Recent Chan Publications

Objectives. This study developed a musculoskeletal ultrasound (MSUS) protocol to evaluate rehabilitation outcomes in systemic sclerosis.

Materials and Methods. Three MSUS methods (gray-scale, Doppler, strain elastography) and two acquisition techniques (long- vs short-axis; transducer on skin vs floating on gel) were examined in the forearm before and after rehabilitation treatment. For gray-scale, tissue thickness measures and intrarater and interrater reliability were calculated (intraclass correlation coefficients [ICCs]), and paired t tests examined differences among techniques.

Results. Five people with diffuse cutaneous systemic sclerosis participated. The most valid and reliable gray-scale technique was with the transducer in long-axis, floating on gel. Doppler and strain elastography did not detect changes. Both dermal and subcutaneous thickness measurement error was small; intrarater and interrater reliability was good to excellent. Preliminary data indicate that treatment may lead to dermal thinning.

Conclusion. A replicable protocol was established and may be an adjunct to rehabilitation outcome measurement in systemic sclerosis.

Keywords. musculoskeletal ultrasound, scleroderma, rehabilitation, protocol

Aim. Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.

Study design. Ninety-one infants (44 preterm infants born ≤32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).

Results. Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = −0.44), but were not related to BPFAS scores (p = 0.17; r = −0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p < 0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).

Discussion. Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.

Keywords. Oral motor, Neonatal intensive care unit, Development, Assessment, Neonatal Eating Outcome Assessment, Outcome

A deficit in pre‐cognitively mirroring other people's actions and experiences may be related to the social impairments observed in autism spectrum disorder (ASD). However, it is unclear whether such embodied simulation deficits are unique to ASD or instead are related to motor impairment, which is commonly comorbid with ASD. Here we aim to disentangle how, neurologically, motor impairments contribute to simulation deficits and identify unique neural signatures of ASD. We compare children with ASD (N = 30) to children with Developmental Coordination Disorder (DCD; N = 23) as well as a typically developing group (N = 33) during fMRI tasks in which children observe, imitate, and mentalize about other people's actions. Results indicate a unique neural signature in ASD: during action observation, only the ASD group shows hypoactivity in a region important for simulation (inferior frontal gyrus, pars opercularis, IFGop). However, during a motor production task (imitation), the IFGop is hypoactive for both ASD and DCD groups. For all tasks, we find correlations across groups with motor ability, even after controlling for age, IQ, and social impairment. Conversely, across groups, mentalizing ability is correlated with activity in the dorsomedial prefrontal cortex when controlling for motor ability. These findings help identify the unique neurobiological basis of ASD for aspects of social processing. Furthermore, as no previous fMRI studies correlated brain activity with motor impairment in ASD, these findings help explain prior conflicting reports in these simulation networks.

Aim. Early therapy can improve developmental outcomes for preterm infants. However, preterm infants who are referred have low enrollment in early therapy services following neonatal intensive care unit (NICU) discharge. This manuscript aims to investigate the relationship between infant medical and sociodemographic factors and enrollment in early therapy services post‐NICU discharge, when system‐related barriers to access are minimized.

Methods. This was a retrospective investigation of 89 families with infants born ≤ 32 weeks gestation. Families were approached for enrollment into early therapy services following NICU discharge through Baby Bridge programming, which aims to improve access to therapy services following NICU discharge.

Results. Seventy‐three (82%) families enrolled in early therapy services, and 16 (18%) families declined. Parents were more likely to enroll in early therapy if they had public insurance (p=0.01), a maternal psychiatric diagnosis (p=0.02), or additional children under 18 years in the home (p=0.01). No infant medical factors were related to enrollment.

Conclusion. Although enrollment rates were high, 18% of families refused therapy services, despite removing system‐related barriers to access. Targeted interventions can be developed to increase enrollment in early therapy services among populations who are most likely to refuse therapy services after NICU discharge.

Keywords. Baby Bridge program; birth to three; development; early intervention; preterm infant

Objective. To understand impacts of social, behavioral and physical factors on well-being of office workstation users during COVID-19 work from home (WFH).

Methods. A questionnaire was deployed from April 24 to June 11, 2020 and 988 responses were valid. Linear regression, multinomial logistic regression and chi-square tests were used to understand factors associated with overall physical and mental health statuses and number of new physical and mental health issues.

Results. Decreased overall physical and mental well-being after WFH were associated with physical exercise, food intake, communication with coworkers, children at home, distractions while working, adjusted work hours, workstation set-up and satisfaction with workspace indoor environmental factors.

Conclusion. This study highlights factors that impact workers’ physical and mental health well-being while WFH and provides a foundation for considering how to best support a positive WFH experience.

Keywords. COVID-19 pandemic, home office, mental well-being, physical well-being, work from home

Heating, ventilation, and air conditioning (HVAC) systems account for 43% of building energy consumption, yet only 38% of commercial building occupants are satisfied with the thermal environment. The primary reasons for low occupant satisfaction are that HVAC operations do not integrate occupant comfort requirements nor control the thermal environment at the individual level. Personal comfort systems (PCS) enable local control of the thermal environment around each occupant. However, full manual control of PCS can be inefficient, and fully automated PCS reduces an occupant’s perceived control over the environment, which can then lead to lower satisfaction. A better solution might lie somewhere between fully manual and fully automated environmental control. In this paper, we describe the development and implementation of an internet of things (IoT) based intelligent agent that learns individual occupant comfort requirements and controls the thermal environment using PCS (i.e., a local fan and a heater). We tested different levels of automation where control is shared between an intelligent agent and the end user. Our results show that PCS use improves occupant satisfaction and including some level of automation can improve occupant satisfaction further than what is possible with manually operated PCS. Among the levels of automation investigated, Inquisitive Automation, where the user approves/declines the control actions of the intelligent agent before execution, led to highest occupant satisfaction with the thermal environment.

Keywords. building automation, thermal comfort, smart systems, smart buildings, indoor environments

Neurofeedback training has been shown to influence behavior in healthy participants as well as to alleviate clinical symptoms in neurological, psychosomatic, and psychiatric patient populations. However, many real‐time fMRI neurofeedback studies report large inter‐individual differences in learning success. The factors that cause this vast variability between participants remain unknown and their identification could enhance treatment success. Thus, here we employed a meta‐analytic approach including data from 24 different neurofeedback studies with a total of 401 participants, including 140 patients, to determine whether levels of activity in target brain regions during pretraining functional localizer or no‐feedback runs (i.e., self‐regulation in the absence of neurofeedback) could predict neurofeedback learning success. We observed a slightly positive correlation between pretraining activity levels during a functional localizer run and neurofeedback learning success, but we were not able to identify common brain‐based success predictors across our diverse cohort of studies. Therefore, advances need to be made in finding robust models and measures of general neurofeedback learning, and in increasing the current study database to allow for investigating further factors that might influence neurofeedback learning.

As stroke mortality rates decrease, there has been a surge of effort to study poststroke dementia (PSD) to improve long‐term quality of life for stroke survivors. Hippocampal volume may be an important neuroimaging biomarker in poststroke dementia, as it has been associated with many other forms of dementia. However, studying hippocampal volume using MRI requires hippocampal segmentation. Advances in automated segmentation methods have allowed for studying the hippocampus on a large scale, which is important for robust results in the heterogeneous stroke population. However, most of these automated methods use a single atlas‐based approach and may fail in the presence of severe structural abnormalities common in stroke. Hippodeep, a new convolutional neural network‐based hippocampal segmentation method, does not rely solely on a single atlas‐based approach and thus may be better suited for stroke populations. Here, we compared quality control and the accuracy of segmentations generated by Hippodeep and two well‐accepted hippocampal segmentation methods on stroke MRIs (FreeSurfer 6.0 whole hippocampus and FreeSurfer 6.0 sum of hippocampal subfields). Quality control was performed using a stringent protocol for visual inspection of the segmentations, and accuracy was measured as volumetric correlation with manual segmentations. Hippodeep performed significantly better than both FreeSurfer methods in terms of quality control. All three automated segmentation methods had good correlation with manual segmentations and no one method was significantly more correlated than the others. Overall, this study suggests that both Hippodeep and FreeSurfer may be useful for hippocampal segmentation in stroke rehabilitation research, but Hippodeep may be more robust to stroke lesion anatomy.

Keywords. convolutional neural network, hippocampus, image segmentation, lesion, MRI, stroke

The 2008 recession had long-lasting economic effects that made everyday experiences of precarity more prevalent in many countries. Within a broader neoliberal context, however, the prevalence of precarity and its social production tends to be obscured, leading to a need for actions aimed at enhancing social awareness and informing social change. In this article, we illustrate how the precarity associated with long-term unemployment, which persisted at historically high levels through 2018, can be made visible by analyzing the mobilities of occupational engagement. Our illustrations derive from a larger four-phase collaborative ethnography conducted in the United States and Canada between 2014 and 2018. Informed by a critical occupational science perspective, the study utilized multiple methods to generate data with participants who self-identified as being long-term unemployed. One of those methods, occupational mapping, explored how participants negotiated daily routines and occupations at the local scale during their unemployment. Analysis of four exemplar cases, as informed by the mobilities paradigm, illuminates the lived impacts and geospatial effects of precarity on everyday occupations in situations of long-term unemployment. Findings contribute to the wider examination of how precarity is spatially experienced within the situation of long-term unemployment as reflected in people’s (im)mobilities and occupational engagement.

Keywords. Occupational science; Activation; Ethnography; Mobilities; Occupational mapping; Long-term unemployment; Precarity

Purpose. Dental hygiene graduates often experience significant psychological stress while transitioning from the educational setting to clinical practice environments. The purpose of this study was to characterize the duration of dental hygiene activities and tasks and explore efficiency within appointments, by students in educational programs.

Methods. Right-handed female dental hygiene students were recruited from two dental hygiene education programs. Each participant was video recorded while providing patient care during 3 sessions, once per term, over 3 consecutive terms. Activities, tasks, and student postures and positions were coded across the patient visit. Descriptive analyses were conducted to characterize overall durations and distributions across each category. Time spent on non-dental hygiene related activities was compared to other durations, as well as across the education/training time points and by patient type.

Results. Fifty-three videos were analyzed from nineteen participants. The average patient visit length was 155.06 ± 35.63 minutes; approximately half the visit was dedicated to instrumentation activities. Nearly 20% of the visit was categorized as activities or tasks unrelated to education or patient care. Although most participants completed the patient visit more quickly by the third time point, the percentage of non-dental hygiene activities did not decrease, and there were no associations between patient category type and the duration of the patient visit.

Conclusion. Patient visits were roughly three times the length of the typical dental hygiene care appointment, indicating a disconnect between training and practice. In addition to spending more time on hand scaling tasks, participants spent a lot of time on equipment setup and interacting with or waiting for faculty members. These findings have implications for improving efficiency in educational settings, particularly to facilitate a successful transition to clinical practice.

Aim. To (a) define the early home auditory environment of high‐risk infants within one month of neonatal intensive care unit (NICU) discharge, (b) compare auditory exposures in the home environment to the NICU environment, and (c) define relationships between maternal/infant factors and auditory exposures within the home.

Methods. Seventy‐three high‐risk infants (48 high‐risk infants in the NICU at term‐equivalent age and 25 high‐risk infants in the home following NICU discharge) had auditory exposures measured.

Results. An average of 1.3 hours more noise (P ≤ .001) and 2 hours less silence (P = .01) were observed in the NICU compared with the home, but differences varied based on whether comparing to an open ward or private room. Infants with public insurance, lower household income and mothers without a college education were exposed to an average of 2.8, 3.0 and 2.3 hours more TV/electronic sounds respectively (P < .05). An average of 1744 fewer adult words (P = .03) were spoken in households with public insurance. There was an average of 3.1 hours less silence and 4.5 dB louder stimuli among households with lower income (P < .05).

Conclusion. Elucidating differences across environments can lead to interventions to foster appropriate auditory exposures to improve language development of high‐risk infants.

Inquiries that rely on temporal framings to demarcate long-term unemployment risk generating partial understandings and grounding unrealistic policy solutions. In contrast, this four-phase two-context study aimed to generate complex understandings of post-recession long-term unemployment in North America. Grounded in a critical occupational perspective, this collaborative ethnographic study also drew on street-level bureaucracy and governmentality perspectives to understand how social policies and discursive constructions shaped people’s everyday ‘doing’ within the arena of long-term unemployment. Across three phases, study methods included interviews with 15 organizational stakeholders who oversaw employment support services; interviews, participant observations, and focus groups with 18 people who provided front-line employment support services; and interviews, participant observations, time diaries, and occupational mapping with 23 people who self-identified as being long-term unemployed. We draw on selected interviews and mapping data to illustrate how participants’ definitions and experiences of long-term unemployment reflected and moved beyond dominant temporally based framings. These findings reinforce the need to expand the dominant conceptualizations of long-term unemployment that shape scholarly inquiries and policy responses. Reflections on the benefits and challenges of this study’s design also reinforce the need to use multiple, flexible methods to center the complexity of long-term unemployment as it is experienced in everyday life.

Keywords. long-term unemployment; critical occupational perspective; methods

Importance. Head-mounted displays for virtual reality (HMD–VR) may be used as a therapeutic medium in physical rehabilitation because of their ability to immerse patients in safe, controlled, and engaging virtual worlds.

Objective. To explore how HMD–VR has been used in adult physical rehabilitation.

Data Sources. A systematic search of MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO, and ERIC produced 11,453 abstracts, of which 777 underwent full-text review.

Study Selection and Data Collection. This scoping review includes 21 experimental studies that reported an assessment or intervention using HMD–VR in a physical rehabilitation context and within the scope of occupational therapy practice.

Findings. HMD–VR was used for assessment and intervention for patients with a range of disorders, including stroke, multiple sclerosis, spinal cord injury, and Parkinson’s disease.

Conclusions and Relevance. HMD–VR is an emerging technology with many uses in adult physical rehabilitation. Higher quality clinical implementation studies are needed to examine effects on patient outcomes.

What This Article Adds. We review existing research on how immersive virtual reality (e.g., using head-mounted displays) has been used for different clinical populations in adult physical rehabilitation and highlight emerging opportunities in this field for occupational therapists.

Background. Carpal tunnel syndrome (CTS) symptoms are problematic especially when signs and symptoms are not substantial enough to require surgical intervention. Conservative treatments have mixed effectiveness, yet are one of the best options for mild to moderate CTS. Kinesio tape is an emerging modality, as it provides biomechanical support while allowing movement.

Purpose. The purpose of this study was to determine the efficacy of dorsal application of Kinesio tape on occupational performance as measured by pain and function in individuals with mild to moderate CTS, as compared with the accepted nonsurgical intervention of general cockup orthosis and lumbrical stretching exercises versus sham tape.

Study Design. Single-blind randomized controlled trial.

Methods. Forty-four participants (68 wrists) with CTS were randomized to one of three interventions: Kinesio tape group, sham group, or standard protocol group. Each completed baseline and four subsequent measurements of numeric pain rating scale, visual analog scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), grip and pinch, with application of intervention every three days. Daily symptom journals were completed, standard protocol group recorded wearing schedule and exercises.

