Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence

Macciocchi S, Seel RT, Thompson N, Byams R, Bowman B. Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence.

Objectives

To examine prospectively the incidence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI) and to describe a TBI assessment process for SCI rehabilitation professionals.

Design

A prospective, cohort design to collect and analyze clinical variables relevant for diagnosing co-occurring TBI.

Setting

An urban, single-center National Institute of Disability and Rehabilitation Research Model Spinal Cord Injury System in the Southeastern United States.

Participants

People (N=198) who met inclusion criteria and provided consent within an 18-month recruitment window.

Interventions

Not applicable.

Main Outcome Measure

FIM cognitive scale.

Results

Based on participants' presence and duration of posttraumatic amnesia, initial Glasgow Coma Scale total score, and presence of cerebral lesion documented by neuroimaging, 60% of our traumatic SCI sample also sustained a TBI (n=118). Most co-occurring TBIs were mild (34%). Co-occurring mild complicated (10%), moderate (6%), and severe TBI (10%) were less common but still occurred in a significant percentage (26%) of persons with traumatic SCI. Persons with traumatic SCI who were injured in motor vehicle collisions and falls were more likely to sustain a co-occurring TBI. Cervical level traumatic SCI was associated with greater rates of TBI but not more severe injuries. Tree analyses established a practical algorithm for classifying TBI severity associated with traumatic SCI. Analysis of variance established criterion validity for the algorithm's TBI severity classifications.

Conclusions

Findings from our prospective study provide strong support that TBI is a common co-occurring injury with traumatic SCI. Incomplete acute care medical record documentation of TBI in the traumatic SCI population remains a considerable issue, and there is a significant need to educate emergency department and acute care personnel on the TBI clinical data needs of acute rehabilitation providers. A systematic algorithm for reviewing acute care medical records can yield valid estimates of TBI severity in the traumatic SCI population.     

Mean flow velocity in the middle cerebral artery is associated with rehabilitation success in ischemic stroke patients

Treger I, Aidinof L, Lutsky L, Kalichman L. Mean flow velocity in the middle cerebral artery is associated with rehabilitation success in ischemic stroke patients.

Objective

To evaluate the association between mean flow velocity (MFV) in the middle cerebral artery (MCA) measured by using transcranial Doppler (TCD) and functional and neurologic impairment change during rehabilitation after acute stroke.

Design

Cross-sectional observational study.

Setting

Acute neurologic rehabilitation department.

Participants

Consecutive patients (N=67; 53 men, 14 women; mean ± SD age, 61.54±8.92y) referred to the rehabilitation center during the first 6 months of 2006 for a first ischemic stroke in the MCA area.

Interventions

Not applicable.

Main Outcome Measures

All subjects were evaluated on admission and at discharge by using the National Institutes of Health Stroke Scale (NIHSS) and the FIM. TCD measurements of MFV of the ipsilateral and contralateral MCA were performed on admission (during the first 20 days after stroke) and a few days before discharge.

Results

Contralateral MFV at admission was associated significantly with all indexes of functional rehabilitation success (FIM score at discharge [β=.169; P=.010], change in FIM score [β=.554; P=.010], relative improvement in FIM score [β=.783; P=.003]). No significant association was found between indexes of NIHSS change and ipsilateral or contralateral MFV.

Conclusions

Ipsilateral or contralateral MFV measured at admission did not change during the 2-month rehabilitation period. Our data showed a significant association between blood flow velocity in the contralateral MCA and functional rehabilitation parameters of patients after first ischemic stroke in the MCA area.     

Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome

Mazzini L, Campini R, Angelino E, Rognone F, Pastore I, Oliveri G. Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil 2003;84:1637-41.

Objectives

To detect the clinical and radiologic characteristics of posttraumatic hydrocephalus (PTH), to define its prognostic value, and to assess the effects of shunt surgery.

Design

Correlational study on a prospective cohort.

Setting

Brain injury rehabilitation center.

Participants

One hundred forty patients with severe traumatic brain injury (TBI) referred to an inpatient intensive rehabilitation unit of primary care in a university-based system.

Interventions

Not applicable.

Main outcome measures

The Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), FIM™ instrument, and Neurobehavioural Rating Scale (NRS), as well as single-photon emission computed tomography (SPECT) and magnetic resonance imaging.

