Recent Chan Publications

Starting with the foundation established by Black feminist scholar Kimberlé Crenshaw, intersectionality has been adopted and adapted within various disciplinary contexts. The purpose of this chapter is to present the origin, key principles, and current use of intersectionality theory and to consider its contribution to understanding occupation and occupational therapy by addressing its key postulations and constructs. As further discussed below, integrating an intersectionality lens in occupational therapy and occupational science is relatively recent. There is a growing recognition in the occupation-based literature of the need to examine intersections of diverse social positionings. More recent studies have also begun extending the analysis beyond an initial focus on race and gender. Explicitly applying an intersectionality lens to occupation-based knowledge, theories, and frameworks can further advance understanding of how diverse identities intersect within power structures and the implications of these complex intersections for occupation.

Purpose/Objectives. This study examined the relationship between environmental factors (e.g., working position, patient position, and scaling instruments) and poor posture in dental hygiene students.

Methods. A longitudinal cohort study was conducted from 2017 to 2019 to observe dental hygiene students' clinical rotation performance at two undergraduate universities. Samples of video observations (n = 1487) of dental hygiene students performing scaling activities during oral care sessions were evaluated using the Rapid Upper Limb Assessment (RULA). Descriptive analysis and exploratory prediction modeling were performed to assess clinical environmental factors that predicted higher risks of developing WMSDs.

Results. RULA scores (mean = 4.8, median = 5, range = 2–7) indicate dental hygiene students are at high risk of developing upper extremity MSDs. The type of scaling instrument, clock positioning relative to the patient, and sitting versus standing had statistically significant associations (p < 0.001) with the RULA outcome. In univariate analyses, clock positions 7 and 8 were the worst, having an increased risk of poor RULA outcomes (scores 5–7) by nearly nine times over working in clock position 12 (odds ratio [OR] 9.11, 95% CI 5.48–15.60). Multivariate predictive modeling indicated that the riskiest combination of factors is using a manual scaling instrument (OR 1.67, 95% CI 1.28–2.18), standing (OR 1.42, 95% CI 1.03–1.96), and working clock positions 7 and 8 (OR 8.4, 95% CI 5.02–14.50).

Conclusions. There is a need to consider the combined contribution of multiple environmental factors on working positions to optimize ergonomic training during dental hygiene and protect emerging dental health professionals from the negative health impacts of prolonged awkward postures.

Objective: Currently, no standardized sonography protocol for evaluating the distal flexor tendons in the hand exists. The aims of this research were to (1) establish an image acquisition protocol to standardize assessment and (2) describe typical variations in the morphology of flexor tendons in healthy individuals.

Materials and Methods: A sonography protocol was developed, refined, and deployed in a cohort of healthy volunteers to collect images and cine clips of flexor tendons beginning at the mid-palm through insertion at the distal phalanx. Longitudinal and cross-sectional images of the tendons were measured at each joint space (e.g., the metacarpophalangeal, proximal interphalangeal, and distal phalangeal joints). Through an iterative process, images from each location were compared across participants.

Results: The anatomic patterns and unique presentations of hand flexor tendons in 15 healthy volunteers were identified and described, including the bifurcation of the flexor digitorum superficialis tendon and the atypical presentation of muscle bellies in the distal hand. Best practices for imaging and morphologic variability were described in a final detailed imaging protocol.

Conclusion: A detailed sonography protocol was established, and standardization in imaging practices using such a protocol should be considered when scanning tendons in the distal hand to enhance rigor and reliability in clinical and research evaluations of the flexor tendons.

The COVID-19 pandemic necessitated a transition to telehealth. Research supports the use of telehealth; however, there is a paucity of literature on the ethical considerations of this shift. This study explored ethics through narratives of practitioners’ lived experiences of transitioning to telehealth. Semi-structured interviews were conducted virtually with 10 pediatric health care professionals. Transcripts were analyzed from a narrative phenomenological perspective. Discussed themes include responding to the rapid redirection, collaborating with colleagues and caregivers, applying therapeutic use of self, and evolving pragmatic clinical reasoning. Transitioning to telehealth resulted in ethical dilemmas pertaining to clients and practitioners. The need for additional support was salient to ensure clients received beneficial services that would not cause harm (non-maleficence). Communities of practice formed organically as forums to explore strategies for sharing comprehensive and equitable information (veracity and justice). Knowledge generated through providers’ experiences may inform future guidelines on service delivery transitions.

Purpose. The purpose of this retrospective cohort analysis was to investigate sex differences in receipt of standard of care sleep and constipation drug treatments among autistic children and youth with sleep disorder and constipation, respectively.

Methods. We used the data from the OneFlorida + Data Trust to analyze healthcare claims for 19,877 autistic patients with sleep disorder and 32,355 patients with constipation, ages 1 to 22. We used logistic regression to examine sex differences in receiving sleep and constipation treatments, and a multivariate logistic regression model to further assess sex differences in ever receiving sleep and constipation treatments, adjusting for age, race, ethnicity, and urbanicity.

Results. In our multivariate analysis, autistic girls with sleep disorder were 1.27 times more likely than boys to receive sleep treatment (p < 0.0001). Although autistic girls with constipation appeared to be 1.10 times more likely than boys to receive treatment, it was not significantly different after adjusting for demographic and socio-economic characteristics (p = 0.372). Older children were 1.09 times more likely than younger children to receive sleep treatment (p < 0.0001) and 1.07 times more likely to receive constipation treatment (p < 0.0001).

Conclusion. We did not find sex differences among autistic children for treatment of constipation, but autistic girls with sleep disorder were significantly more likely to have ever received treatment, which could indicate that girls experience more significant sleep disorders.

Background. Young adults with type 1 diabetes mellitus often face challenges managing their condition, leading to elevated glucose and heightened psychosocial distress. Diabetes care traditionally focuses on biomedical outcomes, with less emphasis on well-being. Occupational therapy offers a holistic approach to managing diabetes by integrating changes to daily habits and routines and psychosocial support.

Methods. This randomized controlled trial involved participants aged 18–30 with HbA1c ≥ 7.5 % (≥58 mmol/mol). Participants received either telehealth occupational therapy or usual care. The intervention addressed diabetes management, daily habits and routines, and emotional well-being. Data collected at baseline, 3 months, and 6 months included HbA1c, continuous glucose monitoring metrics, and psychosocial outcomes. Analyses employed intent-to-treat principles, using ANCOVA to evaluate between-group differences.

Results. Participants (n = 209) were 24.3 (±3.7) years old, 59.8 % female, 44.5 % non-Hispanic White, and 47.4 % publicly insured. No significant differences were found in glycemic outcomes. Intervention participants had improved diabetes-related quality of life (DQoL; least-squares [LS] mean 0.67, 95 % CI 0.02 to 1.32, p = 0.045) and reduced diabetes distress (LS-mean −0.36, CI −0.65 to −0.07, p = 0.01).

Conclusion. Generalizability may be impacted by external factors related to COVID-19. The findings suggest occupational therapy may be beneficial for young adults experiencing diabetes-related distress and poor DQoL.

Purpose. Intentional communication acts, or purposefully directed vocalizations and gestures, are particularly difficult for infants at elevated likelihood for eventual diagnosis of autism. The ability to measure and track intentional communication in infancy thus has the potential to aid early identification and intervention efforts. This study assesses the validity of a novel measure of intentional communication intended for use within semistructured caregiver–infant interactions.

Method. The Intentional Communication Coding Scale (IC Coding Scale) captures infants' Vocalizations, Gestures, and Combined (vocalizations paired with gestures) acts. Using data from 36 infants at elevated likelihood for autism, we tested the convergent and discriminant validity of the IC Coding Scale with established language measures using Spearman's rho. We tested interrater reliability using intraclass correlation coefficient (ICC) calculations. Finally, we tested responsiveness (i.e., sensitivity to change) using Wilcoxon signed-ranks tests and Spearman's rho.

Results. Our initial psychometric tests suggested adequate levels of convergent and discriminant validity. ICCs ranged from .77 to .92, while confidence intervals were wide, suggesting that Gestures and Combined acts were coded more variably than Vocalizations were among raters. Tests of the scale's responsiveness suggested adequate sensitivity to change across a 12-week period.

Conclusions. This study is an important first step toward validating the IC Coding Scale for use in measuring and tracking intentional communication behaviors in infants at elevated likelihood for autism within more naturalistic, semistructured activities. Additional studies are needed to disentangle the effects of intervention from maturation and to examine types of intentional communication acts in more detail.

Introduction. Occupational therapists are tasked with developing technical, political, and ethical actions that address the suffering and isolation of diverse groups, particularly those historically marginalized. This study focuses on gender and sexual dissidences – a term encompassing individuals who exist beyond or outside of identity categories (such as lesbians, gays, bisexuals, transgenders, among others).

Objectives. To present an overview of the practices of occupational therapists in Brazil with the population who experience dissidence of gender and sexuality.

Method. Data were collected through an online survey using snowball sampling, initially reaching out to seed informants, professional entities, and social media networks. Data organization, analysis, and discussion were conducted using descriptive statistics, supplemented by the theoretical background of social occupational therapy, queer studies, and critical occupational science.

Results. Ninety-five responses were analyzed, with informants reporting various motivations for their involvement with the topic, including personal and familial affinities and needs encountered within their professional contexts. A wide array of practices emerged, developed from distinct approaches across various professional domains. These were grouped into four main categories: individual consultations, group consultations, academic activities, and network articulation. Despite the relevance of theoretical-methodological frameworks, informants infrequently mentioned studies specifically addressing gender, sexuality, or occupational therapy in their responses.

Conclusion: While contributions to the population who experience dissidence of gender and sexuality were noted, we identified no practices explicitly tailored to these populations or themes. Occupational therapists predominantly employ resources aligned with their core professional training and general education.

Keywords. Sexual and gender minorities; Professional Practice; Occupational Therapy; Social Occupational Therapy; Critical Occupational Science.

Early signs of autism can be identified in children as young as 6–9 months; however, screening tools to identify characteristics of autism in young children are underutilized by pediatricians. This qualitative study aimed to 1) understand the role of occupational therapists (OTs) in early intervention teams when identifying and intervening with infants and toddlers demonstrating early markers of autism, and 2) determine the readiness and capability of OTs within early intervention to utilize autism screening tools in practice. Two semi-structured 90-minute focus groups were conducted with 13 OTs with current or past work experience in early intervention settings across Los Angeles, California. Participants expressed pride in their versatile role on early intervention teams; however, they had mixed feelings about the value of formal autism screening. Even when they were confident about their ability to detect early autism signs, participants cited numerous barriers related to knowledge of screening, stigma related to autism, and reliance on other providers such as pediatricians. These qualitative findings illuminate a need for mitigating expressed barriers to service delivery, bolstering education on screening procedures, and capitalizing on the adaptability of OTs in early intervention practice in order to advance the role of OTs in initiating the early autism screening process.

Keywords. Early intervention; screening; autism; occupational therapy; practitioner perspectives

This study drew on familial autoethnographic and narrative methodologies to analyze the lived experiences of a mother (Ruth), the first author’s grandmother, situated within the cultural and societal context of 1950s America, to understand the choice she made at that time to care for her son with Down syndrome rather than place him in an institution. This study sought to better understand the contextual factors that influenced this mother to make decisions outside of her cultural contexts, while also recognizing the cultural and personal factors that may support or enable such decisions. We then discuss how such factors may be relevant for contemporary contexts.

Keywords. Disability; lived experiences; narrative; familial autoethnography; motherhood; cultural context

Health services research (HSR) is a field of study that examines how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and health and well-being. HSR approaches can help build the occupational therapy evidence base, particularly in relation to population health. Data from electronic health record (EHR) systems provide a rich resource for applying HSR approaches to examine the value of occupational therapy services. Transparency about data preparation procedures is important for interpreting results. Based on our findings, we describe a six-step cleaning protocol for preparing EHR and billing data from an inpatient rehabilitation facility for research and provide recommendations for the field based on our experience. Using and reporting similar strategies across studies will improve efficiency and transparency, and facilitate comparability of results.

Purpose. The purposes of this article were (a) to compare the developmental skills of toddlers whose scores on the First Years Inventory–Lite (FYI-Lite), an early screening tool, indicated an elevated likelihood of a later diagnosis of autism (ELA) to the developmental skills of toddlers at a lower likelihood of a later diagnosis of autism (LLA) and (b) to examine how autism characteristics are correlated with communication measures in toddlers at an ELA.

Method. We assessed the language, social communication (SC) skills, and characteristics of autism demonstrated by 45 toddlers at an ELA and 37 toddlers at an LLA between the ages of 11 and 18 months and compared group scores on these measures. We also examined the correlations between the characteristics of autism and language measures within the ELA group.

Results. Toddlers at an ELA demonstrated lower scores on measures of global expressive and receptive language, receptive vocabulary, gestures, and response to joint attention bids as well as SC characteristics of autism when compared to those demonstrated by toddlers at an LLA. There were no significant differences between groups on expressive vocabulary, language profiles (i.e., the relationship between receptive and expressive scores), or restrictive and repetitive behaviors. Within the ELA group, the SC characteristics of autism were significantly associated with their global receptive and expressive language skills.

Conclusions. On the basis of the FYI-Lite screening tool, toddlers at an ELA are demonstrating delays in language and SC skills when compared to toddlers identified with an LLA. For toddlers at an ELA, the SC characteristics of autism are significantly associated with early language skills.

Autism spectrum disorder (ASD) and Developmental Coordination Disorder (DCD) are distinct clinical groups with overlapping motor features. We attempted to (1) differentiate children with ASD from those with DCD, and from those typically developing (TD) (ages 8–17; 18 ASD, 16 DCD, 20 TD) using a 5-min coloring game on a smart tablet and (2) identify neural correlates of these differences. We utilized standardized behavioral motor assessments (e.g. fine motor, gross motor, and balance skills) and video recordings of a smart tablet task to capture any visible motor, behavioral, posture, or engagement differences. We employed machine learning analytics of motor kinematics during a 5-min coloring game on a smart tablet. Imaging data was captured using functional magnetic resonance imaging (fMRI) during action production tasks. While subject-rated motor assessments could not differentiate the two clinical groups, machine learning computational analysis provided good predictive discrimination: between TD and ASD (76% accuracy), TD and DCD (78% accuracy), and ASD and DCD (71% accuracy). Two kinematic markers which strongly drove categorization were significantly correlated with cerebellar activity. Findings demonstrate unique neuromotor patterns between ASD and DCD relate to cerebellar function and present a promising route for computational techniques in early identification. These are promising preliminary results that warrant replication with larger samples.

Keywords. Autism spectrum disorders, Developmental coordination disorder, Machine learning, fMRI, Early detection, Smart tablet

Importance: Patients in intensive care units (ICUs) experience complex functional, physical, and cognitive needs that affect their engagement in activities of daily living (ADLs). Occupational therapy practitioners are uniquely positioned to address these needs to optimize patients’ functional recovery.

Objective: To examine occupational therapy–specific interventions as they relate to early engagement for patients in the ICU.

Data Sources: CINAHL, PubMed, ProQuest, OTseeker, and Cochrane Library databases.

Study Selection and Data Collection: The Cochrane methodology was used to collect, evaluate, and analyze articles, then reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines for conducting a systematic review. Articles published from January 2012 to December 2021 evaluating adults who received occupational therapy interventions in ICUs with Level 1b, 2b, or 3b evidence were included.

Findings: Nine articles met the inclusion criteria and the research objective. Findings showed moderate evidence for ADLs, physical rehabilitation, and cognitive interventions in promoting functional outcomes for patients in the ICU.

Conclusions and Relevance: This systematic review introduces the term early engagement to describe occupational therapy–specific interventions for patients recovering in the ICU and supports occupational therapy’s role in this setting. Further research is needed to strengthen the evidence for occupational therapy–specific interventions and early engagement in the ICU.

Plain-Language Summary: Patients in the intensive care unit experience complex needs that affect their participation in activities of daily living (ADLs). Current research demonstrates moderate evidence for early engagement with ADLs, physical rehabilitation, and cognitive interventions performed by occupational therapy practitioners. This systematic review introduces the term early engagement, which captures how occupational therapy practitioners provide holistic interventions for patients in the intensive care unit to promote patient well-being and functional recovery.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also referred to as the novel coronavirus (Covid-19), belongs to the Sarbecovirus subgenus of the genus Betacoronavirus. In December 2019, unbiased sequencing in samples obtained from a cluster of patients symptomatic for pneumonia of unknown cause led to the discovery of Covid-19. The virus was highly transmittable and rapidly spreading, which led to the declaration of a global pandemic by the World Health Organization in March 2020. The symptoms of infection with Covid-19 replicated those seen in viral pneumonia and included cough, fever, and chest congestion and discomfort. More than two-thirds of patients hospitalized with the disease suffered from damage to the central nervous system in addition to respiratory symptoms. Along with neurological manifestations, evidence of psychiatric and cognitive involvement was also recorded in Covid-19 infection. Commonly reported psychiatric and neuropsychiatric presentations included depression, anxiety, post-traumatic stress disorder, delirium, altered consciousness, and dysexecutive syndrome. Cognitive decline because of Covid-19 infection was observed in functioning related to memory, executive functioning, and verbal fluency. This chapter discusses the multifold acute as well as persistent neuropsychiatric, cognitive, and neurological manifestations of Covid-19.

Keywords. SARS-CoV-2, coronavirus, Covid-19, neuropsychiatric, neurocognitive, neurological, post-Covid-19

Arguments about human occupation have always acknowledged that context influences various dimensions of what people can do, are expected to do, and cannot do. Occupational science and occupational therapy literature published through the early 2000s particularly emphasized how immediate physical, social, and temporal environments shaped people’s occupational engagements. In recent years, scholars have shown how consideration of broader conditions, such as social power relations, yields more fulsome explanations of how occupation is both shaped by and helps to (re)shape life contexts. These “situated” approaches have generated increasingly rich and complex knowledge about occupation’s political, social, cultural, and historical embeddedness and significance. Through selected examples about cooking and food provisioning occupations, this chapter provokes critical reflexivity regarding evolving understandings about the situated nature of human occupation and how they can inform occupation-based practices from individual to systemic levels.

Critical perspectives provide concepts and a lens that can be used to problematize and reformulate occupational issues, practices, and assumptions that maintain an individualist focus and neglect socially inequitable conditions that differentially affect groups in society. Critical perspectives provide a broader understanding of the socioeconomic and political conditions that shape occupation. Numerous examples have emerged in the literature to support the value added by integrating these perspectives into occupation-based practices. Applying critical perspectives can contribute to social transformation by shifting ways of thinking and doing, such that the socioeconomic and political roots of occupational inequities are addressed. This chapter interweaves critical reflexive vignettes and examples of the authors’ work to exemplify how critical perspectives have helped reframe issues and solutions in ways that expand beyond a primary focus on individual doing. This chapter builds on previous work that calls for continuous reflexivity and problematization of socially dominant norms as strategies to resist individualistic tendencies and contribute to enacting social transformation and promoting equity-oriented practices.

Unsustainable patterns of human occupation have detrimentally affected the natural world, disrupted ecosystems, and placed the long-term health of humanity at risk, making environmental sustainability a topic of paramount importance to occupational therapists. To minimize damage to the natural environment and promote human health, well-being, and justice, occupational therapists should develop knowledge of environmental sustainability and human occupations. This chapter aims to provide readers with a basic understanding of the impact that human occupation has on the environment, the effects of climate change on human occupation, and the ethical dimensions of sustainability. Additionally, this chapter will introduce readers to the application of occupational therapy theory to environmental sustainability concepts, as well as initiate a discussion of environmental sustainability in occupational therapy practice settings, treatment, and education.

This chapter discusses a growing body of theoretical and practical work by occupational therapists interested in developing practices around social transformation. A corresponding interest is also developing around the concept of collective occupations. Our intended audience is students and entry-level professionals in occupational therapy who will most likely find themselves in mainly corporatized health care systems. The chapter introduces Occupational Reconstruction Theory to students and practitioners of occupational therapy. Occupational Reconstruction Theory grows out of interdisciplinary scholarship in occupational science, social anthropology, 20th-century pragmatism, narrative studies, social movement studies, and occupational therapy. The purpose of Occupational Reconstruction Theory is to identify the key underlying principles guiding social transformation practice in occupational therapy. The chapter also discusses why practitioners need some familiarity with philosophical frameworks of thought to justify changes they may wish to make to theory and practice, as well as to adequately evaluate and critique changes proposed or enacted by others. Finally, the chapter discusses the Occupational Reconstruction Theory, which identifies a set of elements that appear to be common among documented instances of transformative social action. It also discusses how an occupational therapist could use Occupational Reconstruction Theory as a practical framework for social transformation practice.

In this chapter the authors engage their personal experiences as “close-to-home” researchers to interrogate knowledge production and practices of inclusion in psychological anthropology. They mobilize abolitionist theory and praxis as exemplified in models of transformative justice and bell hooks’s “love ethic,” to develop a loving critique of our subfield’s disciplinary past and potential future. With the subfield’s emphasis on lived experience, emotion, morality/ethics, care, compassion, and trauma, psychological anthropology is uniquely primed to lead the way in a more liberatory anthropological practice. This depends, however, on how people working in the subfield can move their engagement with lived experience off the page and into our relationships with each other.

Objectives. Stiff shoulder, including primary and secondary types, poses diagnostic challenges due to vague definitions and criteria. This study evaluates the diagnostic potential of ultrasound-measured axillary recess (AR) thickness in shoulder stiffness.

Designs. In this cross-sectional study, 35 patients with unilateral shoulder stiffness were assessed. AR thickness was measured using high-resolution ultrasound. Parameters like passive range of motion (PROM), Numerical Rating Scale (NRS), and Constant-Murley (CM) score were evaluated to find correlations with AR thickness.

Results. The average age was 50.7 years, and mean BMI was 22.7. AR thickness in stiff shoulders (average 3.19 mm) was significantly higher than in unaffected shoulders (average 1.93 mm, p < 0.001). A cutoff of 3.0 mm for AR thickness yielded 73.3% sensitivity and 84.6% specificity for primary stiffness; 2.6 mm cutoff resulted in 57.9% sensitivity and 88.2% specificity for secondary stiffness. Significant correlations were found between AR thickness and PROM, especially in shoulder external rotation and extension.

Conclusion. AR thickness measured by ultrasound might serve as a valuable diagnostic and evaluation parameter in shoulder stiffness.

Objective. To examine associations among the time and content of rehabilitation treatment with self-care and mobility functional gain rate for adults with acquired brain injury.

Design. Retrospective cohort study using electronic health record and administrative billing data.

Setting. Inpatient rehabilitation unit at a large, academic medical center.

Participants. Adults with primary diagnosis of stroke, traumatic brain injury, or nontraumatic brain injury admitted to the inpatient rehabilitation unit between 2012 and 2017 (N=799).

Interventions. Not applicable.

Main Outcome Measures. Gain rate in self-care and mobility function, using the Functional Independence Measure. Hierarchical regression models were used to identify the contributions of baseline characteristics, units, and content of occupational therapy, physical therapy, and speech-language pathology treatment to functional gain rates.

Results. Median length of rehabilitation stay was 10 days (interquartile range, 8-13d). Patients received an mean of 10.62 units of therapy (SD, 2.05) daily. For self-care care gain rate, the best-fitting model accounted for 32% of the variance. Occupational therapy activities of daily living units were positively associated with gain rate. For mobility gain rate, the best-fitting model accounted for 37% of the variance. Higher amounts of physical therapy bed mobility training were inversely associated with mobility gain rate.

Conclusions. More activities of daily living in occupational therapy is associated with faster improvement on self-care function for adults with acquired brain injury, whereas more bed mobility in physical therapy was associated with slower improvement. A potential challenge with value-based payments is the alignment between clinically appropriate therapy activities and the metrics by which patient improvement are evaluated. There is a risk that therapists and facilities will prioritize activities that drive improvement on metrics and deemphasize other patient-centered goals.

Keywords. Brain injuries; Electronic health records; Recovery of function; Rehabilitation; Stroke

Objective. To describe the state of W&I occupational therapy practice and to identify challenges and opportunities in this specialty practice area.

Design. Cross-sectional survey conducted June 12 to July 17, 2020.

Setting. Online survey distributed through direct email invitations and online platforms (i.e., CommunOT, LinkedIn).

Participants. One hundred twenty occupational therapy practitioners who had worked in W&I within the most recent 5 yr.

Outcomes and Measures. We used 30 multiple-choice, Likert-scale, and free-response questions across three topics: (1) training, resources, and research; (2) challenges and barriers; and (3) opportunities.