Results. In the forearm and wrist, a significant reduction in median numeric pain rating scale pain scores in Kinesio tape group was observed (r = 0.76, P = .01; r = 0.77, P = .01; respectively), but not in the standard protocol group (r = 0.51, P = .17; r = 0.53, P = .11) and sham group (r = 0.46, P = .30; r = 0.39, P = .43) with a minimal clinically important difference of 1.0. In the Kinesio tape group, the forearm (24%) and wrist (36%) reached the clinical significance as compared with the standard protocol forearm (18%) and wrist (32%).

The minimal clinically important difference for pain reduction on the visual analog scale was 1.64. Kinesio tape and sham group had significant improvement in function, but not the standard protocol group.

Discussion. This study provides promising evidence for the use of Kinesio tape as a possible conservative intervention for management of symptoms in individuals with mild to moderate CTS. The study also illuminates new considerations of younger, active individuals reporting signs and symptoms of CTS as well as mechanism of effects on pain reduction.

Conclusions. Kinesio tape provided additional improvement in pain and function as compared to the standard approach.

Keywords. Carpal tunnel syndrome, Kinesio tape, Conservative interventions, Functional performance

This article introduces social network analysis (SNA), a theoretical perspective accompanied by a set of methodologies, to occupational science. The convergence of SNA and occupational science is timely for both fields. By providing methodological approaches that flesh out a structural view of social networks, SNA measurements and mathematical terminology can effectively bridge the complexity of diverse interpretive frameworks used to understand occupational engagement and other constructs for humans as socially occupied beings. By focusing attention on the relationship of occupations to connectivity between agents, occupational science can make significant contributions to the ways in which the mattering or meaning of what people do with others nurtures the development and sustainability of social networks. We provide a brief history and roots of SNA in naturalistic observation, current terminology, and four widely used SNA research designs: egocentric, sociometric, sequenced, and two-mode. Drawing examples from our decade-long journey using SNA with narrative phenomenological conceptual frameworks, we illustrate how we used SNA with experience-near ethnographies to meet different objectives. In the discussion, we reflect on the parallax view created by the synergies between the disciplines and how the disruptive-productive effects that occur with mixing narrative phenomenology and SNA methods could address (mutual) methodological gaps that have seemingly limited conceptual development in the social sciences.

Keywords. Occupational science, Sociality, Intersubjectivity, Connectivity, Social network analysis, Social structure, Network interventions

Aim. To describe neurodevelopmental outcomes during early childhood among infants born very preterm and define the relationships between neurobehavior of very preterm infants and neurodevelopmental outcomes at 4 years.

Methods. Forty‐eight infants born ≤32 weeks gestation had neurobehavior assessed at term equivalent age using the NICU Network Neurobehavioral Scale (NNNS). Outcomes at 4 years were assessed with the Ages and Stages Questionnaire (ASQ‐3), the Sensory Profile – Short Form (SF), and the Behavior Rating Inventory of Executive Function – Preschool version (BRIEF‐P).

Results. At 4 years, 23 (48%) children had at least one below average score on the ASQ‐3, 15 (31%) had a below average total score on the Sensory Profile‐SF, and 3 (6%) had an abnormal total score on the BRIEF‐P. Children with lower fine motor scores at 4 years had poorer orientation (p=.03) and self‐regulation (p=.03), hypertonia (p=.01), and more sub‐optimal reflexes (p=.02) as neonates. Children with lower gross motor scores at 4 years of age had more sub-optimal reflexes (p=.03) and lethargy (p=.046) as neonates. Children with tactile sensitivity at 4 years of age had poorer orientation (p=.01) and tolerance of handling (p=.03) as neonates. Children with decreased responsiveness at 4 years of age had low arousal (p=.02) as neonates, and those with poor auditory filtering at age 4 years had hypotonia (p=.03) as neonates.

Conclusion. Early neurobehavior is related to neurodevelopmental outcome in early childhood.

This article draws on empirically derived illustrations of return to work and unemployment to critically explore how a narrow understanding of work pervades contemporary social policies and programmes. This is particularly relevant in economic and labour market transitions aligned with neoliberalism that individualise the social problem of unemployment and thus restrict occupational possibilities related to work. An overview of how work and related concepts have been conceptualised in occupational science scholarship is presented. After describing the theoretical orientation of the paper, three illustrations derived from a secondary analysis of data from projects conducted in Sweden and the United States are presented. The three empirically grounded illustrations are integrated with theory to highlight tensions between the politically informed structures that shape social policies and programmes and the individual experiences of work, unemployment, and return to work that users and providers of these programmes communicate. By asserting that success in work-related placement programmes is not synonymous with meaningful employment, we attempt to heighten awareness of the potential risks associated with a reliance on measuring work by merely being in paid formal employment.

Keywords. Critical occupational science; Labour market; Return to work; Unemployment

The Baby Bridge program was developed to ensure timely and continuous therapy services following neonatal intensive care unit (NICU) discharge. A systematic process for development of the Baby Bridge program included a review of the evidence, integration of theory, and input from NICU health care professionals, early intervention leadership, and parents of preterm infants. Using the Consolidated Framework for Implementation Research, we aimed to (a) assess organizational readiness for the new programming; (b) determine adoptability, acceptability, and fidelity following implementation; and (c) evaluate the program. Following the development of Baby Bridge programming, readiness for implementation was observed at the study site. Baby Bridge programming was adopted by the team, acceptable to health care staff and parents, achieved the key features defined, and resulted in more infants born ≤30 weeks receiving early therapy services (n = 58/60, 97% compared with n = 44/57, 77%; p < .0001) an average of 85 days earlier, p < .0001, β = −84.7 (–70.2 to −99.2), than historical controls.

Keywords. Part C services, home visiting, neonates, transition, family collaboration and support, disabilities and developmental delays, preterm, NICU

Research shows that personal and public health are intrinsically intertwined with ecological conditions and that actions that promote environmental sustainability are good prescriptions for health and wellness. I call this awareness and its implications for occupational therapists ‘environmentally-informed occupational therapy’ (EIOT). EIOT is an approach to occupational therapy founded in the growing body of scientific evidence that demonstrates that what is good for the environment is good for human health and well-being. It looks to nature to inform interventions and helps occupational therapists support their clients, students and communities to make lifestyle choices that contribute to their personal health while protecting and ideally enhancing the environment, e.g. while reducing global warming, preserving natural resources, preventing biodiversity loss, and more. Clinical and educational examples of EIOT are described.

This article proposes that ‘meliorism’—a philosophical belief in people’s abilities to improve lived experience through engaged problem-solving—is a useful concept to describe and orient occupational science research, given the challenges of our time. This proposal derives from an intensive period of discussion through occupational science seminars, strategic planning sessions, and other activities at the University of Southern California’s Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, including preparations for the 26th Occupational Science Symposium in 2019. While many disciplines and professions express a melioristic intent, we believe that occupational science and occupational therapy exemplify a particular understanding of meliorism, given the view of occupation that they share, as: 1) engaged activity that has meaning and purpose; and 2) a powerful tool that builds consciousness and practices that can promote desired change. We suggest that occupational scientists’ aim to develop impactful research manifests these conceptual foundations. Further, we argue that a commitment to meliorism requires concerted efforts to mobilize knowledge by intentionally planning for stakeholder engagement and societal impact across all phases of research. We suggest that active knowledge mobilization will enhance the knowledge base of occupational science and help to realize its meliorist potential in both research and practice contexts.

Keywords. Occupational science; Knowledge mobilization; Meliorism; History of academic disciplines; Pragmatism

Difficulty processing sensory information may impede progress in school for students with autism spectrum disorder (ASD). We explore the relationship between sensory processing and school performance in 26 high‐functioning youths with ASD and 26 controls (age 8–14) using measures of sensory, social, cognitive, and academic functioning. In the ASD group, bivariate Pearson correlations indicated a significant positive relationship between intelligence quotient (IQ) and the School Competence Scale (SCS) of the Child Behavior Checklist (CBCL), and a significant negative relationship between Dunn's Sensory Processing Framework and SCS scores. Final hierarchical multiple linear regression model accounting for SCS scores in ASD included IQ, ADHD symptoms, and sensory features. An interaction between increased sensory sensitivity with reduced sensory avoidance behaviors explained the greatest amount of variance in SCS, meaning school performance is lowest for children with greater hypersensitivity and fewer avoidance behaviors. Results indicate a strong impact of sensory processing on school performance in ASD.

Objective. This study examined post-acute care (PAC) rehabilitation practitioner’s perspectives on communication.

Method. This is a secondary data analysis of a larger qualitative study, which included PAC rehabilitation provider (n = 99) focus groups that were held in a purposive sample of 13 skilled nursing facilities (SNFs).

Results. Participants emphasized the importance of bidirectional communication between rehabilitation and nursing. Three themes were identified: (a) communication between rehabilitation practitioners and registered nurses or licensed practical nurses, (b) communication between rehabilitation practitioners and certified nursing assistants, and (c) communication between rehabilitation practitioners and nursing leaders. Two subthemes within each of the three themes were further characterized to understand how information was exchanged: (a) static communication and (b) action-oriented communication.

Conclusion. Our findings highlight opportunities for better communication in PAC between rehabilitation practitioners and nursing and thus lay a foundation for future efforts to improve care coordination through enhancing interdisciplinary communication.

Severe impairment of limb movement after stroke can be challenging to address in the chronic stage of stroke (e.g., greater than 6 months post stroke). Recent evidence suggests that physical therapy can still promote meaningful recovery after this stage, but the required high amount of therapy is difficult to deliver within the scope of standard clinical practice. Digital gaming technologies are now being combined with brain–computer interfaces to motivate engaging and frequent exercise and promote neural recovery. However, the complexity and expense of acquiring brain signals has held back widespread utilization of these rehabilitation systems. Furthermore, for people that have residual muscle activity, electromyography (EMG) might be a simpler and equally effective alternative. In this pilot study, we evaluate the feasibility and efficacy of an EMG-based variant of our REINVENT virtual reality (VR) neurofeedback rehabilitation system to increase volitional muscle activity while reducing unintended co-contractions. We recruited four participants in the chronic stage of stroke recovery, all with severely restricted active wrist movement. They completed seven 1-hour training sessions during which our head-mounted VR system reinforced activation of the wrist extensor muscles without flexor activation. Before and after training, participants underwent a battery of clinical and neuromuscular assessments. We found that training improved scores on standardized clinical assessments, equivalent to those previously reported for brain–computer interfaces. Additionally, training may have induced changes in corticospinal communication, as indexed by an increase in 12–30 Hz corticomuscular coherence and by an improved ability to maintain a constant level of wrist muscle activity. Our data support the feasibility of using muscle–computer interfaces in severe chronic stroke, as well as their potential to promote functional recovery and trigger neural plasticity.

Keywords: biofeedback; stroke; brain–computer interface; neurorehabilitation; corticomuscular coherence; electromyography; co-contraction; virtual reality

Importance. A key objective of the Americans With Disabilities Act of 1990 (ADA) is community integration; yet, nearly 30 yr later, little is known about the participation of people with disabilities who transition from institutions to the community.

Objective. To understand how people with disabilities describe full participation after transitioning from an institution to the community and to identify environmental barriers and facilitators to participation during and after this transition.

Design. The ADA–Participatory Action Research Consortium (ADA–PARC), a collaboration among researchers, people with disabilities, and community organizations, is implementing a multimethod, participatory action research study of participation among people with disabilities posttransition. This article presents qualitative findings from semistructured interviews collected as part of the larger ADA–PARC project.

Setting. ADA–PARC community partners across the United States.

Participants. One hundred fifty-three adults with disabilities.

Outcomes and Measures. We used a semistructured interview guide to ask participants about their experiences during and after transition to the community.

Results. We identified four themes: (1) the process of transition as ongoing rather than a single event, (2) access to everyday occupations as full participation and what fully represents “living a life,” (3) environmental barriers to participation, and (4) social identity as participation as the transformative process of moving from the disempowering isolation of the institution to being integrated into the community.

Conclusions and Relevance. As people with disabilities transition into community settings, they require ongoing supports to facilitate their full, long-term participation.

What This Article Adds. People with disabilities reported that transitioning from institutions to the community was itself not enough to support their full community participation; rather, they viewed transition as an ongoing process, and they needed services and supports to fully participate. Occupational therapy practitioners working in institutional and community settings can partner with local disability advocacy communities to support their clients’ sense of identity and self-confidence during and after transition to the community.

Aims. To determine 1) the relationship between infant medical factors and early neurobehavior, and 2) the relationship between early neurobehavior at 30 weeks postmenstrual age (PMA) and neurobehavior at term equivalent age.

Study design. In this prospective longitudinal study, 88 very preterm infants born ≤30 weeks estimated gestational age (EGA) had neurobehavioral assessments at 30 weeks PMA using the Premie-Neuro and at term equivalent age using the NICU Network Neurobehavioral Scale (NNNS) and Hammersmith Neonatal Neurological Evaluation (HNNE).

Results. Lower Premie-Neuro scores at 30 weeks PMA were related to being more immature at birth (p = 0.01; β = 3.87); the presence of patent ductus arteriosus (PDA; p < 0.01; β = −16.50) and cerebral injury (p < 0.01; β = −20.46); and prolonged exposure to oxygen therapy (p < 0.01; β = −0.01), endotracheal intubation (p < 0.01; β = −0.23), and total parenteral nutrition (p < 0.01; β = −0.35). After controlling for EGA, PDA, and number of days of endotracheal intubation, lower Premie-Neuro scores at 30 weeks PMA were independently related to lower total HNNE scores at term (p < 0.01; β = 0.12) and worse outcome on the NNNS with poorer quality of movement (p < 0.01; β = 0.02) and more stress (p < 0.01; ß = −0.004), asymmetry (p = 0.01; β = −0.04), excitability (p < 0.01; β = −0.05) and suboptimal reflexes (p < 0.01; ß = −0.06).

Conclusion. Medical factors were associated with early neurobehavioral performance at 30 weeks PMA. Early neurobehavior at 30 weeks PMA was a good marker of adverse neurobehavior at NICU discharge.

Keywords. Preterm; Neurobehavior; Neonatal intensive care unit, outcome, development

Introduction. Translational evidence for mind–body interventions in hand therapy is limited. This pilot study aimed to determine potential benefits of including a mindful body scan or sonographic biofeedback at the outset of a hand therapy session on key psychological states.

Methods. A randomized, repeated-measures, cross-over design was used to evaluate a mindful body scan and sonographic biofeedback at the outset of a hand therapy session. Measures of pain, anxiety, and stress (i.e. salivary cortisol) were obtained from 21 hand therapy patients at the start, after 20 min, and at the end of each of three 60-min treatments. Trends were examined, and mixed-effects regression compared effects across time within and across the sessions for each of the outcome measures.