Results

PTH was found in 45% of patients. Risk factors for PTH were as follows: age (P<.04), duration of coma (P<.0001), and decompressive craniectomy (P<.0001). PTH correlated with the degree of hypoperfusion in the temporal lobes (P<.001). Patients who showed clinical deterioration improved after surgery. PTH correlated significantly with GOS, DRS, FIM, and NRS (P<.0001) 1 year after the trauma, and it influenced the appearance of posttraumatic epilepsy (P<.02).

Conclusions

PTH concerns about 50% of patients with severe TBI. It influences functional and behavioral outcome and the appearance of posttraumatic epilepsy. The selection of patients for surgery can be defined principally on a clinical basis. SPECT may be helpful for differentiating ventricular enlargement due to cortical atrophy and hydrocephalus.     

Rehabilitation Outcomes in a Population of Nonagenarians and Younger Seniors With Hip Fracture, Heart Failure, or Cerebral Vascular Accident

Conner D, Barnes C, Harrison-Felix C, Reznickova N. Rehabilitation outcomes in a population of nonagenarians and younger seniors with hip fracture, heart failure, or cerebral vascular accident.

Objectives

To compare rehabilitation characteristics and patient outcomes between nonagenarians and younger seniors with hip fracture (HFx), heart failure (HF), or cerebral vascular accident (CVA).

Design

Data only, retrospective cohort.

Setting

Seven skilled nursing facilities providing rehabilitation services to a managed care organization.

Participants

Subjects (N=2563; age, ≥65y) with HFx, HF, or CVA receiving rehabilitation services.

Interventions

Not applicable.

Main Outcome Measures

Patient and rehabilitation characteristics influencing FIM score at discharge and the proportion of patients discharged to the community were compared between nonagenarians and younger seniors with HFx, HF, or CVA.

Results

Patients with higher admission FIM scores were discharged with better function. Different patient characteristics were important for successful rehabilitation for different conditions and outcomes. Except for HFx, nonagenarians had admission and discharge characteristics similar to those of younger seniors, although fewer were discharged to the community. Nonagenarians and younger seniors with CVA were most similar for all measures.

Conclusions

Fewer nonagenarians were admitted from the community and fewer were discharged to the community, even if admitted from the community. Nonagenarians with HFx differed most strikingly from their younger counterparts in admission and discharge measures, as well as total discharge FIM score and discharge to the community. Nonagenarians and younger seniors with CVA were most similar for all measures. Our results suggest that a large proportion of the nonagenarian population can benefit from rehabilitation efforts for these 3 conditions; however, more rehabilitation resources may be required for some conditions to achieve similar outcomes.     

Impact of age on long-term recovery from traumatic brain injury

Marquez de la Plata CD, Hart T, Hammond FM, Frol AB, Hudak A, Harper CR, O'Neil-Pirozzi TM, Whyte J, Carlile M, Diaz-Arrastia R. Impact of age on long-term recovery from traumatic brain injury.

Objective

To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI).

Design

Longitudinal cohort study.

Setting

Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.

Participants

Subjects enrolled in the TBIMS national dataset.

Interventions

Not applicable.

Main Outcome Measures

Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended.

Results

Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (≥40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates.

Conclusions

This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.     

Electrical Stimulation Therapy Increases Rate of Healing of Pressure Ulcers in Community-Dwelling People With Spinal Cord Injury

Houghton PE, Campbell KE, Fraser CH, Harris C, Keast DH, Potter PJ, Hayes KC, Woodbury MG. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury.

Objective

To investigate whether electric stimulation therapy (EST) administered as part of a community-based, interdisciplinary wound care program accelerates healing of pressure ulcers in people with spinal cord injury (SCI).

Design

Single-blind, parallel-group, randomized, controlled, clinical trial.

Setting

Community-based home care setting, Ontario, Canada.

Participants

Adults (N=34; mean age ± SD, 51±14y) with SCI and stage II to IV pressure ulcers.

Interventions

Subjects were stratified based on wound severity and duration and randomly assigned to receive either a customized, community-based standard wound care (SWC) program that included pressure management or the wound care program plus high-voltage pulsed current applied to the wound bed (EST+SWC).

Main Outcome Measures

Wound healing measured by reduction in wound size and improvement in wound appearance at 3 months of treatment with EST+SWC or SWC.