Results. Most respondents were occupational therapy practitioners working in clinical settings with >5 yr of experience; 29.2% identified as male. The most frequently provided services were ergonomic consultation and worksite evaluation; clinic-based W&I services were less frequently provided. Workplace injury prevention, management of psychosocial issues, and employee wellness programs were ranked as the top opportunities for occupational therapy in W&I. A shortage of accessible training and resources to support W&I practice was found, particularly mentoring and occupational therapy–focused research evidence. Maintaining referrals, competition from other professions, and limited support from professional organizations were key challenges.

Conclusions and Relevance. This study illustrates the evolution of W&I occupational therapy practice and highlights an urgent need for increased professional recognition and educational support to maintain occupational therapy’s presence in this practice area.

Background. One criterion for infant NICU discharge is the ability to meet all nutritional needs by mouth, therefore, it is important to understand interventions that can improve the trajectory to full oral feeding. While many oral motor and feeding interventions are used in clinical practice, it remains unclear which are supported by the literature.

Aim. The aim of this integrative review was to identify and understand what oral motor interventions are defined in the literature to support positive outcomes for preterm infants and their parents.

Methods. An integrative review of studies published from 2002 to 2022 focusing on applied oral motor interventions and their impact on feeding-related outcomes was completed. The systematic search used databases including PubMed, Cochrane, CINAHL, Scopus, and Google Scholar. Studies were included if they used a study population of preterm infants born

Results. Forty articles met inclusion criteria with four different interventions (or a combination of them) identified: nonnutritive sucking, oral motor stimulation [Fucile's protocol, Premature Infant Oral Motor Intervention (PIOMI)], NTrainer, and swallowing exercises.

Discussion. All interventions were associated with positive outcomes and began between 29- and 30-weeks PMA. Detailed information on adverse events (both physiologic and behavioral) in future research could allow for better risk-benefit analysis. The methodology and quality of the studies differed too much to allow for quantitative analysis; however, there does not appear to be compelling evidence that more stimulatory interventions are superior to less stimulatory interventions – a key consideration when working with preterm infants.

Background. Occupational science scholarship has long recognized the relationship of person, occupation, and context, with less focus on the role of occupation in placemaking. Inquiries about ‘third places’ beyond home and work can develop knowledge about how occupations help (re)create and maintain places; such knowledge is especially relevant for understanding how people navigate precarious social and economic conditions.

Methods. Through a 5-step scoping review, we surveyed the state of knowledge about ‘third places’ and the roles they play in the lives of precariously employed individuals. Our review covered English-language literature published between 2012 and 2022 that was indexed in eight academic journal databases. We descriptively and thematically analyzed 24 multidisciplinary articles.

Findings. Included articles were concentrated among relatively few disciplinary, geographical, and methodological bases. Within these studies, situations of financial precarity and social exclusion prompted precarious workers to access and create alternative physical and virtual third places; these third places were characterized by having low barriers to entry, affording diverse forms of participation, and engendering few obligations or commitments. Occupations occurring through these places played a central role in placemaking and reflected the multifaceted purposes of third places and the diverse needs experienced within precarious lives.

Implications. These findings support the need to reconceptualize ‘third places’ in ways that attend to occupation and foreground inclusionary and exclusionary potentials. Further research on third places can extend occupational science theorization of dynamic person-occupation-place relationships and advance interdisciplinary social transformation efforts through occupation-based community development work.

Objective. Burnout in sonographers is a prevalent and complex professional hazard associated with poorer quality of work life, productivity, and patient outcomes. This study aimed to understand the prevalence of and work systems factors associated with burnout among a large sample of sonographers.

Materials and Methods. Research study registry participants (n = 3659) were invited to complete a follow-up survey about personal and work environment factors, including work hours, break time, coworker and supervisor support, and job satisfaction, overall health, and sleep quality. The Copenhagen Burnout Inventory assessed personal, work-related, and client burnout. Simple and multiple linear regressions were used to identify work systems factors associated with burnout.

Results. Of 1389 respondents, over half reported moderate-to-severe personal and work-related burnout, while one-quarter reported moderate-to-severe client burnout. Higher work-related burnout was associated with younger age, working in the Western United States, working full-time, taking fewer weekly break hours, poorer overall health and sleep quality, and lower supervisor support and job satisfaction. Client burnout was associated with poorer sleep quality and lower job satisfaction.

Conclusion. Burnout was prevalent in a large sample of sonographers. Multilevel work systems factors are associated with burnout, suggesting collaboration among sonographers, administrators, and organizations is needed to address burnout.

Carpal tunnel syndrome (CTS) is highly prevalent, resulting in decreased function and increased need for costly healthcare services. External wrist ratio (depth/width >0.70) is a strong predictor of the development of CTS and has been suggested to be a proxy for internal carpal tunnel (CT) shape. Conversely, sonography can more directly evaluate CT shape. The purpose of our study was to explore the relationship between wrist ratio and sonographic CT measurements to (1) evaluate the reliability of sonographic CT measurements and (2) explore how external wrist measures relate to anthropometric features of the CT. We used sonographic imaging on a sample of healthy participants (n = 226) to measure CT cross-sectional area, depth, width, and depth/width ratio. We conducted exploratory correlation and regression analyses to identify relationships of these measures with external wrist ratio. Reliability for dominant and nondominant sonographic CT measures ranged from good to excellent (0.79–0.95). Despite a moderate correlation between CT width and depth and their external wrist counterparts (0.33–0.41, p < 0.001), wrist ratio and CT ratio demonstrated weak to no correlation (dominant: r = 0.12, p = 0.053; nondominant: r = 0.20, p = 0.002) and the mean CT ratio was far lower than the mean wrist ratio (0.45 vs. 0.71 bilaterally). Supporting this, we observed several key differences in the relationship between external wrist measures compared to corresponding CT measures. Additionally, regression analyses combining participant factors and CT measurements produced models accounting for less than 15% of the variability in external wrist ratio (linear models) or correctly predicting less than 68% of wrist ratio-based risk categorization (logistic models). Overall, among healthy young adults, wrist shape is not an adequate proxy for CT shape.

Exposure to repetitive head impacts in contact sports is associated with neurodegenerative disorders including chronic traumatic encephalopathy (CTE), which currently can be diagnosed only at post-mortem. American football players are at higher risk of developing CTE given their exposure to repetitive head impacts. One promising approach for diagnosing CTE in vivo is to explore known neuropathological abnormalities at post-mortem in living individuals using structural MRI.

MRI brain morphometry was evaluated in 170 male former American football players ages 45–74 years (n = 114 professional; n = 56 college) and 54 same-age unexposed asymptomatic male controls (n = 54, age range 45–74). Cortical thickness and volume of regions of interest were selected based on established CTE pathology findings and were assessed using FreeSurfer. Group differences and interactions with age and exposure factors were evaluated using a generalized least squares model. A separate logistic regression and independent multinomial model were performed to predict each traumatic encephalopathy syndrome (TES) diagnosis, core clinical features and provisional level of certainty for CTE pathology using brain regions of interest.

Former college and professional American football players (combined) showed significant cortical thickness and/or volume reductions compared to unexposed asymptomatic controls in the hippocampus, amygdala, entorhinal cortex, parahippocampal gyrus, insula, temporal pole and superior frontal gyrus. Post hoc analyses identified group-level differences between former professional players and unexposed asymptomatic controls in the hippocampus, amygdala, entorhinal cortex, parahippocampal gyrus, insula and superior frontal gyrus. Former college players showed significant volume reductions in the hippocampus, amygdala and superior frontal gyrus compared to the unexposed asymptomatic controls. We did not observe Age × Group interactions for brain morphometric measures. Interactions between morphometry and exposure measures were limited to a single significant positive association between the age of first exposure to organized tackle football and right insular volume. We found no significant relationship between brain morphometric measures and the TES diagnosis core clinical features and provisional level of certainty for CTE pathology outcomes.

These findings suggested that MRI morphometrics detect abnormalities in individuals with a history of repetitive head impact exposure that resemble the anatomic distribution of pathological findings from post-mortem CTE studies. The lack of findings associating MRI measures with exposure metrics (except for one significant relationship) or TES diagnosis and core clinical features suggested that brain morphometry must be complemented by other types of measures to characterize individuals with repetitive head impacts.

Keywords. neuroimaging, structural MRI, sports-related head injury, repetitive head impact, former American football players

Occupational therapy literature contains little evidence of the added value of clinical doctorate education, the professional identity of a Doctor of Occupational Therapy, or distinctions between master’s-prepared and doctorate-prepared occupational therapists. This study is intended to add to the literature base through the systematic and in-depth exploration of the experiences of graduates from a post-professional clinical doctorate program in occupational therapy. The goal of this study was to examine the professional identity transformation experienced by occupational therapists completing a doctorate degree, and to better understand the Doctor of Occupational Therapy identity. The study followed a qualitative descriptive design, including participant focus group interviews and document review. Participants included sixteen recent graduates, two male and fourteen female, of a post-professional doctorate program in occupational therapy. Data analysis revealed recent graduates’ perceptions of the leadership characteristics and capacities they developed throughout their learning experiences in the program and contributing to their professional identities as Doctors of Occupational Therapy. Results may have implications for the capacity for leadership within the profession. Further study is warranted to examine the impact of occupational therapy doctoral education on professional identity and capacities.

The involvement of occupational therapy (OT) providers in work and industry (W&I) has noticeably diminished despite the historical and ontological connection between work and occupation. Clear career expectations are necessary to introduce and retain the OT workforce in this underrepresented yet essential practice area. This study aimed to describe OT practitioners’ experiences exploring and developing careers in the W&I practice area. We used an inductive thematic analysis in a multi-step, iterative process to explore experiences shared through comments and stories in response to an open-ended question in a cross-sectional online survey. Four semantic-level themes emerged, including career pathways, accumulation of expertise, professional identity, and challenges in W&I practice. Novel career paths revealed in the article underlined the limited recognition of W&I practice in OT. Structured career planning support is needed to promote the growth of this practice area.

Background. The Neonatal Eating Outcome Assessment determines feeding performance based on the infant’s postmenstrual age (PMA).

Objective. To examine item-level measurement properties of this assessment’s rating scale.

Methodology. In this retrospective study, Rasch analysis was completed on clinical data from the Neonatal Eating Outcome Assessment for 100 infants (52 preterm and 48 full-term) using Winsteps version 3.93.1. Instead of PMA-based scores, ordered letters converted to numerical scores were analyzed.

Results. Analysis demonstrated that Section I (Pre-Feeding Skills) represents a separate construct from Sections II and III (Oral Feeding and End of Feeding, respectively). Sections II and III were adequately unidimensional to complete Rasch analysis. These sections fit the Rasch model overall, but rating scale category underuse was common, which may be attributed to sample characteristics.

This lecture explores the topic of uncertainty — defined from a Deweyan perspective as a quality of experience — and its relationship to understandings about occupation. Part I traces the evolution of a focus on uncertainty in my research and scholarship as an occupational scientist. Part II describes an initial descriptive literature review that aimed to survey the extent to which uncertainty has featured in theorizations of occupation in published occupational science literature. Part III charts future directions for both exploring uncertainty in extant occupational science work and bringing uncertainty more centrally into theorizations of occupation and occupational participation.

Keywords. Occupational science; transactional perspective; theory; conditions of association; precarity

With the exponential rise in the prevalence of automation, trust in such technology has become more critical than ever before. Trust is confidence in a particular entity, especially in regard to the consequences they can have for the trustor, and calibrated trust is the extent to which the judgments of trust are accurate. The focus of this paper is to reevaluate the general understanding of calibrating trust in automation, update this understanding, and apply it to worker’s trust in automation in the workplace. Seminal models of trust in automation were designed for automation that was already common in workforces, where the machine’s “intelligence” (i.e., capacity for decision making, cognition, and/or understanding) was limited. Now, burgeoning automation with more human-like intelligence is intended to be more interactive with workers, serving in roles such as decision aid, assistant, or collaborative coworker. Thus, we revise “calibrated trust in automation” to include more intelligent automated systems.

Keywords. trust, automation, calibrated trust, workers

We open this article by asking you to consider that the magnitude of racism present in clinical spaces is much larger and more in depth than we can ever begin to cover. In this spirit, we are going to provide you with some context to think about the problem of racism and mental health and disability and ways to deconstruct the problem through the lens of structural violence and structural racism. We offer you a brief discussion on and a definition of structural violence and structural racism and then tie them to two case studies to help contextualize how racism currently exists within the medical field. We hope that the language and framework of structural violence and structural racism will help you think anew about racism and your own interactions with it. Although the difficulties with racial and structural violence are much too pervasive and will take collective action to dismantle, we do think that giving a framework to think and talk about racism may help the ways that you choose to interact with your patients, engage in clinical assessments, diagnosis, treatment, and navigate systems from your current role within the medical field.

Stress experiences can have dire consequences for worker performance and well-being, and the social environment of the workplace is a key contributor to worker experience. This study investigated the relationship between hybrid workers’ self-ratings of productivity, mood, and stress with perceptions of positive (eustress) and negative (distress) stress states. We hypothesized that self-ratings would vary across combinations of eustress and distress experiences and that these differences would differ based on the social context. Ecological momentary assessments (EMA) were used to obtain ecologically valid data at four data points each workday across a 4-month study period in a cohort of seven office workers. Findings aligned with the Yerkes–Dodson law, such that higher states of arousal were associated with greater self-perceived productivity, and higher stress magnitudes were found when distress existed. Compared to other states, eustress was associated with higher productivity in work-related activities and better mood across all activity types.

Objective. These Practice Guidelines aim to assist occupational therapy practitioners, educators, and researchers in applying evidence and expert opinion to occupational therapy practice across the cancer continuum of care, including identifying gaps in care. Key focus areas include psychosocial function, fatigue, cognition, pain, sleep, and physical activity. These guidelines can serve as a reference for policymakers, health care professionals, health care managers, regulators, third-party payers, and managed care organizations to manage, reimburse, and set policy.

Method. We examined, synthesized, and integrated the results of systematic reviews, supporting literature, and expert opinion to develop and provide clinical recommendations for practice in the care of adults living with and beyond cancer.

Results. Sixteen systematic reviews with moderate to strong strength of evidence published between 2019 and 2022 served as the foundation for these Practice Guidelines.

Conclusions and Recommendations. To support symptom management for adults living with and beyond cancer, occupational therapy practitioners can consider using psychosocial interventions for anxiety, depression, posttraumatic growth, and overall psychological distress. Practitioners can consider using physical activity interventions for cancer-related fatigue, cognitive performance, and sleep. Practitioners could also consider using interventions for cognition, pain management, and self-management for the improvement of cancer-related symptoms.

Keywords. adult, cancer, occupational therapists, practice guidelines, fatigue, systematic reviews

The purpose of this study was to differentiate clinically meaningful improvement or deterioration from normal fluctuations in patients with disorders of consciousness (DoC) following severe brain injury. We computed indices of responsiveness for the Coma Recovery Scale-Revised (CRS-R) using data from a clinical trial of 180 participants with DoC. We used CRS-R scores from baseline (enrollment in a clinical trial) and a four-week follow-up assessment period for these calculations. To improve precision, we transformed ordinal CRS-R total scores (0 to 23 points) to equal-interval measures on a 0-to-100-unit scale using Rasch Measurement theory. Using the 0-to-100 unit total Rasch measures, we calculated distribution-based 0.5 standard deviation (SD) minimal clinically important difference, minimal detectable change using 95% confidence intervals, and conditional minimal detectable change using 95% confidence intervals. The distribution-based minimal clinically important difference evaluates group-level changes, whereas the minimal detectable change values evaluate individual-level changes. The minimal clinically important difference and minimal detectable change are derived using the overall variability across total measures at baseline and four weeks. The conditional minimal detectable change is generated for each possible pair of CRS-R Rasch person measures and accounts for variation in standard error across the scale. We applied these indices to determine the proportions of participants who made a change beyond measurement error within each of the two sub-groups, based on treatment arm (amantadine hydrochloride or placebo) or categorization of baseline Rasch person measure to states of consciousness (i.e., unresponsive wakefulness syndrome and minimally conscious state). We compared the proportion of participants in each treatment arm who made a change according to the minimal detectable change and determined whether they also changed to another state of consciousness. CRS-R indices of responsiveness (using the 0-100 transformed scale) were as follows: 0.5SD minimal clinically important difference = 9 units, minimal detectable change = 11 units, and the conditional minimal detectable change ranged from 11 to 42 units. For the amantadine and placebo groups, 67% and 58% of participants showed change beyond measurement error using the minimal detectable change, respectively. For the unresponsive wakefulness syndrome and minimally conscious state groups, 52% and 67% of participants changed beyond measurement error using the minimal detectable change, respectively. Among 115 participants (64% of the total sample) who made a change beyond measurement error, 29 participants (25%) did not change state of consciousness. CRS-R indices of responsiveness can support clinicians and researchers in discerning when behavioral changes in patients with DoC exceed measurement error. Notably, the minimal detectable change can support the detection of patients who make a ‘true’ change within or across states of consciousness. Our findings highlight that continued use of ordinal scores may result in incorrect inferences about the degree and relevance of a change score.

Committed to the necessity of international dialogues in occupational therapy and occupational science, we have developed a proposal for alliance between social occupational therapy and critical occupational science based on a series of theoretical dialogues between Brazilian and Canadian researchers. Through these dialogues, we have aimed to understand and propose contributions that articulate the shared intent of social transformation enhancing social justice of these disciplines. While acknowledging points of difference, we propose an alliance based on points of convergence, including emergence from concerns related to justice and equity; development coming from the ‘margins’; mobilization of critical social theory to orient knowledge production and question power relations within and outside the discipline and the profession; and an intent to work towards social justice, especially with marginalized groups. Our key arguments are informed by theoretical concepts from three authors: Judith Butler’s conceptualizations of vulnerability, precarity, and alliance; Nancy Fraser’s propositions regarding social justice; and Paulo Freire’s concept of dialogue. Through dialogue that recognizes and respects different knowledges and practices, an alliance is produced toward social justice, one that aims to realize more complex theoretical and practical resources for critical thinking about social reality. In turn, possibilities for apprehending how different oppressions impact and influence the possibilities of living can be expanded, informing approaches to building inhabitable worlds and proposing practices of freedom with persons and communities facing oppression.

Keywords. Occupational science; Occupational therapy; Social justice; Dialogue; Critical thinking; Coalition

Study Design. This study was a scoping review.

Background. Continued advances in musculoskeletal sonography technology and access have increased the feasibility of point-of-care use to support day-to-day clinical care and decision-making. Sonography can help improve therapeutic outcomes in upper extremity (UE) rehabilitation by enabling clinicians to visualize underlying structures during treatment.

Purpose of the Study. This study aimed to (1) evaluate the growth, range, extent, and composition of sonography literature supporting UE rehabilitation; (2) identify trends, gaps, and opportunities with regard to anatomic areas and diagnoses examined and ultrasound techniques used; and (3) evaluate potential research and practice utility.

Methods. Searches were completed in PubMed, CINAHL, SPORTDiscus, PsycINFO, and BIOSIS. We included data-driven articles using ultrasound imaging for upper extremity structures in rehabilitation-related conditions. Articles directly applicable to UE rehabilitation were labeled direct articles, while those requiring translation were labeled indirect articles. Articles were further categorized by ultrasound imaging purpose. Article content between the two groups was descriptively compared, and direct articles underwent an evaluation of evidence levels and narrative synthesis to explore potential clinical utility.

Results. Average publication rates for the final included articles (n = 337) steadily increased. Indirect articles (n = 288) used sonography to explore condition etiology, assess measurement properties, inform medical procedure choice, and grade condition severity. Direct articles (n = 49) used sonography to assess outcomes, inform clinical reasoning, and aid intervention delivery. Acute UE conditions and emerging sonography technology were rarely examined, while tendon, muscle, and soft tissue conditions and grayscale imaging were common. Rheumatic and peripheral nerve conditions and Doppler imaging were more prevalent in indirect than direct articles. Among reported sonography service providers, there was a high proportion of nonradiologist clinicians.

Conclusion. Sonography literature for UE rehabilitation demonstrates potential utility in evaluating outcomes, informing clinical reasoning, and assisting intervention delivery. A large peripheral knowledge base provides opportunities for clinical applications; however, further research is needed to determine clinical efficacy and impact for specific applications.

Keywords. Ultrasound imaging; Sonography; Upper extremity; Musculoskeletal; Scoping review

Neuro-occupation was developed to study the relationship between the nervous system and occupation. Pragmatic implications of neuro-occupation have not been previously summarized. This study aimed to determine how neuro-occupation has been defined, applied across relevant fields, and evolved over time. We performed a scoping review following the Arksey and O’Malley framework. Twenty-five works related to neuro-occupation published between 1997 and 2020 were included. We found that neuro-occupation evolved from utilization primarily in the United States to an international term applied to different clinical populations. Common themes were: (a) the reciprocal relationship between the nervous system and occupations; (b) the Intention, Meaning, and Perception (IMP) model of neuro-occupation; and (c) pragmatic implications for occupational therapy practice and interventions. We suggest an updated definition of neuro-occupation. In addition, we contend that although the term neuro-occupation was developed in response to historical debates in occupational therapy, continued use creates more confusion than clarity.

Previous studies have solely focused on establishing Machine Learning (ML) models for automated detection of stress arousal. However, these studies do not recognize stress appraisal and presume stress is a negative mental state. Yet, stress can be classified according to its influence on individuals; the way people perceive a stressor determines whether the stress reaction is considered as eustress (positive stress) or distress (negative stress). Thus, this study aims to assess the potential of using an ML approach to determine stress appraisal and identify eustress and distress instances using physiological and behavioral features. The results indicate that distress leads to higher perceived stress arousal compared to eustress. An XGBoost model that combined physiological and behavioral features using a 30 second time window had 83.38% and 78.79% F₁-scores for predicting eustress and distress, respectively. Gender-based models resulted in an average increase of 2-4% in eustress and distress prediction accuracy. Finally, a model to predict the simultaneous assessment of eustress and distress, distinguishing between pure eustress, pure distress, eustress-distress coexistence, and the absence of stress achieved a moderate F₁-score of 65.12%. The results of this study lay the foundation for work management interventions to maximize eustress and minimize distress in the workplace.

While a growing body of interprofessional education (IPE) literature demonstrates a positive impact on learner knowledge, there is limited data on its long-term impact on collaborative practice (CP). With the growth of the aging population globally, understanding both the long-term impact on CP and sustainability of community-based geriatric experiential IPE programs are imperative. This study explores the impact of the Interprofessional Geriatric Curriculum (IPGC), a community-based geriatric IPE program, on post-graduate clinical practice among seven health professions. This study utilized a cross-sectional descriptive design, where both qualitative and quantitative data were collected in the same online survey of health professionals’ to measure their perceptions of the impact IPGC has had on their respective clinical practice 1–3 years post-graduation. Forty-six per cent of health profession graduates provided clinical care for people 65 years of age or older; 81% worked in interprofessional teams; 80% reported the IPGC experience significantly impacted their practice (N = 137), and all used validated assessment tools taught in the IPGC program in their practice. Eight themes emerged from the list of what health professionals learned from IPGC that they use regularly in their clinical practice: four themes were interprofessional in nature (i.e. teamwork and team-based care, interprofessional communication, roles/responsibilities, and personal/professional) and four themes related to geriatrics (i.e. aging, screening and assessment, medications, and didactic content). This study is one of the first to describe the sustained influence of a community-based IPE program across multiple health professional disciplines on clinical geriatric practice.

Importance: Play has been viewed as a critical occupation supporting health since the founding of occupational therapy, but the complexity of play presents challenges to scholars who study adults. Researchers in occupational science and occupational therapy often address experiential qualities of occupations, including those considered to be play. However, the literature lacks clear descriptions of what constitutes adult play as well as the experiences of adults during preferred activities.

Objective: To contribute to the body of knowledge on the wide range of preferred activities adults in the United States pursue and may perceive as play experiences. We refer to these activities as adult play because they contain experiential qualities of play described in key play literature.

Design: Cross-sectional survey study.

Setting: A 31-item survey, the Daily Occupational Experience Survey–revised (DOESr), was uploaded to Qualtrics for data collection using snowball sampling. The online survey link was distributed to participants aged 18–64 years.

Participants: The survey was completed by 491 participants. Exploratory factor analysis was used to extract the most prevalent patterns of play experiences reported. Internal consistency and content validity were also examined.

Results: The factor analysis yielded an optimal solution of five factors representing distinct patterns of adult play experiences: Creativity–Adventure, Restoration, Deep Engagement, Ludos, and Mastery.