Results. For all intervention types, anxiety and stress decreased across the treatment session (p < 0.001); no statistically significant changes were noted in pain. Using either mind–body intervention before standard care resulted in a meaningful decrease and statistical trend toward improvement in stress. The use of a mindful body scan produced an immediate, statistically significant reduction in anxiety (β = − 0.14, p = 0.03), a lowered level that was maintained throughout the therapy session.

Discussion. These data provide preliminary support for integrating mind–body interventions as preparatory activities in hand therapy. Mindful body scans may prepare patients for therapeutic interventions by more quickly reducing anxiety, and the use of either intervention may reduce patient stress more than would occur during a standard care session. These effects should be evaluated in an adequately powered clinical trial.

Keywords. Therapeutics, integrative health, sonography, mindfulness.

Objective. The aim of this project was to determine revenues and costs over time to assess the sustainability of the Baby Bridge program.

Methods. The Baby Bridge program was developed to promote timely, consistent and high quality early therapy services for high-risk infants following neonatal intensive care unit (NICU) discharge. Key features of the Baby Bridge program were defined as: 1) having the therapist establish rapport with the family while in the NICU, 2) scheduling the first home visit within one week of discharge and continuing weekly visits until other services commence, 3) conducting comprehensive assessments to inform targeted interventions by a skilled, single provider, and 4) using a comprehensive therapeutic approach while collaborating with the NICU medical team and community therapy providers. The Baby Bridge program was implemented with infants hospitalized in an urban Level IV NICU from January 2016 to January 2018. The number of infants enrolled increased gradually over the first several months to reach the case-load capacity associated with one full-time therapist by mid-2017. Costs of the therapists delivering Baby Bridge services, travel, and equipment were tracked and compared with claim records of participants. The operational cost of Baby Bridge programming at capacity was estimated based on the completed and anticipated claims and reimbursement of therapy services as a means to inform possible scale-ups of the program.

Results. In 2016, the first year of programming, the Baby Bridge program experienced a loss of $26,460, with revenue to the program totaling $11,138 and expenses totaling $37,598. In 2017, the Baby Bridge program experienced a net positive income of $2,969, with revenues to the program totaling $53,989 and expenses totaling $51,020. By Spring 2017, 16 months after initiating Baby Bridge programming, program revenue began to exceed cost. It is projected that cumulative revenue would have exceeded cumulative costs by January 2019, 3 years following implementation. Net annual program income, once scaled up to capacity, would be approximately $16,308.

Discussion. There were initial losses during phase-in of Baby Bridge programming associated with operating far below capacity, yet the program achieved sustainability within 16 months of implementation. These costs related to implementation do not consider the potential cost reduction due to mitigated health burden for the community and families, particularly due to earlier receipt of therapy services, which is an important area for further inquiry.

Purpose. This study aimed to develop a subjective categorization of nerve shape and to examine the relationship of shape categorizations to measurement of nerve circularity.

Methods. Wrists were evaluated with sonography in healthy participants. Images of the median nerve were obtained in the transverse plane at the level of pisiform with the fingers resting, gripping, and pinching. Nerves were categorized as ovoid, angular, or irregular, and the cross-sectional area and perimeter were measured to calculate nerve circularity.

Results. Across 167 participants, the median nerve shifted from being primarily ovoid at rest to angular shaped when the fingers were in a full fist or pinching. Approximately three-quarters of subjects exhibited a shape change during dynamic movement. Irregular nerves had the lowest circularity values; however, the majority of nerves had similar circularity measures despite having different shapes.

Conclusions. Subjective categorization of shape has the potential to be a valid technique for evaluation of the median nerve using sonography, and this evaluation may provide additional information regarding nerve compression that is not fully captured by a circularity measure. Further investigation is needed to determine how these two techniques may be best used individually or together to advance clinical diagnosis, prevention, and rehabilitative interventions.

Keywords. sonography, carpal tunnel syndrome, median nerve, circularity

Aim. To explore differences in maternal mental health and infant neurobehavioral outcome among infants who received and did not receive the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

Study design. Eighty preterm infants (50 receiving standard-of-care and 30 receiving the SENSE program) born ≤32 weeks gestation were enrolled within the first week of life in a prospective quasi-experimental design, using a historical control group for comparison. Standard-of-care consisted of tactile (skin-to-skin, touch, holding) and olfactory (scent cloth, close maternal contact) interventions as determined to be appropriate by health care professionals and parents. The SENSE group received specific doses of tactile (skin-to-skin care, holding, massage, touch), auditory (human speech, music), olfactory (scent cloth, close maternal contact), kinesthetic/vestibular (movement, rocking/transfers), and visual (dim or cycled light) exposures, based on the infant's postmenstrual age and tailored to medical status and infant cues according to the SENSE program. The SENSE program includes the intentional delivery of positive, age-appropriate sensory exposures by parents (or a sensory support team, when parents are unavailable) each day of NICU hospitalization. Infant neurobehavioral outcome, as well as maternal mental health and confidence, were assessed prior to NICU discharge, using standardized measures.

Results. Seventy-three infants were included in the final analysis. Mothers whose infants received the SENSE program demonstrated higher scores on the Maternal Confidence Questionnaire (p = 0.01). Infants who received the SENSE program demonstrated less asymmetry on the NICU Network Neurobehavioral Scale (p = 0.02; mean difference 0.9) and higher scores on the Hammersmith Neonatal Neurological Evaluation (p < 0.001; mean difference 4.8).

Discussion. Preliminary evidence demonstrates improvements in maternal confidence and infant neurobehavioral performance following SENSE implementation.

Although permanent supportive housing (PSH) has been credited with a decline in the number of chronically homeless adults in the United States since 2007, the extent to which PSH can accommodate the needs of a prematurely aging population, including reducing the likelihood of falls, is unclear. The objective of this study is to examine the prevalence and correlates of falls with a sample of 237 tenants (45‐ to 80‐year olds) from two PSH programmes in Los Angeles from 1 January 2017 to 10 August 2017. We also explore the location and severity of fall‐related injury using a subsample of 66 tenants. Standard surveys queried demographics, health status, history of homelessness and falls. Multivariable logistic regression assessed the correlates of falling in the past year. More than half of the sample had fallen and more than 40% had multiple falls in the past year. Functional impairment, frailty and persistent pain were all associated with increased fall risk. For the 66 tenants who provided more detailed fall information, more than 40% fell at home and of those nearly half fell in their bathroom. Fall‐related injuries were common, with more than one‐third of the subsample experiencing serious injury. These findings suggest that fall prevention is needed in PSH but that more research is needed to understand the degree to which individual and environmental risk factors are contributing to falls.

Importance. This Practice Guideline provides stakeholders with a condensed summary of a large number of effectiveness studies. It is a valuable tool for facilitating decision making related to occupational therapy interventions for children ages birth–5 yr.

Objective. Early childhood (birth–5 yr) is a critical period in which the foundation of key life occupations is developed (e.g., eating, dressing, play, learning, social participation, rest and sleep, and chores). The development of cognitive, motor, social–emotional, and self-care skills is important to support these occupations. This Practice Guideline synthesizes recent systematic reviews (SRs) on these areas of development to promote decision making for and high-quality interventions with this population.

Method. Four SRs related to cognition, mental health, motor function, and ADLs analyzed studies published from 2010 to 2017 retrieved from six electronic databases (MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane).

Results. A total of 196 articles were included in the SRs, which served as a guide to final clinical recommendations. Case studies describe translation and application to practice.

Conclusions and Recommendations. A variety of interventions within the domain of occupational therapy were found to support the development of cognitive, social–emotional, motor, and self-care skills. Although some of these interventions are typically implemented by occupational therapy practitioners, others can be implemented by parents after training or by teams working in preschool settings. These findings should be used to inform evidence-based practice provided by occupational therapy practitioners working in various early childhood settings.

What This Article Adds. This Practice Guideline gives occupational therapy practitioners clear information about which interventions will be effective for specific outcomes. Better intervention choices mean better outcomes for young children and their families.

Background. As front-line service providers who often work in systems regulated by governmental bodies, occupational therapists can be conceptualized as “street-level bureaucrats” (Lipsky, 1980/2010) who effect and are affected by policy.

Purpose. Drawing on understandings from a study of long-term unemployment, this article proposes that occupational therapists, as street-level bureaucrats, respond to inter-related policies and systems in ways that can perpetuate, resist, or transform opportunities for doing and being.

Key Issues. By highlighting practitioners’ everyday negotiation of governmental, organizational, and professional power relations, the notion of street-level bureaucracy illuminates the political nature of practice as well as the possibilities and boundaries that policy can place on ideal forms and outcomes of practice.

Implications. Framing occupational therapists as street-level bureaucrats reinforces practitioners’ situatedness as political actors. Mobilizing this framing can enhance awareness of occupational therapists’ exercise of discretion, which can be investigated as a basis for occupation-focused and emancipatory forms of practice.

Keywords. Occupational therapy, Policy, Practice, Street level; Bureaucratie de la rue, Ergothérapie, Politique, Pratique

While there is emerging evidence on the prevalence of physical and mental health conditions among autistic adults, less is known about this population’s needs during older adulthood (aged 65+). We conducted a cross-sectional retrospective cohort study of 2016–2017 Medicare data to compare the prevalence of physical and mental health conditions in a national sample of autistic older adults (N = 4685) to a matched population comparison (N = 46,850) cohort. Autistic older adults had significantly greater odds of nearly all physical health conditions including epilepsy (odds ratio = 18.9; 95% confidence interval = 17.2–20.7), Parkinson’s disease (odds ratio = 6.1; 95% confidence interval = 5.3–7.0), and gastrointestinal conditions (odds ratio = 5.2; 95% confidence interval = 4.9–5.5). Most mental health conditions were more common among autistic older adults, including schizophrenia and psychotic disorders (odds ratio = 25.3; 95% confidence interval = 22.4–28.7), attention deficit disorders (odds ratio = 24.4; 95% confidence interval = 16.2–31.0), personality disorders (odds ratio = 24.1; 95% confidence interval = 17.8–32.5), and suicidality or self-inflicted injury (odds ratio = 11.1; 95% confidence interval = 8.9–13.8). Health conditions commonly associated with advanced age in the general population (e.g. osteoporosis, cognitive disorders, heart disease, cancer, cerebrovascular disease, osteoarthritis) were also significantly more common among autistic older adults. By highlighting the significant physical and mental health needs for which autistic older adults require care, our findings can inform healthcare systems, healthcare providers, and public health initiatives seeking to promote well-being in this growing population.

Objective. To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants.

Study design. Ninety-two infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had a standardized oral feeding assessment.

Result. Preterm infants at term equivalent age had lower Neonatal Eating Outcome Assessment scores (67.8 ± 13.6 compared with 82.2 ± 8.1; p < 0.001) and were more likely to have poor arousal (p = 0.04), poor tongue positioning (p = 0.04), suck–swallow–breathe discoordination (p < 0.001), inadequate sucking bursts (p = 0.01), tonal abnormalities (p < 0.001), discoordination of the jaw and tongue during sucking (p < 0.001), lack of positive engagement with the feeder and/or discomfort (p < 0.001), signs of aspiration (p < 0.001), difficulty regulating breathing (p < 0.001), and have an inability to maintain an appropriate state (p < 0.001), and complete the feeding (p < 0.001).

Conclusion. A broad range of feeding-related difficulties appear to remain evident in preterm infants at term equivalent age.

Mind–body interventions are a viable holistic approach to rehabilitation; however, evidence for mind–body approaches in hand therapy is lacking. This study explored the experiences of clients with musculoskeletal disorders undergoing two mind–body interventions within hand therapy. Qualitative data were obtained from clients who received mindfulness meditation and sonographic biofeedback as part of hand therapy. Semi-structured interviews conducted after four therapy sessions elicited participants’ experiences and acceptability. Emergent themes were identified through an iterative, qualitative descriptive process. The following three themes emerged as results: insight on the body, relaxation and relief, and I am in control. A fourth theme was identified in the acceptability data, that is, mindfulness as a meaningful activity. At least one of the interventions was acceptable to each participant. Positive participant experiences support further consideration of mind–body interventions as a useful holistic approach in hand therapy to support wellness, quality of care, and participation in recovery.

Keywords. therapeutics, hand therapy, integrative medicine, mindfulness, biofeedback

Importance: In Chinese-speaking societies, a reliable and valid measure is needed to enable early identification of young children’s challenges in sensory processing.

Objective: To examine the psychometric properties of the Chinese version of the Infant/Toddler Sensory Profile (ITSP–C) when used with Taiwanese children.

Design: Prospective study.

Setting: Multiple settings.

Participants: Participants were 367 typically developing (TD) infants ages 0–6 mo (mean [M] age = 3.44 mo, standard deviation [SD] = 1.82) and 677 toddlers ages 7–36 mo (M age = 22.33 mo, SD = 8.15), along with 42 toddlers with developmental disabilities (DD; M age = 28.4 mo, SD = 6.7).

Outcomes and Measures: The ITSP, a caregiver questionnaire that measures how children respond to sensory events in daily life, was translated and cross-culturally adapted into a Chinese version (ITSP–C).

Results: Internal consistency was high for the 0–6 mo subscale (α = .80) and the 7–36 mo subscale (α = .82). Test–retest reliability was excellent for the 7–36 mo subscale (intraclass correlation coefficient = .94). Logistic regression analysis demonstrated that the ITSP–C discriminated between children with DD and TD children.

Conclusions and Relevance: The ITSP was successfully adapted to Chinese with similar reliability and validity to the original ITSP. The 7–36 mo subscale had a higher level of reliability than the 0–6 mo subscale, and quadrant scores were more reliable than section scores. Moreover, the ITSP–C discriminated children with DD from TD children on the basis of their sensory processing patterns.

What This Article Adds: The ITSP–C has sound psychometric properties and support for its use in early identification of sensory processing difficulties in young Chinese-speaking children.

Parkinson's disease (PD) is typically diagnosed and evaluated on the basis of overt motor dysfunction, however, subtle changes in the frequency spectrum of neural drive to muscles have been reported as well. During dynamic actions, coactive muscles of healthy adults often share a common source of 6–15 Hz (alpha-band) neural drive, creating synchronous alpha-band activity in their EMG signals. Individuals with PD commonly exhibit kinetic action tremor at similar frequencies, but the potential relationship between the intermuscular alpha-band neural drive seen in healthy adults and the action tremor associated with PD is not well-understood. A close relationship is most tenable during voluntary dynamic tasks where alpha-band neural drive is strongest in healthy adults, and where neural circuits affected by PD are most engaged. In this study, we characterized the frequency spectrum of EMG synchronization (intermuscular coherence) in 16 participants with PD and 15 age-matched controls during two dynamic motor tasks: (1) rotation of a dial between the thumb and index finger, and (2) dynamic scaling of isometric precision pinch force. These tasks produce different profiles of coherence between the first dorsal interosseous and abductor pollicis brevis muscles. We sought to determine if alpha-band intermuscular coherence would be amplified in participants with PD relative to controls, if such differences would be task-specific, and if they would correlate with symptom severity. We found that relative to controls, the PD group displayed amplified, but similarly task-dependent, coherence in the alpha-band. The magnitude of coherence during the rotation task correlated with overall symptom severity as per the UPDRS rating scale. Finally, we explored the potential for our coherence measures, with no additional information, to discriminate individuals with PD from controls. The area under the Receiver Operating Characteristic curve (AUC) indicated a clear separation between groups (AUC = 0.96), even though participants with PD were on their typical medication and displayed only mild-moderate symptoms. We conclude that a task-dependent, intermuscular neural drive within the alpha-band is amplified in PD. Its quantification via intermuscular coherence analysis may provide a useful tool for detecting the presence of PD, or assessing its progression.

