Masculine role variables and outcomes among men with spinal cord injury

Purpose. Few studies have considered the impact of masculine role variables on outcome and adjustment to SCI among men. The present study examined the relations among SCI, views of masculinity, psychological adjustment, and rehabilitation outcomes among men with SCI.

Method. The sample included 20 men with SCI receiving inpatient rehabilitation, with a mean age of 45 years. Data included demographic variables as well as Conformity to Masculine Norms Inventory (CMNI), Gender Role Conflict Scale (GRCS), Functional Independence Measure (FIM), and Satisfaction with Life Scale ratings, and change in marital status.

Results. The findings revealed that satisfaction with life was positively related to scores on the CMNI Violence scale, FIM change from admission to discharge was positively related to the CMNI Emotional Control scale and negatively related to the CMNI Dominance scale. Change in marital status was inversely related to the CMNI Emotional Control and Primacy of Work scales and the GRCS Restricted Emotionality and Power, Success, and Competition scales.

Conclusions. The findings show that certain aspects of the traditional masculine role (i.e., ability to modulate strong emotions) may be adaptive in the rehabilitation process, whereas other aspects (i.e., a dominant interpersonal style) may present a barrier to effective rehabilitation.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose. To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method. One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results. The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions. Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

The system for medical rehabilitation in Croatia

Purpose. To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.

Methods. Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.

Results. The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.

Conclusion. Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.     

Rehabilitation following hip fracture surgery: a comparative study of females and males

Purpose: To compare patient, fracture and rehabilitation variables between male and female patients during the rehabilitation period immediately following surgical repair of hip fracture (HF).

Methods: A prospective cohort study was conducted in a rehabilitation geriatric ward in a tertiary university hospital in southern Israel. The study group consisted of 808 elderly patients, 65 years of age or older, selected for hospitalized rehabilitation following surgery for HF. The measurements included functional studies by the Functional Independence Measure (FIM™) scale, mental status by Folstein Minimental Test and Clock Drawing Test, Geriatric Depression Screening Scale (GDS), demographic and social parameters, laboratory tests, length of rehabilitation, complications and mortality during rehabilitation.

Results: Six hundred and fourteen patients (76%) were women and 194 (24%) were men. The mean age ( ± SD) of the women was 78.4 ± 7.1 years and of the men was 77.8 ± 7.5 (NS). There were no significant differences between women and men in terms of the anatomic site of the fracture or the type of surgery, the complication rate or mortality during rehabilitation, the length of time needed for rehabilitation, the framework to which the patient was discharged, FIM values before the HF, on admission and at the end of rehabilitation, or the difference between FIM scores at these last two points in time.

Conclusions: In selected elderly patients with HF gender does not affect variables associated with hip fracture, the rehabilitation process immediately following the fracture, or the results of rehabilitation.     

Performance of activities of daily living in multiple sclerosis

Purpose: To assess the performance of activities of daily living (ADL) in individuals with moderate to severe multiple sclerosis (MS).

Method: A total of 12 men and 32 women with MS (Expanded Disability Status Scale, EDSS, 6.0 - 8.5) were studied. The performance of personal ADL (P-ADL) and instrumental ADL (I-ADL) was assessed with the Functional Independence Measure (FIM) and the Assessment of Motor and Process Skills (AMPS).

Results: Twenty-four of the 44 individuals were rated dependent in P-ADL by the FIM motor score, mainly due to limitations in some areas of self-care and in transfers and locomotion. Only three individuals were rated dependent by the FIM cognitive score, indicating no or little cognitive disability. Two thirds of the individuals who were rated independent/modified independent in P-ADL by the FIM were rated dependent in I-ADL by the AMPS. Only the FIM motor score was significantly related to the EDSS score, indicating that ADL performance and disease severity is weakly related.

Conclusions: Moderate to severe MS reduces the ability to perform both P-ADL and I-ADL. An individual with MS can be independent in P-ADL but still unable to perform I-ADL satisfactorily. Assessments of both P-ADL and I-ADL are advocated to evaluate ADL performance in order to implement appropriate management strategies for individuals with MS.     

The work of rehabilitation

Purpose.?To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation.

Method.?A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000?–?2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores.

Results.?Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM.

Conclusions.?The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.     

Long-term outcomes after moderate to severe traumatic brain injury

Objective: This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI).

Design: Retrospective cohort study.

Setting and subjects: We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury.

Main outcome measures: Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services.

Results: Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living.

Conclusion: Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.     

Rehabilitation medicine in countries of Central/Eastern Europe

Purpose. To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges.

Methods. Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries.

Results. CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content.

Conclusion. The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.     

Simulation-based executive cognitive assessment and rehabilitation after traumatic frontal lobe injury: a case report

Purpose. To investigate whether identifying specific deficits after brain injury can lead to a more focused and potentially effective cognitive rehabilitation technology.

Method. Cognitive simulation assessment was undertaken in a 47-year-old man with trauma-related prefrontal damage and persisting occupational and cognitive-behavioral difficulties at 15 months post brain injury.