As the occupational therapy profession is rooted in Western ideals, it may encounter complexities in culturally traditional settings like Palestine, especially for adults. This study reveals the challenges faced by occupational therapists in Palestine. A phenomenological qualitative approach was used, interviewing six experienced female therapists using semi-structured interviews. Purposive sampling ensured a diverse participant selection. Thematic analysis revealed several key themes, such as the continuous adaptation to Western practices to fit the Palestinian context, the value of interdependence, and the unique life balance. Results show that cultural and gender norms significantly shape occupational therapy practices in Palestine. The discussion emphasizes the theoretical necessity for cultural sensitivity in occupational therapy, advocating alignment with local values and addressing resource limitations for effective service delivery.

Keywords. Adult settings; cultural characteristics; gender; occupational therapy; palestine; therapists

Objectives. Investigate relationships between aEEG in the first 72 h in extremely preterm infants with 1) infant, medical, and environmental factors, and 2) infant feeding and neurobehavioral outcomes at term and school-age.

Methods.. Sixty-four preterm infants (≤28 weeks gestation) were enrolled within the first 24-hours of life and had two-channel aEEG until 72 h of life. Standardized neurobehavioral and feeding assessments were conducted at term, and parent-reported outcomes were documented at 5–7 years.

Results. Lower aEEG Burdjalov scores (adjusted for gestational age) were related to vaginal delivery (p = 0.04), cerebral injury (p = 0.01), Black race (p < 0.01) and having unmarried parents (p = 0.02). Lower Burdjalov scores related to less NICU Network Neurobehavioral Scale arousal (p = 0.002) at term and poorer BRIEF global executive function (p = 0.004), inhibition (p = 0.007), working memory (p = 0.02), material organization (p = 0.0008), metacognition (p = 0.01), and behavioral regulation (p = 0.02) at 5–7 years. We did not observe relationships of early aEEG to feeding outcomes or sensory processing measures.

Conclusion. Early aEEG within the first 72 h of life was related to medical and sociodemographic factors as well as cognitive outcome at 5–7 years.

Objective. This systematic review aims to determine the extent, scope, and nature of research using the sonographic measurement of intraneural blood flow within the median nerve and to identify, characterize, and compare image acquisition and analysis protocols that have been reported as potential candidate techniques for standardizing research and clinical applications.

Materials and Methods. This systematic review summarizes image acquisition protocols and analysis methodologies from 52 current research studies using Doppler ultrasound to examine median nerve intraneural blood flow.

Results. Four types of Doppler technologies were identified: power Doppler, color Doppler, spectral Doppler, and Superb Microvascular Imaging, but there were inconsistencies in how images were acquired and analyzed. Intraneural blood flow measurements were categorized into four types based on a combination of measurement level (e.g., binary, ordinal, continuous) and type of flow indicator (e.g., pixel count, intensity, velocity).

Conclusion. Standardized imaging protocols and reporting guidelines are needed to improve consistency. Future studies should evaluate the accuracy and reliability of different image acquisition methods and analysis measurements.

While exteroceptive sensory processing is a hallmark of autism spectrum disorder, how interoceptive processing may impact and contribute to symptomatology remains unclear. In this comprehensive narrative review on interoception in autism, we discuss: 1) difficulties with assessing interoception; 2) potential interoceptive differences; 3) interactions between neural systems for interoception, attention, sensorimotor processing, and cognition; and 4) potential differences in neural circuits involved in interoception. In general, there are mixed findings on potential interoception differences in autism. Nevertheless, some data indicate differences in integration of interoceptive and exteroceptive information may contribute to autism symptomatology. Neurologically, interoceptive processing in autism may be impacted by potential differences in the development, morphometry, and connectivity of key interoceptive hubs (vagal processing, brainstem, thalamus, insula), though much work is needed on this topic.

In the professional education of mental health practitioners, including occupational therapists, there has been a lack of meaningful inclusion of people labeled with mental illness into curricula, beyond guest speaker panels and presentations. This study explored the experiences of students, faculty, and 'Experts by Experience' within a mental health occupational therapy course that incorporated Experts with lived experience as co-facilitators of weekly fieldwork debriefs. The study utilized focus groups and interviews to understand the experiences of students, mental health faculty, and 'Experts by Experience'. Key themes that emerged from the qualitative data analysis were organized under three broad categories: 1) Students experienced powerful insights, 2) Experts conveyed the complexity of the work, and 3) Faculty grew from co-creating learning experiences with the Experts. This research makes a significant contribution to occupational therapy education by shifting the Expert's role beyond traditional speaker panels or storytelling. This broader responsibility elevated experiential knowledge into the realm of practice in clinical reasoning by shifting the context of the knowledge from storytelling to support practice reasoning. While this created significant learning opportunities for the students, it also did appear to cause emotional risk for the 'Experts by Experience'. It is important that efforts to include 'Experts by Experience' in curriculum also include sources of support and financial remuneration.

Parental language input influences child language outcomes but may vary based on certain characteristics. This research examined how parental language differs during two contexts for toddlers at varying likelihood of autism based on their developmental skills. Parental language (quantity, quality, and pragmatic functions) was analyzed during dyadic play and mealtime interactions as a secondary data analysis of observational data from a study of toddlers at elevated and lower likelihood of autism. Child developmental skills and sensory processing were also assessed. Parents used more words per minute, directives, and verbs during play and more adjectives, descriptions, and questions during mealtime. Parental language differed based on child fine motor skills, receptive language, and levels of sensory hyporesponsiveness but not autism likelihood. Overall, this study found that parental language varies based on context and child developmental skills. Future research examining parental language should include pragmatic functions and context across developmental trajectories.

Keywords. autism; parental language; early intervention; play; mealtime

Introduction. Patients recovering from cardiothoracic surgery in acute care experience physical and psychosocial challenges impacting participation in activities of daily living. Occupational therapists are well positioned to address these needs; however, there is little evidence exploring occupational therapy’s role in this area.

Method. This retrospective study of electronic medical records examined changes in activities of daily living participation for adult patients (n = 37) who received occupational therapy in acute care while recovering from cardiothoracic surgery via median sternotomy. Wilcoxon signed-rank tests and paired t-tests compared patients’ scores on the Functional Independence Measure (FIM) and Activity Measure for Post-Acute Care “6-Clicks” Daily Activity Inpatient Short Form at occupational therapy evaluation and discharge from their inpatient stay.

Results. Patients showed statistically significant improvements on both assessments in activities of daily living participation while receiving occupational therapy services following cardiothoracic surgery. Lower body dressing, toileting, and bed mobility showed the greatest increases in the FIM categories.

Conclusion. Occupational therapists are valuable in addressing the complex needs of patients recovering from cardiothoracic surgery in acute care. Continued research is needed to provide further evidence supporting occupational therapy’s unique role in this setting.

Camouflaging, the masking of neurodivergent traits to blend in with the dominant neurotypical society, is reported among autistic women. At the core of camouflaging, however, is the desire to belong, which is yet to be explored in the literature despite its costly impacts on one's quality of life. Occupational science, a discipline concerned with human doing and belonging is uniquely situated to address camouflaging. Yet, camouflaging has not been explored from an occupational science lens. Therefore, in this conceptual article, we first explore the unique perspective that occupational science contributes to camouflaging scholarship. Given the dearth of camouflaging research and scholarship on autistic women with intersecting identities (e.g., Black autistic women), we draw from Bailey and Mobley's Black Feminist Disability Framework. Second, analyzing existing qualitative narratives in camouflaging research, we illuminate “occupational disruptions,” or potential risk factors of camouflaging, focusing on the work environment, educational settings, and interpersonal and intimate relationships. We highlight the importance of understanding Black autistic women's unique experiences of occupational disruptions. Third, we consider how unmasking is a privilege not granted to those beyond the margins. Finally, we conclude with implications and future directions for interdisciplinary research and scholarship, including a critique of our discipline's paradoxical relationship between belonging theory and camouflaging, therapeutic considerations (masking vs. unmasking safely), and a call to action for scholars, practitioners, and allies to challenge the need for camouflaging to belong, thereby mitigating existing occupational disruptions.

What was the purpose of this article? We (the authors) are concerned about the negative outcomes that autistic women experience related to camouflaging. Camouflaging, sometimes called “masking” or “passing as neurotypical,” is something that neurodivergent people might do to hide their neurodivergent traits so that they are accepted by other people, or to be safe in a neurotypical society. In this article, we discuss camouflaging from an occupational science perspective. Occupational science is an academic discipline that is related to occupational therapy that focuses on human doing and belonging.

Why is this article important? This article is important for several reasons. First, camouflaging impacts the quality of life of autistic people, and we believe that it is closely associated with the deep human need for belonging. In this article, we use occupational science concepts to add a new perspective to current discussions among autistic people and researchers about camouflaging. Recognizing that Black autistic women are almost entirely ignored by researchers and that they might be marginalized based on their race, gender, and neurotype, we also use a Black Feminist Disability Framework to highlight the unique experiences of people with intersecting marginalized identities. Finally, the authors, both neurodivergent and allistic (nonautistic), from various racial and ethnic backgrounds, bring a richness of perspectives based on our diverse life experiences and areas of expertise.

What did the authors do? We applied our unique occupational science perspective to camouflaging. First, we discussed camouflaging in relation to the occupational science concept of belonging and described a Black Feminist Disability Framework. Second, we analyzed the lived experiences of autistic women, using quotes from academic articles. We brought the readers' attention to the lack of diversity within camouflaging literature, which has amplified the voices of White autistic women, while marginalizing women of color. Third, we showed how unmasking is a privilege for White autistic women, but not for autistic women with intersecting identities.

What did the authors conclude? We concluded that camouflaging disrupts various occupations, or important activities people want to do. We also provided a call to action for occupational scientists, occupational therapists, the broader research community, and allies to make environments more inclusive and safer for diverse autistic people.

How does this information help autistic adults? We hope our analysis provides autistic women with the words to describe their experiences, including how camouflaging may have caused occupational disruptions in their lives. We also hope that our call to action contributes to making spaces safer for autistic women.

The articles in this Special Issue on Recovery of Function After Neurological Injury include an impressive range of clinical diagnoses, scientific approaches, and theoretical frameworks that demonstrate the breadth and depth of occupational therapy in the restoration of function after neurological injury. An emerging theme throughout is the need for the profession of occupational therapy to identify and use more efficient methods for diagnosing and treating people with neurological injuries to improve their quality of life and the impact of care.

Aim. To identify relationships between early medical factors and preterm infant feeding behaviors at term-equivalent age.

Methods. Forty-three very preterm infants born ≤32 weeks gestation had standardized feeding assessments using the Neonatal Eating Outcome Assessment at term-equivalent age (36–42 weeks postmenstrual age). Medical factors were collected and analyses were run to determine if associations between different medical factors and feeding performance exist.

Results. Lower Neonatal Eating Outcome Assessment scores at term-equivalent age were associated with lower estimated gestational age (p < .01), lower birthweight (p < .01), older postmenstrual age at discharge (p < .01), longer length of stay in the neonatal intensive care unit (p < .01), chronic lung disease (p = .03), as well as more days on total parenteral nutrition (p = .03), endotracheal intubation (p < .01), and noninvasive mechanical ventilation (p < .01).

Conclusion. More feeding problems are observed in infants born earlier, with longer hospital stays, and with complex medical courses. Knowledge of the association between these medical factors and feeding difficulties allows for identification of infants who may benefit from early, targeted interventions to optimize the feeding process.

Objective. This study aimed to (1) define the prevalence of motor, cognitive, and language delays in preterm infants born <32 weeks estimated gestational age (EGA); and (2) identify the relationship between the timing of discharge from the neonatal intensive care unit (NICU) and neurodevelopmental outcome in early childhood.

Study Design. This retrospective study of 172 preterm infants born <32 weeks EGA and hospitalized in a level-IV NICU captured medical factors, including timing of discharge, from the NICU stay. Standardized developmental testing at 1 to 2 years corrected age was conducted in the newborn follow-up clinic.

Results. At 1 to 2 years corrected age, the sample had an average Bayley Scales of Infant and Toddler Development (Bayley-III) cognitive composite score of 91.5 ± 17.4, language composite score of 84.5 ± 17.3, and motor composite score of 88.9 ± 18.4. Lower EGA at birth, necrotizing enterocolitis, patent ductus arteriosus, and oxygen requirement for >28 days were independently associated with higher postmenstrual age (PMA) at NICU discharge. Higher PMA at discharge was associated with poorer cognitive outcome [p < 0.001, β = −1.1 (−1.6, −0.7)], poorer language outcome [p = 0.049, β = −0.5 (−0.9, −0.003)], and poorer motor outcome [p <0.001, β = −1.0 (−1.5, −0.5)]. For every additional week of hospitalization, scores were an average of 1.1 points lower in cognitive, 1.0 point lower in motor, and 0.5 points lower in language domains of the Bayley-III assessment.

Conclusion. Poorer cognitive, language, and motor outcomes were associated with longer hospitalization, even after controlling for medical risk factors known to be associated with poorer outcome. This provides further evidence for the potential role of the environment in impacting developmental outcomes of infants hospitalized in the NICU.

Keywords. hospitalization; neonatal intensive care unit; length of stay; postmenstrual age; outcomes; child development; risk factors; environment

Occupational therapy is a profession with origins rooted in Western values. As culture plays an important role in shaping theory and practice, the curriculum design of academic programs that train future rehabilitation professionals should reflect the local context. As part of an international partnership, a dual-degree graduate program in occupational therapy was established between a Chinese and an American university. A team composed of members from both institutions collaborated on culturally adapting an entry-level master’s program in occupational therapy for China, based on a U.S. program, which welcomed its first cohort in September 2019. This article details the timeline and process of program design and adaptation from conception, through implementation to evaluation and revision, with the aim of offering a framework for curriculum adaptation of other academic programs in the U.S. and internationally. The adapted curriculum includes the program mission, vision, and philosophy; the curriculum model with program outcomes and threads; the program scope and sequence; materials and resources; and course-specific objectives, learning activities, and assessments. The authors also share lessons learned through this experience of international collaboration as well as next steps for program evaluation and sustainability. The detailed overview of this international collaboration offers suggestions for individuals and institutions seeking to develop global partnerships and adapt curricula across cultural contexts.

Youth diagnosed with autism spectrum disorder (ASD) and those with developmental coordination disorder (DCD) are at heightened risk for co-occurring mental health diagnoses, especially anxiety and attention-deficit/hyperactivity disorder (ADHD). However, caregiver-child agreement on presence of related symptoms in populations with neurodevelopmental conditions is not well understood. Here, we examine the extent to which 37 ASD, 26 DCD, and 40 typically developing children and their caregivers agree on the degree of the child's symptoms of anxiety and ADHD. All caregiver-child dyads completed the Screen for Child Anxiety Related Emotional Disorders and Conners 3 ADHD Index. Across groups, intraclass correlations indicated generally poor agreement on anxiety and ADHD symptomatology. Although youth generally reported greater internalizing symptoms (i.e., anxiety), caregivers tended to report more observable externalizing behaviors (i.e., ADHD). Together, the results of this study support the need for a multi-informant approach in assessments of anxiety and ADHD in youth with neurodevelopmental disorders.

Objective. Work-related injuries have a major effect on worker health and well-being. This is particularly true in sonography, where work-related musculoskeletal disorders (WRMSDs) are common. In response to the current challenge of understanding strategy implementation across social and organizational dimensions, this research captured sonographers’, echocardiographers’, and vascular technologists’ perceptions of critical administrative, organizational, and general health and training challenges, and potential solutions for improving worker health and well-being.

Materials and Methods. A survey invitation was sent to the WRMSD Grand Challenge longitudinal study registry participants. Open-ended questions on the online questionnaire allowed respondents to share comments, ideas, or potential solutions to improve worker health and well-being regarding the administrative and organizational environment or through training and general health interventions. There were 377 free-text responses that were qualitatively analyzed using a grounded theory approach to generate overarching themes and identify emerging theory, supported by initial coding, focused coding, and reflexive memoing. A member check was conducted by interviewing four participants to refine and confirm the findings.

Results. Five themes were identified: “Limits and Guidelines,” “Injury Education,” “Ergonomics Training Constraints,” “Resources and Equipment,” and “Individual Habits.” Participant suggestions within these themes were categorized and mapped onto a sociotechnical systems model that was developed previously to study the healthcare system(s) in which sonography users work. This conceptual mapping revealed how these solutions were situated to impact different levels of the work environment. The themes and mapping supported an emerging grounded theory: Risk Reduction Relies on Proper Employee Representation.

Conclusion. These qualitative findings align with contemporary guidelines and recommendations for mitigating injuries in sonographers, illuminating challenges and solutions targeting levels of influence beyond the staff sonographers’ scope. The need for representation of sonographers at higher-level administrative levels has not heretofore been addressed by WRMSD guidelines.

Importance. Complex telehealth interventions can facilitate remote occupational therapy services and improve access for people living with chronic neurological conditions. Understanding the factors that influence the uptake of these technologies is important.

Objective. To explore the fit between electromyography (EMG) biofeedback and telerehabilitation for stroke survivors, optimize EMG biofeedback interventions, and, more broadly, support other efforts to develop complex telerehabilitation interventions.

Design. Pre-implementation mixed-methods analysis of usability and acceptability data collected during a pilot and feasibility study.

Setting. Community.

Participants. Adult stroke survivors with hemiparesis (N = 11; M age = 54 yr).

Intervention. Game-based EMG biofeedback system for arm sensorimotor rehabilitation, delivered via telehealth.

Outcomes and Measures. Post-Study System Usability Questionnaire, an extended Unified Theory of Acceptance and Use of Technology model questionnaire, and semistructured interview. We coded the interview data using questionnaire constructs.

Results.. Participants used an EMG biofeedback intervention at home. Quantitative measures show high levels of perceived usability and acceptability, supported by qualitative findings describing specific facilitators and barriers.

Conclusions and Relevance. Pre-implementation studies can improve the design and relevance of complex telehealth interventions. One major conclusion from this study is the influence of therapy providers on acceptability and usability of complex telehealth interventions.

Plain-Language Summary. This study contributes to an emerging body of literature that examines the use of complex telehealth interventions with survivors of neurological injury. The findings highlight the value and support the development and use of complex telehealth interventions, which have the potential to improve remote access to occupational therapy for clients living with chronic neurological conditions. Complex telehealth interventions can open doors for survivors of neurological injury who face barriers to accessing occupational therapy and would benefit from technology-enabled therapy at home.

Paulo Freire’s work is important to support the praxis of Social Occupational Therapy. The purpose of this study is to expand the scope and deepen the character of the academic presence of Paulo Freire in Social Occupational Therapy. A scoping review was carried out as a methodological approach, including studies published in four Brazilian journals and three international databases. The searches were conducted only in Portuguese; no year parameters were stipulated. The review considered articles published at any time up to February 2023. A total of 18 studies with Freire’s works in their references were included; “Pedagogy of the Oppressed” and “Education, the Practice of Freedom” are the works that mostly appeared in the articles included. The refinement of the Freirean categories was carried out, and 42 categories were verified: conscientization, eleven times, transformation/transformative action, and praxis/ action-reflection, both ten times. With the data obtained in the study, it was possible to verify the increase in the number of publications in Social Occupational Therapy that use Freire’s theoretical framework. The author’s work has contributed significantly to the construction of a problematizing and emancipating Social Occupational Therapy.

Keywords. social change, occupational therapy, education

Sensory-based subtypes among autistic children have been well documented, but little is known about longitudinal sensory subtypes beyond autistic populations. This prospective study aimed to identify subtypes based on trajectories of parent-reported sensory features measured at 6–19 months, 3–4, and 6–7 years of age among a community-based birth cohort (N = 1,517), and to examine their associations with school-age clinical and adaptive/maladaptive outcomes on a subset sample (N = 389). Latent class growth analysis revealed five trajectory subtypes varying in intensity and change rates across three sensory domains. In contrast to an Adaptive-All Improving subtype (35%) with very low sensory features and overall better school-age outcomes, an Elevated-All Worsening subtype (3%), comprised of more boys and children of parents with less education, was associated with most elevated autistic traits and poorest adaptive/maladaptive outcomes. Three other subtypes (62% in total) were generally characterized by stable or improving patterns of sensory features at mild to moderate levels, and challenges in certain outcome domains. Our findings indicate that characterizing children based on early sensory trajectories may contribute to earlier detection of subgroups of children with sensory challenges who are more likely to experience developmental challenges by school age, followed by early targeted interventions for improved long-term outcomes.

Keywords. autism, community sample, latent-class trajectory, school-age outcomes, sensory features

Objectives. To 1) estimate the total pool of neonatal therapists and the average number represented in each US-based NICU, and 2) investigate the relationships between the number and type of neonatal therapy team members to NICU/hospital, population, and therapy factors.

Study Design. This study used several methods of data collection (surveys, phone calls, website searches) that were combined to establish a comprehensive list of factors across each NICU in the US.

Results. We estimate 2333 neonatal therapy FTEs, with 4232 neonatal therapists covering those FTEs in the US. Among 564 NICUs, 432 (76%) had a dedicated therapy team, 103 (18%) had PRN therapy coverage only, and 35 (6%) had no neonatal therapy team. Having a dedicated therapy team was more likely in level IV (n=112; 97%) and III (n=269; 83%) NICUs compared to level II NICUs (n=51; 42%) (p<0.001). Having a dedicated therapy team was related to having more NICU beds (p<0.001), being part of a free-standing children’s hospital or children’s hospital within a hospital (p<0.001), and being part of an academic medical center or community hospital (p<0.001). Having a dedicated therapy team was more common in the Southeast, Midwest, Southwest, and West (p=0.001), but was not related to the proportion of the community living in poverty or belonging to racial/ethnic minorities (p>0.05). There was an average of 17 beds per neonatal therapy FTE, a good marker of therapy coverage based on NICU size. Three-hundred US-based NICUs (22%) had at least one Certified Neonatal Therapist (CNT) in early 2020, with CNT presence being more likely in higher acuity NICUs (59% of Level IV NICUs had at least one CNT).

Conclusions. Understanding the composition of neonatal therapy teams at different hospitals across the US can drive change to expand neonatal therapy aimed at optimizing outcomes of high-risk families.

Previous studies have primarily focused on predicting stress arousal, encompassing physiological, behavioral, and psychological responses to stressors, while neglecting the examination of stress appraisal. Stress appraisal involves the cognitive evaluation of a situation as stressful or non-stressful, and as a threat/pressure or a challenge/opportunity. In this study, we investigated several research questions related to the association between states of stress appraisal (i.e., boredom, eustress, coexisting eustress-distress, distress) and various factors such as stress levels, mood, productivity, physiological and behavioral responses, as well as the most effective ML algorithms and data signals for predicting stress appraisal. The results support the Yerkes-Dodson law, showing that a moderate stress level is associated with increased productivity and positive mood, while low and high levels of stress are related to decreased productivity and negative mood, with distress overpowering eustress when they coexist. Changes in stress appraisal relative to physiological and behavioral features were examined through the lenses of stress arousal, activity engagement, and performance. An XGBOOST model achieved the best prediction accuracies of stress appraisal, reaching 82.78% when combining physiological and behavioral features and 79.55% using only the physiological dataset. The small accuracy difference of 3% indicates that physiological data alone may be adequate to accurately predict stress appraisal, and the feature importance results identified electrodermal activity, skin temperature, and blood volume pulse as the most useful physiologic features. Implementing these models within work environments can serve as a foundation for designing workplace policies, practices, and stress management strategies that prioritize the promotion of eustress while reducing distress and boredom. Such efforts can foster a supportive work environment to enhance employee well-being and productivity.

Introduction. Older adults experiencing subjective cognitive decline (SCD) have a higher risk of dementia. Reducing this risk through behavioral interventions, which can increase emotional well-being (mindfulness and compassion) and physical activity, is crucial in SCD.

Methods. SCD-Well is a multicenter, observer-blind, randomized, controlled, superiority trial. Three hundred forty-seven participants (mean [standard deviation] age: 72.7 [6.9] years; 64.6% women) were recruited from memory clinics in four European sites to assess the impact of an 8-week caring mindfulness-based approach for seniors (CMBAS) and a health self-management program (HSMP) on mindfulness, self-compassion, and physical activity.

Results. CMBAS showed a significant within-group increase in self-compassion from baseline to post-intervention and both a within- and between-group increase to follow-up visit (24 weeks). HSMP showed a significant within- and between-group increase in physical activity from baseline to post-intervention and to follow-up visit.