Background. Virtual reality viewed using a head-mounted display (HMD-VR) has the potential to be a useful tool for motor learning and rehabilitation. However, when developing tools for these purposes, it is important to design applications that will effectively transfer to the real world. Therefore, it is essential to understand whether motor skills transfer between HMD-VR and conventional screen-based environments and what factors predict transfer.

Methods. We randomized 70 healthy participants into two groups. Both groups trained on a well-established measure of motor skill acquisition, the Sequential Visual Isometric Pinch Task (SVIPT), either in HMD-VR or in a conventional environment (i.e., computer screen). We then tested whether the motor skills transferred from HMD-VR to the computer screen, and vice versa. After the completion of the experiment, participants responded to questions relating to their presence in their respective training environment, age, gender, video game use, and previous HMD-VR experience. Using multivariate and univariate linear regression, we then examined whether any personal factors from the questionnaires predicted individual differences in motor skill transfer between environments.

Results. Our results suggest that motor skill acquisition of this task occurs at the same rate in both HMD-VR and conventional screen environments. However, the motor skills acquired in HMD-VR did not transfer to the screen environment. While this decrease in motor skill performance when moving to the screen environment was not significantly predicted by self-reported factors, there were trends for correlations with presence and previous HMD-VR experience. Conversely, motor skills acquired in a conventional screen environment not only transferred but improved in HMD-VR, and this increase in motor skill performance could be predicted by self-reported factors of presence, gender, age and video game use.

Conclusions. These findings suggest that personal factors may predict who is likely to have better transfer of motor skill to and from HMD-VR. Future work should examine whether these and other predictors (i.e., additional personal factors such as immersive tendencies and task-specific factors such as fidelity or feedback) also apply to motor skill transfer from HMD-VR to more dynamic physical environments.

The goal of the Enhancing Neuroimaging Genetics through Meta‐Analysis (ENIGMA) Stroke Recovery working group is to understand brain and behavior relationships using well‐powered meta‐ and mega‐analytic approaches. ENIGMA Stroke Recovery has data from over 2,100 stroke patients collected across 39 research studies and 10 countries around the world, comprising the largest multisite retrospective stroke data collaboration to date. This article outlines the efforts taken by the ENIGMA Stroke Recovery working group to develop neuroinformatics protocols and methods to manage multisite stroke brain magnetic resonance imaging, behavioral and demographics data. Specifically, the processes for scalable data intake and preprocessing, multisite data harmonization, and large‐scale stroke lesion analysis are described, and challenges unique to this type of big data collaboration in stroke research are discussed. Finally, future directions and limitations, as well as recommendations for improved data harmonization through prospective data collection and data management, are provided.

This review summarizes the last decade of work by the ENIGMA (Enhancing NeuroImaging Genetics through Meta Analysis) Consortium, a global alliance of over 1400 scientists across 43 countries, studying the human brain in health and disease. Building on large-scale genetic studies that discovered the first robustly replicated genetic loci associated with brain metrics, ENIGMA has diversified into over 50 working groups (WGs), pooling worldwide data and expertise to answer fundamental questions in neuroscience, psychiatry, neurology, and genetics. Most ENIGMA WGs focus on specific psychiatric and neurological conditions, other WGs study normal variation due to sex and gender differences, or development and aging; still other WGs develop methodological pipelines and tools to facilitate harmonized analyses of “big data” (i.e., genetic and epigenetic data, multimodal MRI, and electroencephalography data). These international efforts have yielded the largest neuroimaging studies to date in schizophrenia, bipolar disorder, major depressive disorder, post-traumatic stress disorder, substance use disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism spectrum disorders, epilepsy, and 22q11.2 deletion syndrome. More recent ENIGMA WGs have formed to study anxiety disorders, suicidal thoughts and behavior, sleep and insomnia, eating disorders, irritability, brain injury, antisocial personality and conduct disorder, and dissociative identity disorder. Here, we summarize the first decade of ENIGMA’s activities and ongoing projects, and describe the successes and challenges encountered along the way. We highlight the advantages of collaborative large-scale coordinated data analyses for testing reproducibility and robustness of findings, offering the opportunity to identify brain systems involved in clinical syndromes across diverse samples and associated genetic, environmental, demographic, cognitive, and psychosocial factors.

Observational research benefits from inclusion of diverse cohorts. To characterize racial and ethnic diversity in observational and natural history research studies of Duchenne muscular dystrophy (DMD), highly cited and influential observational studies were identified. Fourteen United States-based articles were included. All studies cited >70% White participants with the majority having few racial minority participants. Enrollment of Black/African American individuals was particularly limited (<5% in all but one study), and Hispanic/Latino participants ranged from 3.3– 26.5% of cohorts. These results suggest a need for effective strategies to recruit, enroll, and retain racially and ethnically diverse populations into observational research in DMD.

A balance between stressful and restful occupations is an important component of lifestyle balance (LB). We argue that excessive physiological activation from the stress of everyday engagement in occupation, and/or inadequate engagement in restful occupations, can lead to negative health outcomes through accumulation of allostatic load (AL), or physiological wear and tear on the body. This physiological activation manifests as increased heart rate, blood pressure, and activation of the hypothalamic-pituitary-adrenal (HPA) axis, resulting in elevations in serum levels of hormones such as cortisol and catecholamines. “Stress,” as the term is used colloquially, is just one possible source of physiological activation. Other possible sources include cognitive challenges and high motivation tasks. The purpose of this paper is twofold: 1) to present an explanatory model for how the LB component of a “pattern of occupations with a balance between stressful and restful engagements” can affect health and 2) to discuss metrics to measure physiological activation from stress/rest and explore how these metrics relate to existing measures of lifestyle and occupational balance. We speculate that these metrics may relate to existing measures of lifestyle and occupational balance in ways that help explain the mechanisms underlying them, with the amount of physiological activation that individuals experience on a daily basis determining their long-term health outcomes. There remains a need to develop innovative lifestyle interventions that support management of stress related physiological activation to promote health and well-being.

Keywords. Occupational science, Life balance, Occupational balance, Restful occupations, Strenuous occupations, Physiological stress, Explanatory mechanisms, Allostatic load

Importance. It is critical for providers to use evidence-based interventions to address mental health and behavioral barriers to occupational performance during early childhood.

Objective. To identify evidence-based interventions within the scope of occupational therapy practice to improve mental health and positive behavior for children ages 0–5 yr and their families.

Data Sources. PsycINFO, Cochrane, ERIC, MEDLINE, and OTseeker databases were searched for publications from 2010 through March 2017.

Study Selection and Data Collection. This review was completed in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Risk of bias was assessed for each article using either A Measurement Tool to Assess Systematic Reviews (AMSTAR) or the Cochrane method. Articles meeting inclusion criteria were critically appraised.

Findings. Forty-six articles met inclusion criteria and were organized into three themes: touch-based interventions (n = 9), parent–child interaction therapy (PCIT; n = 4), and instruction-based interventions (n = 33). Statistically significant findings and overall risk of bias supported the use of touch-based interventions, PCIT, and parent training.

Conclusions and Relevance. The evidence indicates that touch-based interventions can improve infant self-regulation (strong), social behavior, and attachment (moderate) and reduce maternal stress, anxiety, and depression (low). Moderate-strength evidence supports PCIT to improve child behavior. The evidence indicates that parent training can improve parent behavior, maternal–infant attachment (strong), and parent mental health (moderate). Teacher training can improve mental health and behavior (moderate). Group-based parent training and sleep training have insufficient support (low).

What This Article Adds. Occupational therapy professionals working with children younger than age 5 yr can use the results of this systematic review to guide clinical decision making related to mental health and behavioral outcomes.

Electroencephalography (EEG)-based brain–computer interfaces (BCIs) for motor rehabilitation aim to “close the loop” between attempted motor commands and sensory feedback by providing supplemental information when individuals successfully achieve specific brain patterns. Existing EEG-based BCIs use various displays to provide feedback, ranging from displays considered more immersive (e.g., head-mounted display virtual reality (HMD-VR)) to displays considered less immersive (e.g., computer screens). However, it is not clear whether more immersive displays improve neurofeedback performance and whether there are individual performance differences in HMD-VR versus screen-based neurofeedback. In this pilot study, we compared neurofeedback performance in HMD-VR versus a computer screen in 12 healthy individuals and examined whether individual differences on two measures (i.e., presence, embodiment) were related to neurofeedback performance in either environment. We found that, while participants’ performance on the BCI was similar between display conditions, the participants’ reported levels of embodiment were significantly different. Specifically, participants experienced higher levels of embodiment in HMD-VR compared to a computer screen. We further found that reported levels of embodiment positively correlated with neurofeedback performance only in HMD-VR. Overall, these preliminary results suggest that embodiment may relate to better performance on EEG-based BCIs and that HMD-VR may increase embodiment compared to computer screens.

Keywords: brain–computer interface; neurofeedback; immersive virtual reality; head-mounted display; electroencephalography; presence; embodiment

The objective of this study is to assess the impact of inflammatory arthritis on young adults’ activity participation using quantitative and qualitative methods to advance the field’s conceptualization of functional status. Young adults diagnosed with juvenile idiopathic arthritis or rheumatoid arthritis completed (1) the Health Assessment Questionnaire-Disability Index to determine functional status and (2) the day reconstruction method to explore experiential dimensions of function, including functional performance, functional satisfaction, and severity of arthritis symptoms during activities on the previous day. Bivariate analyses were conducted to examine relationships between functional status, experiential variables, and demographic variables. Open-ended questions were provided for participants to report ways that arthritis affected their participation that were not otherwise reflected within survey questions; responses were numerically coded using summative content analysis. Among 37 participants (24.8 ± 3.3 years old), 70% reported moderate-to-severe disability. On average, participants experienced pain, stiffness, or fatigue for more than 50% of their waking hours. Functional status significantly correlated with functional performance (r = − 0.39, p = 0.02) and satisfaction (r = − 0.39, p = 0.02), yet did not correlate with stiffness or fatigue severity or duration of symptoms throughout the day. Participants described strategies that improved their ability to participate in certain activities but reduced their overall quality of activity engagement and caused emotional distress. Young adults with arthritis may experience more significant functional limitations than previously reported. Traditional measures of functional assessment may not capture experiential components of activity that affect participation, such as severity of stiffness or fatigue or the duration of symptoms throughout the day.

Keywords. Health status, Quality of life, Juvenile idiopathic arthritis, Rheumatoid arthritis, Young adult, Patient reported outcome

This special issue of the American Journal of Occupational Therapy on interventions for children and youth highlights the current developments in and evidence for the effectiveness of occupational therapy interventions and psychometric properties of assessments for children and youth. In this guest editorial, we identify various factors that challenge the implementation of evidence-based strategies in daily clinical practice. We assert that scholars, educators, and practitioners need to address several strategic steps. To facilitate critical consumption of evidence in practice, efforts need to be made to build capacity for evidence production and evidence use through implementation science and to ensure that evidence-based practice is not only taught but also reflectively applied across the educational curriculum and that clinicians are given more access to resources that are easy to translate to daily clinical practice.

Importance. Few neonatal feeding assessments are currently available, and the Neonatal Eating Outcome Assessment is the only one that identifies feeding impairment while considering the developmental changes that occur from preterm birth to term-equivalent age.

Objective. To determine the interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment.

Design. Prospective, observational study.

Setting. Level 4 neonatal intensive care unit.

Participants. A convenience sample of 7 neonatal therapists participated in reliability testing. For concurrent validity, a prospective cohort of 52 preterm infants born ≤32 wk gestation had feeding assessed at term-equivalent age.

Outcomes and Measures. Intraclass correlations (ICCs) and Fleiss’s κ statistics were used to define reliability across therapists, who independently scored five videos of preterm infants orally feeding using the Neonatal Eating Outcome Assessment. Concurrent validity was determined by evaluating relationships between the Neonatal Oral Motor Assessment Scale (NOMAS) and the Neonatal Eating Outcome Assessment using an independent-samples t test and χ² analysis.

Results. The ICC for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]). Fleiss’s κ scores for the 19 scorable items on the Neonatal Eating Outcome Assessment had predominately moderate, fair, and slight agreement, with 3 items having poor agreement. Dysfunctional NOMAS scores were related to lower Neonatal Eating Outcome Assessment scores (t[49.4] = 3.72, mean difference = 12.2, 95% CI [5.60, 18.75], p = .001).

Conclusions and Relevance. The Neonatal Eating Outcome Assessment has excellent reliability. Concurrent validity was established.

What This Article Adds. This article reports that the final version of the Neonatal Eating Outcome Assessment (Version 5.7) has excellent interrater and concurrent validity and is an important tool to assess the occupation of infant feeding in clinical practice.

The purpose of this study was to (1) define medical and sociodemographic factors related to maternal milk feedings and (2) explore relationships between maternal milk feeding and early neurobehavioral outcome. Ninety-two preterm infants born ≤ 32 weeks gestation had maternal milk feeding and breastfeeding tracked in this retrospective analysis. At 34 to 41 weeks postmenstrual age (PMA), neurobehavior was assessed with the NICU Network Neurobehavioral Scale. Maternal milk feeding was often delayed by the use of total parenteral nutrition, administered for a median of 11 (7-26) days, impacting the timing of gastric feeding initiation. Seventy-nine (86%) infants received some maternal milk during neonatal intensive care unit (NICU) hospitalization. Twenty-one (27%) infants continued to receive maternal milk at 34 to 41 weeks PMA, with 10 (48%) of those receiving maternal milk exclusively. Among mothers who initiated maternal milk feeds, 20 (25%) put their infants directly at the breast at least once during hospitalization. Mothers who were younger (P = .02), non-Caucasian (P < .001), or on public insurance (P < .001) were less likely to provide exclusive maternal milk feedings by 34 to 41 weeks PMA. Infants who received maternal milk at 34 to 41 weeks PMA demonstrated better orientation (P = .03), indicating they had better visual and auditory attention to people and objects in the environment. Our findings demonstrate a relationship between maternal milk feedings and better neurobehavior, which is evident before the infant is discharged home from the NICU.