Results

The percentage decrease in wound surface area (WSA) at the end of the intervention period was significantly greater in the EST+SWC group (mean ± SD, 70±25%) than in the SWC group (36±61%; P=.048). The proportion of stage III, IV, or X pressure ulcers improving by at least 50% WSA was significantly greater in the EST+SWC group than in the SWC group (P=.02). Wound appearance assessed using the photographic wound assessment tool was improved in wounds treated with EST+SWC but not SWC alone.

Conclusions

These results demonstrate that EST can stimulate healing of pressure ulcers of people with SCI. EST can be incorporated successfully into an interdisciplinary wound care program in the community.     

Predictors of Extended Rehabilitation Length of Stay After Traumatic Brain Injury

Arango-Lasprilla JC, Ketchum JM, Cifu D, Hammond F, Castillo C, Nicholls E, Watanabe T, Lequerica A, Deng X. Predictors of extended rehabilitation length of stay after traumatic brain injury.

Objective

To develop a prediction rule for acutely identifying patients at risk for extended rehabilitation length of stay (LOS) after traumatic brain injury (TBI) by using demographic and injury characteristics.

Design

Retrospective cohort study.

Setting

Traumatic Brain Injury Model Systems.

Participants

Sample of TBI survivors (N=7284) with injuries occurring between 1999 and 2009.

Interventions

Not applicable.

Main Outcome Measures

Extended rehabilitation LOS defined as 67 days or longer.

Results

A multivariable model was built containing FIM motor and cognitive scores at admission, preinjury level of education, cause of injury, punctate/petechial hemorrhage, acute-care LOS, and primary payor source. The model had good calibration, excellent discrimination (area under the receiver operating characteristic curve = .875), and validated well. Based on this model, a formula for determining the probability of extended rehabilitation LOS and a prediction rule that classifies patients with predicted probabilities greater than 4.9% as at risk for extended rehabilitation LOS were developed.

Conclusions

The current predictor model for TBI survivors who require extended inpatient rehabilitation may allow for enhanced rehabilitation team planning, improved patient and family education, and better use of health care resources. Cross-validation of this model with other TBI populations is recommended.     

Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

Berlowitz DR, Hoenig H, Cowper DC, Duncan PW, Vogel WB. Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

Objectives

To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures—the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)—in how well they predict these outcomes.

Design

Inception cohort of patients followed for 6 months.

Setting

Department of Veterans Affairs (VA) hospitals.

Participants

A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database.

Interventions

Not applicable.

Main Outcome Measures

Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score.

Results

During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R² values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R² of .111 for change in FIM score.

Conclusions

Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.     

Utility of Functional Status for Classifying Community Versus Institutional Discharges After Inpatient Rehabilitation for Stroke

Reistetter TA, Graham JE, Deutsch A, Granger CV, Markello S, Ottenbacher KJ. Utility of functional status for classifying community versus institutional discharges after inpatient rehabilitation for stroke.

Objective

To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke.

Design

Retrospective cross-sectional design.

Setting

Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation.

Participants

Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007.

Interventions

Not applicable.

Main Outcome Measure

Discharge FIM rating and discharge setting (community vs institutional).

Results

Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77).

Conclusions

Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings.     

Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions

Deutscher D, Horn SD, Smout RJ, DeJong G, Putman K. Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions.

Objective

To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions.

Design

Multicenter prospective observational cohort study of poststroke rehabilitation.

Setting

Six U.S. inpatient rehabilitation facilities.

Participants

Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104-107 for moderate strokes [n=397], CMGs 108-114 for severe strokes [n=335]).

Interventions

Not applicable.

Main Outcome Measure

Discharge Motor FIM.

Results

Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R²) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R² to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes.

Conclusions

After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke.     

Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation

Horn SD, Deutscher D, Smout RJ, DeJong G, Putman K. Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation.

Objective

To describe racial differences in patient characteristics, nontherapy ancillaries, physical therapy (PT), occupational therapy (OT), and functional outcomes at discharge in stroke rehabilitation.

Design

Multicenter prospective observational cohort study of poststroke rehabilitation.

Setting

Six U.S. inpatient rehabilitation facilities.

Participants

Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moderate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335).

Interventions

Not applicable.

Main Outcome Measure

FIM.

Results

Significant black-white differences in multiple patient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differences in unadjusted stroke rehabilitation outcomes were found.

Conclusions

Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians' choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes.     

Action Observation Treatment Improves Recovery of Postsurgical Orthopedic Patients: Evidence for a Top-Down Effect?