Discussion. Non-pharmacological interventions can differentially promote modifiable factors linked to healthy aging in older adults with SCD.

Importance. The Supporting and Enhancing NICU Sensory Experiences (SENSE) program is an evidence-based intervention that promotes daily, positive sensory exposures for infants in the neonatal intensive care unit (NICU). Understanding program implementation across sites may aid in optimizing strategies for uptake of the program and subsequently improve outcomes for infants and families.

Objective. To investigate health care professionals’ perceptions of implementing the SENSE program.

Design. The SENSE Program Implementation Survey was developed using Proctor et al.’s model and the BARRIERS scale to probe organizational practices across sites worldwide.

Setting. Survey distributed to 211 hospitals with a SENSE program license obtained before March 2020.

Participants. One hundred fourteen NICU personnel (response rate = 54%).

Outcomes and Measures. The survey sought to understand barriers and facilitators, adaptations during implementation, and associated costs.

Results. Of the 53% (n = 57 of 107) of respondents who had implemented the SENSE program, many (n = 14; 31%) experienced quick timing (<1 mo) to use, including spread to nearly all infants in their NICU within 6 mo (n = 18; 35%). Most reported the program was used to educate families ≤3 days of birth (n = 20/59; 34%). Most of the sensory interventions in the program were performed by parents (n = 38; 67%) and therapists (n = 44; 77%). Barriers and facilitators at the organizational and individual levels were identified. No additional staff were hired to implement the program.

Conclusions and Relevance. Given perceived successes and challenges, strategic enhancement of implementation can inform future administrations of the SENSE program.

Although occupational therapy has its roots in mental health practice, the profession has not been able to adequately and consistently address mental health issues that face society today. As we continue to experience both the protracted coronavirus disease 2019 pandemic and political and social unrest, occupational therapy professionals must take action at individual, state, and national levels to assist in mitigating the current mental health tsunami and improving a fractured mental health care system. In this column, we define and explore issues facing the mental health care system and the different roles and perspectives that are relevant to occupational therapy professionals. Recommendations for the future are provided: actions that can be facilitated at the individual level, in practice, education, and research; at the state level, through state organizations and strategic partnerships; and at the national level, through the American Occupational Therapy Association and other means of advocacy. We want to honor Mary Reilly’s vision that occupational therapy become one of the greatest ideas of our time.

Associations between various forms of activity engagement (e.g. work, leisure) and the experience of stress in workers have been widely documented. The mechanisms underlying these effects, however, are not fully understood. Our goal was to investigate if perceived whole day workload accounted for the relationships between daily frequencies of activities (i.e. work hours and leisure/rest) and daily stress. We analysed data from 56 workers with type 1 diabetes (T1D) who completed approximately two weeks of intensive longitudinal assessments. Daily whole day workload was measured with an adapted version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX). A variety of occupations were reported, including lawyer, housekeeper and teacher. In multilevel path analyses, day-to-day changes in whole day workload mediated 67% (p < .001), 61% (p < .001), 38% (p < .001), and 55% (p < .001) of the within-person relationships between stress and work hours, rest frequency, active leisure frequency, and day of week, respectively. Our results provided evidence that whole day workload perception may contribute to the processes linking daily activities with daily stress in workers with T1D. Perceived whole day workload may deserve greater attention as a possible stress intervention target, ones that perhaps ergonomists would be especially suited to address.

Keywords. Workload, stress, rest, work hours, type 1 diabetes

Objective. Explore the differing associations of Sonography Work Systems (SWS) model factors with work-related discomfort outcomes among sonographers in four sonographic practice areas.

Materials and Methods. Survey data from a national cross-disciplinary cohort of sonographers was analyzed to explore experiences of work factors and work-related discomfort in sonographers across four practice areas: abdominal (ABD+), adult echocardiography (Echo), obstetrics/gynecology (OB/GYN), and vascular technology (VT). One-way analyses of variance (ANOVAs) and chi-square tests were conducted on SWS factors and work-related discomfort to examine differences across practice area groups. Associative analyses were conducted between upper extremity musculoskeletal discomfort and hand used during sonography examinations. For each practice group, regression analyses examined associations of SWS factors with work-related discomfort (i.e., musculoskeletal and visual discomfort, headaches).

Results. 2924 survey respondents (n = 1747 ABD+, n = 519 Echo, n = 351 VT, and n = 307 OB/GYN) were identified. Descriptive differences were identified in SWS factors and discomfort across practice area groups. Significant differences were noted in distribution of upper extremity pain compared with the hand used to complete sonography examinations (P < .001).

Conclusion. This study identified multiple organizational, tool, and process factors commonly associated with discomfort across specialties, which underscores the need for multidimensional approaches to worker health that include effective administrative and engineering controls.

Workload experienced over the whole day, not just work periods, may impact worker cognitive performance. We hypothesized that experiencing greater than typical whole day workload would be associated with lower visual processing speed and lower sustained attention ability, on the next day. To test this, we used dynamic structural equation modeling to analyze data from 56 workers with type 1 diabetes. For a two-week period, on smartphones they answered questions about whole day workload at the end of each day, and completed cognitive tests 5 or 6 times throughout each day. Repeated smartphone cognitive tests were used, instead of traditional one- time cognitive assessment in the laboratory, to increase the ecological validity of the cognitive tests. Examples of reported occupations in our sample included housekeeper, teacher, physician, and cashier. On workdays, the mean number of work hours reported was 6.58 (SD 3.5). At the within-person level, greater whole day workload predicted decreased mean processing speed the next day (standardized estimate=-0.10, 95% CI -0.18 to -0.01) using a random intercept model; the relationship was not significant and only demonstrated a tendency toward the expected effect (standardized estimate= -0.07, 95% CI -0.15 to 0.01) in a model with a random intercept and a random regression slope. Whole day workload was not found to be associated with next-day mean sustained attention ability. Study results suggested that just one day of greater than average workload could impact next day processing speed, but future studies with larger sample sizes are needed to corroborate this finding.

Keywords. Whole day workload; Sustained attention; Processing speed; Cognitive performance; Type 1 diabetes

Neonatal intensive care unit (NICU) co-occupations may impact parent–infant outcomes. The main objective of this study was to explore relationships between parent and infant outcomes based on whether sensory-based interventions (co-occupations) occurred most often between parent–infant dyads or provider/volunteer–infant dyads. Thirty-five families received the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, which includes education defining specific amounts of sensory exposures for infants to receive each day of NICU hospitalization (with a preference for parent delivery). Infant sensory experiences in the NICU were logged, and dyads were grouped based on who conducted most of the sensory interventions with the infant in the NICU into a Parent–Infant Co-occupation group or Other Administered group. The Parent–Infant Co-occupation group had infants with less lethargy on the NICU Network Neurobehavioral Scale (p = .04), and parents with lower scores on the Parental Stress Scale (p = .003) and State-Trait Anxiety Inventory-state (p = .047). Parent–infant engagement in co-occupations was related to parental mental health and infant neurobehavior.

Keywords. development; engagement; environment; family-centered care; intervention; parent mental health; parent–infant interaction; participation; sensory.

Infants at elevated likelihood of developing autism display differences in sensory reactivity, especially hyporeactivity, as early as 7 months of age, potentially contributing to a developmental cascade of autism symptoms. Caregiver responsiveness, which has been linked to positive social communication outcomes, has not been adequately examined with regard to infant sensory reactivity. This study examined the multiplicative impact of infant sensory hypo- and hyperreactivity on caregiver responsiveness to sensory reactivity and regulation cues in 43 infants at elevated likelihood of autism. Sensory hyperreactivity was found to moderate the association between sensory hyporeactivity and caregiver responsiveness, such that caregivers of infants with moderately high sensory hypo- and hyperreactivity demonstrated higher responsiveness.

Keywords. Early risk signs; Sensory reactivity; Caregiver responsiveness; Community sample

Purpose/Objective. Brain injuries are often “invisible” injuries that can have lifelong consequences including changes in identity, functional independence, relationships, and reduced participation in daily activities. Survivors of brain injury experience stigma and challenges related to the misattribution of symptoms to other causes that are significant barriers to recovery and adjustment. Changes in policy and other large-scale interventions are cited as an underexplored, yet critical path to reducing the impact of brain injury. The present study sought to comprehensively characterize the impact of one such initiative—Brain Injury Identification Cards—among survivors to further refine the resource.

Research Method/Design. In this cross-sectional qualitative focus group study, we recruited 16 individuals with a history of brain injury via email listservs of individuals who registered for a Brain Injury Identification Card. We used rapid data analysis with a hybrid of deductive and inductive analytic strategies to identify themes within a priori domains.

Results. We extracted themes within four domains: (a) process and reasons for obtaining cards; (b) overall impressions of the cards; (c) uses of the cards; and (d) feedback and proposed changes. Participants described the process of obtaining cards as straightforward and shared wide-ranging benefits across domains, including improving survivors’ sense of safety, self-advocacy, and ability to participate in daily activities.

Conclusions/Implications. Findings highlight the utility of Brain Injury Identification Cards for improving community understanding of brain injury symptoms and how injury-related challenges may manifest in daily life.

50 Studies Every Occupational Therapist Should Know presents a curated collection of the most influential studies guiding occupational therapy practice today. The text is organized into six practice areas, following the American Occupational Therapy Association (AOTA) framework for OT practice: productive aging, health and wellness, work and industry, rehabilitation and disability, children and youth, and mental health. Each section contains a series of chapters, each of which outlines the design, findings, and implications of a key study from that area of practice. Each chapter also includes a case scenario designed to illustrate how the findings of the study relate to clinical practice. This text will be a valuable resource for occupational therapy students and practitioners seeking to understand the breadth, rigor, and trustworthiness of research informing occupational therapy practice, and for others interested in better understanding the profession.

Keywords. Occupational therapy, evidence-based practice, qualitative research, quantitative research, rehabilitation, allied health

The purpose of this chapter is unapologetically to further one of the goals of global racialised communities: ending racism. Farias et al. (2020, p: 243) explains that the “… racialisation of life and the production of racial inequality permeates the everyday life of all agents, whether those who suffer violence, whether those who practice and/or legitimise violence, or those who watch them”. Measuring antiracism is a small aspect but necessary action of the antiracism approach, yet it does not follow that racism with its roots in colonialism is easily circumscribable nor open to being scrutinised and grappled with. This chapter will argue why and how measures of antiracism require nothing less than the collaborative strength of collectives using multiple strategies across multiple spheres of influence to bring transformation. We outline a stepwise antiracism programme that includes honest identification of sites of racism, bespoke and contextualised plans, in full and transparent collaboration with expert collectives. As antiracism and decolonisation are entirely contextual, we do not endorse standardised antiracism measures, closed protocols, or universals. Thus, the critical question that guides this chapter is: How can we suggest possibilities for an antiracist praxis in occupational therapy, considering different contexts, breaking with an universalist approach?

This chapter will address diabetes and the related issues that the occupational therapy practitioner can address in primary care. The chapter will outline the basic role of the primary care physician, as well as the evaluation techniques and intervention strategies employed by the occupational therapy practitioner.

This chapter will address depression and related issues that the occupational therapy practitioner can address in primary care. The chapter will outline the basic role of the primary care physician, as well as the evaluation techniques and intervention strategies employed by the occupational therapy practitioner.

This chapter will address anxiety and related issues that the occupational therapy practitioner can address in primary care. The chapter will outline the basic role of the primary care physician, as well as the evaluation techniques and intervention strategies employed by the occupational therapy practitioner.

To successfully integrate occupational therapy services in a primary care setting, it is essential to consider the administrative needs of the organization. This chapter addresses creating a strategic plan, considerations for the primary care environment, reimbursement, populations served, regulatory bodies, and service delivery models of primary care occupational therapy.

The chapter “Energy Conservation Interventions for Multiple Sclerosis” provides a detailed review of a randomized controlled trial studying the impact of an occupational therapy delivered 6-week energy conservation course on fatigue, self-efficacy, and quality of life for individuals with multiple sclerosis. Additionally, this chapter reviews related relevant literature, including 1-year follow-up data, energy conservation group delivery for individuals with progressive multiple sclerosis, teleconference delivery of the energy conservation protocol, and one-to-one implementation of the energy conservation protocol. The chapter concludes with clinical implications and a case study to demonstrate clinical decision-making recommendations for energy conservation programming in the multiple sclerosis population.

Keywords. multiple sclerosis, fatigue, energy conservation, group intervention, quality of life, self-efficacy, occupational therapy

This chapter presents findings from a study analyzing occupational therapy intervention outcomes to elucidate the relationship between lifestyle changes and pressure ulcer development. The complexities of lifestyle and behavior changes contributed to different patterns which impacted the development and progression of pressure ulcers. The four identified patterns included positive pressure ulcer changes accompanied by positive lifestyle and behavior changes, negative or no pressure ulcer changes accompanied by positive lifestyle and behavior changes, positive pressure ulcer changes accompanied by minor or no lifestyle or behavior changes, and negative or no pressure ulcer changes accompanied by minor or no lifestyle changes. Community-based occupational therapy practice provides an opportunity to comprehensively address important lifestyle factors impacting pressure ulcer development.

Keywords. occupational therapy, lifestyle, behavior, pressure ulcer, community-based practice

Lawlor and Mattingly utilize data collected from three different studies to illustrate the need for a model of family-centered care that addresses the challenges, or “daily dilemmas,” that arise when attempting to create family–practitioner partnerships. Two macro-categories, Situating Family-Centered Care in Cultural Contexts and Daily Dilemmas within Family-Centered Care, were identified. Practitioners often have to overcome the expert model of treatment, the dilemma of “real work,” “turf battles,” and the blurring of professional boundaries while also recognizing the efforts that parents, often mothers, have to make to engage in these partnerships. To be implemented successfully, effective family-centered care requires a radical shift in traditional power dynamics.

Keywords. family-centered care, patient-centered care, special healthcare need, pediatrics, barrier, occupational therapy

Dyads of 427 parents and children, aged 6–14 years and with a range of health and developmental difficulties, were surveyed, interviewed, and scored on three structured tools to evaluate the perceptions of barriers to participation in school, recreation, and community activities. Perceived barriers were noted in all contexts, ranked highest to lowest in school and work, natural and built environments, policies, services and assistance, and attitudes, respectively. The authors recorded environmental characteristics of accessibility, accommodation, resource availability, social support, and equality as interfering factors and barriers to participation. Adolescents, children with behavioral challenges, and young children with physical limitations were demographic groups with greater perceived barriers.

Keywords. children, adolescent, physical disability, participation, parent perception, environmental barrier, social barrier, cerebral palsy, behavior challenge, occupational therapy

This chapter describes the OPTIMAL study, a randomized controlled trial of an occupational therapy-led community-based program for adults with multiple chronic conditions referred to the program from a network of primary care clinics. Participants in the OPTIMAL program, compared to those in a wait-list control condition, had improved activity participation, self-efficacy, and quality of life. The OPTIMAL study adds to the literature demonstrating that occupational therapy is effective in improving function and quality of life among individuals with chronic conditions. The chapter summarizes the study methodology and findings, reviews related literature, and provides an illustrative case example relating the findings of the OPTIMAL study to occupational therapy practice.

Keywords. occupational therapy, multiple chronic conditions, chronic disease management, primary care, self-management

Occupational therapists apply a holistic and transactional approach that differentiates them from other professionals who provide injury prevention services. The study reviewed in this chapter provides one example of how occupational therapists can provide an ergonomics intervention to promote healthy habits and postures, even in non-work settings. Specifically, the study by Feingold and Jacobs describes how a 30-minute ergonomics education session tailored to middle school children resulted in a change in backpack-wearing habits and reports of discomfort. This study is related to a national campaign led by occupational therapists for backpack safety awareness that includes an annual backpack awareness day at the start of each school year in the fall. Additional studies are noted that provide support for occupational therapy’s role in promoting healthy behaviors and reducing occupational and work-related injuries both within the profession and in other areas through ergonomic assessments, education, intervention, and product design.

Keywords. ergonomics, posture, school-aged child, trunk, musculoskeletal, occupational therapy, health education, prevention

This systematic review highlights the effectiveness of activity- and occupation-based interventions utilized with people recovering from traumatic brain injury (TBI), to improve participation in daily activities and social participation. Five themes emerged from the synthesis of 19 studies: the use of multidisciplinary and interdisciplinary intervention approaches, community-based rehabilitation programs, client-centered goals and relevant contexts, interventions including social skills training and peer mentoring, and community mobility interventions. There was moderate evidence that multidisciplinary and interdisciplinary approaches, community-based rehabilitation programs, and a focus on client-centered goals delivered in a relevant context by an occupational therapist could improve occupational performance following TBI. Limited evidence was found for the best approach to improving social skills and community mobility. The specific contribution of occupational therapy intervention for this patient population has not been well studied, and additional research is needed to determine the nature and extent of occupational therapy intervention for individual patients.

Keywords. traumatic brain injury, occupation-based practice, comprehensive rehabilitation, interdisciplinary team, community-based rehabilitation, client-centered rehabilitation, occupational therapy

The chapter describes a study, “Autism during Infancy: A Retrospective Video Analysis of the Sensory-Motor and Social Behaviors at 9–12 Months of Age,” that used retrospective video analysis to identify several sensory-motor and social behaviors that discriminated between children with autism, children with developmental disabilities, and neurotypical children between the ages of 9 and 12 months. There were 19 boys and 13 girls whose families had taken high-quality home videos of them. Nine categories of behaviors were identified and coded: affective expressions, looking, gaze aversion, response to name, social touch responses, anticipatory posture, motor stereotypies, object stereotypes, and sensory modulation. This was the first retrospective study to identify early sensory-motor indicators of autism in children.

Keywords. autism, early identification, sensory-motor, social behavior, occupational therapy

Despite falls being a common reason older adults present to the emergency room, current practice lacks systematic assessment processes to determine cause, consequence, and prevention of falls in this population. A randomized controlled trial was undertaken to compare a combined medical and occupational therapy interdisciplinary approach to assessment and referral (n = 184) versus usual care (n = 213). Outcomes were analyzed at 4, 8, and 12 months. Cumulative number of falls was significantly lower in the intervention group (183) versus the control group (510; p = 0.0002) at 1-year follow-up. The intervention group demonstrated reduced risk of falling (odds ratio 0.39; 95% confidence interval 0.23–0.66), reduced risk of recurrent falls (0.33; 0.16–0.68), and reduced likelihood to return to hospital (0.61; 0.35–1.05). The control group had a more significant decline in function (p < 0.00001). The study concluded that the medical–occupational therapy interdisciplinary approach to assessment and referral reduces falls risk and slows functional decline.

Keywords. fall, older adult, randomized controlled trial, occupational therapy, interdisciplinary, fall prevention, hospital admission, functional status

This study examined the response to sensory integration therapy (SIT) in a group of children with learning disabilities. Ninety-two children were divided into two groups of 46. The control group received special education alone. The experimental group received both SIT and special education. Children in both groups were tested with the Southern California Postrotary Nystagmus Test (SCPNT) and language and academic tests. In the experimental group, children who tested below –1.0 standard deviation in the SCPNT (hyporesponsive to vestibular input) were better responders to SIT than children who were not hyporesponders. In the control group, fewer children with hyporesponsiveness to vestibular input benefited from special education compared to those without hyporesponsiveness. Hyporesponsiveness to vestibular input was also linked to language concerns. Children who were hyperresponsive to vestibular input exhibited more generalized sensory-motor problems than children who were hyporesponsive.

Keywords. sensory integration treatment, intervention, sensory processing, vestibular function, postrotary nystagmus, occupational therapy

This chapter explores how people with psychiatric disorders use personal medicine, non-pharmaceutical personal coping tools, as a mechanism for their recovery from mental illness. Personal medicine involves engaging in activities that are meaningful or activities to support self-care. The study examined how individuals use personal medicine to cope with symptoms, to improve wellness, and to bring greater meaning and purpose to their lives. The study includes narratives illustrating how individuals use personal medicine, why they often do not share these experiences with their providers, and how experiences of personal medicine intersect with use of psychiatric medications. Suggestions are provided for how providers can support recovery by eliciting information about personal medicine and supporting individuals to identify and use it.

Keywords. resilience, coping, psychiatric disorder, mental illness, mental health recovery, psychiatric medication, non-pharmaceutical therapy

Occupational therapy (OT) has the potential to mitigate against the health risks associated with older adulthood but traditionally has been applied only after catastrophic health events. The Well Elderly study included a randomized controlled trial comparing preventive OT services to non-professionally led social activity and a non-treatment control condition in 361 independent-living, multiethnic older adults (60+ years old). Physical, social, and mental health outcomes were measured at baseline, 9 months (intervention end), and 15 months. Results showed significant benefits for the OT group in overall health, functional status, and life satisfaction compared with both control conditions. The social activity control group did not differ significantly in outcomes compared with the non-treatment control. This study provides support for preventive OT service provision to promote the health and well-being of independent-living older adults, above and beyond mere participation in group-based social activities.

Keywords. occupational therapy, older adult, independent living, Well Elderly, health promotion, well-being, function, social activity, life satisfaction

The articles “Systematic Review of Occupational Therapy and Adult Cancer Rehabilitation,” part 1 and part 2, examine the evidence of the effectiveness of occupational therapy interventions on adults with cancer. The systematic review highlights the importance of interventions including physical activity, symptom management, multidisciplinary rehabilitation programs, and interventions targeting psychosocial concerns, sexuality, and return to work. Strong evidence indicates that physical exercise is safe and beneficial for most cancer survivors, most notably to address cancer-related fatigue. Strong evidence supports the benefit of multidisciplinary rehabilitation for cancer survivors as well as the benefit of psychosocial intervention in reducing anxiety and depression. Moderate evidence supports the effectiveness of interventions on sexuality and return to work; however, further research in this area is needed. This systematic review provides support for occupational therapy intervention in addressing the activity and participation needs of adult cancer survivors.

Keywords. adult cancer rehabilitation, occupational therapy, oncology rehabilitation, activity, participation, exercise, psychosocial, physical activity

This chapter outlines the findings of Donnelly et al.’s article describing the integration of occupational therapy on interprofessional primary healthcare teams. A case study approach was used to identify the structures and processes that support successful integration of occupational therapy within family health teams. The findings illustrate that key factors supporting integration include developing team members’ understanding of the role of occupational therapy in primary care, creating a culture of collaboration, and developing trust and understanding among team members. The chapter outlines key findings of the Donnelly et al. article, highlights related studies evaluating the role and outcomes of occupational therapy in primary care settings, and provides a descriptive case study relating the chapter content to current occupational therapy practice.

Keywords. primary healthcare, patient care team, interprofessional care, collaborative care, occupational therapy, organizational case study

Traditional assessment measurements fail the disability community in that “participation” has unique qualities for people who have different abilities, resources, and needs. Participation includes not only active engagement in life situations at the societal level, but also the personal meaning and satisfaction resulting from that engagement. Participation is a right based on access, opportunity, respect, and inclusion. Participation should include not only the physical aspects of “doing,” but also the choice and control to participate in ways individually perceived as meaningful. The medical and rehabilitation fields need subjective and value-based participation assessment tools that reflect a non-hierarchical conceptualization of participation created with the voice of the disability community, which is contrary to the assumptions of traditional measurement. Researchers must critically examine conventional means of measuring participation via performance of a standard set of roles and activities that do not make sense for all people.

Keywords. disability community, disability perspective, participation, inclusion, social justice, assessment, occupational therapy

Occupational therapy is the only hospital cost category in which increased spending is statistically significantly associated with reduced readmission rates for conditions covered in the Centers for Medicare and Medicaid Services’ Hospital Readmission Reduction Program. These conditions are heart failure, acute myocardial infarction, and pneumonia. With approximately 75% of patients with heart failure, acute myocardial infarction, or pneumonia who are admitted not typically receiving occupational therapy services, the findings of this study suggest a low-cost and high-yield way for hospitals to improve the quality of care and reduce the number of readmissions by investing in occupational therapy services for more patients.

Keywords. hospital, readmission, quality, cardiovascular, pulmonary, rehabilitation

Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice presents the findings of a multiyear qualitative study of the clinical reasoning of occupational therapists through ethnographic and action research methods. The clinical reasoning of 14 therapists in a large teaching hospital was examined by a team of researchers, including several of the therapists themselves, through participant observation, review of videos, and extensive interviews with the therapists and some patients. Findings revealed three different types of clinical reasoning, procedural, interactive, and conditional, which expert therapists combined in what authors named a three-track mind. Due to the profession’s core values and commitment to treating the whole person and, especially, the phenomenological or lived experience of illness or disability, many occupational therapists experienced tensions between expectations of the institution’s focus on the medical model and their professional commitment to treating the personal and complex experiences associated with navigating disability and illness in everyday life.