As more individuals from diverse backgrounds are diagnosed with Type 1 Diabetes (T1D), the need to address resulting disparities in diabetes outcomes among these populations also escalates. Although young adulthood proves challenging for all patients with diabetes, young adults (YA) from racial/ethnic minorities and low socioeconomic backgrounds face even greater T1D management obstacles. The poorer outcomes in these populations drive an urgent need for alternative care models to improve YA's engagement in their T1D clinical care and address barriers to improved health outcomes. Previous telemedicine initiatives for T1D have yielded positive diabetes care results, especially in YA, offering one promising way to reach this high-risk population. To serve these patients better, an established and successful home telehealth group appointment model, “CoYoT1 Clinic” (Colorado Young Adults with T1D), was adapted to provide care to YA with T1D at a large urban children's hospital in Southern California. At this location, ~70% of patients have public/no insurance, and 85% are racial/ethnic minorities. In this paper, we report the process of adapting the CoYoT1 Clinic model and designing a randomized controlled trial (RCT) to evaluate its efficacy. The adapted model uses meticulous study-design methods that incorporate patient advisors, quantitative and qualitative data collection, collaboration with local stakeholders, intervention development, and patient randomization into a factorial design analyzing telemedicine versus in-person and patient-centered versus standard care. The new model addresses the needs of high-risk YA in Southern California, with the goal of increasing access to care, improving follow-up frequency, and strengthening patient and provider satisfaction.

Keywords. Young adults; Telehealth; Group appointments; Type 1 diabetes; Shared medical appointments; Telemedicine

Purpose. Medically underserved adults with spinal cord injury (SCI) remain at high risk of incurring medically serious pressure injuries even after receiving education in prevention techniques. The purpose of this research is to identify circumstances leading to medically serious pressure injury development in medically underserved adults with SCI during a lifestyle-based pressure injury prevention program, and provide recommendations for future rehabilitation approaches and intervention design.

Methods. This study entailed a qualitative secondary case analysis of treatment notes from a randomized controlled trial. Participants were 25 community-dwelling, medically underserved adults with SCI who developed medically serious pressure injuries during the course of the intervention of the RCT.

Results and conclusions. Among the 25 participants, 40 unique medically serious pressure injuries were detected. The six themes related to medically serious pressure injury development were: (1) lack of rudimentary knowledge pertaining to wound care; (2) equipment and supply issues; (3) comorbidities; (4) non-adherence to prescribed bed rest; (5) inactivity; and (6) circumstances beyond the intervention’s reach. Together, these factors may have undermined the effectiveness of the intervention program. Modifications, such as assessing health literacy levels of patients prior to providing care, providing tailored wound care education, and focusing on equipment needs, have potential for altering future rehabilitation programs and improving health outcomes.

Keywords. Spinal cord injuries, pressure injury, lifestyle, intervention, cultural diversity

Type 1 diabetes and type 2 diabetes are prevalent endocrine conditions, with over 25,000 youth newly diagnosed with diabetes each year. Late adolescence and young adulthood is a particularly risky time for youth with diabetes. In addition to the normative challenges experienced during this developmental period, most youth with diabetes also must transfer from pediatric to adult health care. This chapter reviews key developmental and psychosocial considerations that may influence diabetes management and evidence-based guidelines informing the treatment of transition-aged youth with type 1 diabetes or type 2 diabetes. Specific recommendations to support transition efforts at the patient, provider, and health-care system levels are presented, and key resources to facilitate developmentally tailored, continuous care for youth with diabetes are highlighted.

Keywords. Type 1 diabetes, Type 2 diabetes, Transition to adult care, Health-care delivery, Adolescents, Young adults, Psychosocial screening, Adolescent development

This study examined the performance of the First Year Inventory (FYI; version 2.0), a community-normed parent-reported screening instrument, in a high-risk (HR) sample of 12-month-olds with older siblings diagnosed with autism spectrum disorder (ASD). The FYI 2.0 was completed by parents of 86 HR infants and 35 low-risk control infants at age 12 months, followed by clinical diagnosis at 36 months. HR infants later diagnosed with ASD had significantly higher FYI 2.0 risk scores in both the social-communication and sensory-regulatory domains than typically developing infants. New FYI 2.0 cutoff scores for HR sample were explored by evaluating various cutoff options after considering tradeoffs between sensitivity and specificity and sample characteristics.

Patients are experts on their own lives and the ways in which an illness, injury, or disability affects their health, activity, and quality of life. With its longstanding foundations in participatory action research, patient engagement has been gaining momentum across health care and related research. This momentum is supported by investments from several key research and federal policy–related organizations, including the Patient-Centered Outcomes Research Institute, National Institutes of Health, and Agency for Healthcare Research and Quality. Occupational therapy practitioners are uniquely positioned to champion patient collaborations. In this article, we discuss ways in which patient perspectives can be embraced in occupational therapy research, and we share insights from a research planning collaborative with adolescents and young adults that was led by occupational therapy researchers.

Objective. To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

Study Design. Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA with the NTrainer System. Oral feeding was assessed at 38 weeks PMA.

Results. There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = –1.4) was related to feeding success at 38 weeks PMA.

Conclusion. Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Keywords. non-nutritive sucking, preterm, medical factors, oral feeding

Background. The authors’ objective in this systematic review was to describe the evidence for preventive and rehabilitative interventions for musculoskeletal disorders in oral health care.

Types of Studies Reviewed. The authors conducted systematic search, screening, and eligibility processes to identify experimental, quasiexperimental, observational, and survey research studies in which the investigators either directly evaluated or predicted the effects of preventive or rehabilitative interventions on the reduction of musculoskeletal symptoms in oral health care professionals.

Results. The authors identified and screened 3,571 unique abstracts, assessed 256 full-text articles for eligibility, and included 34 articles in the review. Investigators in 17 experimental studies described the results of preventive or rehabilitation interventions and in 17 survey research studies predicted or correlated preventive or protective techniques to a reduction in musculoskeletal symptoms. The primary techniques evaluated in the studies included equipment modification, ergonomic training, and physical exercise.

Conclusions and Practical Implications. The evidence suggests that magnification loupes and indirect-vision techniques have a positive effect on the reduction of musculoskeletal symptoms. In terms of evaluating intervention efficacy, other techniques have mixed evidence or are limited by low-level study design.

Keywords. Ergonomics; injury prevention; musculoskeletal disorders; dentists; dental hygienists

Readmissions to health care facilities are undesirable outcomes that indicate the quality of the care transitions. Although there is a growing evidence-base for preventing readmissions, the focus has been on acute care. Postacute care (PAC) patients are often excluded from these studies, and thus there is limited evidence guiding practitioners’ efforts to facilitate an effective community transition after PAC rehabilitation. To provide direction for PAC research and clinical practice, this scoping review summarizes current community transition interventions and identifies practices that facilitate successful community discharge. Thirteen care processes emerged from 35 studies, of which 5 were included in at least 60% of the studies, including coaching on the care transition process, medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up. These findings can inform the development, evaluation, and implementation of PAC community transition interventions.

Rehabilitation for stroke patients with severe motor impairments is burdensome and demanding because most of the current rehabilitation options require some volitional movement to train the affected side. However, research has shown that survivors of severe stroke may receive modest benefits from action observation, virtual reality (VR), and brain-computer interfaces (BCIs). These approaches have shown some success in strengthening key motor pathways thought to support motor recovery after stroke. The purpose of this study was to combine the principles of action observation, VR, and BCI in a platform called REINVENT and assess its effects on four chronic stroke patients across different levels of motor impairment. REINVENT acquires post-stroke EEG signals that indicate an attempt to move and drives the movement of a virtual avatar arm, allowing patient-driven action observation neurofeedback in VR. In addition, synchronous electromyography (EMG) data were also captured to monitor overt muscle activity. Our results show that this EEG-based BCI can be used by stroke survivors across a wide range of motor disabilities. Finally, individual results suggest that patients with more severe motor impairments benefit the most from EEG-based neurofeedback, while patients with more mild impairments may benefit more from EMG-based feedback, harnessing existing sensorimotor pathways. Future research is needed to confirm these findings in a larger and more diverse population.

The everyday landscape of occupational therapy (OT) in oncology is underexplored, hindering targeted improvements. The purpose of the present study was to identify the OT interventions commonly provided and reimbursed in oncology. A survey utilizing snowball sampling was disseminated online to OT working in oncology care; 167 surveys were received from 21 states in the United States. Results found that over 90% of therapists reported focusing on physical impairment, weakness, fatigue, and activities of daily living. Interventions for emotional/social support, self‐advocacy, quality of life, lifestyle management, and cognitive impairment were not directly billed. More than 90% of therapists reported that, in the absence of barriers, they would address quality of life, emotional difficulties, lifestyle management, and home safety. Overall, the findings suggested that OT in the United States primarily provide physical interventions for oncology patients. However, they also provide psychosocial services and client/caregiver education, but often do not bill directly for this care. Reimbursement structures should be modified to allow for the direct billing of mental/psychosocial and educational interventions in OT for cancer care.

Purpose. To assess the impact of a home telemedicine clinic model (CoYoT1 Clinic) on psychosocial and behavioral outcomes designed for young adults (YAs) with type 1 diabetes (T1D).

Methods. YAs self-selected to participate in the CoYoT1 Clinic or serve as a usual care control. CoYoT1 Clinic visits consisted of an individual appointment with a provider and a group appointment with other YAs with T1D using home telemedicine. Psychosocial and behavioral functioning was assessed by 4 measures: Diabetes Distress Scale, Self-Efficacy for Diabetes Scale, Self-Management of Type 1 Diabetes in Adolescence Scale, and Center for Epidemiologic Studies Depression Scale.

Results. Forty-two patients participated in the CoYoT1 Clinic and 39 patients served as controls. CoYoT1 participants reported lower levels of distress (P = .03), increased diabetes self-efficacy (P = .01), and improved ability to communicate with others about diabetes (P = .04) over the study period compared to controls. YA males in the control group reported increases in depressive symptoms (P = .03) during the study period, but CoYoT1 participants showed no changes.

Conclusion. Group home telemedicine for YAs with T1D positively affects diabetes distress, self-efficacy, and diabetes-specific communication. These positive findings have the potential to also affect the YAs’ long-term diabetes outcomes. Further investigation of the model is needed.

When designing international educational collaborations, occupational science and occupational therapy educators must consider how occupational justice can be a linchpin for students’ learning. This article describes an international collaboration involving 52 undergraduate occupational science students in the United States and 41 undergraduate occupational therapy students in South Africa. The students participated in six synchronous video conferences in 2016, during which they gave group presentations about four occupational science constructs and engaged in general question-and-answer sessions. Forty percent of the students provided feedback about the interactions using a six-item open-ended electronic questionnaire, which we analyzed using directed content analysis. Our findings suggest that the collaboration helped the students develop more nuanced understandings of disciplinary constructs, international peers, and themselves, providing a platform from which to engage with the big idea of occupational justice. Refinements to this collaboration are aimed at drawing on students’ increased critical consciousness to further develop their knowledge about occupational justice.

People spend most of their day in buildings, and a large portion of the energy in buildings is used to control the indoor environment for creating acceptable conditions for occupants. However, majority of the building systems are controlled based on a ‘one size fits all’ scheme which cannot account for individual occupant preferences. This leads to discomfort, low satisfaction and negative impacts on occupants’ productivity, health and well-being. In this paper, we describe our vision of how recent advances in Internet of Things (IoT) and machine learning can be used to add intelligence to an office desk to personalize the environment around the user. The smart desk can learn individual user preferences for the indoor environment, personalize the environment based on user preferences, and act as an intelligent support system for improving user comfort, health and productivity. We briefly describe the recent advances made in different domains that can be leveraged to enhance occupant experience in buildings and describe the overall framework for the smart desk. We conclude the paper with a discussion of possible avenues for further research.

Keywords: Personalized environments, Smart desks, IoT (internet of things), Smart buildings, Indoor environment quality (IEQ)

The solution to a problem might manifest itself as a burst of unexpected, unpredictable clarity. Such Eureka! events, or Insight moments, are among the most fascinating mysteries of human cognition, whose neurophysiological substrate seems to include a role for oscillatory activity within the α and γ bands in the right parietal and temporal brain regions. We tested this hypothesis on thirty-one healthy participants using transcranial Alternating Current Stimulation (tACS) to externally amplify α (10 Hz) and γ (40 Hz) activity in the right parietal and temporal lobes, respectively. During γ-tACS over the right temporal lobe, we observed an increase in accuracy on a verbal insight task. Furthermore, electroencephalography (EEG) data revealed an increase in γ spectral power over bilateral temporal lobes after stimulation. Additionally, resting-state functional MRI data acquired before the stimulation session suggested a correlation between behavioral response to right temporal lobe tACS and functional connectivity of bilateral temporal lobes, in line with the bilateral increase in γ band revealed by EEG. Overall, results suggest the possibility of enhancing the probability of generating Eureka! moments in humans by means of frequency-specific noninvasive brain stimulation.

Abnormal sensory-based behaviors are a defining feature of autism spectrum disorders (ASD). Dr. A. Jean Ayres was the first occupational therapist to conceptualize Sensory Integration (SI) theories and therapies to address these deficits. Her work was based on neurological knowledge of the 1970s. Since then, advancements in neuroimaging techniques make it possible to better understand the brain areas that may underlie sensory processing deficits in ASD. In this article, we explore the postulates proposed by Ayres (i.e., registration, modulation, motivation) through current neuroimaging literature. To this end, we review the neural underpinnings of sensory processing and integration in ASD by examining the literature on neurophysiological responses to sensory stimuli in individuals with ASD as well as structural and network organization using a variety of neuroimaging techniques. Many aspects of Ayres’ hypotheses about the nature of the disorder were found to be highly consistent with current literature on sensory processing in children with ASD but there are some discrepancies across various methodological techniques and ASD development. With additional characterization, neurophysiological profiles of sensory processing in ASD may serve as valuable biomarkers for diagnosis and monitoring of therapeutic interventions, such as SI therapy.

Keywords: Autism Spectrum Disorder (ASD); Ayres Sensory Integration (ASI); sensory processing; functional magnetic resonance imaging (fMRI)

Recent research has reported motor impairment similarities between children with developmental coordination disorder (DCD) and a subgroup of individuals with autism spectrum disorder (ASD). However, there is a debate as to whether DCD is a co-occurring diagnosis in individuals with ASD and motor impairments (ASDd), or if motor impairments in ASD are distinct from DCD. However, the etiology of motor impairments is not well understood in either disorder. Clarifying comorbidities in ASD is important to determine different etiopathological phenotyping clusters in ASD and to understand the variety of genetic and environmental factors that contribute to the disorder. Furthermore, this distinction has important therapeutic relevance. Here we explore the current neuroimaging findings in ASD and DCD and discusses possible neural mechanisms that underlie similarities and differences between the disorders.

Keywords: Autism spectrum disorder (ASD); developmental coordination disorder (DCD); action observation network (AON); functional magnetic resonance imaging (fMRI); resting state; diffusion weighted imaging (DWI)

Oral health is an important yet often neglected component of overall health, linked to heart disease, stroke, and diabetic complications. Disparities exist for many groups, including racial and ethnic minorities such as African Americans. The purpose of this study was to examine the potential factors that perpetuate oral health care disparities in African American children in the United States. A systematic search of three literature databases produced 795 articles; 23 articles were included in the final review. Articles were analyzed using a template coding approach based on the social ecological model. The review identified structural, sociocultural, and familial factors that impact the ability of African Americans to utilize oral care services, highlighting the importance of the parent/caregiver role and the patient–provider relationship; policy-level processes that impact access to quality care; the value of autonomy in treatment and prevention options; and the impact of sociocultural factors on food choices (e.g., food deserts, gestures of affection). In conclusion, oral health care remains an underutilized service by African American children, despite increasing access to oral care secondary to improvements in insurance coverage and community-based programs.

