itself. However, it is unclear how common it is for physical therapists to address multiple diagnoses at once using a wellness model. Therefore, the purpose of this scoping review was to examine current evidence regarding the role of physical therapy in addressing modifiable risk factors for individuals after stroke, to identify gaps in research associated with physical therapy management of related comorbid diagnoses during treatment for stroke. Methods: A scoping review methodology was utilized searching PubMed and CINAHL databases to identify interventional research studies specifically addressing multiple modifiable risk factors utilizing physical therapy for individuals after stroke. Results: The initial search yielded 5358 articles and 12 articles met full inclusion criteria. Only 2 studies included participants with significant mobility impairments, and none included individuals with communication impairments. Only 4 of the 12 studies provided education in their design. Eight studies did not include any patient-reported outcome measures. Only 3 studies included long-term follow-up assessments. Discussion: Secondary stroke risk factors can be positively addressed using physical therapy interventions; however, more research is needed regarding individuals with moderate to severe mobility or communication deficits. Opportunities for physical therapy research to address stroke risk factors in this complex population include expanding follow-up periods, improving educational interventions, and including caregivers in study design. Conclusions: This review highlights the need for better integration of clinical considerations into stroke rehabilitation research as a whole, along with the need for additional research regarding the role physical therapy can play in addressing multimorbidity in individuals with stroke.

Background: Vascular risk factors, such as diabetes mellitus (DM), are associated with poorer outcomes following many neurodegenerative diseases, including hemorrhagic stroke and Alzheimer's disease (AD). Combined AD and DM co-morbidities are associated with an increased risk of hemorrhagic stroke and increased Medicare costs. Therefore, we hypothesized that patients with DM in combination with AD, termed DM/AD, would have increased hemorrhagic stroke severity. Methods: Kentucky Appalachian Stroke Registry (KApSR) is a database of demographic and clinical data from patients that live in Appalachia, a distinct region with increased health disparities and stroke severity. Inpatients with a primary indication of hemorrhagic stroke were selected from KApSR for retrospective analysis and were separated into four groups: DM only, AD only, neither, or both. Results: Hemorrhagic stroke patients (2,071 total) presented with either intracerebral hemorrhage (ICH), n=1,448, or subarachnoid hemorrhage (SAH), n=623. When examining all four groups, subjects with AD were significantly older (AD+, 80.9 +/- 6.6 yrs) (DM+/AD+, 77.4 +/- 10.0 yrs) than non AD subjects (DM-/AD-, 61.3 +/- 16.5 yrs) and (DM+, 66.0 +/- 12.5 yrs). A higher percentage of females were among the AD+ group and a higher percentage of males among the DM+/AD+ group. Interestingly, after adjusting for multiple comparison, DM+/AD+ subjects were ten times as likely to suffer a moderate to severe stroke based on a National Institute of Health Stroke (NIHSS) upon admission [odds ratio (95% CI)] compared to DM-/AD- [0.1 (0.02-0.55)], DM+ [0.11 (0.02-0.59)], and AD+ [0.09(0.01-0.63)]. The odds of DM+/AD+ subjects having an unfavorable discharge destination (death, hospice, long-term care) was significant (P<0.05) from DM-/AD- [0.26 (0.07-0.96)] when adjusting for sex, age, and comorbidities. Conclusions: In our retrospective analysis utilizing KApSR, regardless of adjusting for age, sex, and comorbidities, DM+/AD+ patients were significantly more likely to have had a moderate or severe stroke leading to an unfavorable outcome following hemorrhagic stroke.

Introduction: Moyamoya is a chronic cerebrovascular condition of unclear etiology characterized by progressive occlusion of 1 or both internal carotid arteries with neovascular collateral formation. With both an idiopathic form (moya-moya disease) and congenital condition-associated form (moyamoya syndrome), it can cause ischemic and hemorrhagic stroke. Recent findings in Kentucky have challenged traditional estimates of its incidence in US populations. Using the Kentucky Appalachian Stroke Registry (KApSR), our aim was to further characterize its incidence as a cause of stroke and to understand the patient population in Appalachia. Methods: A retrospective review of moyamoya patients was performed using the KApSR database. Data collected included demographics, county location, risk factors, comorbidities, and health-care encounters from January 1, 2012, to December 31, 2016. Results: Sixty-seven patients were identified; 36 (53.7%) resided in Appalachian counties. The cohort accounted for 125 of 6,305 stroke admissions, representing an incidence of 1,983 per 100,000 stroke admissions. Patients presented with ischemic strokes rather than hemorrhagic strokes (odds ratio 5.50, 95% CI: 2.74-11.04, p < 0.01). Eleven patients (16.4%) exhibited autoimmune disorders. Compared to the general population with autoimmune disorder prevalence of 4.5%, the presence of autoimmunity within the cohort was significantly higher (p < 0.01). Compared to non-Appalachian patients, Appalachian patients tended to present with lower frequencies of tobacco use (p = 0.08), diabetes mellitus (p = 0.13), and hypertension (p = 0.16). Conclusions: Moyamoya accounts for a substantial number of stroke admissions in Kentucky; these patients were more likely to develop an ischemic stroke rather than a hemorrhagic stroke. Autoimmune disorders were more prevalent in moyamoya patients than in the general population. The reduced frequency of traditional stroke risk factors within the Appalachian group suggests an etiology distinct to the population.