Keywords. clinical reasoning, three-track mind, novice versus expert, underground practice, phenomenology, occupational therapy

The Canadian Occupational Performance Measure is a standardized outcome measure that assists in structuring and focusing the occupational therapy assessment, reassessment, and intervention process. Using a semi-structured interview with patients who have a wide range of diagnoses in various practice settings, the information gathered by the Canadian Occupational Performance Measure reflects the importance of the skill or activity to the client in the areas of self-care, productivity, and leisure. The Canadian Occupational Performance Measure is designed to assist the occupational therapist in establishing occupational performance goals based on client perceptions of need and measures the change in defined problem areas.

Keywords. COPM, client-centered interview, outcome measure, self-care, productivity, leisure

The “Combined Cognitive-Strategy and Task-Specific Training Improve Transfer to Untrained Activities in Subacute Stroke: An Exploratory Randomized Controlled Trial” article analyzed the effect of the Cognitive Orientation to Daily Occupational Performance (CO-OP) approach against regular outpatient occupational therapy (OT) on improving participants’ occupational performance and participation post-stroke. It employed an exploratory, randomized controlled trial at two outpatient OT clinics in Canada and the United States. Outcomes were measured using the Canadian Occupational Performance Measure, the Performance Quality Rating Scale (PQRS), the Community Participation Index, the Stroke Impact Scale, and the Self-Efficacy Gauge. Twenty-six participants were evaluated. At post-intervention, CO-OP over usual care had a medium effect size for PQRS trained activities and a large effect for PQRS untrained activities. At 3-month follow-up, CO-OP over usual care had large effect sizes for PQRS trained and untrained activities and medium effect sizes for change in participation via the Community Participation Index and self-efficacy.

Keywords. occupational therapy, neurorehabilitation, outpatient therapy, CO-OP, stroke, rehabilitation, cognition, self-efficacy

The objective of this study was to examine the application of moderate-pressure massage and kinesthetic stimulation versus light-pressure massage and kinesthetic stimulation on preterm infant behavioral states, heart rate/vagal tone, and weight. Preterm infants (n = 68; M gestational age = 30 weeks) in the neonatal intensive care unit (NICU) were randomly assigned to a moderate- or light-pressure massage therapy plus kinesthetic stimulation condition, receiving massages three times per day for 15 minutes each for 5 consecutive days. Infants who received moderate-pressure massage therapy demonstrated significant improvements in behavioral states (e.g., active sleep, fussing, crying, movement, stress behavior), deep sleep, heart rate/vagal tone, and weight gain compared to the light-pressure massage therapy group. Overall, the data indicate that providing moderate-pressure massage therapy and kinesthetic stimulation has the potential to improve outcomes for stable preterm infants in the NICU.

Keywords. occupational therapy, massage therapy, preterm infant, weight gain, vagal tone, tactile-kinesthetic stimulation

With therapy minutes generally closely aligned with regulatory and reimbursement requirements, there is little room to consider patient characteristics, time (length of stay [LOS]), and clinical judgment in determining the most cost-effective and clinically optimal plan of care. This study provides valuable insight into client-centered variables (comorbidities, functional outcomes, burden of care) that bring meaning and perspective into determining a value-based rehabilitation plan rather than one based on arbitrary required and assigned minutes. In this study, patients are assigned to one of nine recovery groups following hip fracture surgery. Recovery groups are based on therapy minutes per LOS as low, medium, or high and functional gains in self-care and mobility as measured by the Functional Independence Measure as low, medium, or high. All groups are compared on LOS, providing insight into the role of clinical decision-making and consideration of patient characteristics in determining the dose and intensity of therapy services.

Keywords. post-acute, skilled nursing facility, inpatient rehabilitation facility, acute rehabilitation unit, hip fracture, length of stay, fee-for-service, burden of care, value-based, occupational therapy

This chapter explores the content validity of the Pediatric Evaluation of Disability Inventory (PEDI). Rather than concentrating on developmental items (e.g., stacking blocks) that may not be relevant to each family and child, the authors set out to explore daily-level activities and items. The authors developed and defined 20 complex activities related to mobility, self-care, toileting, and social cognition. Similarly, they provided opinions about the appropriateness on three measurement scales (functional skills/behaviors, caregiver assistance, and modifications). These items and domains were reviewed by a panel of experts in the fields of occupational therapy, physical therapy, physiatry, speech and language therapy, and special education, who were not familiar with items or domains. Results were positive, with 80% of experts rating the overall PEDI as either good or excellent on the two major content validity issues including measuring functional disability in children and determining the comprehensiveness of the item sampling.

Keywords. pediatric assessment, content validity, self-care, adaptive testing, occupational therapy

The purpose of this study was to examine the reliability and validity of the Test of Playfulness (ToP) with children with physical disabilities and no known cognitive limitations, compare their scores with those of able-bodied peers, and examine patterns of difference in test items. Data from all of the children in the normative data set meeting inclusion criteria (n = 25) were paired with those from able-bodied children matched on gender and age. Data were gathered during two 15-minute videotaped free-play sessions. Rasch analysis revealed 100% rater reliability, and 88% of the children with physical disabilities conformed to playfulness patterns represented in the normative data. Mean ToP scores did not differ between groups. Based on the study results, the ToP is a highly reliable assessment for children with physical disabilities. However, person-response validity did not achieve 95%. Further investigation is needed to determine ToP validity for children with physical disabilities and environmental influences on playfulness.

Keywords. physical disability, play, assessment, Rasch analysis, reliability, validity, occupational therapy

This chapter highlights the results of a two-part meta-analysis that was completed to examine the effectiveness of occupational therapy interventions on activity and task performance, role restoration, and the remediation of bodily impairment functions for persons who have had a stroke. The first part of the meta-analysis synthesizes the research findings regarding the impact of occupational therapy interventions on client participation in life roles, basic activities of daily living, and instrumental activities of daily living. The second part of the meta-analysis synthesizes the research findings regarding the impact of occupational therapy interventions on the remediation of psychosocial, cognitive-perceptual, and sensorimotor impairments experienced by persons with stroke. It was concluded that occupational therapy improves client participation in activities after a stroke and facilitates improved cognitive-perceptual skills and motor coordination when specific task practice in client-identified activities and feedback are provided. It was determined that additional research is needed in these areas to verify these findings and provide further guidance for clinical practice.

Keywords. stroke, occupational therapy, meta-analysis, task-specific training, bodily function impairment

The chapter “An Adapted Model of Constraint-Induced Movement Therapy for Young Children with Hemiplegic Cerebral Palsy” describes a study examining the effects of a modified constraint-induced movement therapy on children between 18 months and 4 years of age who were diagnosed with hemiplegic cerebral palsy. The results showed that the 6-month modified constraint-induced movement therapy significantly improved voluntary hand use on the affected hand after 2 months of treatment with 2 hours of use daily. The chapter also provides information about related research evaluating the modified constraint-induced movement therapy among children with cerebral palsy and presents a case study applying the study’s findings to clinical practice.

Keywords. constraint, movement therapy, pediatric rehabilitation, hemiplegia, cerebral palsy, occupational therapy

Background. Type 1 diabetes (T1D) is a chronic condition affecting nearly 1.9 million people in the United States. Young adults (YAs) with T1D face unique challenges in managing their condition, experiencing poorer health and well-being than other age groups. The current study is evaluating the Resilient, Empowered, Active Living (REAL) intervention, previously shown to improve glucose levels and quality of life among YAs with diabetes, using telehealth delivery (REAL-T) to expand reach and accessibility. This paper reports on the methodology and baseline participant characteristics of the REAL-T study.

Methods. REAL-T is a two-arm randomized controlled trial that recruited 18–30 year olds with T1D via clinics and social media advertising. Data collection, which was adapted to be fully remote due to COVID-19, occurs every three months for one year. Participants receive either usual care or a 6-month telehealth occupational therapy intervention. The primary outcome is glycated hemoglobin (A1c); secondary outcomes include diabetes distress, quality of life, and continuous glucose monitor-derived measures.

Results. The study enrolled a diverse sample of 209 YAs with T1D. Analysis of baseline data indicates equivalence between the intervention and control groups. Study participants have notably higher diabetes distress and poorer mental well-being than similar populations.

Conclusion. The REAL-T study successfully adapted to remote implementation during the COVID-19 pandemic. By examining long-term outcomes, mediating pathways, and cost-effectiveness, the study will contribute knowledge of the impact of tailored interventions for YAs with T1D, designed to reduce disparities and improve health and well-being in this population.

The contemporary increase in precarious employment has shaped lives marked by employment, economic, and social instability for many workers. While research has demonstrated deleterious physical and mental implications of precarious work, less attention has been paid to social implications, including heightened risk for social isolation. Using a 5-step scoping review process, this paper investigates what is known about the types and characteristics of physical and virtual ‘third places’ outside of home and work that help maintain social connectedness and ameliorate social isolation in the lives of precarious workers. Descriptive and thematic analysis of 24 interdisciplinary articles revealed that precarious workers navigating conditions marked by spatial exclusion enact collective agency to create and sustain alternative ‘third places’ that align with the conditions of precarious lives. Although places created could be associated with social risks, obligations, and exclusions, they were also mobilised to address diverse social needs, including: a sense of belonging to a collective of ‘similar’ others; temporary respite from the conditions of precarity; assertion of presence and visibility; and exchange of diverse resources and forms of care. These results inform critical reflections on the kinds of spaces that can serve as ‘third places’ within societies marked by growing precarity.

Keywords. Work; precariousness; place; social isolation

This essay traces my personal roots as an Asian-American woman with a father diagnosed with bipolar disorder and the impact of my lived experiences on my professional journey as a pediatric mental health occupational therapist. I highlight three exemplary client stories from my year as a doctoral resident at a community-based mental health agency that have furthered my critical analysis of our current child welfare system. Finally, I reflect upon the importance of collectively developing an abolitionist praxis as occupational therapists and health workers at large who are committed to building equitable systems of care that do not further harm structurally marginalized community members.

Keywords. child welfare system, abolition, transformative justice, BIPOC mental health

This research pioneers the application of a machine learning framework to predict the perceived productivity of office workers using physiological, behavioral, and psychological features. Two approaches were compared: the baseline model, predicting productivity based on physiological and behavioral characteristics, and the extended model, incorporating predictions of psychological states such as stress, eustress, distress, and mood. Various machine learning models were utilized and compared to assess their predictive accuracy for psychological states and productivity, with XGBoost emerging as the top performer. The extended model outperformed the baseline model, achieving an R² of 0.60 and a lower MAE of 10.52, compared to the baseline model’s R² of 0.48 and MAE of 16.62. The extended model’s feature importance analysis revealed valuable insights into the key predictors of productivity, shedding light on the role of psychological states in the prediction process. Notably, mood and eustress emerged as significant predictors of productivity. Physiological and behavioral features, including skin temperature, electrodermal activity, facial movements, and wrist acceleration, were also identified. Lastly, a comparative analysis revealed that wearable devices (Empatica E4 and H10 Polar) outperformed workstation addons (Kinect camera and computer-usage monitoring application) in predicting productivity, emphasizing the potential utility of wearable devices as an independent tool for assessment of productivity. Implementing the model within smart workstations allows for adaptable environments that boost productivity and overall well-being among office workers.

Keywords. productivity; stress; mood; eustress; distress; psychological state; physiological features; behavioral features

We investigated the physiological (heart rate variability) and psychological (state of anxiety, pleasantness, and comfort) effects of ambient bergamot scent on the stress levels of office workers by exposing them to the scent while stressors persisted as the workers continued to work on the office tasks. Forty-eight young adults were randomly assigned to either a control or scent group. Our results show that the stress restoration effect of bergamot scent depends on gender. The change in heart rate variability revealed that bergamot scent increased stress among males but not for females. The reported pleasantness and comfort followed the same trend. Compared to the control groups, females in the scent group thought the office smelled pleasant and felt more comfortable, but males in the scent group reported the opposite. However, no gender effect was found in the level of state anxiety. Specifically, compared to the control groups, both males and females exposed to the bergamot scent self-reported decreasing stress levels. This inconsistency between self-reported stress and physiological measurements is not uncommon, especially among males who are socialized to downplay emotional experiences. Our data suggest that there is indeed a gender difference in the effectiveness of the bergamot scent for reducing stress in office workers.

For the 2023 Eleanor Clarke Slagle Lecture, Dr. Mary Lawlor discusses how some events that may seem inconsequential, just moments in passing, may carry the weight of what really matters. Tentative points of connection are often gateways to the really big things that are difficult to give voice to or reflect on in our practice worlds. What could little things mean, why do they matter, and what work do they do to help us understand each other well enough to effectively “partner up”? The little things may provide opportunities to identify and explore new grounds for healing, connectedness, and understanding in occupational therapy practice.

This AOTA Position Statement defines the distinct role and value of occupational therapy practitioners in critical care settings across the lifespan. Occupational therapy practitioners are essential interprofessional team members who address the needs of critically ill individuals by implementing evidence-based critical care guidelines that aim to improve the quality of survivorship.

Background. Active patient engagement and adherence are essential for successful rehabilitation outcomes, particularly in complex cases such as work-related musculoskeletal injuries. Although the therapist-patient relationship is a significant component of successful care coordination, there has been limited examination of this relationship within upper extremity musculoskeletal rehabilitation.

Objective. To explore therapists’ perspectives on how the therapist-patient relationship intersects with engagement and adherence in the provision of holistic and collaborative rehabilitation services.

Methods. Data were collected from four therapists over three months. Descriptive statistics were generated from the Sport Injury Rehabilitation Adherence Scale (SIRAS) and the Rehabilitation Therapy Engagement Scale (RTES) completed by therapists following visits from a sub-sample of patients (n = 14). Weekly semi-structured group interviews (n = 13) were analyzed using an iterative grounded theory-informed process. Emerging themes were identified, refined, and situated within the context of quantitative results.

Results. SIRAS scores averaged 14.4 (SD: 1.0) and RTES scores averaged 42.5 (SD: 3.5), indicating high perceived patient engagement and adherence. Four themes emerged from therapist interviews: (1) dynamic power; (2) co-constructed engagement; (3) emotional states; (4) complementary therapy contexts.

Conclusion. In this engaged and adherent setting, therapist-patient relationships were complex and intimate, and extended beyond education and physical interventions. Careful management of this relationship was central to active patient participation and engagement. Incorporating holistic techniques may provide more structure for managing and communicating these aspects of care. These findings provide a preliminary understanding of the impact of therapeutic relationships on engagement and collaborative care.

Keywords. Qualitative research, occupational therapy, musculoskeletal diseases, return to work

Objective. This study examined the implementation of a Doppler sonography imaging protocol to assess intraneural blood flow, within the median nerve, in healthy individuals.

Materials and Methods. A total of 176 participants were examined, and this involved 717 retrospective observations of the images collected. The implemented imaging protocol was assessed, and the data that were collected were cleaned and checked for fidelity and validity.

Results. A large percentage of missing evidence (11%–35%) across proximal, mid, and distal carpal tunnel locations. Only a quarter of cases with evidence of intraneural blood flow had the strongest evidence of a power Doppler video clip, of which only three-quarters were valid. The study identified potential areas for improving the imaging protocol to reduce missing data and improve data quality.

Conclusion. This study demonstrates the significance of a standardized imaging protocol to guide the sonographic acquisition of Doppler images and provides important insights into potential issues with data quality. The recommendations have the potential to help future studies assess intraneural blood flow in healthy populations in a more rigorous and reliable way. Incorporating the study’s recommendations into a standardized protocol, there is potential to enhance the diagnostic accuracy of carpal tunnel syndrome and improve diagnosis and treatment.

Despite documented healthcare disparities among Latino autistic children, little is known about how their families experience the autism “diagnostic odyssey.” Pediatricians have a critical role in the “diagnostic odyssey,” but when it becomes arduous, parents may also use complementary health approaches, particularly when conventional care does not adequately address their concerns. Shared decision-making is important in healthcare for autistic children, especially when parents also choose complementary health approaches; but little is known about shared decision-making among Latino parents of autistic children. We conducted a 12-month ethnography with 12 bicultural/bilingual Latino families of autistic children to understand their healthcare experiences (conventional and complementary health approaches) for their children, focusing on shared decision-making. Thematic analysis revealed: (1) most pediatricians were involved early in the “diagnostic odyssey” but were largely uninvolved thereafter; (2) conventional healthcare was satisfactory to the parents for physical health, but not developmental issues; and (3) parents who used complementary health approaches were more frustrated about a lack of autism information from pediatricians than those who did not. Finally, (4) we describe two exemplars of successful shared decision-making between Latino parents and pediatricians. Increasing pediatricians’ autism knowledge and ability to discuss complementary health approaches may facilitate shared decision-making and reduce healthcare disparities for Latino autistic children.

Purpose. This two-phased study aimed to collate, summarize and characterize – through the lens of an occupation-based, person-centred framework – ongoing research and practice featuring activity participation-supportive digital health technology (DHT) for direct use by older persons with mild cognitive impairment or Alzheimer’s disease and related dementias (PwMCI/ADRD).

Materials and methods. Phase 1: Using scoping review procedures, PubMed, MEDLINE and PsycInfo were searched to identify primary research studies. Phase 2: Semi-structured interviews were completed with MCI/ADRD expert stakeholders identified through publicly available biographies and snowball referral. Thematic analysis was used to identify, synthesize and cross-compare emergent themes from both data sources that were subsequently organized into core facets of the Human Activity Assistive Technology (HAAT) model.

Results. The scoping review resulted in 28 studies, which were primarily feasibility work with small sample sizes. Interviewed experts (N = 17) had 4+ years of MCI/ADRD experience, came from a variety of settings, and held myriad roles. Real world and research-based use of DHTs held some commonalities, particularly around support for social participation and instrumental activities of daily engagement. No DHT for sleep or work/volunteerism were noted in either phase. People with milder MCI/ADRD conditions were most often targeted users. Soft technology strategies facilitating implementation centred on product design (e.g., prompting software, customisability, multimedia/multisensory experiences), instructional methods and technology partner involvement.

Conclusions. This study demonstrates that although DHT supportive of activity participation is being studied and integrated into the lives of PwMCI/ADRD, there are still key opportunities for growth to meet the needs of diverse MCI/ADRD end users.

Keywords. Alzheimer’s disease and related dementias; digital health technology; activity participation; scoping review; older adults; activities of daily living; digital divide

Introduction. Children born very preterm (VP) remain at risk for long-term neurodevelopmental impairment. Patterns of brain growth and injury, and how early neuropromotive therapies might mitigate developmental risk in VP infants remain insufficiently understood.

Methods. This is a prospective cohort study of VP infants born at/before 32 weeks gestation. The study will enroll n = 75 consecutively-born VP infants in a level-III NICU. Exposed infants will be categorized into two groups (group 1: low-risk, n = 25 or group 2: high-risk, n = 25) based on the degree of neurological injury on early brain magnetic resonance imaging (MRI) at enrollment. Infants in the low-risk group (i.e., without significant injury defined as intraventricular hemorrhage with dilation, moderate or severe white matter injury, or cerebellar hemorrhage) will receive neurodevelopmental support utilizing the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, while infants in the high-risk group (with neurological injury) will receive more intensive neurorehabilitative support (SENSE-plus). Age-specific, tailored sensory experiences will be facilitated contingently, preferentially by the infant's family with coaching from NICU staff. VP infants in exposure groups will undergo a brain MRI approximately every 2 weeks from enrollment until term-equivalent to monitor brain growth and evolution of injury. Exposed infants will be compared with a reference group (group 3: n = 25), i.e. VP infants whose families decline initial enrollment in SENSE, and subsequently undergo a term-equivalent brain MRI for other purposes. The primary aim of this study is characterization of term-equivalent brain growth and development among VP infants receiving NICU-based neuropromotive interventions compared to VP infants receiving the standard of care. Secondary aims include defining the timing and factors associated with total and regional brain growth on serial brain MRI among VP infants, (Aim 2), and using early imaging to tailor developmental intervention in the NICU while exploring associations with outcomes in VP infants at discharge and at two years corrected age (Aim 3).

Discussion. This study will address gaps in understanding patterns of brain growth and injury drawing on serial MRI of hospitalized VP infants. These data will also explore the impact of intensive, tailored neuropromotive support delivered prior to term-equivalent on child and family outcomes.

Keywords. preterm, neurodevelopment, neurorehabilitation, multisensory experience, developmental care, NICU environment

The Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed in 2017 to guide parents in providing age-appropriate positive sensory exposures to their preterm infants each day of NICU hospitalization. The development of the guideline followed a systematic process with an integrative review to identify evidence-supported sensory exposures, interviews and focus groups with stakeholders, and a pilot study and a randomized controlled trial. Recently, another integrative review was conducted to identify newly published studies on sensory exposures in the NICU, and a SENSE advisory team was recruited to inform updates to the guideline to ensure that the latest evidence related to sensory exposures in the NICU was incorporated. Daily sensory activities that are supported by evidence are listed in the parent education booklet, allowing parents autonomy in selecting appropriate sensory activities to engage in with their infants as they grow and develop in the NICU, as well as enabling choices of activities to provide for infants with different levels of medical support. The healthcare team regularly monitors infant tolerance and development as described in the SENSE implementation manual. While implementation training is available, the program can be implemented by NICUs following a self-paced review of the implementation materials. The SENSE program implementation aims to optimize the NICU environment to improve infant brain development and parent confidence while facilitating their transition into their parental roles.

Keywords. high-risk infants, parenting, NICU, sensory stimulation, environmental modification, program, premature

While Indoor Environmental Quality (IEQ) factors in an environment co-exist, the interaction effects of these factors and their impacts on cognitive functioning and perceived comfort have not been comprehensively examined. In this study, the interaction effects between temperature, lighting Correlated Color Temperature (CCT), and noise levels on selective attention, sustained attention, creativity, acoustics, thermal, visual, and overall IEQ comfort of young adults in open-plan offices in North American Mediterranean climate were presented. In a mixed-design controlled experimental setting, 52 young adults were recruited, and their objective cognitive performance and subjective comfort were assessed through statistical analysis. The experimental set points included [20 °C, 25 °C], [2700 K, 6500 K], and [50 dB, 65 dB] for temperature, lighting color, and noise, respectively. Additionally, the work took into consideration the gender and Body Mass Index (BMI) of participants. The results show that temperature moderated the effect of noise level and lighting CCT on selective attention, while no effect of IEQ factors on sustained attention was found. Creativity was influenced by gender and its interaction with the noise level. Concerning perceived comfort, acoustic comfort varied significantly with temperature. Thermal comfort was influenced by the combined moderating effect of lighting CCT and BMI on temperature, while visual comfort was driven by the moderation effect of gender on lighting CCT. Overall comfort was affected by the noise level and temperature. Finally, cognitive performance indicators were correlated with perceived IEQ comfort votes. Based on the findings of this study, considerations of interactions between noise, lighting CCT, temperature, gender, and BMI can shape occupant-centric priorities for enhanced cognitive functioning and comfort.

Diversity, equity, and inclusion is one of five pillars upholding the American Occupational Therapy Association’s (AOTA) strategic plan. Ensuring organizational, educational and governance structures, policies, programs, and services all reflect diversity, equity, inclusion, justice and accessibility (DEIJA) is a priority for the profession. Yet, addressing DEIJA remains a significant challenge in the occupational therapy academic community. Educational programs are a gateway to the profession and play a critical role in whether minoritized persons feel they belong in occupational therapy. This paper proposes a set of Generative Disruptive Questions (GDQ) that can be used to critically examine practices within education that reflect commitment and action towards DEIJA and to facilitate focused conversations that accelerate the creation of measurable, action steps that ensure DEIJA practices are effectively addressed within occupational therapy educational programs. These questions are intended to foster authentic reflection and brave discussions that will dismantle processes and practices that perpetuate systemic injustices. These conversation starters could help faculty, staff and learners engage in courageous conversations that may, at times, be challenging, but which can lead to transformative changes. The questions promote reflective analysis of DEIJA in multiple aspects of the educational process from examination of vision and mission and DEIJA processes and practices in the broad institutional context to more focused analysis of the culture, climate, recruitment, retention, and teaching practices.

Background. Transitioning to a new electronic health record (EHR) presents different challenges than transitions from paper to electronic records. We synthesized the body of peer-reviewed literature on EHR-to-EHR transitions to evaluate the generalizability of published work and identify knowledge gaps where more evidence is needed.