Bellelli G, Buccino G, Bernardini B, Padovani A, Trabucchi M. Action observation treatment improves recovery of postsurgical orthopedic patients: evidence for a top-down effect?

Objective

To assess whether action observation treatment (AOT) may also improve motor recovery in postsurgical orthopedic patients, in addition to conventional physiotherapy.

Design

Randomized controlled trial.

Setting

Department of rehabilitation.

Participants

Patients (N=60) admitted to our department postorthopedic surgery were randomly assigned to either a case (n=30) or control (n=30) group. Exclusion criteria were age 18 years or younger and 90 years or older, Mini-Mental State Examination score of 21 of 30 or lower, no ambulating order, advanced vision impairment, malignancy, pneumonia, or heart failure.

Interventions

All participants underwent conventional physiotherapy. In addition, patients in the case group were asked to observe video clips showing daily actions and to imitate them afterward. Patients in the control group were asked to observe video clips with no motor content and to execute the same actions as patients in the case group afterward. Participants were scored on functional scales at baseline and after treatment by a physician blinded to group assignment.

Main Outcomes Measures

Changes in FIM and Tinetti scale scores, and dependence on walking aids.

Results

At baseline, groups did not differ in clinical and functional scale scores. After treatment, patients in the case group scored better than patients in the control group (FIM total score, P=.02; FIM motor subscore, P=.001; Tinetti scale score, P=.04); patients in the case group were assigned more frequently to 1 crutch (P=.01).

Conclusions

In addition to conventional physiotherapy, AOT is effective in the rehabilitation of postsurgical orthopedic patients. The present results strongly support top-down effects of this treatment in motor recovery, even in nonneurologic patients.     

Interrater Reliability of Functional Status Scores for Patients Transferred From One Rehabilitation Setting to Another

Kohler F, Redmond H, Dickson H, Connolly C, Estell J. Interrater reliability of functional status scores for patients transferred from one rehabilitation setting to another.

Objective

To report the interrater reliability of FIM total score, FIM motor subscore, and FIM cognitive subscore from scoring that occurred in routine clinical practice in 2 closely linked inpatient rehabilitation services in Sydney, Australia.

Design

A natural-experiment blind clinical interrater reliability cohort study of the FIM across 2 rehabilitation units.

Setting

This study is set in 2 inpatient rehabilitation units immediately adjacent to each other in southwestern Sydney, New South Wales, Australia.

Participants

All patients (N=143) who were transferred between the 2 rehabilitation units between August 2006 and October 2007 were included in the study.

Intervention

Discharge FIMs were scored by the first unit and an admission FIM was scored independently by the second unit within a few days. The FIM scores were analyzed for agreement and systematic bias.

Main Outcome Measure

Intraclass correlation coefficients, kappa statistic, weighted kappa statistic, and Bland-Altman plots were used.

Results

There were 143 sets of scores identified. The range of differences between the 2 FIM totals was −32 to 50, between the FIM motor subscores was −22 to 43, and between the FIM cognitive subscores was −14 to 21. Bland-Altman plots demonstrated poor agreement. Few FIM totals were perfectly matched. The intraclass correlation coefficients ranged from .872 for the FIM total to .830 for the cognitive subscales. Values for kappa ranged from −.007 (FIM motor subscore) to .123 (FIM cognitive subscore). Values for weighted kappa ranged from .465 (FIM cognitive subscore) to .521 (FIM total).

Conclusions

There was no systematic scoring bias evident. Intraclass correlation coefficients were high, but tests of agreement demonstrated poor agreement. These findings have implications for the use of the FIM and any patient classification or funding system based on the FIM, especially if poor levels of agreement were found in the presence of all staff being FIM credentialed and standardization of methods of assessment. This study indicates that further investigation of agreement of both FIM totals and FIM item scores in the clinical setting is warranted.     

An exploratory analysis of functional staging using an item response theory approach

Tao W, Haley SM, Coster WJ, Ni P, Jette AM. An exploratory analysis of functional staging using an item response theory approach.

Objectives

To develop and explore the feasibility of a functional staging system (defined as the process of assigning subjects, according to predetermined standards, into a set of hierarchic levels with regard to their functioning performance in mobility, daily activities, and cognitive skills) based on item response theory (IRT) methods using short forms of the Activity Measure for Post-Acute Care (AM-PAC) and to compare the criterion validity and sensitivity of the IRT-based staging system to a non-IRT-based staging system developed for the FIM instrument.