BACKGROUND:In rural communities, individuals living with neurological conditions, such as stroke, traumatic brain injury (TBI), or spinal cord injury (SCI) and their caregivers face limited resources, decreased support, and a lack of access to health information and research. Little information exists on how to engage these individuals in community-based research.OBJECTIVES:We sought to 1) determine the most effective method(s) for engaging individuals with stroke, TBI, or SCI, and their caregivers in rural communities; 2) determine the perceived value of patient-centered outcomes research (PCOR) in their health care and clinical decision making; 3) to determine their health needs and related research priorities; and 4) to establish a community-based research team to support the development of relevant questions.METHODS:Targeting a population of individuals with stroke, TBI, or SCI and their caregivers, as well as health care providers, 17 in-depth interviews were conducted, followed by seven focus groups, and two half-day meetings to establish a community-based research team and develop a research agenda.RESULTS:Recruitment through trusted community networks was found to be the most beneficial for engaging participants. Participants placed high value on health research, but reported difficulties in accessing health information and in finding the information most relevant to them. A research team was established and research priorities centered on access to care and education.CONCLUSIONS:It is imperative to involve those living with a diagnosis or in an under-resourced community to develop the solutions that will work for them in their settings.

Introduction Cerebral Venous Sinus Thrombosis (CVST) has an estimated incidence of 1.32–1.57/100,000/yr, with death or severe disability in less than 10%. There is a reported elevated incidence in young -middle age females. The majority of reported epidemiologic and outcome data has been collected outside the United States (US). Available US data shows low representation of the Appalachian region, which has relatively a higher burden of disease and lower socioeconomic level. The objective of this study was to examine the gender characteristics of CVST patients in the United States, with greater representation of the Appalachian region. Methods Data were collected in a retrospective cohort using the Kentucky Appalachian Stroke Registry (KApSR), collected from admissions in a Comprehensive Stroke Center serving 554,300 from the central-eastern United States. All diagnosed CVST patients found in the database from 2010–2018 greater than 18 years of age were included in the data set. Descriptive data were computed using SPSS statistics. Results 101 patients diagnosed with CVST were included. 58 patients were female (57.4%). Median age was 44 years. The National Institutes of Health Stoke Scale (NIHSS) was reported for 32 female and 21 male patients. Median NIHSS was.5 in females and 0 in males at admission. Median length of stay was 7 days in females vs. 4 days in males. Discharge data were available for 51 female and 33 Male patients. Of female patients, 28 (55%) were discharged to home, 17(33%) were transferred to continued care, 4(8%) were transferred to hospice and 2(4%) died within 48 hours of admission. Of male patients, 25(76%) were discharged to home, 7 (21%) were transferred to continued care, and 1 (3%) was transferred to hospice. Female patients had a higher burden or comorbidities and multimorbidity compared to male patients. Conclusion The results of this study indicate a higher burden of comorbidity, more severe presentation, and worse prognosis in female patients. This is in contrast to the majority of CVST research, many of which have found the male sex to be an independent risk factor for worse outcomes. This may reflect a particular variant among the Appalachian population Disclosures S. Walsh-Blackmore: 1; C; University of Kentucky Center for Clnical and Translational Sciences Professional Student Mentored Research Fellowship. J. Fraser: None. P. Kitzman: None. M. Dobbs: None.