Methods. We conducted a broad search in PubMed through July 2022 and collected all publications from two prior reviews. Peer-reviewed publications reporting on data from an EHR-to-EHR transition were included. We extracted data on study design, setting, sample size, EHR systems involved, dates of transition and data collection, outcomes reported, and key findings.

Results. The 40 included publications were grouped into thematic categories for narrative synthesis: clinical care outcomes (n = 15), provider perspectives (n = 11), data migration (n = 8), patient experience (n = 4), and other topics (n = 5). Many studies described single sites that are early adopters of technology with robust research resources, switching from a homegrown system to a commercial system, and emphasized the dynamic effect of transitioning on important clinical care and other outcomes over time.

Discussion. The published literature represents a heterogeneous mix of study designs and outcome measures, and while some of the stronger studies in this review used longitudinal approaches to compare outcomes across more sites, the current literature is primarily descriptive and is not designed to offer recommendations that can guide future EHR transitions. Transitioning from one EHR to another constitutes a major organizational change that requires nearly every person in the organization to change how they do their work. Future research should include human factors as well as diverse methodological approaches such as mixed methods and implementation science.

Keywords. systematic review, electronic health records, organizational change

Background. The U.S. Department of Veterans Affairs (VA) is undergoing an enterprise-wide transition from a homegrown electronic health record (EHR) system to a commercial off-the-shelf product. Because of the far-reaching effects of the EHR transformation through all aspects of the healthcare system, VA Health Services Research and Development identified a need to develop a research agenda that aligned with health system priorities so that work may inform evidence-based improvements in implementation processes and outcomes.

Objective. The purpose of this paper is to report on the development of a research agenda designed to optimize the EHR transition processes and implementation outcomes in a large, national integrated delivery system.

Design. We used a sequential mixed-methods approach (portfolio assessment, literature review) combined with multi-level stakeholder engagement approach that included research, informatics, and healthcare operations experts in EHR transitions in and outside the VA. Data from each stage were integrated iteratively to identify and prioritize key research areas within and across all stakeholder groups.

Participants. VA informatics researchers, regional VA health system leaders, national VA program office leaders, and external informatics experts with EHR transition experience.

Key Results. Through three rounds of stakeholder engagement, priority research topics were identified that focused on operations, user experience, patient safety, clinical outcomes, value realization, and informatics innovations.

Conclusions. The resulting EHR-focused research agenda was designed to guide development and conduct of rigorous research evidence aimed at providing actionable results to address the needs of operations partners, clinicians, clinical staff, patients, and other stakeholders. Continued investment in research and evaluation from both research and operations divisions of VA will be critical to executing the research agenda, ensuring its salience and value to the health system and its end users, and ultimately realizing the promise of this EHR transition.

Keywords. electronic health records, informatics, Veterans health services, United States Department of Veterans Affairs

Purpose of Review. While there are reports of differences in emotion processing in autism, it is less understood whether the emotion of disgust, in particular, plays a significant role in these effects. Here, we review literature on potential disgust processing differences in autism and its possible associations with autistic traits.

Recent Findings. In autism, there is evidence for differences in physical disgust processing, pica behaviors, attention away from other’s disgust facial expressions, and differences in neural activity related to disgust processing. In typically developing individuals, disgust processing is related to moral processing, but modulated by individual differences in interoception and alexithymia.

Summary. Autistic individuals may experience atypical disgust, which may lead to difficulty avoiding contaminants and affect socio-emotional processing. In autism, such outcomes may lead to increased occurrences of illness, contribute to gastrointestinal issues, diminish vicarious learning of disgust expression and behaviors, and potentially contribute to differences in processes related to moral reasoning, though further research is needed.

In this paper, I explore how autistic behaviors are rendered Othered transgressive acts in general research and in the figured world of occupation. I assess how the normalization agenda, which aims to condition autistic people into appearing abled, is associated with endemic disparities. I contend that occupational science has often countered anti-autistic stigma. However, I analyze how the field has perpetuated ableism by replicating normalization ideology and through its silence on the occupational significance of autistic behaviors. To contrast dominant assumptions, I examine autistic ways of being within occupational frameworks. I propose that the field can foster inclusion, rethink its figured worlds, and recognize autistic behaviors to promote social responsiveness. I argue these steps are ethically imperative as evidence on the harms of normalization accumulates.

Keywords. Occupational science; Autism; Intersectionality; Occupational justice; Social justice; Ableism

Few studies have investigated the short-term, momentary relationships between physical activity (PA) and well-being. This study focuses on investigating the dynamic relationships between PA and affective well-being among adults with type 1 diabetes. Participants (n = 122) wore an accelerometer and completed daily EMA surveys of current activities and affective states (e.g., happy, stressed, excited, anxious) via smartphone over 14 days. Within-person, increased sedentary time was associated with less positive affect (r = − 0.11, p < 0.001), while more PA of any intensity was associated with greater positive affect and reduced fatigue, three hours later. Between-person, increased light PA was associated with increased stress (r = 0.21, p = 0.02) and diabetes distress (r = 0.30, p = 0.001). This study provides evidence that positive affect and fatigue are predicted by previous activity regardless of the different activities that people engaged in. Positive affect increased after engaging in PA. However, participants with higher amounts of light PA reported higher stress ratings.

Keywords. Ecological momentary assessments; Accelerometry; Physical activity; Mood; Type 1 diabetes

Background. While the literature is abundant on hand therapy assessment and treatment of nonsurgical thumb carpometacarpal (CMC) osteoarthritis (OA), clarity and uniformity are meager, making it a desirable diagnosis to establish expert consensus.

Purpose. This study aimed to ascertain if consensus exists for the assessment and treatment of nonsurgical management of thumb CMC OA in the hand therapy clinical setting.

Study Design. This was a consensus paper via the modified Delphi approach.

Methods. A modified Delphi method was used to determine consensus among an expert panel, including hand therapists and hand surgeons, via two online surveys. A consensus paper steering committee (from the American Society of Hand Therapist’s research division) designed the surveys and analyzed responses. Consensus was established as 75% agreement among the expert panel. Demographic information was collected from the expert panel.

Results. The expert panel included 34 hand therapists and seven hand surgeons. The survey response rates were 93.6% for the first survey and 90.2% for the second survey. Consensus recommendations were classified according to the World Health Organization categorization. These included evaluating the body structures for clinical signs/clinical testing and body functions for pain, range of motion for palmar abduction, radial abduction, opposition, and thumb metacarpal phalangeal flexion/extension, and grip and tripod pinch strength. Further consensus recommendations were for the assessment of function using a region-specific, upper extremity patient-reported outcome measure (activity and participation), environmental factors, outcome expectation, and illness perception within the patient’s unique environmental and social contexts. Treatment recommendations included the use of an orthosis during painful activities, a dynamic stability program (stable C posture, release of tight adductors, and strengthening of stabilizers), patient education, joint protection techniques, adaptive equipment, and functional-based intervention.

Conclusions. The findings describe the consensus of a group of experts and provide a clinical reference tool on the hand therapy assessment and treatment of nonsurgical thumb CMC joint OA.

Keywords. Thumb carpometacarpal osteoarthritis; Assessment; Treatment

Background. Integrity of the corticospinal tract (CST) is an important biomarker for upper limb motor function following stroke. However, when structurally compromised, other tracts may become relevant for compensation or recovery of function.

Methods. We used the ENIGMA Stroke Recovery data set, a multicenter, retrospective, and cross-sectional collection of patients with upper limb impairment during the chronic phase of stroke to test the relevance of tracts in individuals with less and more severe (laterality index of CST fractional anisotropy ≥0.25) CST damage in an observational study design. White matter integrity was quantified using fractional anisotropy for the CST, the superior longitudinal fascicle, and the callosal fibers interconnecting the primary motor cortices between hemispheres. Optic radiations served as a control tract as they have no a priori relevance for the motor system. Pearson correlation was used for testing correlation with upper limb motor function (Fugl-Meyer upper extremity).

Results. From 1235 available data sets, 166 were selected (by imaging, Fugl-Meyer upper extremity, covariates, stroke location, and stage) for analyses. Only individuals with severe CST damage showed a positive association of fractional anisotropy in both callosal fibers interconnecting the primary motor cortices (r[21]=0.49; P=0.025) and superior longitudinal fascicle (r[21]=0.51; P=0.018) with Fugl-Meyer upper extremity.

Conclusions. Our data support the notion that individuals with more severe damage of the CST depend on residual pathways for achieving better upper limb outcome than those with less affected CST.

Keywords. corticospinal tract; white matter; neuroimaging; diffusion tensor imaging; stroke; upper extremity

Background. Microstructural changes in the corpus callosum (CC) are associated with more severe motor impairment in the paretic hand, poor recovery, and general disability. The purpose of this study was to determine if CC microstructure predicts bimanual motor performance in chronic stroke survivors.

Methods. We examined the relationship between the fractional anisotropy (FA) across the CC, in both the sensorimotor and non-sensorimotor regions, and movement times for two self-initiated and self-paced bimanual tasks in 41 chronic stroke survivors. Using publicly available control datasets (n = 52), matched closely for imaging acquisition parameters, we also explored the effect of stroke and age on callosal microstructure.

Results. In mild-to-moderate chronic stroke survivors with relatively localized lesions to the motor areas, lower callosal FA values, suggestive of a more disorganized microstructure, were associated with slower bimanual performance. Associations were strongest for the primary motor fibers (b = −2.19 ± 1.03, p = .035), followed closely by premotor/supplementary motor (b = −2.07 ± 1.07, p = .041) and prefrontal (b = −1.92 ± 0.97, p = .05) fibers of the callosum. Secondary analysis revealed that compared to neurologically age-similar adults, chronic stroke survivors exhibited significantly lower mean FA in all regions of the CC, except the splenium.

Conclusion. Remote widespread changes in the callosal genu and body are associated with slower performance on cooperative bimanual tasks that require precise and interdependent coordination of the hands. Measures of callosal microstructure may prove to be a useful predictor of real-world bimanual performance in chronic stroke survivors.

Keywords. Diffusion tensor imaging; stroke; corpus callosum; bimanual; recovery; behavior

Objective. This work aimed to explore how the COVID-19 pandemic affected the work of sonographers and vascular technologists.

Materials and Methods. A follow-up questionnaire was sent to an established registry of ultrasonography users who opted into a longitudinal research study examining worker health and wellbeing. Multiple questions related to the general impacts of COVID-19 on sonography work practices, workload, and considerations of remaining or leaving their current job were included; responses to these questions were descriptively tabulated. Participants indicated specific changes that occurred and provided general comments related to COVID-19 impacts in two free-text questions. These comments were qualitatively analyzed by two sonographers who used an interpretive grounded theory approach to formatively code and memo the comments. Four summative interviews were conducted with participants who represented varied practice areas to gain deeper insights into the experiences expressed by the total respondent pool. Qualitative coding of the free-text responses and interview transcripts was completed independently by the two sonographers using the Sonography Work Systems (SWS) framework, and the full research team contributed to the interpretation of the findings.

Results. A total of 1389 ultrasonography users completed the questionnaire. The pandemic changed the ways in which examinations were performed for approximately half of the respondents. A higher or somewhat higher workload was noted by 48% of the sample, while only 10% experienced a lower or somewhat lower workload. Components of the work system were a major concern for respondents, and a lack of support from supervisors and hospital administration was a key finding. Participants felt limited in their ability to provide care, experienced posttraumatic stress, and reported a lack of reciprocity, which were all underscored as undesirable outcomes.

Conclusion. Sonographers and vascular technologists suffered negative consequences during the COVID-19 pandemic. The most marked outcome was the undesirable effects on the work system, which resulted in the need for these workers to engage in herculean efforts over a sustained period. Findings suggest that these health care heroes may have experienced physical and mental harm while trying to provide health care services, despite numerous institutional challenges.

As the U.S. population shifts away from a White majority, it is imperative that the health care workforce reflect the diversity of client populations served. Increased diversity in the health care workforce fosters access to more personalized, culturally responsive, and client-centered care, thereby facilitating improved outcomes and reduced health disparities. Occupational therapy education programs function as gatekeepers for diversity and need to be accountable for representation in the profession and to produce graduates who reflect the diversity of the broader population. Holistic admission practices, which ensure that no single factor excludes an applicant from admission, are recognized as a meaningful strategy for increasing student diversity in higher education and provide a pathway to create a representative workforce with the ability to improve care disparities and client outcomes. As one of the largest occupational therapy programs in the country, and located in a diverse urban area, the University of Southern California’s Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy has embraced the profession’s responsibility toward greater health equity through holistic admissions. In this column, we discuss holistic admission best practices and report diversity outcomes resulting from enactment of these practices within our occupational therapy education program.

Introduction. A positive therapeutic relationship is characterized by trust and mutually perceived genuineness. It is positively associated with patients’ adherence to treatment, satisfaction, and health outcomes. When service members with a history of mild traumatic brain injury (mTBI) present to rehabilitation clinics with nonspecific symptoms, a disparity between their experience of disability and clinical expectations of mTBI may disrupt the establishment of a positive therapeutic relationship between patients and providers. The objectives of this study are to (1) explore disparities between military service members and rehabilitation clinicians about the clinical diagnosis and illness experience of mTBI and (2) identify barriers to the establishment of a positive therapeutic relationship.

Materials and Methods. This is a qualitative descriptive study of military service members with prior mTBI (n = 18) and clinicians (n = 16) who participated in interviews and focus groups. Data were analyzed thematically using Kleinman’s framing of illness experience and clinical diagnosis.

Results. Three themes reflected the potential breakdowns in the therapeutic relationship. The first theme, clinical expectations for post-injury recovery versus patients’ experience of ongoing disability, reflects the inconsistency between clinicians’ expectations of symptom resolution within 90 days following mTBI and service members’ experiences of symptoms that worsened over several months or years. The second theme, symptom attribution to mental health conditions versus tissue injury, describes the difficulty in attributing symptoms to the physical impact of the mTBI or mental health diagnoses that may also stem from the injury event. The third theme, suspected malingering versus valid disability, describes clinicians’ reports of frustration with cases in which they suspected malingering for secondary gains in contrast with service members’ feelings that their problems were not taken seriously by clinicians.

Conclusions. This study extended previous research on therapeutic relationships by examining the situation of mTBI rehabilitation services for military service members. The findings reinforce the best practice recommendations of acknowledging patients’ experiences, addressing the presenting symptoms and problems, and encouraging progressive return to activity following mTBI. Acknowledgment of and attention to patients’ illness experience by rehabilitation clinicians is necessary and important for supporting a positive therapeutic relationship and ultimately to optimize patients’ health outcomes and reduce disability.

Objective. Social support is an important component of recovery-based interventions for individuals living with severe mental illness (IWSMI). Clubhouses are local community centers that facilitate the development of meaningful relationships among IWSMI through an empowering structure and engagement with the work-ordered day. This review synthesizes research on social networks in Clubhouses to provide insights on the role of supportive relationships in mental illness recovery, including the size and features of social networks of Clubhouse members, methodological trends and gaps, and the associations between social networks and demographic variables, recovery, health, and perceived social support.

Method. Research on social networks within Clubhouses were identified and analyzed following a systematic six-stage scoping review design.

Results. Twelve articles across six studies were included. Results revealed considerable variation in social network interview methods and network size and features. Overall findings suggest that network size is not consistently associated with reported loneliness, social support, recovery, or quality of life. A deep relationship with at least one supportive person, level of perceived affiliation with Clubhouses, or positive comments from network members may be more or equally valuable than a larger network. Some studies found that types of relationships were associated with unique benefits. Stronger peer networks were associated with relationship satisfaction, while increased connections with health care professionals and family were associated with reduced hospitalizations.

Conclusions and Implications for Practice. Future research should diversify research designs, expand the use of social network analysis and visualization, measure additional outcomes including recovery and health, and increase sample diversity.

Objective. Establish median nerve cross-sectional area (CSA) reference values and identify patient-level factors impacting diagnostic thresholds.

Materials and Methods. Studies were identified through a robust search of multiple databases, and quality assessment was conducted using a modified version of the National Institute of Health Study Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A meta-analysis was performed to identify normative values stratified by anatomic location. A meta-regression was conducted to examine heterogeneity effects of age, sex, and laterality.

Results. The meta-analysis included 73 studies; 41 (56.2%) were high quality. The median nerve CSA [95% confidence interval, CI] was 6.46 mm² [6.09–6.84], 8.68 mm² [8.22–9.13], and 8.60 mm² [8.23–8.97] at the proximal forearm, the carpal tunnel inlet, and the proximal carpal tunnel, respectively. Age was positively associated with CSA at the level of proximal carpal tunnel (β = 0.03 mm², P = .047). Men (9.42 mm² [8.06–10.78]) had statistically larger proximal tunnel CSA (P = .03) as compared with women (7.71 mm² [7.01–8.42]). No difference was noted in laterality.

Conclusion. A reference value for median nerve CSA in the carpal tunnel is 8.60 mm². Adjustments may be required in pediatrics or older adults. The diagnostic threshold of 10.0 mm² for male patients should be cautiously applied as the upper limit of normative averages surpasses this threshold.

Background. Health-Related Quality of Life (HRQoL) values based on the accurate and reliable European Quality of Life Five Dimension (EQ-5D) questionnaire gives health-state utilities as a helpful data set for studying socio-demographic and socio-economic inequalities in health status in the general population. We aimed to do a population-based study to see how HRQoL varies by socio-demographics and socioeconomic status (SES).

Materials and Methods. The study was a cross-sectional population-based study in Shiraz, Iran's southwest. Data was gathered utilizing a personal digital assistant (PDA). A trained interviewer administered the EQ-5D questionnaire to a representative sample of 1036 inhabitants. Principal component analysis (PCA) was used to create SES indices. Because of the skewed distribution, quantile regression was utilized to model the quartiles of HRQoL values. STATA 12.0 was used to perform all statistical analyses. P <0.05 was considered statistically significant.

Results. In 1036 study respondents, women had a mean HRQoL of 0.67 ± 0.28, whereas men had a mean HRQoL of 0.78 ± 0.25. Gender and age remained significant in all quartiles of HRQoL value. Participants with insurance showed 0.14 and 0.08 higher HRQoL values in the first and second HRQoL quartiles than those without coverage, respectively. Education [95% CI: 0.034, 0.111)], economy [95% CI: 0.013, 0.077], and assets [95% CI: 0.003, 0.069] all had an impact on HRQoL value in the lowest quintile.

Conclusion. In all quartiles of HRQoL value, women had lower reported HRQoL than men. Insurance programs aimed at more disadvantaged groups with poorer HRQoL may help to minimize inequity. Education, economics, and assets all had an impact on the lower quartiles of HRQoL value, emphasizing the importance of general policies in determining public health status.

Keywords. Health-related quality of life, Iran, socioeconomic status

Relationships between activity engagement and health related quality of life (HRQOL) can differ based on the level of analyses. For instance, greater exercise on average may be linked with lower fatigue across individuals (between-person level), whereas the momentary experience of exercise may be associated with increased fatigue within an individual (within-person level). Disentangling the between- and within-person associations between everyday activities and HRQOL outcomes may provide insights for personalized lifestyle-oriented health promotion efforts for individuals with chronic conditions. The purpose of this paper was to examine the between- and within-person relationships between activity engagement and HRQOL relevant measures in a sample of 92 workers with type 1 diabetes (T1D), from whom we collected ecological momentary assessment (EMA) data 5–6 times daily over 14 days. At each EMA prompt, information was collected on the activity participants just engaged in, and HRQOL relevant metrics (e.g. mental health, blood glucose, fatigue, functioning). Momentary reports of “caring for others”, and more frequently “caring for others”, were both associated with decreased HRQOL. Reporting napping 10% or more of the time during a person’s waking hours, but not the momentary experience of napping, was associated with decreased HRQOL. Momentary reports of sleeping were associated with low activity satisfaction relative to other activities, but higher activity importance. Study results provided a quantitative representation of the lived experience of T1D covering multiple types of activity engagement, which potentially has health promotion implications for workers with T1D.

Keywords. Ecological momentary assessment; Health promotion; Human activities; Type 1 diabetes; Workers

Background. Executive function is an important determinant of independent living among stroke survivors. Patients with post-stroke executive dysfunction (PSED) have a lower engagement in therapy activities and reduced independent living abilities. One potential method for improving executive function and engagement is arts and crafts therapy (ACT). This study aimed to explore the effects of ACT on patients with PSED.

Methods. The study was a pilot randomized controlled trial (RCT) with two groups: an experimental intervention group receiving ACT combined with individual rehabilitation therapy (IRT) and an active control group receiving IRT only. Fifty-seven patients with PSED participated. Outcome measures included the Trail Making Test (parts A and B), the Stroop test, the Tower of Hanoi (TOH), and the Lawton–Brody Instrumental Activities of Daily Living Scale. Two groups were compared at baseline and 4 weeks after the completion of the training.

Results. There were significant differences in the Trail Making Test part A (TMT-A; time; p < 0.01), the TMT part B (TMT-B; p < 0.05), the TMT-B (errors; p < 0.01), and the Stroop test (time; p < 0.01) between the experimental and the control group after 4 weeks. There were no significant differences in TMT-A (errors), Stroop test (errors), TOH, and Instrumental Activities of Daily Living Scale.

Conclusion. The therapeutic use of arts and crafts could be an effective intervention to improve executive function and self-efficacy for stroke survivors.

Background. The Department of Veterans Affairs (VA) has embarked on the largest system-wide electronic health record (EHR) transition in history. To date, most research on EHR-to-EHR transitions has focused on employee and system transition-related needs, with limited focus on how patients experience transitions.

Objective. (1) Understand patients’ preferences for information and support prior to an EHR transition, and (2) examine actual patient experiences that occurred at facilities that implemented a new EHR.

Design. We used a two-step approach. We had discussions with geographically diverse patient advisory groups. Discussions informed semi-structured, qualitative interviews with patients.

Participants. Patients affected by the EHR transition.

Main Measures. We met with four patient advisory groups at sites that had not transitioned their EHR. Interviews were conducted with patients who received care at one of two facilities that recently transitioned to the new EHR.

Key Results. Patient advisors identified key areas important to patients during an EHR transition. 1) Use a range of communication strategies to reach diverse populations, especially older, rural patients. 2) Information about the EHR transition should be clear and reinforce trustworthiness. 3) Patients will need guidance using the new patient portal. From the patient interviews, we learned if and how these key areas mapped onto patients’ experiences. Patients at the sites that had transitioned learned about the new EHR through a variety of modalities, including letters and banners on the patient portal. However, their experiences varied in terms of information quality, leading to frustrations during and between healthcare encounters. Patient portal issues exacerbated frustrations. These raised concerns about the accuracy and security of the overall EHR.

Conclusions. Maintaining clear communication across patients, local leadership, and providers throughout an EHR transition is essential for successful implementation. Patient-facing communications can set expectations, and help patients receive adequate support, particularly related to the patient portal.

Keywords. electronic health record, patient portal, qualitative, patient experience, patient engagement

Prior studies show differences in empathy and affect-recognition ability between those with autism spectrum disorder (ASD) and typically developing (TD) individuals. Autistic individuals also exhibit increased behavioral, gastrointestinal, and sleep issues. In the current study, we explored the differences in empathy and affect recognition between the ASD and TD groups; and we investigated their associations with conditions co-occurring in ASD. A total of 54 TD and 56 ASD children (8–17 years) were included. As compared to the TD group, the ASD group showed lower scores for affect recognition and perspective taking (PT) and higher scores for personal distress (PD). Interestingly, results from hierarchical linear regressions suggested that disparities in the PD and PT between the groups were primarily attributable to attenuated levels of alexithymia, rather than being mediated by the presence of an autism diagnosis. Differences in affect-recognition ability, however, were mediated by both an autism diagnosis and alexithymia. We also found significant correlations between empathy and affect recognition and measures of related conditions common in ASD. Alexithymia, hence, contributes to difficulties in empathy while both alexithymia and autism are associated with affect-recognition ability in ASD. Additionally, the association between affect recognition and empathic ability with co-occurring conditions in ASD needs to be considered during assessments and interventions.

Keywords. autism; alexithymia; empathy; affect recognition; anxiety; sleep; gastrointestinal issues

Purpose. The purpose of this study was to conduct a scoping review of literature focused on the effects of developmental language disorder (DLD) on writing skills across the life span to highlight gaps in our knowledge of how to support writing for this population.

Method. We adopted the five-step framework for conducting scoping reviews outlined by Arksey and O'Malley (2005) to identify literature focused on writing outcomes for individuals with DLD in childhood, adolescence, and adulthood.