Objective. In this study, we examined if 6–9 Hz jaw tremor, an indirect indicator of Periodontal Mechanoreceptor (PMR) activity, is different in bruxists compared to healthy participants during production of a low-level constant bite force.

Methods. Bite force and surface EMG from the masseter muscle were recorded simultaneously as participants (13 patients, 15 controls) held a force transducer between the upper and lower incisors very gently.

Results. Tremor in 6–9 Hz band for bruxists was greater on average compared to controls, but the difference was not significant, both for force recordings and EMG activity.

Conclusions. The low effect sizes measured with the current protocol contrast highly with those of our previous study, where larger, dynamic bite forces were used, and where jaw tremor was markedly different in bruxists compared with controls.

Significance. We have now gained important insight into the conditions under which abnormal jaw tremor can be elicited in bruxism. From a scientific standpoint, this is critical for understanding the ‘abnormality’ of PMR feedback in bruxism. From a clinical perspective, our results represent progress towards the development of an optimal protocol in which jaw tremor can serve as a biological marker of bruxism.

Keywords. Tremor; Jaw; Bruxism; Periodontal mechanoreceptors; Bite force

The time is ripe to integrate burgeoning evidence of the important role of sensory and motor functioning in mental health within the National Institute of Mental Health’s [NIMH] Research Domain Criteria [RDoC] framework (National Institute of Mental Health, n.d.a), a multi-dimensional method of characterizing mental functioning in health and disease across all neurobiological levels of analysis ranging from genetic to behavioral. As the importance of motor processing in psychopathology has been recognized (Bernard & Mittal, 2015; Garvey & Cuthbert, 2017; National Institute of Mental Health, 2019), here we focus on sensory processing. First, we review the current design of the RDoC matrix, noting sensory features missing despite their prevalence in multiple mental illnesses. We identify two missing classes of sensory symptoms that we widely define as (1) sensory processing, including sensory sensitivity and active sensing, and (2) domains of perceptual signaling, including interoception and proprioception, which are currently absent or underdeveloped in the perception construct of the cognitive systems domain. Then, we describe the neurobiological basis of these psychological constructs and examine why these sensory features are important for understanding psychopathology. Where appropriate, we examine links between sensory processing and the domains currently included in the RDoC matrix. Throughout, we emphasize how the addition of these sensory features to the RDoC matrix is important for understanding a range of mental health disorders. We conclude with the suggestion that a separate sensation and perception domain can enhance the current RDoC framework, while discussing what we see as important principles and promising directions for the future development and use of the RDoC.

Prior research on the stability of sensory processing problems in children with autism spectrum disorder (ASD) or other developmental disabilities (DD) has produced inconsistent results. We employed a longitudinal study design to assess the stability of three clinical sensory response patterns: hyporesponsiveness; hyperresponsiveness; and sensory interests, repetitions, and seeking behaviors (SIRS). Parents of children with ASD (n = 55) or DD (n = 35) responded to sensory questionnaires at two time points (T1 and T2) separated by 3.3 years on average, with the children aged 2–12 years (M = 5.69 ± 2.46) at the first assessment. For each sensory response pattern, regression analysis revealed that, for both ASD and DD groups, scores at T1 were strong predictors of scores at T2. Over the longitudinal assessment interval, there was a significant mean decline in severity for SIRS in both groups and for hyporesponsiveness in the ASD group. Parental estimates of the amount of therapy services received were positively associated with the severity of sensory features at T2, an outcome that may result from increased intervention dosages being administered to children who fail to improve over time. The results are discussed in terms of person‐centered and environmental considerations, which, in combination, have the capacity to affect stability outcomes for sensory features.

This study examined the feasibility of an adapted 2-week mindfulness meditation protocol for chronic stroke survivors. In addition, preliminary effects of this adapted intervention on spasticity and quality of life in individuals after stroke were explored. Ten chronic stroke survivors with spasticity listened to 2 weeks of short mindfulness meditation recordings, adapted from Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction course, in a pre/post repeated measures design. Measures of spasticity, quality of life, mindfulness, and anxiety, along with qualitative data from participants’ daily journals, were assessed. On average, participants reported meditating 12.5 days of the full 15 days (mean 12.5 days, SD 0.94, range 8-15 days). Seven of the 10 participants wrote comments in their journals. In addition, there were no adverse effects due to the intervention. Exploratory preliminary analyses also showed statistically significant improvements in spasticity in both the elbow (P = .032) and wrist (P = .023) after 2 weeks of meditation, along with improvements in quality of life measures for Energy (P = .013), Personality (P = .026), and Work/Productivity (P = .032). This feasibility study suggests that individuals with spasticity following stroke are able to adhere to a 2-week home-based mindfulness meditation program. In addition, preliminary results also suggest that this adapted, short mindfulness meditation program might be a promising approach for individuals with spasticity following stroke. Future research should expand on these preliminary findings with a larger sample size and control group.

Keywords: stroke, mindfulness, spasticity, rehabilitation

Older, rural-dwelling Latinos face multiple health disparities. We describe the protocol of a pilot study of a community health worker–occupational therapist-led lifestyle program, ¡Vivir Mi Vida! (¡VMV!), designed for delivery in primary care and adapted for late-midlife, Latino rural-living patients. Using mixed methods, we collected feasibility, acceptability, and preliminary efficacy data on ¡VMV!. Forty 50- to 64-year-old Latinos participated in a 16-week lifestyle intervention led by a community health worker–occupational therapist team. We conducted pre- and post-intervention assessments to evaluate the efficacy of ¡VMV! in improving psychosocial and clinical health outcomes. Focus groups and interviews were held post-intervention with participants and key stakeholders to assess feasibility and acceptability. This is the first trial designed to evaluate a lifestyle intervention that includes collaboration between occupational therapists and community health workers within primary care. The detailed description of methodology promotes research transparency and reproducibility of a community health worker–occupational therapist-led lifestyle intervention.

Study Design. Mapping review.

Introduction. Although published literature and evidence to support medical practice is becoming more abundant, it is not known how well available evidence supports the full spectrum of hand therapy practice.

Purpose of the Study. The aim of this mapping review was to identify strengths and/or gaps in the available literature as compared with the hand therapy scope of practice to guide future research.

Methods. A systematic search and screening was conducted to identify evidence published from 2006 to 2015. Descriptive data from 191 studies were extracted, and the diagnoses, interventions, and outcomes used in the literature were compared with the hand therapy scope of practice.

Results. Osteoarthritis, tendon surgeries, and carpal tunnel syndrome were most frequently studied. Exercise, education, and orthotic interventions were most common, each used in more than 100 studies; only 12 studies used activity-based interventions. Primary outcome measures included range of motion, pain/symptoms, strength, and functional status.

Discussion. Abundant high-quality research exists for a portion of the hand therapy scope of practice; however, there is a paucity of evidence for numerous diagnoses and interventions.

Conclusions. More evidence is needed for complex diagnoses and activity-based interventions as well as behavioral and quality-of-care outcomes.

Level of Evidence. Not applicable.

Context/Objective. Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

Design. A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

Setting. Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

Participants. Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

Interventions. The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

Outcome Measures. Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

Results. Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

Conclusions. Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

Trial Registration. ClinicalTrials.gov NCT01999816.

Background. Median nerve cross-sectional area (CSA) is the primary sonographic parameter for assessing and diagnosing median nerve pathology, such as carpal tunnel syndrome. However, variability in the sensitivity of diagnostic thresholds exists, which may be due to a lack of standardized normative reference values. Current estimates of normal median nerve CSA stem largely from small studies using a local pool of healthy controls. A systematic review and meta-analysis will be conducted to identify all available data for median nerve CSA in healthy, asymptomatic individuals to create a comprehensive set of normative reference values.

Methods. Articles that include sonographic measures of median nerve CSA will be identified through a rigorous search of published evidence, a hand search through tables of contents of key journals, and the gray literature, including ClinicalTrials.gov and conference abstracts. Each abstract and full text will be reviewed by multiple raters to identify studies from 2000 to present that include original data. Any study that provides median nerve CSA values from healthy individuals will be included (e.g., reference value study, control participants in a diagnostic study). Studies will be assessed for quality using a modified version of the National Institute of Health Study Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, with primary focus on the use of a detailed and acceptable image acquisition and analysis protocol. Using data from included studies, reference values will be calculated for median nerve CSA by anatomical regions, including the distal forearm, wrist, and carpal tunnel at the level of the pisiform. Reference values will be stratified by gender, ethnicity, and age based upon the specificity of the data provided by the included articles.

Discussion. A comprehensive set of normative reference values of median nerve CSA will reduce variability across studies, allowing future research to more accurately evaluate and establish diagnostic thresholds. Additionally, normative values can serve as a reference for evaluating treatment outcomes and provide a means to investigate and understand minor nuances in CSA changes that may be indicative of preclinical stages of median nerve pathology.

Systematic review registration. PROSPERO 2016 CRD42016037286

Keywords. Meta-analysis, Systematic review, Musculoskeletal sonography, Median nerve, Reference values

Purpose. Oral health is important to physical and psychological health. Individuals with autism spectrum disorder (ASD) experience significant oral care challenges, but little research exists that examines efficacious interventions to improve care. The purpose of this study was to qualitatively explore parental and dentist reports of successful strategies implemented during dental care with children with ASD.

Methods. Focus groups were conducted with parents of children with ASD (N = two groups) and dentists treating children with ASD (N = two groups). Focus group transcripts were transcribed verbatim and analyzed using a thematic analysis approach.

Results. Three key themes were identified from the parent focus groups: (1) what makes a good dentist; (2) flexibility and techniques—strategies used by the dentist; and (3) preparation—strategies for parents and caregivers of children with ASD. Four themes emerged from the dentist groups: (1) parents know best; (2) practice; (3) flexibility; and (4) a network of colleagues. Areas of overlap between the parents and dental providers included the importance of preparation, necessity of flexibility and creativity, and value of collaboration.

Conclusions. Our findings provide insight into techniques perceived by parents and dental providers to facilitate successful dental encounters for children with ASD.

Background. Pressure injuries negatively impact quality of life and participation for individuals with spinal cord injury (SCI).

Objective. To examine the factors that may protect against the development of medically serious pressure injuries in adults with SCI.

Methods. A qualitative analysis was conducted using treatment notes regarding 50 socioeconomically disadvantaged individuals who did not develop medically serious pressure injuries during a 12-month pressure injury prevention intervention program.

Results. Eight types of potentially protective factors were identified: meaningful activity, motivation to prevent negative health outcomes, stability/resources, equipment, communication and self-advocacy skills, personal traits, physical factors, and behaviors/activities.

Conclusions. Some protective factors (e.g., personal traits) may be inherent to certain individuals and nonmodifiable. However, future interventions for this population may benefit from a focus on acquisition of medical equipment and facilitation of sustainable, health-promoting habits and routines. Substantive policy changes may be necessary to facilitate access to adequate resources, particularly housing and equipment, for socioeconomically disadvantaged individuals with SCI. Further research is needed to understand the complex interplay of risk and protective factors for pressure injuries in adults with SCI, particularly in underserved groups.

Complex rule‐based auditory processing is abnormal in individuals with long‐term schizophrenia (SZ), as demonstrated by reduced mismatch negativity (MMN) to deviants in rule‐based patterns and reduced auditory sustained potential (ASP) that appears when grouping tones together. Together, this suggests deficits later in the auditory processing hierarchy in Sz. Here, MMN and ASP were elicited by deviations from a complex zig‐zag pitch pattern that cannot be predicted by simple linear rules. Twenty‐seven SZ and 26 matched healthy controls (HC) participated. Frequent groups of patterns contained eight tones that zig‐zagged in a two‐up one‐down pitch‐based paradigm. There were two deviant patterns: the final tone was either higher in pitch than expected (creating a jump in pitch) or was repeated. Simple MMN to pitch‐deviants among repetitive tones was measured for comparison. Sz exhibited a smaller pitch MMN compared to HC as expected. HC produced a late MMN in response to the repeat and jump‐deviant and a larger ASP to the standard group of tones, all of which were significantly blunted in SZ. In Sz, the amplitude of the late complex MMN was related to neuropsychological functioning, whereas ASP was not. ASP and late MMN did not significantly correlate in HC or in Sz, suggesting that they are not dependent on one another and may originate within distinct processing streams. Together, this suggests multiple deficits later in the auditory sensory‐perceptual hierarchy in Sz, with impairments evident in both segmentation and deviance detection abilities.

Experiences are multidimensional, impactful, and often rooted in occupations, where meaning is felt, and people engage with others and learn about themselves and the world. Experiences are complex phenomena influenced by a multitude of factors, and they have a strong connection to health and well-being. Studies of lived experiences have been central to the development of occupational science. Capturing the essence of experiences can be challenging, but integrating data from multiple perspectives in research designs is a valuable strategy to address challenges to understanding experiences, including their interpersonal, interdependent, and intersubjective natures. This is especially critical for understanding circumstances in which two or more people share experiences or coordinate action together, such as in cases of caregiving. In this paper, we outline the strength and utility of methodological approaches that integrate multiple perspectives in order to understand experiences as they are situated beyond the individual. We draw on original data from a narrative and phenomenological study of lived experiences among adolescents and young adults with spinal cord injuries and their caregivers as an exemplar for discussion. Relative contributions to occupational science and limitations of a multi-perspective approach are considered.

Keywords. Occupational science, Qualitative research, Personal narratives, Methods, Caregivers, Spinal cord injuries

Throughout the past 3 decades, treatment of injured musicians in a health care setting has been reported; however, the quality of care from a musician’s standpoint is poor. As musicians are speaking up more about their pain, the profession of occupational therapy has the capacity to make an impact on the way musicians are treated from a rehabilitative perspective. Musicians often do not trust medical practitioners who follow the traditional medical model because their symptoms and concerns are not addressed. Occupational therapists, especially those working in the realm of hand rehabilitation, are well equipped to treat injured musicians using our unique activity analysis skills and holistic frame of reference; the goal is to return them back to their prior levels of playing. To support the Occupational Therapy Practice Framework: Domain and Process’s vision, this article discusses evaluation and treatment of the unique musician emphasizing the musician’s point of view through an occupation-based, client-centered, and evidence-based practice.