Introduction: Moyamoya is a chronic cerebrovascular condition of unclear etiology characterized by progressive occlusion of one or both internal carotid arteries with neovascular collateral formation. With both a congenital juvenile form and a likely secondary adult form (moyamoya syndrome), it can cause ischemic and hemorrhagic stroke. Recent findings in the region have challenged traditional estimates of its incidence in US populations. Using the Kentucky Appalachian Stroke Registry (KApSR), our aim was to further characterize its incidence as a cause of stroke, and to understand the particular patient population in our region. Methods: A retrospective review was performed of patients identified with moyamoya within the KApSR database. Data collected included demographics, risk factors, comorbidities and healthcare encounters from January 1, 2012 to December 31, 2017. Statistical analyses were completed in SPSS 24 (IBM Corp., Armonk, NY, USA). Results: Sixty-seven patients were identified; 36 (53.7%) resided in Appalachian counties. The cohort accounted for 125 of 6305 stroke admissions, representing a prevalence of 1983 per 100000 stroke admissions. Most patients presented with ischemic strokes rather than hemorrhagic (OR 5.50, 95% CI:2.74-11.04, p<0.0001). Eleven patients (16.4%) exhibited autoimmune disorders. Compared to the general population autoimmune disorder prevalence of 4.5%, the presence of autoimmunity within the cohort was significantly higher (p<0.0001). Comparing Appalachian to non-Appalachian, Appalachian patients tended to present with lower frequencies of tobacco use (p=0.073), diabetes mellitus (p=0.086), hypertension (p=0.141) and autoimmunity (p=0.322). Conclusion: The prevalence of moyamoya accounts for a significant portion of stroke admissions in Appalachia and these patients were more likely to develop an ischemic stroke than hemorrhagic. Autoimmune disorders were more prevalent in moyamoya patients compared to the general population. Finally, the reduced frequency of risk factors within the Appalachian group suggests an etiology distinct to the population.

Total knee replacement (TKR) surgery has been found to achieve positive outcomes for many patients such as reduced pain and increased function. However, some patients experience suboptimal outcomes including falls, readmission to hospital, and reduced functional performance. Preparation for discharge after TKR surgery is often defined related to pain control, walking, knee function, and ability to climb stairs. These measures may not fully encompass aspects of recovery that impact patients' readiness for discharge after surgery. The purpose of this article is to review discharge readiness following TKR surgery and discuss factors that are known to impact preparedness for discharge.

Introduction: Mechanical thrombectomy has become standard of care for emergent large vessel occlusive stroke. Estimates of incidence for thrombectomy eligibility vary significantly. National Institutes of Health Stroke Scale (NIHSS) of 10 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated temporal trends in stroke admissions with NIHSS ≥10 to determine patient characteristics among that group along with effects and needs in thrombectomy utilization. Methods: Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS ≥10. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was used as an indicator of inpatient outcome. Results: Between 2010 and 2016, 1,510 patients were admitted with NIHSS ≥10. 87.2% had high blood pressure, 69.6% had dyslipidemia, and 41.7% used tobacco. There were significant sex differences in the types of patients presenting with NIHSS ≥10 with females being older on average and having more atrial fibrillation and obesity. There was an increase in thrombectomy utilization from 2010 to 2016, but only 7.5% of the potentially eligible patients underwent the procedure. In comparison to the period 2010–2014, the 2015–2016 period had higher rates of obesity and tobacco abuse. Conclusion: Among patients with significant burden of ischemic stroke, the most common coexisting medical condition was high blood pressure. Patients who underwent thrombectomy had significantly better inpatient clinical improvement. These data support the need to maximize utilization of thrombectomy along with need to devote increased resources on modifiable stroke risk factors.

Background: The majority of studies on multimorbidity have been in aging populations and there is a paucity of data on individuals following stroke. Objective: In order to better understand the overall complexity of the stroke population in rural Kentucky, we examined the prevalence of multimorbidity that impact the overall long-term health and health care for these individuals. Methods: A secondary analysis examined whether there are gender or age differences in this stroke population related to the prevalence of multimorbidity. A total of 5325 individuals, 18 years of age and older, seen at an academic medical center for the primary diagnosis of acute ischemic stroke or transient ischemic attack between the years of 2010-2017 were identified using the Kentucky Appalachian Stroke Registry. Descriptive analysis was used to report the prevalence of each comorbidity in the rural population by age group, gender, and level of multimorbidity by looking at concurrent frequencies. Results: Overall, hypertension, dyslipidemia, tobacco use, diabetes, and obesity were the comorbidities with the highest prevalence in our population irrespective of gender. Over 78% (n = 4153) of the individuals had 3 or more comorbidities while 61% (n = 3285) had at least 3 out of the top 5 comorbidities (hypertension, hyperlipidemia, tobacco, obesity, diabetes). With respect to age, 15% (n = 795) of the sample was under the age of 50, while 32% (n = 1704) were between the age of 50 and 64 and 53% (n = 2826) of the sample were 65 years or older. Conclusions: The results of this study indicate the majority of individuals affected by stroke in rural Appalachia Kentucky have multimorbidity. In addition, almost half of these individuals are having their strokes at a younger age, which will require a shift in the focus for therapeutic interventions (eg, reintegration into the workforce versus just community reintegration).