Results. Seventy-two studies from 1991 to 2022 met review criteria. Results indicated that spelling may be an area of relative weakness for individuals with DLD across the life span. Children and adolescents with DLD also may have relative difficulty with grammar, organization, cohesion, and length of written output. Research on the writing skills of adults with DLD is too sparse to draw broad conclusions about the writing skills of this subset of the population with DLD.

Conclusions. Overall, research into the writing skills of individuals with DLD is limited, and more information is needed to inform functional evidence-based approaches to assessment and intervention of writing for those with DLD from childhood through adulthood. Additionally, more focus on electronic writing in research is needed, as only two studies included in this review examined typed writing in any form. Results of this review also indicate a need for systematic, uniform approaches to defining and measuring writing skills for those who experience language difficulties.

Background. Parents report elevated stress during their infant's NICU hospitalization. Real-time measures may improve our understanding of parental stress in the NICU.

Aim. Examine the feasibility of wearable sensors to describe parental stress in the NICU.

Study design. In this prospective feasibility study of 12 parent-infant dyads, parents wore an Empatica E4 wristband to measure psychophysiological stress via electrodermal activity (EDA) during sensory interventions (holding, massage, reading, touch, etc.) with their babies. Baseline and intervention periods were delineated during which concurrent monitoring and clinical observations of infant behavior and environmental factors were recorded. Feasibility was assessed by investigating recruitment/enrollment, retention/adherence, acceptability, sensor usability, and changes in EDA waveforms based on potential stressors. For the latter, independent samples t-tests and ANOVA were used to examine differences in EDA from baseline to intervention, and the impact of environmental and infant factors on parent stress were visually analyzed against EDA waveforms.

Results. Wearable sensor use in the NICU appeared feasible as assessed by all methods. Preliminary data analysis indicated that overall parent EDA levels during parent-infant interactions were low, and engagement in sensory intervention(s) led to a non-significant increase in parental EDA, measured by both skin conductance levels and non-specific skin conductance responses. Three main patterns of EDA emerged: a temporary increase in EDA at the beginning of the intervention followed by a decrease and plateau, a plateau in EDA from baseline to intervention, and a gradual rise in EDA throughout intervention. Specific environmental and infant factors, such as infant stress and health care providers entering the room, appeared to impact parent stress levels.

Conclusion. Although these preliminary findings provide support for use of EDA in the NICU, future studies are needed.

Objective. To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.

Design. Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.

Participants. The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.

Results. The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that ‘the diagnostic label ‘concussion’ may be used interchangeably with ‘mild TBI’ when neuroimaging is normal or not clinically indicated.’

Conclusions. New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Keywords. Craniocerebral Trauma, Concussion, Brain Injury, Diagnostic, Consensus

Purpose. The purpose of this study was to investigate the association between loneliness and cancer-related cognitive impairment (CRCI) in a cohort of breast cancer survivors.

Methods. Female breast cancer survivors (stage I-III) reporting cognitive impairments 2 months to 5 years after chemotherapy (n = 61) participated in a prospective, nonblinded, waitlist-controlled pilot study. The intervention was a tailored cognitive rehabilitation program. Data were collected pre-/post-intervention. Loneliness was measured using the UCLA Loneliness Scale. Perceived cognitive function was measured using two subscales of the FACT-Cog and two PROMIS - Applied Cognition short forms. Spearman correlation coefficients were calculated to determine the relationship between loneliness and perceived cognitive function (PCF).

Results. Participants' loneliness severity was correlated with diminished PCF across all cognitive measures (Spearman r= -0.63 FACT-Cog Perceived Cognitive Impairment, p < 0.0001; r= -0.6 FACT-Cog Perceived Cognitive Abilities, p < 0.0001; r= -0.49 PROMIS Cognitive Ability, p = 0.0002; r = 0.50 PROMIS General Concerns, p = 0.0002). Loneliness scores significantly decreased following participation in the cognitive rehabilitation program in intervention participants as compared to wait-list controls [-5.0 ± 7.24, 95% CI (-8.06, -1.94), p = 0.0025].

Conclusions. Perceived loneliness was significantly and consistently correlated with PCF. The intervention may have served a dual purpose in both addressing cognitive deficits and loneliness. Additional research dedicated to understanding the association between loneliness and cognitive function, as well as screening for and addressing loneliness in clinical oncology settings, may be warranted. IMPLICATIONS FOR REHABILITATION Screening for and addressing loneliness in oncology rehabilitation settings is warranted. Rehabilitation professionals are well-positioned to screen for and address loneliness during clinic visits as part of routine cancer rehabilitation care. Group settings may be appropriate for addressing cancer-related cognitive impairment in rehabilitation, as these groups may serve the dual purpose of addressing cognitive impairment and loneliness simultaneously.

Importance. Although occupational balance (OB) is a construct of importance to occupational therapy, existing OB assessments have not been validated in clinical populations.

Objective. To examine the validity and reliability of the 11-item version of the Occupational Balance Questionnaire (OBQ11) in U.S. adults with Type 1 diabetes.

Design. Data were analyzed from adults with Type 1 diabetes enrolled in a larger longitudinal study examining the relationships among blood glucose, emotion, and functioning. Dimensionality of the OBQ11 was assessed with item response theory (IRT); convergent validity was tested by examining whether associations between the OBQ11 and other constructs were consistent with a priori hypotheses.

Setting. Three outpatient clinical sites in the United States.

Participants. Data from 208 U.S. adults with Type 1 diabetes were included in the analyses (42% Latino, 29% White, 14% African American, 7% multiethnic, and 8% other).

Outcomes and Measures. Assessments administered include the OBQ11, Patient Health Questionnaire (depression), and Diabetes Self-Management Questionnaire.

Results. Overall, results from IRT models and correlational tests supported the reliability and validity of the OBQ11. For instance, higher scores on the OBQ11 were significantly associated with better self-ratings of diabetes management behaviors (r = .28, p < .001), lower depression symptoms (r = −.53, p < .001), and greater positive affect (r = .32, p < .001). A single-factor generalized partial credit model fit the OBQ11 acceptably well, supporting its unidimensionality.

Conclusions and Relevance. The OBQ11 may be a reliable and valid measure of OB appropriate for use in clinical populations such as adults with diabetes.

Keywords. adult, blood glucose, depressive disorders, diabetes mellitus, diabetes mellitus, type 1, diabetes mellitus, type 2, health, self-management, chronic disease, personal satisfaction

Telehealth is effective for service delivery in pediatric occupational therapy across ages and diagnoses. Remote parent coaching provides unique benefits for both parents and infants. As a result of COVID-19, practitioners and researchers pivoted to remote assessment and intervention without much preparation or training. It is critical that we evaluate the quality of these telehealth services. One important component of remote evaluations is assessment fidelity. To examine assessment fidelity of a telehealth-delivered observational autism screening tool for infants. An assessment fidelity checklist was applied as the primary outcome measure. Parents conducted assessments with 82% adherence to the fidelity checklist. Implications: A parent coaching telehealth approach may be valid for assessment in pediatric telehealth. Continually monitoring the assessment fidelity of a tool is critical for the valid administration of remote services.

Objective. While there is evidence that functioning, or ability to perform daily life activities, can be adversely influenced by type 1 diabetes, the impact of acute fluctuations in glucose levels on functioning is poorly understood.

Research design and methods. Using dynamic structural equation modeling, we examined whether overnight glucose (coefficient of variation[CV], percent time <70 mg/dL, percent time >250 mg/dL) predicted seven next-day functioning outcomes (mobile cognitive tasks, accelerometry-derived physical activity, self-reported activity participation) in adults with type 1 diabetes. We examined mediation, moderation, and whether short-term relationships were predictive of global patient-reported outcomes.

Results. Overall next-day functioning was significantly predicted from overnight CV (P = 0.017) and percent time >250 mg/dL (P = 0.037). Pairwise tests indicate that higher CV is associated with poorer sustained attention (P = 0.028) and lower engagement in demanding activities (P = 0.028), time <70 mg/dL is associated with poorer sustained attention (P = 0.007), and time >250 mg/dL is associated with more sedentary time (P = 0.024). The impact of CV on sustained attention is partially mediated by sleep fragmentation. Individual differences in the effect of overnight time <70 mg/dL on sustained attention predict global illness intrusiveness (P = 0.016) and diabetes-related quality of life (P = 0.036).

Conclusions. Overnight glucose predicts problems with objective and self-reported next-day functioning and can adversely impact global patient-reported outcomes. These findings across diverse outcomes highlight the wide-ranging effects of glucose fluctuations on functioning in adults with type 1 diabetes.

Electromyography (EMG) biofeedback delivered via telerehabilitation can increase access to occupational therapy services for stroke survivors with severe impairment, but there is limited research on its acceptability. This study identified factors influencing the acceptability of a complex, muscle biofeedback system (Tele-REINVENT) for upper extremity sensorimotor stroke telerehabilitation among stroke survivors. We conducted interviews with stroke survivors (n = 4) who used Tele-REINVENT at home for 6 weeks and analyzed the data with reflexive thematic analysis. Biofeedback, customization, gamification, and predictability affected the acceptability of Tele-REINVENT among stroke survivors. Across themes, features and experiences that gave participants agency and control were more acceptable. Our findings contribute to the design and development of at-home EMG biofeedback interventions, which can improve access to advanced occupational therapy treatment options for those who need it most.

Objective. Work-related discomfort is a pervasive issue among ultrasonography users. The Sonography Work Systems (SWS) framework was constructed as a means of examining relationships within and across components of the sonography work systems, work processes, and work/worker outcomes. A database of ultrasonography users was established as a foundation for a longitudinal survey study to examine worker health and well-being and explore the most salient work systems and process factors associated with work-related discomfort.

Materials and Methods. An estimated 100 000 unique ultrasonography users were invited to complete the online questionnaire through an e-mail campaign. Snowball sampling occurred through social media posts and encouragement for respondents to share the survey link with colleagues. The questionnaire included items that examined participant demographics, selected constructs from the SWS, and the prevalence of work-related musculoskeletal discomfort, visual discomfort, and headaches. Individual and multi-factorial regression models were conducted to examine SWS factors associated with the likelihood of experiencing the three types of work-related discomfort.

Results. A total of 3659 valid responses were included in the analysis, with 86% of respondents reporting that they regularly experienced musculoskeletal discomfort that they directly attributed to their work. About half (54.2%) of the respondents have engaged in sonography-related ergonomics training, and respondents indicated using adjustable equipment approximately 74% of the time. Workplace culture was rated as primarily positive, but respondents indicated that employers implement only two of seven commonly recommended ergonomic policies and procedures. Working in an organization with more policies, using adjustable equipment more frequently, taking more work breaks, engaging in a positive work culture, and minimizing interruptions to workflow were key factors associated with reduced likelihood of work-related discomfort.

Conclusion. This study provides a new framework for examining and addressing factors that contribute to ultrasonography users’ experience of work-related discomfort. Despite increased participation in ergonomics training and the use of adjustable equipment, the prevalence of work-related discomfort remains high among ultrasonography users. The findings highlight the need for attention to be directed at organizational factors and work processes to identify and implement evidence-based solutions to improve the health and well-being of medical ultrasound users.

The Baby Bridge program is an implementation strategy to improve access to in-person early therapy services following neonatal intensive care unit (NICU) discharge. The objective of this study was to evaluate acceptability of Baby Bridge telehealth services among health care providers. Interviews with health care providers were conducted, transcribed, and coded in NVivo. Deductive analysis was used to organize data into negative and positive comments, suggestions for optimization, and perceptions about the first visit. Next, a conventional approach was used to organize the data into themes. Telehealth was viewed as an acceptable, but not necessarily preferable, form of Baby Bridge delivery. Providers identified how telehealth may improve access to care, but with potential challenges in delivery. Suggestions for optimization of the Baby Bridge telehealth model were proposed. Identified themes included delivery model, family demographics, therapist and organizational characteristics, parent engagement, and therapy facilitation. These findings provide important insights to consider when transitioning from in-person therapy to telehealth.

Keywords. family-centered practice; neonate; pediatrics; qualitative research; services.

Background. Type one diabetes (T1D) management is challenging for adolescents and young adults (AYAs) due to physiological changes, psychosocial challenges, and increasing independence, resulting in increased diabetes distress and hemoglobin A1c (HbA1c). Alternative care models that engage AYAs and improve diabetes-related health outcomes are needed.

Methods. A 15-month study evaluated an adaptation of the Colorado Young Adults with T1D (CoYoT1) Care model. CoYoT1 Care includes person-centered care, virtual peer groups, and physician training delivered via telehealth. AYAs (aged 16-25 years) were partially randomized to CoYoT1 or standard care, delivered via telehealth or in-person. As the study was ending, the COVID-19 pandemic forced all AYAs to transition to primarily telehealth appointments. This secondary analysis compares changes in clinic attendance, T1D-related distress, HbA1c, and device use between those who attended more than 50% of diabetes clinic visits via telehealth and those who attended more sessions in-person throughout the course of the study.

Results. Out of 68 AYA participants, individuals (n = 39, 57%) who attended most (>50%) study visits by telehealth completed more diabetes care visits (3.3 visits) than those (n = 29, 43%) who primarily attended visits in-person (2.5 visits; P = .007). AYAs who primarily attended visits via telehealth maintained stable physician-related distress, while those who attended more in-person visits reported increases in physician-related distress (P = .04).

Conclusions. Greater usage of telehealth improved AYA engagement with their care, resulting in increased clinic attendance and reduced physician-related diabetes distress. A person-centered care model delivered via telehealth effectively meets the needs of AYAs with T1D.

Pre-pandemic, telehealth occupational therapy (OT) for autistic children appeared promising, but research was limited. The pandemic provided a unique opportunity to investigate how clinics transitioned to telehealth. The purpose of this study was to examine barriers and facilitators that influenced delivery of OT services through telehealth for autistic children during the pandemic. We conducted semi-structured qualitative interviews with 13 participants (three administrators, six OTs, and four parents of autistic children) at three Los Angeles area clinics over a 7-month period. We used narrative and thematic analysis to identify four themes. We identified (a) Challenges and (b) Facilitators to Conducting Telehealth OT, including practical strategies for successful facilitation, and (c) Negative and (d) Positive Outcomes of Conducting Telehealth OT. As telehealth will likely remain a viable means of OT service delivery in the future, our findings provide insight into ways that it can be improved and sustained.

Telehealth delivery of Lifestyle Redesign®, an occupational therapy intervention framework addressing health and quality of life among people with chronic conditions, is understudied. The objective of this study was to evaluate the effectiveness, satisfaction, and engagement of telehealth Lifestyle Redesign for young adults with diabetes. Using process data from two randomized controlled trials, we compared in-person and telehealth intervention effects. Among telehealth clients, effectiveness was assessed using pre-post changes in occupational performance, occupational satisfaction, and health management; a survey captured telehealth satisfaction. Attendance and engagement in in-person versus telehealth therapy were compared. Preliminary results indicate telehealth clients had significant increases in occupational performance, occupational satisfaction, and health management (all p < .02), and high levels of telehealth satisfaction. Intervention engagement (p = .59) and attendance (p = .42) were similar across treatment modalities. Telehealth delivery of Lifestyle Redesign occupational therapy is feasible and potentially efficacious, and continued advocacy is needed to ensure access to occupational therapy through telehealth.

While the COVID-19 pandemic introduced wide expansion of telehealth access in health care, evidence concerning telehealth use in occupational therapy (OT) for cancer survivors remains limited. The objective of this study was to identify the prevalence and perceptions of telehealth services among occupational therapy practitioners (OTPs) in oncology. Descriptive statistics and qualitative content analysis were used to analyze data from a pre-pandemic national survey of OTPs (n = 126) focusing on telehealth. Most OTPs in oncology settings support telehealth use, despite a dearth of access prior to the pandemic. The highest levels of telehealth endorsement among OTPs related to ease of accessibility (48%). Treatments rated as best suited for OT oncology telehealth sessions included education (41%), quality of life/well-being/lifestyle (21%), and psychosocial interventions (19%). These data suggest widespread benefits of telehealth-delivered OT treatment in oncology. Advocacy is needed to ensure the continuation of legislation allowing expanded telehealth access and reimbursement for OT.

To inform changes to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, studies investigating sensory-based interventions in the NICU with preterm infants born ≤32 weeks were identified. Studies published between October 2015 to December 2020, and with outcomes related to infant development or parent well-being, were included in this integrative review. The systematic search used databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar. Fifty-seven articles (15 tactile, 9 auditory, 5 visual, 1 gustatory/olfactory, 5 kinesthetic, and 22 multimodal) were identified. The majority of the sensory interventions that were identified within the articles were reported in a previous integrative review (1995–2015) and already included in the SENSE program. New evidence has led to refinements of the SENSE program, notably the addition of position changes across postmenstrual age (PMA) and visual tracking starting at 34 weeks PMA.

Importance Autistic children have poorer oral health and greater oral care challenges, which are often associated with sensory overresponsivity, than neurotypical peers. It is important to identify innovative solutions enabling dentists to successfully perform standard clinic-based procedures for this population.

Objective To determine whether a sensory-adapted dental environment (SADE) reduces physiological and behavioral distress in autistic children undergoing dental cleanings, compared with a regular dental environment (RDE).

Design, Setting, and Participants This randomized crossover trial was conducted at a pediatric dentistry clinic in a large urban children’s hospital between May 2016 and April 2022. Coders were blinded to study condition for physiological but not behavioral measurements. Autistic children aged 6 to 12 years were identified and invited to participate. Interested families were enrolled consecutively; after confirmation of autism diagnosis, children were randomized. Analysis for this per-protocol study were conducted from April to October 2022.

Intervention Each child underwent 1 RDE and 1 SADE dental cleaning, administered in randomized and counterbalanced order approximately 6 months apart. SADE included modified visual, auditory, and tactile stimuli.

Main Outcomes and Measures The primary outcome was physiological stress, assessed by electrodermal activity. The secondary outcome was behavioral distress measured from video recordings.

Results Among 452 families invited to participate, 220 children were enrolled, and 162 children (mean [SD] age, 9.16 [1.99] years; 136 [84.0%] male) with confirmed autism were randomized, with 83 children receiving RDE first and 80 children receiving SADE first. Most children (94 children [58.0%]) had moderate autism severity. Children had significantly lower physiological stress during dental care in SADE compared with RDE (mean difference in skin conductance level, −1.22 [95% CI, −2.17 to −0.27] μS), suggesting decreased sympathetic activity and increased relaxation during SADE dental care. No significant differences were found in nonspecific skin conductance responses (mean difference, −0.30 [95% CI, −0.86 to 0.25] per min). Video-coded frequency and duration of behavioral distress (but not questionnaire) measures were significantly lower in SADE vs RDE (Cohen d = −0.84 to −1.19). Physiological stress was associated with behavioral distress during the dental cleaning (eg, nonspecific skin conductance responses associated with the Frankl Scale: β = −0.29; 95% CI, −0.39 to −0.19); age, IQ, and expressive communication moderated the intervention’s success. No participants withdrew due to adverse effects.

Conclusions and Relevance In this randomized crossover trial of autistic children, using SADE was safe and efficacious in decreasing physiological and behavioral distress during dental care. This is important because enhancing oral care is critical for autistic children; this intervention may also be beneficial for populations beyond autism.

Trial Registration ClinicalTrials.gov Identifier: NCT02430051

Objective. To 1) define the number and characteristics of NICUs in the United States (US) and 2) identify hospital and population characteristics related to US NICUs.

Study design. Cohort study of US NICUs.

Results. There were 1424 NICUs identified in the US. Higher number of NICU beds was positively associated with higher NICU level (p < 0.0001). Higher acuity level and number of NICU beds related to being in a children’s hospital (p < 0.0001;p < 0.0001), part of an academic center (p = 0.006;p = 0.001), and in a state with Certificate of Need legislation (p = 0.023;p = 0.046). Higher acuity level related to higher population density (p < 0.0001), and higher number of beds related to increasing proportions of minorities in the population up until 50% minorities. There was also significant variation in NICU level by region.

Conclusions. This study contributes new knowledge by describing an updated registry of NICUs in the US in 2021 that can be used for comparisons and benchmarking.

Photovoice is a participatory, photo-based research method that differs from conventional (non-participatory) research in that the process is meant to be empowering and beneficial. However, empirical research on the Photovoice process remains very limited. Based on feedback from participants who reported Photovoice helped them develop closer relationships, we examine whether engaging in Photovoice fosters social support. Transcripts from a Photovoice study on wellness in mental health Clubhouses (voluntary, community mental health centers) were retrospectively analyzed for instrumental support, appraisal, informational support, and emotional support. Appraisal was the most common form of social support identified, and was primarily expressed through peer praise for photos and insights. Informational support included advice on managing symptoms, promoting wellness, and navigating challenges. Instrumental support was fostered by learning the tangible skill of digital photography and by supporting fellow members with physical or visual limitations to participate in the process. Emotional support was cultivated through encouragement, identification of shared experiences, and connection through humor. In sum, the findings suggest that Photovoice has the potential to foster social support, which may support relational empowerment.

The Supporting and Enhancing NICU Sensory Experiences (SENSE) program promotes consistent, age-appropriate, responsive, and evidence-based positive sensory exposures for preterm infants each day of NICU hospitalization to optimize infant and parent outcomes. The initial development included an integrative review, stakeholder input (NICU parents and healthcare professionals), and feasibility focus groups. To keep the program updated and evidence-based, a review of the recent evidence and engagement with an advisory team will occur every 5 years to inform changes to the SENSE program. Prior to the launch of the 2nd edition of the SENSE program in 2022, information from a new integrative review of 57 articles, clinician feedback, and a survey identifying the barriers and facilitators to the SENSE program’s implementation in a real-world context were combined to inform initial changes. Subsequently, 27 stakeholders (neonatologists, nurse practitioners, clinical nurse specialists, bedside nurses, occupational therapists, physical therapists, speech-language pathologists, and parents) carefully considered the suggested changes, and refinements were made until near consensus was achieved. While the 2nd edition is largely the same as the original SENSE program, the refinements include the following: more inclusive language, clarification on recommended minimum doses, adaptations to allow for variability in how hospitals achieve different levels of light, the addition of visual tracking in the visual domain, and the addition of position changes in the kinesthetic domain.

Keywords. sensory-based interventions; sensory integration; sensation; exposure; environment; preterm; neonatal intensive care unit; NICU; tactile; auditory; multimodal; multisensory; vestibular; kinesthetic; visual; olfactory; gustatory; parenting; SENSE; review; program development

The chronic disease burden among American workers leads to substantial expenditures on healthcare, lost productivity at work, and reduced quality of life. Workers from communities of lower socioeconomic status (SES) shoulder a disproportionate burden of chronic diseases and costs. A promising strategy for addressing this population health burden is to develop and implement participatory worker health promotion interventions in workplaces. Part of this effort to develop and implement these programs entails improving the quality of evaluation tools and approaches. Thus, we completed a series of secondary analyses of a large participatory worker health promotion program trial called Working For You. Our first aim was to explore the structural and content validity of the Multifaceted Organizational Health Climate Assessment (MOHCA), a measure of organizational health climate not previously tested in low SES populations. We found that the MOCHA generates valid and reliable scores of participants’ perceived organizational health climate among a low SES population. Importantly, we found that in our lower SES worker population, model fit was better when the MOCHA organizational climate scale was divided into two subscales, including a novel organizational responsiveness subscale that may represent a unique facet of organizational health climate and inform other work. Our second aim was to develop a program logic model and demonstrate the utility of a new process measure of implementation quality called the Process Evaluation Rating Sheet (PERS) in our sample of workers of lower SES. Included in this aim was the demonstration that our Modified PERS demonstrated associations between implementation quality and program efficacy. Our third aim was to establish an association between upstream organizational health climate and perceived organizational support with downstream health behaviors, namely use of workplace health supports. We demonstrated an association between organizational health climate and use of workplace health supports, and found that use of instrumental and informational health supports differed by age and race. These aims together contributed evidence for the utility of current tools and approaches to evaluate and implement participatory worker health promotion programs among lower SES and minoritized workers.

Background. CAPABLE is a time-limited, evidence-based intervention that helps older adults live independently. It has not been previously tested for use among formerly homeless adults in permanent supportive housing (PSH) who experience accelerated aging that can jeopardize their ability to live independently and age in place.

Methods. A pilot randomized controlled trial with PSH tenants with an average age of 63 years old was conducted to examine the impact of CAPABLE on basic and instrumental activities of daily living (ADL) (and other function-related parameters). Twenty-seven PSH tenants received the intervention and 30 PSH tenants were assigned to a waitlist control group.