Results. Results revealed significant difficulties in measured levels of activity, initiative, information utilization, response flexibility, and effective decision-making strategies which accorded well with his real-life complaints despite normal neuropsychological test scores. This profile of findings was then used to design a two-stage intervention program. The first stage focused on participant education and awareness about his simulation-based problem solving difficulties. In the second stage specific goals were formulated to improve problem solving impairments that were then the target of weekly training sessions using pertinent decision-making and problem-solving vignettes. A parallel version of the cognitive simulation assessment was undertaken post-cognitive training (3 months after initial assessment) and revealed significant improvements in targeted executive cognitive-behavioral areas.

Conclusion. Results of this cognitive rehabilitation probe supported the feasibility and validity of undertaking a cognitive simulation approach to identify residual executive function deficits after traumatic brain injury, even with a normal neuropsychological test profile. Further studies are needed to establish the reliability, generalizability and maintenance of such gains.     

Effects on work resumption of a co-operation project in vocational rehabilitation. Systematic, multi-professional, client-centred and solution-oriented co-operation

Purpose. The present aim was to evaluate the effect of systematic multi-professional co-ordinated rehabilitation (the Stockholm Co-operation Project) on the number of days' sick leave during the first and second half-years after the rehabilitation co-ordination period, compared to the year before. Another aim was to evaluate the economic effects at national level.

Method. A matched-pairs design was used. The study group was based on 64 rehabilitees employed by a public employer in Stockholm, who took part in a systematic multi-professional co-operation project. To obtain pairs, the 64 individuals were individually matched with 64 people who received conventionally organised rehabilitation. Thus, there were 128 subjects altogether.

Results. The study group had substantially less sick leave days per month than the comparison group during the second half-year after the rehabilitation co-ordination period. The effect was even greater in a subgroup with more previous sick leave. During the first half-year after the intervention the comparison group had relatively more sick leave. No effect was found for a subgroup with less previous sick leave. The economic benefit of the intervention was estimated to €1,278 per month and person based on the whole group, and to €2,405 per month and person based on those with more sick leave.

Conclusions. People who undergo co-ordinated rehabilitation have more working days after the intervention period than those with conventional rehabilitation. This way for rehabilitation actors to co-operate gives better outcomes for rehabilitation cases with long previous sick leave, but not for cases with less previous sick leave. It also generates economic gains at several levels.     

Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: how guidelines change management

Purpose. To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).

Method. A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.

Results. Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.

Conclusions. Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.     

The QE Health Scale (QEHS): assessment of the clinical reliability and validity of a spiritually based holistic health measure

Purpose. To assess the clinical reliability and validity of a holistic health measure, the QE Health Scale (QEHS), for use with people with physical disabilities.

Method. A test-retest design saw the QEHS administered and compared with established measures of health at admission and discharge from three-week inpatient rehabilitation programmes. Data was analysed by factor and correlation analysis. Clinician-reported credibility and usefulness of the theoretical basis of the QEHS, the QEHS itself, and Patient Profiles derived from the QEHS were also used to evaluate clinical validity.

Results. The QEHS was judged to possess satisfactory reliability and validity.

Conclusion. The QEHS is a clinically reliable, valid, credible and useful holistic health instrument to facilitate client-centred therapeutic interventions, inform decision-making and evaluate outcomes for people with physical disabilities.     

Recovery from unilateral neglect after right-hemisphere stroke

Purpose: To show the recovery process for different forms of unilateral neglect (UN)—including personal neglect and neglect of far space—in relationship to impairment, disability, cognition and mood.

Method: Patients were tested at 2 - 4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

Results: Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

Conclusions: For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.     

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

Purpose. To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

Method. This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7-24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

Results. Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

Conclusions. The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.     

The value of the Rehabilitation Activities Profile (RAP) as a quality sub-system in rehabilitation medicine

Purpose: To determine whether interdisciplinary team care, using the Rehabilitation Activities Profile (RAP) as a team tool, results in a better rehabilitation outcome.

Method: A multilevel prospective cohort study, with a controlled before and after design. Eighteen rehabilitation teams in eight rehabilitation centres in the Netherlands and Belgium participated. Based on the level of implementation of the RAP, we compared three study groups. Consecutive adult patients (n = 933) with stroke, amputation of the lower limb, spinal cord injury, multiple sclerosis, or other neuromuscular disorders, were followed during inpatient or outpatient rehabilitation. Main outcome measures were Barthel Index, RAP-CPM (sum score of the domains communication, personal care and mobility), Nottingham Health Profile (NHP), length of rehabilitation (LOR) and discharge destination (home vs elsewhere).