Date Presented 4/19/2018 This patient-centered outcomes research–funded project looked at engagement and health care priorities among people with traumatic brain injury, spinal cord injury, and stroke and caregivers living in underserved rural communities. Results contribute to an understanding of the factors influencing health outcomes for this population. Primary Author and Speaker: Elizabeth G. Hunter Additional Authors and Speakers: Patrick Kitzman

Objective: The impact that visual perturbation has on upright postural stability in an athlete with a concussion has not been established. The present study aimed to characterize the influence that visual perturbation stimuli have on upright balance among athletes with acute concussions. Design: A 2X2X2 repeated measure designed was used. Method: The present study examined the influence visual perturbation has on individuals suffering from an acute concussion. Fourteen participants (7 with a concussion and 7 matched controls) underwent various balance assessments with and without visual perturbation. Results: Overall, athletes with acute concussions demonstrated impairments in balance 24-48 hours following a concussion. However, when assessed using a visual perturbation task, athletes with acute concussions demonstrated improved balance, while control subjects did not show any significant changes during the same visual perturbation task. Conclusion: An athlete's ability to disregard visual perturbation stimuli is imperative for successful participation in sports. Due to the observed alterations in balance when given a visual perturbation task, it is suggested that athletes with acute concussions place more attention on the balance task and may disregard other less meaningful tasks.

Background: Mechanical thrombectomy has become standard of care for emergent large vessel occlusive (ELVO) stroke. Estimates of incidence for thrombectomy eligibility vary significantly. NIH Stroke Scale (NIHSS) of 9 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated regional trends in stroke admissions with NIHSS of 10 or more to determine effects and needs in thrombectomy utilization. Methods: Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS > 9 anytime during admission. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was measured as an indicator of inpatient outcome. Summary statistics and analyses were performed on SPSS; p<0.05 was significant. Results: From 2010 to 2016, 2250 patients were included; 132 (5.9%) underwent thrombectomy. 66.8% were admitted with NIHSS > 9. Annual utilization of thrombectomy increased over time from 0.8% in 2010 to 10.6% in 2016. When thrombectomy was considered, median change in NIHSS was -2 (IQR 8) in patients without thrombectomy versus -5 (IQR 12) in patients who underwent thrombectomy; the difference was significant (p<0.001). Furthermore, while the median change in NIHSS remained stable for non-thrombectomy patients, it improved over time for thrombectomy patients (Figure 1). Conclusion: Among patients with significant inpatient ischemic stroke, a majority present with NIHSS greater than 9. While thrombectomy has become more common, it was only utilized in 10.6% of patients in 2016. Furthermore, patients who underwent thrombectomy has significant inpatient clinical improvement compared to those that did not. Thus, further efforts are necessary to maximize the use of thrombectomy when appropriate.

BACKGROUND:The population of rural Kentucky and West Virginia has a disproportionately high incidence of stroke and stroke risk factors. The Kentucky Appalachian Stroke Registry (KApSR) is a novel registry of stroke patients developed to collect demographic and clinical data in real time from these patients' electronic health records.OBJECTIVE:We describe the development of this novel registry and test it for ability to provide the information necessary to identify care gaps and direct clinical management.METHODS:The KApSR was developed as described in this article. To assess utility in patient care, we developed a "Diabetes Quality Assurance Dashboard" by cross-referencing patients in the registry with a diagnosis of ischemic cerebrovascular disease with patients that were tested for hemoglobin A1c (HbA1c) levels, patients with HbA1c levels diagnostic for diabetes mellitus (DM), and patients with an elevated HbA1c that were formally diagnosed with DM.RESULTS:For the 1008 patients treated for ischemic cerebrovascular disease in the year studied, 859 (85%) had their HbA1c tested. Of those, 281 had levels of 6.5 or greater, although only 261 (93%) were discharged with a formal diagnosis of DM.CONCLUSIONS:The KApSR has practical value as a tool to assess a large population of patients quickly for care quality and for research purposes.

BACKGROUND: Limited descriptions of preoperative education programs for total knee replacement (TKR) surgery are provided in the literature, and the most effective program design is currently unknown. PURPOSE: The purpose of this qualitative study is to describe orthopaedic nurses' perceptions of preoperative education prior to TKR surgery. METHODS: Ten participants completed phone interviews and transcripts were analyzed qualitatively for themes among participants. RESULTS: Participants believed that preoperative education was a significant component impacting patient outcomes following surgery. Interprofessional preoperative education was valued, but pragmatic factors were identified as barriers to the inclusion of other disciplines within these programs. Education programs were constantly evolving on the basis of evidence-based practice and changes to orthopaedic protocols. Pragmatic factors influenced all aspects of program design, such as the timing and length of education sessions. CONCLUSIONS: Results from this study provide descriptions of factors that influence program design and can be used to restructure education programs for improved patient outcomes.