The effectiveness of transcranial direct current stimulation (tDCS) placed over the motor hotspot (thought to represent the primary motor cortex (M1)) to modulate motor network excitability is highly variable. The premotor cortex—particularly the dorsal premotor cortex (PMd)—may be a promising alternative target to reliably modulate motor excitability, as it influences motor control across multiple pathways, one independent of M1 and one with direct connections to M1. This double-blind, placebo-controlled preliminary study aimed to differentially excite motor and premotor regions using high-definition tDCS (HD-tDCS) with concurrent functional magnetic resonance imaging (fMRI). HD-tDCS applied over either the motor hotspot or the premotor cortex demonstrated high inter-individual variability in changes on cortical motor excitability. However, HD-tDCS over the premotor cortex led to a higher number of responders and greater changes in local fMRI-based complexity than HD-tDCS over the motor hotspot. Furthermore, an analysis of individual motor hotspot anatomical locations revealed that, in more than half of the participants, the motor hotspot is not located over anatomical M1 boundaries, despite using a canonical definition of the motor hotspot. This heterogeneity in stimulation site may contribute to the variability of tDCS results. Altogether, these preliminary findings provide new considerations to enhance tDCS reliability.

Accurate stroke lesion segmentation is a critical step in the neuroimaging processing pipeline for assessing the relationship between poststroke brain structure, function, and behavior. Many multimodal segmentation algorithms have been developed for acute stroke neuroimaging, yet few algorithms are effective with only a single T1‐weighted (T1w) anatomical MRI. This is a critical gap because multimodal MRI is not commonly available due to time and cost constraints in the stroke rehabilitation setting. Although several attempts to automate the segmentation of chronic lesions on single‐channel T1w MRI have been made, these approaches have not been systematically evaluated on a large dataset. We performed an exhaustive review of the literature and identified one semiautomated and three fully automated approaches for segmentation of chronic stroke lesions using T1w MRI within the last 10 years: Clusterize, automated lesion identification (ALI), Gaussian naïve Bayes lesion detection (lesionGnb), and lesion identification with neighborhood data analysis (LINDA). We evaluated each method on a large T1w stroke dataset (N = 181). LINDA was the most computationally expensive approach, but performed best across the three main evaluation metrics (median values: dice coefficient = 0.50, Hausdorff's distance = 36.34 mm, and average symmetric surface distance = 4.97 mm). lesionGnb had the highest recall/least false negatives (median = 0.80). However, across the automated methods, many lesions were either misclassified (ALI: 28, lesionGnb: 39, LINDA: 45) or not identified (ALI: 24, LINDA: 23, lesionGnb: 0). Segmentation accuracy in all automated methods were influenced by size (small: worst) and stroke territory (brainstem, cerebellum: worst) of the lesion. To facilitate reproducible science, our analysis files have been made publicly available online.

Background. Concussions, or mild traumatic brain injuries, are prevalent among youth and young adults. These injuries may disrupt a person's daily activities (occupations) including school, physical activity, work, and socialization. Rehabilitation professionals, such as occupational therapists (OTs), are experts in providing individualized intervention to address these temporary life changes during recovery.

Objective. This article aims to identify the benefit of having an occupational therapy practitioner on an interdisciplinary treatment team when providing intervention to patients with concussion.

Setting. Concussion clinic at an academic institution.

Participants. Participants ages 12 to 24 years with a reported history of mild traumatic brain injury or concussion were evaluated by a physician, or by a physician and OT, in an initial evaluation appointment.

Design. A single researcher (OT) with training in concussion qualitatively compared reported impacted occupational domains as defined in the Occupational Therapy Practice Framework, using both a retrospective and a prospective cohort. The prospective group differed from the retrospective group in that an OT was present, and participated in the initial evaluation.

Results. The domains of performance patterns (P = .007) and performance skills (P ≤ .001) were identified significantly more often when an occupational therapy practitioner participated in the initial evaluation.

Conclusions. Rehabilitation professionals, such as OTs, play an important role in identifying impacted domains after a concussion, which can help optimize patient care.

Participation refers to a state of health in which a person is able to fully engage in roles and life situations. Adults living with and beyond cancer often report persistent participation restrictions that affect their productivity and quality of life. The American Occupational Therapy Foundation convened a group of scientists from seven different disciplines in a Planning Grant Collective (PGC) to stimulate research to identify scalable ways to preserve and optimize participation among cancer survivors. Participants identified challenges, prioritized solutions, and generated novel research questions that move beyond symptom and impairment mitigation as outcomes to identify interventions that improve participation in roles and life situations. This article summarizes the PGC discussion and recommendations regarding three challenges: (a) the dynamic and multi-faceted nature of participation, (b) a need to integrate the concept of participation within the culture of oncology, and (c) identification of priority areas in which new lines of research regarding participation would be most impactful.

Keywords. cancer, everyday occupations, functional outcomes, participation, disability

Objective. The main objective of this article is to define perceptions of health care professionals regarding current use of sensory-based interventions in the neonatal intensive care unit (NICU).

Study Design. A multidisciplinary group of NICU health care professionals (n = 108) defined the types of sensory-based interventions used in their NICU, the postmenstrual age (PMA) sensory-based interventions are administered, conditions under which sensory-based interventions are used, and personnel who administer sensory-based interventions.

Results. The most commonly reported tactile intervention was infant holding (88% of respondents), the most common auditory intervention was recorded music/singing (69% of respondents), the most common kinesthetic intervention was occupational and physical therapy (85% of respondents), and the most common vestibular intervention was infant swings (86% of respondents). Tactile interventions were initiated most often at 24 to 26 weeks PMA (74% of respondents), auditory interventions at 30 to 32 weeks (60% of respondents), kinesthetic interventions at 30 to 32 weeks (76% of respondents), vestibular interventions at 33 to 34 weeks (86% of respondents), and visual interventions at 32 to 36 weeks (72% of respondents). Conditions under which sensory-based interventions were administered, and personnel who provided them, varied across settings.

Conclusion. Varied use of sensory-based interventions in the NICU were reported. While this study was limited by biased sampling and the identification of health care professionals' perceptions but not real-world practice, this information can be used to build a comprehensive approach to positive sensory exposures in the NICU.

Objective. To examine characteristics of caregiving from the perspectives of adolescents and young adults (AYAs) with spinal cord injuries (SCIs) and their informal caregivers to address outstanding gaps in knowledge relating to definitions of caregiving and its associated practices for this population.

Methods. A multiphase qualitative design was applied, using phenomenological and narrative methods to capture data in participants' homes and communities. Participants were recruited from rehabilitation hospitals and community organizations throughout Los Angeles County, California. Inclusion criteria for AYAs included being 15–22 years old, having acquired an SCI within the previous 5 years, and using a wheelchair for mobility. The AYAs nominated persons they identified as primary caregivers to also participate. Data were collected through individual and group interviews as well as activity observations.

Results. Data from the 17 participants (9 AYAs and 8 informal, primary caregivers) revealed ways in which the meaning of caregiving varied among dyads. Caregiving practices extended beyond physical assistance to include support for a range of day-to-day activities spanning from practical needs to facilitating developmental trajectories. Although AYAs expressed ideas about preferred caregiver characteristics, care partnerships appeared to be guided more by availability than preference.

Conclusion. Phenomenological analysis revealed that the meaning of “caregiving” and its associated practices are highly individualized for AYAs with SCIs. Caregiving is rooted in personal needs related to effects of SCI and developmental goals. Everyday practices are shaped by individual relationships and the beliefs of AYAs and their caregivers. Addressing influences of caregiving on long-term health and function may require attention to developmental processes, caregiver “fit,” and ways care is, or can be, distributed throughout broader networks according to personal needs and preferences.

Background. To date, no study has compared preterm and full term auditory environments.

Aim. To define differences in auditory exposure for preterm infants at term equivalent age in the neonatal intensive care unit (NICU) compared to auditory exposure in hospital rooms on a labor and delivery ward after full term birth.

Study design. Ninety-eight infants (48 preterm infants born 28 weeks gestation in the NICU at term equivalent age and 50 full term infants in a hospital room on the labor and delivery ward within 4 days of birth) had auditory exposure measured over a single 16-hour period using the Language Environment Acquisition (LENA) device.

Results. More language (p < 0.001) was observed on the labor and delivery ward than in the NICU, with an average of 3.3 h more language in a 16-hour period and an average of 14,110 more words spoken around infants in a 16-hour period on the labor and delivery ward (p < 0.001). More electronic sounds were observed in the NICU, with an average of 2.3 h more in the 16-hour period (p < 0.001). The average decibel level in the NICU was lower than in the hospital rooms on the labor and delivery ward (57.16 ± 2.30 dB, compared to 63.31 ± 2.22 dB; p < 0.001).

Conclusion. The NICU auditory environment for preterm infants is different than the auditory environment for full term infants, with less language, more electronic sounds, and quieter stimuli. This understanding can aid in developing appropriate interventions that enhance positive forms of auditory exposures.

Objective. The supply territories of main cerebral arteries are predominantly identified based on distribution of infarct lesions in patients with large arterial occlusion; whereas, there is no consensus atlas regarding the supply territories of smaller end-arteries. In this study, we applied a data-driven approach to construct a stroke atlas of the brain using hierarchical density clustering in large number of infarct lesions, assuming that voxels/regions supplied by a common end-artery tend to infarct together.

Methods. A total of 793 infarct lesions on MRI scans of 458 patients were segmented and coregistered to MNI-152 standard brain space. Applying a voxel-wise data-driven hierarchical density clustering algorithm, we identified those voxels that were most likely to be part of same infarct lesions in our dataset. A step-wise clustering scheme was applied, where the clustering threshold was gradually decreased to form the first 20 mother (>50 cm³) or main (1–50 cm³) clusters in addition to any possible number of tiny clusters (<1 cm³); and then, any resultant mother clusters were iteratively subdivided using the same scheme. Also, in a randomly selected 2/3 subset of our cohort, a bootstrapping cluster analysis with 100 permutations was performed to assess the statistical robustness of proposed clusters.

Results. Approximately 91% of the MNI-152 brain mask was covered by 793 infarct lesions across patients. The covered area of brain was parcellated into 4 mother, 16 main, and 123 tiny clusters at the first hierarchy level. Upon iterative clustering subdivision of mother clusters, the brain tissue was eventually parcellated into 1 mother cluster (62.6 cm³), 181 main clusters (total volume 1107.3 cm³), and 917 tiny clusters (total volume of 264.8 cm³). In bootstrap analysis, only 0.12% of voxels, were labelled as “unstable” — with a greater reachability distance in cluster scheme compared to their corresponding mean bootstrapped reachability distance. On visual assessment, the mother/main clusters were formed along supply territories of main cerebral arteries at initial hierarchical levels, and then tiny clusters emerged in deep white matter and gray matter nuclei prone to small vessel ischemic infarcts.

Conclusions. Applying voxel-wise data-driven hierarchical density clustering on a large number of infarct lesions, we have parcellated the brain tissue into clusters of voxels that tend to be part of same infarct lesion, and presumably representing end-arterial supply territories. This hierarchical stroke atlas of the brain is shared publicly, and can potentially be applied for future infarct location-outcome analysis.

Quantifying, controlling, and monitoring image quality is an essential prerequisite for ensuring the validity and reproducibility of many types of neuroimaging data analyses. Implementation of quality control (QC) procedures is the key to ensuring that neuroimaging data are of high-quality and their validity in the subsequent analyses. We introduce the QC system of the Laboratory of Neuro Imaging (LONI): a web-based system featuring a workflow for the assessment of various modality and contrast brain imaging data. The design allows users to anonymously upload imaging data to the LONI-QC system. It then computes an exhaustive set of QC metrics which aids users to perform a standardized QC by generating a range of scalar and vector statistics. These procedures are performed in parallel using a large compute cluster. Finally, the system offers an automated QC procedure for structural MRI, which can flag each QC metric as being ‘good’ or ‘bad.’ Validation using various sets of data acquired from a single scanner and from multiple sites demonstrated the reproducibility of our QC metrics, and the sensitivity and specificity of the proposed Auto QC to ‘bad’ quality images in comparison to visual inspection. To the best of our knowledge, LONI-QC is the first online QC system that uniquely supports the variety of functionality where we compute numerous QC metrics and perform visual/automated image QC of multi-contrast and multi-modal brain imaging data. The LONI-QC system has been used to assess the quality of large neuroimaging datasets acquired as part of various multi-site studies such as the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study and the Alzheimer’s Disease Neuroimaging Initiative (ADNI). LONI-QC’s functionality is freely available to users worldwide and its adoption by imaging researchers is likely to contribute substantially to upholding high standards of brain image data quality and to implementing these standards across the neuroimaging community.

Objective. Our objective was to identify perceived barriers and strategies to improve primary care encounters, as reported by adults with autism spectrum disorder (ASD), caregivers of adults with ASD, and primary care providers (PCPs) treating adults with ASD.

Method. As part of a larger mixed-methods design, adults with ASD, caregivers, and PCPs (N = 78) in Los Angeles and Philadelphia completed surveys examining barriers to care and strategies to improve care.

Results. Multiple barriers to care were reported by adults with ASD and caregivers, including communication and sensory challenges. Adults with ASD and caregivers reported minimal use of strategies during primary care visits but indicated that those used were helpful during care. Expert PCPs reported using strategies more frequently than novice PCPs. All respondent groups endorsed that strategies had the potential to improve care in the future for adults with ASD.

Conclusion. Opportunities exist for occupational therapy collaboration in primary health care and primary care education to improve care for adults with ASD.

Importance. Sensory symptoms in people with autism spectrum disorder (ASD) are commonly reported by researchers. However, an often overlooked sensory aspect of ASD is sensory discrimination in general, and somatosensory discrimination in particular.

Objective. To examine what has and what has not yet been learned concerning the somatosensory discrimination abilities of people with ASD and to reveal gaps warranting further research.

Design. Scoping review of clinical studies published 1995–2017 located through searches of PsycNET, PubMed, ERIC, and Google Scholar. Inclusion criteria were English-language peer-reviewed studies with (1) participants diagnosed with ASD, (2) a specific somatosensory discrimination measure, and (3) a comparison group. No age or intellectual exclusion criteria were established; studies were excluded if they were theoretical or descriptive, did not incorporate a control group, focused only on neurology or genetics, or used simple threshold detection measures or somatosensory measures integrated with other measures. The final search yielded 12 comparative articles discussing tactile and proprioceptive discrimination in people with ASD.

Results. Overall, most results showed atypical somatosensory discrimination in people with ASD, especially among young children. The relationship between sensory discrimination abilities and other sensory symptoms and ASD symptoms is briefly discussed.

Conclusions and Relevance. Heterogeneous findings concerning somatosensory discrimination in people with ASD shed light on underlying mechanisms of these disorders and can contribute to improvement of occupational therapy intervention for this population.

What This Article Adds. The occupational therapy evaluation of people with ASD can benefit from addressing somatosensory discrimination and its contribution to other clinical symptoms. This type of assessment can help improve intervention strategies for people with ASD by promoting a focus on the effect of discrimination deficits on daily function.