Results: Overall results show that scores on the Barthel Index, the RAP-CPM and the NHP improved, on average, by 18.4%, 12.7%, and 6.7%, respectively. However, treatment from a rehabilitation team that uses the RAP was associated with a significantly lower Barthel score, and small, non-significant effects on the RAP-CPM and the NHP. Partial use of the RAP resulted in non-significant, lower scores on these measures. With respect to discharge destination and LOR, there were also no significant differences between the three study groups, with the exception of a shorter outpatient rehabilitation period for the group in which partial use was made of the RAP.

Conclusion: The RAP, at the current level of implementation, does not improve rehabilitation outcome.     

Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

Purpose: The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study.

Method: Twenty-seven inpatients following stroke (mean age = 67 years, range = 40 - 80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with 'Upper Arm Function', 'Hand Movements', and 'Advanced Hand Activities' items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS.

Results: All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbach's alpha of 0.83 which did not benefit from removal of any items.

Conclusions: The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.     

An evaluation of aftercare following discharge from a specialist in-patient rehabilitation service

Purpose: To evaluate the aftercare of patients discharged from specialist rehabilitation unit with respect to use of equipment and follow-up by therapy and care services and to assess change in dependency and care needs.

Design: Cross-sectional survey of a consecutive cohort of patients discharged from a regional rehabilitation unit with reference to the British Society of Rehabilitation Medicine (BSRM) standards for rehabilitation services.

Subjects and methodology: Fifty-three subjects with neurological disability were discharged during a 15-month period. Structured interviews conducted by telephone with the patient (n = 22) or carer (n = 31) between 8 and 21 (mean 15) months after discharge. Dependency and care needs were assessed using the Northwick Park Dependency Score (NPDS) and Care Needs Assessment (NPCNA)

Results: Approximately half the patients improved in dependency and care needs between discharge and follow-up, but a quarter deteriorated. Fifty-one (96%) were referred for continuing therapy of which 39% expressed dissatisfaction. There was a significant relationship between inadequate therapy follow-up and increased dependency (Chi Squared p = 0.002). However, where care packages were revised downwards this generally reflected improvement in independence and therefore reduced need. Fourteen (26%) discontinued use of equipment early after discharge since they found it unacceptable or unhelpful. Seventeen (38%) of this population experienced late seizures.

Conclusions: Specialist rehabilitation in this group of severely disabled brain injured patients with complex needs can result in sustained improvement of function with resultant reduced care needs. However, appropriately skilled community-based services are required to maintain and build on the benefits, and are currently lacking in many districts. In particular, psychological support was notably absent. A possible relationship between late onset seizures and the use of anti-depressant medication requires further exploration, which is currently underway.     

Reading to stroke unit patients: perceived impact and potential of an innovative arts based therapy

Objective. This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.

Setting. The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.

Design. Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.

Intervention. The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.

Results. Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.

Conclusion. This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.     

A study of the physical rehabilitation and psychological state of patients who sustained limb loss as a result of terrorist activity in Northern Ireland 1969-2003

Objective. To benchmark the psychological state and physical rehabilitation of patients who have sustained limb loss as a result of terrorist activity in Northern Ireland and to determine their satisfaction with the period of primary prosthetic rehabilitation and the artificial limb.

Method. All patients who sustained limb loss as a result of the Troubles and were referred to our rehabilitation centre were sent a questionnaire. The main outcome measures were the SIGAM mobility grades, the General Health Questionnaire (GHQ12) and three screening questions for Post Traumatic Stress Disorder (PTSD).

Results. Out of a 66% response rate, 52 (69%) patients felt that the period of primary prosthetic rehabilitation was adequate; 32 (54%) lower limb amputees graded themselves SIGAM C or D; 45 (60%) patients stated that they were still having significant stump pain. Significant stump pain was associated with poorer mobility. Nine (56%) upper limb amputees used their prosthetic limb in a functional way; 33 (44%) patients showed “psychiatric caseness” on the GHQ 12 and 50 (67%) had symptoms of PTSD.

Conclusions. Most patients felt that the period of physical rehabilitation had been adequate; those who did not were more likely to be having ongoing psychological problems. A high percentage of patients continue to have psychological problems and stump pain.     

Perceptions of persons with multiple sclerosis on cognitive changes and their impact on daily life

Purpose. Cognitive changes occur in over 50% of persons diagnosed with multiple sclerosis (MS). Although previous research has provided information of the nature and severity of cognitive changes among persons with MS, it has offered relatively limited insight on the impact of these changes on levels of functioning and disability. The purpose of this study was to explore the impact of cognitive changes on the lives of four individuals with MS with different life roles (worker, parent, retired older adult).

Method. Qualitative methodologies were used in the study and included multiple open-ended interviews with the study participants and the completion of Cognitive Experience Forms in between interviews. In addition, the Perceived Deficits Questionnaire and a demographics form were administered. Thematic analysis was used to analyse the study data.

Results. Participants described the types of cognitive changes they are experiencing and how these changes affect their ability to participate and engage in desired activities and maintain their primary roles. Participants also talked about how cognitive changes affect their quality of life.

Conclusions. This study points to the complexity of cognitive changes and highlight the importance of addressing these changes in rehabilitation.