Results. Those who received the intervention showed improvements in five of seven health outcomes with small to medium effect sizes (Cohen's d = 0.20–0.47). When compared to the control group, the intervention group showed significantly greater improvements in two health outcomes—namely, reduction in limitations in instrumental ADL (p = 0.03) and depression (p = 0.01)—and greater effect sizes (d = 0.17–0.61).

Conclusions. CAPABLE is an evidence-based practice that can be successfully implemented in PSH to improve outcomes in a population that experiences significant health disparities and premature decline. Further investigation with a larger sample is warranted.

Importance. Feeding difficulties are common among preterm infants during neonatal intensive care unit (NICU) hospitalization. Although most preterm infants achieve full oral feeding by term-equivalent age, whether feeding difficulties persist despite the infant taking full volume and whether these difficulties may relate to other neurobehavioral challenges remain unclear.

Objective. To identify the prevalence of feeding problems among preterm infants and the relationships between infant feeding behaviors and neurobehavior at term-equivalent age.

Design. Cohort study.

Setting. Level 4 NICU with 85 beds.

Participants. Thirty-nine very preterm infants born ≤32 wk gestation (range = 22–32 wk). Exclusion criteria were congenital anomalies, >32 wk gestation at birth, and lack of feeding or neurobehavioral assessment at term-equivalent age.

Outcomes and Measures. Standardized feeding assessments using the Neonatal Eating Outcome Assessment and standardized neurobehavioral evaluation using the NICU Network Neurobehavioral Scale.

Results. Thirty-nine infants (21 female) were included in the final analysis. The mean Neonatal Eating Outcome Assessment score was 66.6 (SD = 13.3). At term-equivalent age, 10 infants (26%) demonstrated feeding challenges, 21 (54%) demonstrated questionable feeding issues, and 8 (21%) demonstrated normal feeding performance. Lower Neonatal Eating Outcome Assessment scores (poorer feeding performance) at term-equivalent age were associated with more suboptimal reflexes (p = .04) and hypotonia (p < .01).

Conclusions and Relevance. Feeding challenges and questionable feeding performance were prevalent among preterm infants at term-equivalent age and appeared in conjunction with suboptimal reflexes and hypotonia. Understanding this finding enables therapists to take a holistic approach to addressing feeding difficulties.

Objective. To describe extracurricular activity participation and explore its relationship with college students’ health.

Participants. 159 college students majoring in dental hygiene or occupational therapy.

Methods. Data were collected prospectively at baseline, one- and two-year follow-ups. Self-reported participation in extracurricular activities over the past six months was grouped into eight categories: Fitness, Sports, Creative arts, Leisure, Social, Work, Caregiving, and Animal care. Physical and mental health were measured using SF-36, a valid tool measuring general health.

Results. Participation in fitness, sports, creative arts, and work significantly decreased at one-year and two-year follow-ups (p < 0.01). Work/volunteer activity participation was associated with poorer physical health (β = –1.4, 95% CI: (–2.2, −0.5), p < 0.01), but a change from nonparticipation to some participation in work/volunteer activity was associated with better mental health (β = 2.6, 95% CI (0.3, 4.9), p = 0.04).

Conclusions. Educators should consider the potential impact of maintaining extracurricular activities on college students’ health when designing academic courses.

Keywords. College student; extracurricular activity; health; SF-36; well-being

Background and objectives. Functional outcomes after stroke are strongly related to focal injury measures. However, the role of global brain health is less clear. Here, we examined the impact of brain age, a measure of neurobiological aging derived from whole brain structural neuroimaging, on post-stroke outcomes, with a focus on sensorimotor performance. We hypothesized that more lesion damage would result in older brain age, which would in turn be associated with poorer outcomes. Related, we expected that brain age would mediate the relationship between lesion damage and outcomes. Finally, we hypothesized that structural brain resilience, which we define in the context of stroke as younger brain age given matched lesion damage, would differentiate people with good versus poor outcomes.

Methods. We conducted a cross-sectional observational study using a multi-site dataset of 3D brain structural MRIs and clinical measures from ENIGMA Stroke Recovery. Brain age was calculated from 77 neuroanatomical features using a ridge regression model trained and validated on 4,314 healthy controls. We performed a three-step mediation analysis with robust mixed-effects linear regression models to examine relationships between brain age, lesion damage, and stroke outcomes. We used propensity score matching and logistic regression to examine whether brain resilience predicts good versus poor outcomes in patients with matched lesion damage.

Results. We examined 963 patients across 38 cohorts. Greater lesion damage was associated with older brain age (β=0.21; 95% CI: 0.04, 0.38, P=0.015), which in turn was associated with poorer outcomes, both in the sensorimotor domain (β=-0.28; 95% CI: -0.41, -0.15, P<0.001) and across multiple domains of function (β=-0.14; 95% CI: -0.22, -0.06, P<0.001). Brain age mediated 15% of the impact of lesion damage on sensorimotor performance (95% CI: 3%, 58%, P=0.01). Greater brain resilience explained why people have better outcomes, given matched lesion damage (OR=1.04, 95% CI: 1.01, 1.08, P=0.004).

Conclusions. We provide evidence that younger brain age is associated with superior post-stroke outcomes and modifies the impact of focal damage. The inclusion of imaging-based assessments of brain age and brain resilience may improve the prediction of post-stroke outcomes compared to focal injury measures alone, opening new possibilities for potential therapeutic targets.

The prevalence of Work-Related Musculoskeletal Disorders (WRMSDs) among ultrasound professionals has been significant. National and international efforts to create industry standards have focused primarily on injuries in sonographers. In addition, the Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety & Health (NIOSH) have published documents related to this occupational exposure. There has also been significant attention on equipment utilization and design to help reduce the prevalence of WRMSDs. The American Institute of Ultrasound in Medicine (AIUM) developed the AIUM Practice Principles for Work-Related Musculoskeletal Disorder in collaboration with other organizations whose members use ultrasound [see Collaborating Societies and Representatives]. This document supports the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography” and aims to expand on these Standards to include safety practices for all health care professionals who utilize ultrasound. These professionals include members of the scientific community, a wide variety of medical professionals, and dental professionals. These ultrasound users and operators will collectively be referred to in this document as “operator(s)” except in those instances where data addressed those holding a specific job title, such as sonographer. In addition, this document will support guidance for quality improvement specific to preventing and reducing injury rates.

Keywords. Ergonomics; occupational exposure; work-related musculoskeletal disorders; WRMSD

Background. Considering the burden of moderate and severe brain injury on families and society, and that trauma is one of the common causes of death and disability in Iran, this study aimed to investigate the frequency of death from severe to moderate brain injury in children with brain trauma.

Methods. In this cross-sectional study, records of 126 patients under 18 years of age with moderate and severe brain injuries admitted to Namazi Hospital, Shiraz, Iran during 2017-2019 were investigated. The relative frequency of mortality, parents’ education level, day of trauma, types of trauma, age, gender, and length of hospitalization were studied. P values were set at 0.05; Chi-square and T-test were used for variable comparisons.

Results. The study’s male-to-female ratio was almost 2:1, and the mean and standard deviation of the age of all children in the study was 6.84±4.33. The relationship between brain injury severity and hospitalization length was significant (P<0.001). 21.4% of patients with moderate and severe brain injury were Afghan. The highest frequency of trauma was related to accidents, with 69.8%, followed by falling down at 23.8%.

Conclusion. The most common cause of death in children with brain injury was trauma caused by an accident. To decrease the burden of severe and moderate brain injury in children, health policymakers may tailor interventions to two important groups, including parents with a low level of education and Afghan nationals.

Keywords. Child Injuries; Brain; Death

People who experience disorders of consciousness (DoC) following a severe traumatic brain injury (TBI) have complex rehabilitation needs addressed by occupational therapy. To examine the effectiveness of interventions to improve arousal and awareness of people with DoC following a TBI. For this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases in collaboration with a research librarian. Twenty-seven studies were included and grouped thematically. Multimodal sensory stimulation, familiar voices telling structured stories, and transcranial direct current stimulation had a moderate level of evidence. Multimodal sensory stimulation had the strongest evidence in support of its use in clinical practice. Occupational therapy practitioners should administer multimodal stimuli frequently as studies reported administering these interventions at least twice daily. Occupational therapy practitioners should incorporate personally relevant, meaningful, salient stimuli into interventions when treating patients with DoC.

Importance. Limited research has elucidated factors predicting occupational therapy–specific service utilization by children with autism. Such research is needed to inform reasons for receipt of services.

Objective. To examine factors associated with occupational therapy service utilization by children with autism. We hypothesized that elevated sensory hyperresponsiveness; greater sensory interests, repetitions, and seeking; and lower adaptive behavior would predict more service utilization.

Design. Analysis of extant data from a prospective, longitudinal survey study about autism symptom severity, adaptive behavior, sensory features, and demographic and service utilization information of children with autism ages 3 to 13 yr.

Setting. Online parent survey regarding child behaviors during daily activities and contexts.

Participants. 892 parents of children with autism from 50 U.S. states.

Outcomes and Measures. We used scores on the Vineland Adaptive Behavior Scale–Second Edition, the Social Responsiveness Scale, and the Sensory Experiences Questionnaire Version 3.0 and responses to a demographic questionnaire. We formulated hypotheses after data collection but before analysis.

Results. Predictors of higher occupational therapy service utilization were lower enhanced perception; lower adaptive behavior; elevated sensory interests, repetitions, and seeking behaviors; younger child age; and higher household income.

Conclusion and Relevance. Results partially support our hypotheses. Sensory interests, repetitions, and seeking behavior predicted occupational therapy service utilization, whereas other sensory response patterns did not, suggesting a possible referral bias for certain sensory response patterns. Occupational therapy practitioners can educate parents and teachers about the scope of practice, which includes addressing sensory features beyond sensory interests, repetitions, and seeking behaviors.

Keywords. autistic disorder, child, adaptive behavior

Occupational balance is a central concept in occupational science, but it is complex and lacks an agreed-upon definition. Further, the concept has not been given significant attention by scholars outside Western societies. Building upon traditional Chinese culture and Chinese scholars’ Human Complex System Theory, this article presents a proposed Model of Occupational Harmony, offering an Eastern understanding of how the orchestration of everyday occupations relates to health and well-being. The notion of occupational harmony highlights harmonious human-environment transactions as the essence of the phenomenon and integrates multiple perspectives in previous occupational balance literature, including activity patterns, time use, occupational characteristics, need satisfaction, and biological rhythms. It is asserted that occupational harmony can be characterized as complex equilibria among three pairs of two-sided occupational characteristics and achieved via harmony among five dimensions of occupational engagement and coherence across multiple levels of human-environment transactions. This article is a beginning theoretical conceptualization of occupational harmony, allowing occupational scientists to embrace the complexity of the orchestration of occupational engagement.

Keywords. Occupational science, Occupational balance, Culture, Occupational engagement, Systems theory

Among individuals who have recovered from COVID-19 around the world, there is a substantial number who would need support in finding their way back to meaningful and productive work. The aims of this paper are to demonstrate the multitude of factors that shape return to work (RTW) practices across and within several countries, and argue for the need to explore RTW from an international perspective during an on-going pandemic, focusing on working age adults who have recovered from COVID-19. Conditions for RTW differ across countries. Occupational therapy has a central role in medical rehabilitation after injury and illness (including COVID-19), but the occupational therapy community has, to the best of our knowledge, yet to raise awareness and advance evidence regarding its role in post-COVID RTW processes. A robust evidence-based knowledge on RTW that can be utilised by occupational therapists during the present and future pandemics is needed.

Keywords. Employment; rehabilitation; long COVID; post COVID; occupational therapy; role emerging practice; return to work

White matter hyperintensities (WMHs) are a risk factor for stroke. Consequently, many individuals who suffer a stroke have comorbid WMHs. The impact of WMHs on stroke recovery is an active area of research. Automated WMH segmentation methods are often employed as they require minimal user input and reduce risk of rater bias; however, these automated methods have not been specifically validated for use in individuals with stroke. Here, we present methodological validation of automated WMH segmentation methods in individuals with stroke. We first optimized parameters for FSL's publicly available WMH segmentation software BIANCA in two independent (multi-site) datasets. Our optimized BIANCA protocol achieved good performance within each independent dataset, when the BIANCA model was trained and tested in the same dataset or trained on mixed-sample data. BIANCA segmentation failed when generalizing a trained model to a new testing dataset. We therefore contrasted BIANCA's performance with SAMSEG, an unsupervised WMH segmentation tool available through FreeSurfer. SAMSEG does not require prior WMH masks for model training and was more robust to handling multi-site data. However, SAMSEG performance was slightly lower than BIANCA when data from a single site were tested. This manuscript will serve as a guide for the development and utilization of WMH analysis pipelines for individuals with stroke.

Keywords. white matter hyperintensity (WMH), stroke, lesion segmentation, SAMSEG, FSL, BIANCA

Background. Atypical sensory processing impacts children with intellectual and developmental disabilities (IDD). Research has focused on SP in individuals with autism spectrum disorder (ASD); comparatively, little has been written regarding individuals with Down syndrome (DS) and IDDs.

Aims. We compared patterns of sensory processing in children with DS to children with ASD, other IDDs, and typically developing (TD) peers examining the relationship among different sensory processing measures.

Methods and procedures. We analyzed cross-sectional data using two caregiver questionnaires (SP, SEQ) and one observational measure (SPA). Groups were compared on three sensory processing patterns: hyporesponsiveness; hyperresponsiveness; and sensory interests, repetitions, and seeking (SIRS) via ANOVA. We assessed concordance through correlations.

Outcomes and results. Children with DS, IDD, and ASD demonstrated more atypical sensory processing behaviors than TD peers. Children with ASD exhibited the most atypical responses across all measures, significantly more than DS children on all but one subscale. The IDD and DS groups differed on several measures. Measurement concordance was higher between caregiver-report versus observational assessment.

Conclusions and implications. Differences between three clinical groups indicate that sensory processing features may differ across clinical populations regardless of cognitive functioning. Lower concordance between caregiver-report and observation measures highlights the need to understand sensory processing expression across different tasks and environments.

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme and/or subthemes, related to a specific topic. This Systematic Review Brief summarizes findings from the systematic review on interventions to improve performance and participation in instrumental activities of daily living among adult stroke survivors. This theme reports on the effectiveness of virtual reality, exercise, vision rehabilitation, and community-based stroke empowerment group interventions.

Keywords. adult, cerebrovascular accident, ischemic stroke, survivors, systematic reviews, blind rehabilitation therapy

Baseline child characteristics may predict treatment outcomes in children with or at elevated likelihood of developing autism (EL-ASD). Little is known about the role of child sensory and language features on treatment outcome. Participants were randomly assigned to a parent-mediated intervention or control condition. Analyses explored the relationship between baseline child sensory and language characteristics and changes in ASD symptoms over approximately 9 months. Higher baseline sensory hyporeactivity was significantly related to less improvement in social communication (SC) for the treatment group only. More baseline atypical vocalizations were significantly related to less improvement on SC across treatment and control groups. This work provides an initial framework to encourage the tailoring of interventions for EL-ASD children, suggesting sensory reactivity and atypical vocalizations may be useful behaviors to consider in treatment planning.

Background. The Glycemia Risk Index (GRI) was introduced as a single value derived from the ambulatory glucose profile that identifies patients who need attention. This study describes participants in each of the five GRI zones and examines the percentage of variation in GRI scores that is explained by sociodemographic and clinical variables among diverse adults with type 1 diabetes.

Methods. A total of 159 participants provided blinded continuous glucose monitoring (CGM) data over 14 days (mean age [SD] = 41.4 [14.5] years; female = 54.1%, Hispanic = 41.5%). Glycemia Risk Index zones were compared on CGM, sociodemographic, and clinical variables. Shapley value analysis examined the percentage of variation in GRI scores explained by different variables. Receiver operating characteristic curves examined GRI cutoffs for those more likely to have experienced ketoacidosis or severe hypoglycemia.

Results. Mean glucose and variability, time in range, and percentage of time in high, and very high, glucose ranges differed across the five GRI zones (P values < .001). Multiple sociodemographic indices also differed across zones, including education level, race/ethnicity, age, and insurance status. Sociodemographic and clinical variables collectively explained 62.2% of variance in GRI scores. A GRI score ≥84.5 reflected greater likelihood of ketoacidosis (area under the curve [AUC] = 0.848), and scores ≥58.2 reflected greater likelihood of severe hypoglycemia (AUC = 0.729) over the previous six months.

Conclusions. Results support the use of the GRI, with GRI zones identifying those in need of clinical attention. Findings highlight the need to address health inequities. Treatment differences associated with the GRI also suggest behavioral and clinical interventions including starting individuals on CGM or automated insulin delivery systems.

The pupil light reflex (PLR), a marker of neuronal response to light, is a well-studied index of autonomic functioning. Studies have found that autistic children and adults have slower and weaker PLR responses compared to non-autistic peers, suggesting lower autonomic control. Altered autonomic control has also been associated with increased sensory difficulties in autistic children. With autistic traits varying in the general population, recent studies have begun to examine similar questions in non-autistic individuals. The current study looked at the PLR in relation to individual differences in autistic traits in non-autistic children and adults, asking how differences in the PLR could lead to variation in autistic traits, and how this might change across development. Children and adults completed a PLR task as a measure of sensitivity to light and autonomic response. Results showed that, in adults, increased levels of restricted and repetitive behaviors (RRB) were associated with a weaker and slower PLR. However, in children, PLR responses were not associated with autistic traits. Differences in PLR were also found across age groups, with adults showing smaller baseline pupil diameter and stronger PLR constriction as compared with children. The current study expanded on past work to examine the PLR and autistic traits in non-autistic children and adults, and the relevance of these findings to sensory processing difficulties is discussed. Future studies should continue to examine the neural pathways that might underlie the links between sensory processing and challenging behaviors.

Background. Mood disturbances have historically remained a core criterion in diagnosing major depressive episode. DSMs have illustrated this criterion with depressed, hopeless, discouraged, cheerless, and irritable mood, suggesting interchangeability. Extant research has examined individual forms of mood disturbance to depression severity. Less examined is the heterogeneity in mood disturbances and its implication to their association to depression presentations and outcomes.

Method. The current study used a nationally representative sample of U.S. adults with unipolar major depressive disorder to study the association between specific forms of mood disturbances to depression severity, chronicity, or symptoms, above and beyond other forms, as well as their relations to functional impairment, suicidal outcomes, and psychiatric comorbidity via generalized linear models.

Results. Cheerless and hopeless mood were associated with depression severity. Hopeless and irritable mood were associated with depression chronicity. Different forms of mood disturbance showed differential relations to depressive symptoms. Cheerless, hopeless, and irritable mood were associated with depression-specific functional interference, incremental to depression severity. Cheerless, hopeless, and discouraged mood were associated with passive suicidal ideation. Hopeless mood was associated with active suicidal ideation. Hopeless and irritable mood were associated with both suicide plan and suicide attempt. Different forms of mood disturbance demonstrated differential associations to comorbid psychiatric conditions.

Discussion. The relations between different forms of mood disturbances and various aspects of depression are nuanced. Theoretically, these relations highlight the potential utility in acknowledging the complexity and heterogeneity in mood disturbances. Clinically, our results suggest potential utility in routinely monitoring mood disturbances.

Keywords. Mood; Depression; Irritability; Hopelessness; Classification

We regularly face stress during our everyday activities, to the extent that stress is recognized by the World Health Organization as the epidemic of the 21st century. Stress is how humans respond physically and psychologically to adjustments, experiences, conditions, and circumstances in their lives. While there are many reasons for stress, work and job pressure remain the main cause. Thus, companies are increasingly interested in creating healthier, more comfortable, and stress-free offices for their workers. The indoor environment can induce environmental stress when it cannot satisfy the individual needs for health and comfort. In fact, office environmental conditions (e.g., thermal, and indoor air conditions, lighting, and noise) and interior design parameters (e.g., office layout, colors, furniture, access to views, distance to window, personal control and biophilic design) have been found to affect office workers' stress levels. A line of research based on the stress recovery theory offers new insights for establishing offices that limit environmental stress and help with work stress recovery. To that end, this paper answers ten questions that explore the relation between the indoor office-built environment and stress levels among workers. The answers to the ten questions are based on an extensive literature review to draw conclusions from what has been achieved to date. Thus, this study presents a foundation for future environmental stress related research in offices.

Keywords. Stress; Indoor environmental quality; Stress recovery; Office; Interior design

Objective. To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits.

Data Sources and Study Setting. Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019.

Study Design. Cross-sectional survey of VA users by age group (18–44 years, 45–64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity.

Data Collection/Extraction Method. Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data.

Principal Findings. In unadjusted analyses, VA users age 18–44 had a higher (−8.2%; CI: −9.0, −7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity.

Conclusions. Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

Although automated methods for stroke lesion segmentation exist, many researchers still rely on manual segmentation as the gold standard. Our detailed, standardized protocol for stroke lesion tracing on high-resolution 3D T1-weighted (T1w) magnetic resonance imaging (MRI) has been used to trace over 1,300 stroke MRI. In the current study, we describe the protocol, including a step-by-step method utilized for training multiple individuals to trace lesions (“tracers”) in a consistent manner and suggestions for distinguishing between lesioned and non-lesioned areas in stroke brains. Inter-rater and intra-rater reliability were calculated across six tracers trained using our protocol, resulting in an average intraclass correlation of 0.98 and 0.99, respectively, as well as a Dice similarity coefficient of 0.727 and 0.839, respectively. This protocol provides a standardized guideline for researchers performing manual lesion segmentation in stroke T1-weighted MRI, with detailed methods to promote reproducibility in stroke research.

Keywords. stroke, manual segmentation, MRI segmentation, stroke lesion, segmentation protocol, T1w MRI, ITK-SNAP

Health literacy is the ability to obtain and utilize health information to make health-related decisions and to navigate health systems. Although health literacy has traditionally been understood as an individual-level construct, current research is revealing the impact that social networks can have on health literacy. To date, no studies have examined associations between health literacy and social networks among people with serious mental illness (PWSMI), who are at high risk of physical illness and premature mortality. To begin to fill this gap, this study explores associations between health literacy, relationships with health discussion partners, and self-reported health outcomes in a racially diverse sample of Clubhouse members in Hawai‘i. Clubhouses are community mental health centers that promote recovery from mental illness through destigmatization, meaningful activity, and strong social relationships. Health literacy was assessed using two single-item screeners (SILS). In a sample of 163 members, 56.2% reported adequate ability to understand health-related instructions or pamphlets, and 43.3% reported adequate confidence filling out medical forms independently. This is consistent with other health literacy studies with PWSMI in the United States, and indicates lower health literacy within this group than is reported in national averages. Multivariate logistic regression revealed a larger Clubhouse staff social network and completing high school were significantly associated with requiring less help to read materials. Higher age, male gender, and being Native Hawaiian and/or Pacific Islander were associated with less confidence filling out medical forms, while higher self-efficacy was associated with higher confidence filling out medical forms. This study provides preliminary evidence that relationships fostered within Clubhouses are associated with health literacy among PWSMI, and highlights the need for more research to examine how social networks and health literacy interventions can be leveraged in community mental health settings to improve health outcomes within this vulnerable population.

Keywords. health literacy; serious mental illness; clubhouse; mental health clubhouse; social networks; distributed health literacy; community mental health

Student veterans may find reintegration into civilian life difficult, largely due to social factors. This study used occupational therapy practitioners to facilitate photovoice to gain insight into participants’ social experiences transitioning from military to student civilian life. Fifteen photovoice pieces were generated from discussions, photos, and narratives from the seven male participants. Five themes were identified: Camaraderie, Alienation, Identifying Challenges, Rising to the Challenges, and Diversity and Military and Veteran Students. The study has disseminated the photovoice pieces to generate awareness and shape programs and services on campus consistent with a respectful, radically welcoming, military-affirming campus supporting student academic success.

Keywords. Higher education; social support; military students; community-based participatory action research; personal narratives

The heteronormative relations are placed in rurality in specific ways, bringing challenges to the experience of dissident sexualities. This article aimed to comprehend the relations of social markers of difference that permeate the territory and sexuality. This is a qualitative research, which uses semi-structured interviews and seeks to comprehend the narratives of a young, homosexual and black man who lived in rural territory, constituting there material, affective and subjective bonds. The heterosexism, compulsory heterosexuality and heteronormativity led the young man to leave their home territory, causing deterritorialization. It was concluded that the trajectory of this young man is marked by the no place, where it was not possible to be constituted as gay in the rural nor fully experience their sexuality in the city, given the urbanocentrism that marks contemporary society.

Keywords. homosexuality; homophobia; rural population; migration; social markers of difference.