As a result of various barriers, several pediatric populations are at risk for poor oral health, including children with disabilities and children from under-represented populations, such as Latinos. To this end, this study aimed to better understand the factors that affect the oral health experiences of 32 Latino parents/caregivers from 18 families (n = 8 with a typically developing child and n = 10 with a child with Autism). Using a qualitative descriptive methodology, each family was interviewed twice. Interviews were audio-recorded, transcribed verbatim, and coded thematically to identify the individual, social, systemic, and culturally rooted factors contributing to oral health disparities in the families. The three themes that arose were “Why would I want to start trouble?”: Latino parents’ dissatisfaction with dental treatments, costs, and fear of the dentist and health care providers because of their ethnic minority status as key factors inhibiting receipt of dental care; “We have to put our children first”: prioritizing the oral care activities of their children over their own individual oral care needs; and “We always keep baking soda around”: familial and cultural influences on oral care habits. Understanding the oral health beliefs and experiences of Latino parents and caregivers of children with and without autism is critical for developing targeted prevention and intervention programs and reducing oral health disparities.

Keywords: Latinos; oral care; health disparities; children; culture; autism spectrum disorder

Background. Although considered an advanced area of practice, there has been insufficient standardization in clinical training and preparedness for occupational therapists (OTs), physical therapists (PTs), and speech-language pathologists (SLPs) practicing in the neonatal intensive care unit (NICU). The first step in developing a neonatal therapy certification process was to conduct a practice analysis.

Purpose. To describe: 1) the collection of OTs, PTs, and SLPs working in NICUs, 2) educational and professional preparation to practice in the NICU, and 3) interest in neonatal therapy national certification.

Methods. An online survey of 468 neonatal therapists was completed in 2015–2016.

Results. There were 208 (47%) participants who were OTs, 140 (32%) PTs, and 94 (21%) SLPs. Among respondents, 187 (50%) neonatal therapists had a clinical doctorate, and 143 (40%) therapists practiced for > 5 years prior to entering NICU practice. There were 299 (88%) therapists who believed oversight and accountability in the NICU are highly important, and 329 (98%) therapists were interested in a neonatal therapy certification program.

Conclusions. Advanced training and skills of neonatal therapists are vital to ensure safe, effective and evidence-based practice. Insufficient standardization in training and variable adherence to education and training guidelines provided credibility for the creation of a neonatal therapy national certification process, which has now been implemented.

Anxiety disorders are prevalent and significantly impact young children and their families. One hypothesized risk factor for anxiety is heightened responses to sensory input. Few studies have explored this hypothesis prospectively. This study had two goals: (1) examine whether sensory over-responsivity is predictive of the development of anxiety in a large prospective sample of children, and (2) identify whether anxiety mediates the relationship between sensory over-responsivity and behavioral challenges. Children's sensory and anxiety symptoms were assessed in a community sample of 917 at 2-5 and again in 191 of these children at 6 years old. Parents also reported on a number of additional behavioral challenges previously found to be associated with both sensory over-responsivity and anxiety separately: irritability, food selectivity, sleep problems, and gastrointestinal problems. Forty three percent of preschool children with sensory over-responsivity also had a concurrent impairing anxiety disorder. Preschool sensory over-responsivity symptoms significantly and positively predicted anxiety symptoms at age six. This relationship was both specific and unidirectional. Finally, school-age anxiety symptoms mediated the relationship between preschool sensory over-responsivity symptoms and both irritability and sleep problems at school-age. These results suggest sensory over-responsivity is a risk factor for anxiety disorders. Furthermore, children who have symptoms of sensory over-responsivity as preschoolers have higher levels of anxiety symptoms at school-age, which in turn is associated with increased levels of school-age behavioral challenges.

IMPORTANCE: A recent reanalysis of data from the Well Elderly (WE) 2 study purportedly indicated that the intervention did not achieve clinically meaningful or statistically significant effects; this article addresses these criticisms.

OBJECTIVE: To contextualize the WE 2 study as targeting a nonclinical population and demonstrate that the intervention produced substantively important, statistically significant effects.

DESIGN: Secondary analysis of WE 2 intervention-based pre–post change scores.

SETTING: The original trial occurred primarily in senior centers and senior housing facilities in greater Los Angeles.

PARTICIPANTS: Independent-living older adults (N = 324) who were assessed before and after intervention.

INTERVENTION: The WE intervention, a version of the Lifestyle Redesign® (LR) approach, was administered by occupational therapists over 6 mo by means of group and individual sessions.

OUTCOMES AND MEASURES: The 36-item Short Form Health Survey, the Life Satisfaction Index–Z, and the Center for Epidemiologic Studies Depression Scale.

RESULTS: The WE intervention was associated with statistically significant improvement on 10 of 12 outcome variables that were examined.

CONCLUSIONS AND RELEVANCE: Because the WE intervention was hypothesized to reduce age-related decline and followed a population-oriented approach, the expectation that average results would be clinically meaningful was inappropriate. The intervention produced positive effects across a wide array of outcome domains. In settings in which clinical meaningfulness is an appropriate index of intervention outcomes, evidence suggests that LR produces effects that are clinically meaningful. As an evidence-based intervention, LR should be considered useful both in population-oriented contexts and in addressing discrete health conditions.

WHAT THIS ARTICLE ADDS: Valid analyses demonstrate that the positive experimental effects of the WE 2 study are, in fact, genuine and cost-effective, and LR in clinically oriented contexts has produced statistically significant, clinically meaningful results. Clearly and accurately representing the evidence base of occupational therapy in prevention and chronic care is of critical importance to advance the field as a whole.

Importance. Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy’s feasibility and efficacy in primary care settings.

Objective. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)–occupational therapy (LR–OT) diabetes management intervention in a primary care clinic.

Design. Patients were randomized to be offered LR–OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods.

Setting. Safety-net primary care clinic.

Participants. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18–75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%.

Intervention. Eight 1-hr individual sessions of LR–OT focused on diabetes management.

Outcomes and Measures. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR–OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations.

Results. Seventy-three patients were offered LR–OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation.

Conclusions and Relevance. LR–OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care.

What This Article Adds. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy’s effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Background. Volunteers can provide staff-directed sensory inputs to infants hospitalized in the NICU, but research on volunteer programs is limited.

Purpose. To evaluate the feasibility of a developmental care partner (DCP) program in a level III NICU and determine its relationship with provider burnout and infant infection rates.

Methods. DCPs were trained to provide sensory input to infants, based on the behavioral cues observed by the occupational therapists and nursing staff, in medically stable infants. Feasibility was assessed by documenting the process of training and utilizing volunteers, as well as tracking duration and frequency of DCP visits. Staff burnout measures were assessed using the Maslach Burnout Inventory Human Services Survey (MBI-HSS) before and after implementation. Infant infection rates before and after the introduction of volunteers were compared.

Results. Seventy-two volunteers were interested, and 25 (35%) completed the DCP competencies and provided sensory exposures to 54 neonates, who were visited an average of 8 times (range 1-15). Twelve (48%) DCPs did once-per-week visits, and 9 (36%) did at least 50 contact hours. MBI-HSS scores for staff emotional exhaustion (P < .001) and depersonalization (P < .006) were lower after DCP implementation. There were no differences in infant infection rates before and after DCP implementation (Fisher exact P = 1.000).

Implications for Practice. Volunteer-based DCP programs may be feasible to implement in community hospitals and could help reduce staff emotional exhaustion and depersonalization without increasing the incidence of infant infections.

Implications for Research. Future research on NICU volunteer programs with larger sample sizes and different infant populations is warranted.

Reilly’s (1962) now deeply cherished statement that “man, through the use of his hands, as they are energized by mind and will, can influence the state of his own health” (p. 1) was followed a few years later with a question to current and future occupational therapy practitioners. In 1966, Reilly asked how the profession would respond to the challenges of an expanding knowledge base, accelerating health care costs, and escalating regulatory burden. Visionary Wilma West, a contemporary of Reilly’s, expanded on these themes by focusing on ways occupational therapy practitioners could leverage the breadth and depth of their practice to confront these challenges. These issues are now paramount in the primary care arena. An expanding body of literature, including the articles in a special section in this issue of the American Journal of Occupational Therapy, supports occupational therapy’s role as a vital part of the solution to contemporary health care challenges. Occupational therapy practitioners are educationally prepared and successfully poised through policy to engage in evidence-based practice in the primary care environment.

School-based occupational therapists are well-equipped to prepare adolescents to transition from the education system to work and live in their communities, but they report challenges in securing their place on post-secondary transition planning teams. We argue that occupational therapists’ efforts to advocate for their role in post-secondary transition could be strengthened by a deeper engagement with what is considered “best practice” in transition planning: improving students’ ability and opportunity to exercise self-determination. In this commentary, we review the self-determination evidence-base; identify congruence between the underlying philosophies of self-determination and occupational therapy; and highlight gaps in existing self-determination models that occupational therapists are uniquely posed to fill by focusing on self-determination as they support transition age students.

Keywords. Self-determination, transition, post-secondary, adolescent.

Urinary dysfunction is commonly reported in primary care contexts. A shortage of primary care providers is affecting access to relevant services. Occupational therapy practitioners work in primary care settings and typically address urinary dysfunction in an outpatient context. Evidence regarding the delivery of occupational therapy interventions for urinary dysfunction in primary care has been limited. In this study, 3 women received 9–14 occupational therapy sessions in a primary care setting to address urinary symptoms. Plan-of-care duration, assessments, and urinary dysfunction interventions were individualized to accommodate personal and environmental factors. Across all case-series participants, Canadian Occupational Performance Measure scores demonstrated clinically significant improvement. Mixed results were found for SF–36 health-related quality-of-life subscale scores. Assessment scores specific to urinary dysfunction decreased, indicating reduced symptom severity and functional impact. This article provides preliminary evidence regarding the feasibility of occupational therapy interventions addressing urinary dysfunction in primary care settings.

Importance. Geriatric, interprofessional primary care training for occupational therapy students is needed.

Objective. To measure occupational therapy student–reported knowledge, attitudes, and skills after participation in interprofessional geriatric educational programs.

Design. Prospective, observational study with pre- and posttests for the three programs.

Participants. Fifty-nine entry-level and postprofessional occupational therapy master’s students.

Outcomes and Measures. Self-reported familiarity with other professionals’ roles, perceptions of interprofessional training, capabilities to conduct assessments, and attitudes of older adults.

Results. Students of the three programs (Interprofessional Geriatrics Curriculum [IPGC], Student Senior Partnership Program [SSPP], and Geriatric Assessment Program [GAP]) reported different improvements in familiarity of roles, capabilities of assessment, and Geriatric Attitudes Scale (GAS) scores. For example, IPGC and SSPP students had changes in total GAS score (3.91–4.08, p = .002, and 3.84–3.99, p = .003, respectively), but no change was found for GAP students (3.85–3.91, p = .523).

Conclusions and Relevance. More structured interprofessional education with older adults appeared to help prepare occupational therapy students to work on geriatric interprofessional teams in primary care.

What This Article Adds. This article expands on growing evidence to support occupational therapy’s role in primary care by addressing the need to train future generations to work on interprofessional geriatric primary care teams.

Introduction. There is evidence to support the use of positive sensory exposures (music, touch, skin-to-skin) with preterm infants in the neonatal intensive care unit (NICU), but strategies to improve their consistent use are lacking. The Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed to promote consistent, age-appropriate, responsive, and evidence-based positive sensory exposures for the preterm infant every day of NICU hospitalization.

Methods. A systematic and rigorous process of development of the SENSE program included an integrative review of evidence on sensory exposures in the NICU, stakeholder feedback, expert opinion, and focus groups.

Results. SENSE implementation materials consist of parent education materials, tailored doses of sensory exposures for each postmenstrual age, an infant assessment of tolerance, bedside logs and implementation considerations for integrating the SENSE program into the NICU.

Discussion. Research is needed to evaluate the SENSE program as an implementation strategy and to assess its impact on parent and infant outcomes.

IMPORTANCE: Children with autism spectrum disorder (ASD) and other developmental disabilities (DD) commonly display unusual responses to sensory input. Previous work has suggested concurrent associations linking sensory features with aspects of family functioning, including activity participation and caregiver strain. What is unknown, however, is the extent to which sensory features affect family functioning over time, as well as the influence of received services on these relationships.

OBJECTIVE: To assess hypothesized longitudinal associations between sensory features and family functioning and examine interactions by group and service usage (i.e., educational and therapy services).

DESIGN: Multigroup longitudinal observational study.

SETTING: Community.

PARTICIPANTS: A volunteer sample of 81 children (50 with ASD, 31 with DD; 76% male), ages 2-12 yr, and their caregivers participated in assessments at two points, 3.3 yr apart on average.

OUTCOMES AND MEASURES: Key measures included the Sensory Experiences Questionnaire, Sensory Profile, Sensory Processing Assessment for Young Children, Tactile Defensiveness and Discrimination Test-Revised, Caregiver Strain Questionnaire, and Home and Community Activities Scale. We also measured the amount of time children received educational and therapy services.

RESULTS: Regression analyses confirmed long-term associations linking sensory features with aspects of activity participation and caregiver strain in this population; group and service usage interactions were also identified.

CONCLUSIONS AND RELEVANCE: Sensory features can affect the everyday experiences of both children and caregivers. It is important for practitioners to understand the potentially enduring effects of children's sensory features on family functioning so as to begin to identify supportive interventions with more optimal long-term effects.

Introduction. Kinesio tape is an alternative non-surgical treatment approach for addressing symptoms of carpal tunnel syndrome. The purpose of the study was to investigate individuals’ experiences with the dorsal application of Kinesio tape for carpal tunnel syndrome management and its impact on pain and function.

Method. The study design was a limited phenomenological design study embedded in a randomized controlled trial. Daily symptom journals and semi-structured interviews were completed with 15 participants who were purposefully recruited and randomly allocated to the intervention group of a single blind randomized controlled trial. Kinesio tape was applied dorsally on the affected forearm, wrist, and digits for a duration of two weeks. Transcribed data were analyzed using descriptive coding, coding schemes, and frequency charts to identify emerging themes.

Results. Three themes emerged: Kinesio tape was positively perceived to be effective on decreasing pain, increasing self-efficacy, and improving daily functional performance on tasks previously avoided or abandoned. The most common problem identified was maintaining Kinesio tape on the hands and fingers, to which the majority of participants expressed a desire to learn application.

Discussion. Results of this study suggest that Kinesio tape is a positively perceived intervention for decreasing pain and increasing function for individuals with carpal tunnel syndrome and warrants further consideration as an alternative conservative intervention for carpal tunnel syndrome.

Keywords. Carpal tunnel syndrome, Kinesio tape, qualitative, functional performance

Musculoskeletal sonography is being widely used for evaluation of structures within the carpal tunnel. While some anatomical variants, such as bifurcated median nerves and persistent median arteries, have been well documented, limited literature describes the sonographic appearance of aberrant muscle bellies within the carpal tunnel. Multiple examples of the sonographic appearance of flexor digitorum superficialis and lumbrical muscle bellies extending into the carpal tunnel are provided. Techniques for static image acquisition and analysis are discussed, and the use of dynamic imaging to confirm which specific muscle belly is involved is described. Knowledge of the potential presence of muscle bellies in these images and ability to identify these structures is vital to avoid misclassification or misdiagnosis as abnormal pathology. The case examples are situated among current published evidence regarding how such anomalies may be related to the development of pathologies, such as carpal tunnel syndrome.

Keywords. carpal tunnel, aberrant muscle, musculoskeletal sonography