Design

Prospective, longitudinal cohort study of patients interviewed at hospital discharge and 1, 6, and 12 months after inpatient rehabilitation.

Setting

Follow-up interviews conducted in patients' homes.

Participants

Convenience sample of 516 patients (47% men; sample mean age, 68.3y) at baseline (retention at the final follow-up, 65%) with neurologic, lower-extremity orthopedic, or complex medical conditions.

Interventions

Not applicable.

Main Outcome Measures

AM-PAC basic mobility, daily activity, and applied cognitive activity stages; FIM executive control, mobility, activities of daily living, and sphincter stages. Stages refer to the hierarchic levels assigned to patients' functioning performances.

Results

We were able to define IRT-based staging definitions and create meaningful cut scores based on the 3 AM-PAC short forms. The IRT stages correlated as well or better to the criterion items than the FIM stages. Both the IRT-based stages and the FIM stages were sensitive to changes throughout the 6-month follow-up period. The FIM stages were more sensitive in detecting changes between baseline and 1-month follow-up visits. The AM-PAC stages were more discriminant in the follow-up visits.

Conclusions

An IRT-based staging approach appeared feasible and effective in classifying patients throughout long-term follow-up. Although these stages were developed from short forms, this staging methodology could also be applied to improve the meaning of scores generated from IRT-based computerized adaptive testing in future work.     

Changes and determinants of life satisfaction after spinal cord injury: a cohort study in the Netherlands

van Koppenhagen CF, Post MW, van der Woude LH, de Witte LP, van Asbeck FW, de Groot S, van den Heuvel W, Lindeman E. Changes and determinants of life satisfaction after spinal cord injury: a cohort study in The Netherlands.

Objective

To determine the impact of spinal cord injury (SCI) on life satisfaction of persons with SCI 1 year after discharge of inpatient rehabilitation.

Design

A cohort study. Life satisfaction before SCI was retrospectively measured at the start of active rehabilitation. One year after discharge from inpatient rehabilitation, current life satisfaction was measured.

Setting

Eight rehabilitation centers in The Netherlands.

Participants

Persons (N=147) aged 18 to 65 and wheelchair-dependent at least for long distances.

Interventions

Not applicable.

Main Outcome Measure

The Life Satisfaction Questionnaire.

Results

Mean satisfaction with life ± SD as a whole was 5.3±0 before SCI and 4.3±1.3 one year after inpatient rehabilitation. Sexual life, self-care, and vocational situation showed the largest impact of SCI (P<.05), whereas the social relationships domains appeared to be the least affected. Decrease of life satisfaction after SCI was larger when using the retrospective ratings than when using general population scores. Significant determinants of life satisfaction after SCI were high lesion level (β=.31, P<.05), pain (β=.19, P<.05), and secondary impairments (β=.22, P<.05).

Conclusions

Life satisfaction decreased in persons with SCI. Level of lesion and suffering secondary impairments or pain were associated with low life satisfaction 1 year after discharge from inpatient rehabilitation.     

Transperineal Injection of Botulinum Toxin A for Treatment of Detrusor Sphincter Dyssynergia: Localization With Combined Fluoroscopic and Electromyographic Guidance

Tsai S-J, Ying T-H, Huang Y-H, Cheng J-W, Bih LI, Lew HL. Transperineal injection of Botulinum Toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance.

Objective

To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI).

Design

A prospective, open-label trial.

Setting

A rehabilitation hospital affiliated with a medical university.

Participants

Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD.

Interventions

100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy.

Main Outcome Measures

(1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI).

Results

Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H₂O, 45cm H₂O, and 92cm H₂O, respectively (all P values <.05). The mean QLI significantly improved from −0.68±0.27 to 0.66±0.19 (P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters.

Conclusion

With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.     

Validity and Responsiveness of the Care and Needs Scale for Assessing Support Needs After Traumatic Brain Injury

So C, Tate RL, Aird V, Allaous J, Browne S, Carr B, Coulston C, Diffley L, Gurka J, Hummell J. Validity and responsiveness of the Care and Needs Scale for assessing support needs after traumatic brain injury.

Objective

To investigate the validity and responsiveness of the Care and Needs Scale (CANS), which was designed to assess support needs of people with traumatic brain injury (TBI).

Design

Two samples of community clients (n=38, n=30) were recruited to examine concurrent, convergent/divergent, and discriminant validity. The ability of the CANS to detect change over a 6-month period from the time of inpatient rehabilitation discharge (predictive validity and responsiveness) was investigated in a third sample of 40 rehabilitation inpatients.

Setting

Two Brain Injury Rehabilitation Units in Sydney, Australia.

Participants

People (N=108) aged between 16 and 70 years admitted for rehabilitation after TBI.

Interventions

Not applicable.

Main Outcome Measures

The CANS, Supervision Rating Scale, FIM, Sydney Psychosocial Reintegration Scale, and Disability Rating Scale.

Results

Evidence for concurrent validity was shown with fair to moderate correlation coefficients between the CANS and measures of supervision, functional independence, and psychosocial functioning (absolute value, r_s=.43-.68; P<.01). Support for convergent and divergent validity was provided by correlation coefficients that were higher for measures tapping similar constructs (absolute value, r_s=46; P<.01) but lower for measures of dissimilar constructs (absolute value, r_s=.07-.26; not significant). In addition, the CANS discriminated between levels of injury severity, functional independence, and overall functioning (P<.01). In terms of predictive validity and responsiveness, CANS scores at inpatient rehabilitation discharge predicted the participant's functioning 6 months later.

Conclusions

These results show the CANS is a valid and responsive tool and, together with its previously shown reliability, is suitable for routine application in clinical and research practice.     

Comparison of the Responsiveness of the FIM and the interRAI Post Acute Care Assessment Instrument in Rehabilitation of Older Adults

Glenny C, Stolee P, Husted J, Thompson M, Berg K. Comparison of the responsiveness of the FIM and the interRAI Post Acute Care Assessment Instrument in rehabilitation of older adults.

Objective

To compare the responsiveness of 2 major systems developed for rehabilitation settings—the FIM and the interRAI Post Acute Care (PAC) assessment—in older patients.

Design

Trained raters assessed patients with both tools at admission and discharge.

Setting

Musculoskeletal (MSK) and geriatric rehabilitation units (GRUs) in 2 rehabilitation hospitals.

Participants

Older adults receiving rehabilitation (N=208; mean age ± SD, 78.5±9.3; 67% women).

Interventions

Not applicable.

Main Outcome Measures

Responsiveness was evaluated using effect size (ES) and standardized response mean (SRM).

Results

ES and SRM were somewhat higher for the FIM motor (GRU ES=1.68, SRM=1.31; MSK ES=2.12, SRM=2.25) than the PAC (GRU ES=1.64, SRM=1.29; MSK ES=1.57, SRM=1.89) in both patient groups. Both tools were more responsive in MSKs than GRUs. This may reflect the greater frailty and clinical complexity of GRU patients.

Conclusions

Both the FIM motor and the PAC were able to detect clinically relevant improvement in functional ability in older rehabilitation inpatients.     

Factors Predicting Inpatient Rehabilitation Length of Stay of Acute Stroke Patients in Singapore

Tan WS, Heng BH, Chua KS, Chan KF. Factors predicting inpatient rehabilitation length of stay of acute stroke patients in Singapore.

Objective

To determine the predictors of hospital length of stay (LOS) of stroke patients at the point of admission.

Design

A retrospective cohort study.

Setting

An acute hospital rehabilitation center in Singapore.

Participants

Stroke patients (N=491) admitted between March 2005 and December 2006.

Interventions

None.

Main Outcome Measures

Rehabilitation LOS was calculated as the total number of rehabilitation days before discharge. We measured the functional status of patients by using the Functional Independence Measure (FIM).

Results

The median LOS was 29 days (mean = 30.8d). Independent clinical and sociodemographic characteristics found to significantly predict rehabilitation LOS were FIM motor score at admission, the presence of more than 3 comorbid conditions at admission, living with nonimmediate relatives before admission, and the hospital subsidy status of the patient. In particular, the admission FIM motor score explained 43% of the variation in LOS and decreased the LOS by approximately 1.1 days for each 1-point increase in score.

Conclusion

Patients' socioeconomic status and family structure was found to influence LOS and should be considered in allocating resources and determining treatment need. The extent of motor function of patients at admission is an important factor influencing rehabilitation LOS and is a useful tool for facilitating rehabilitation resource planning for stroke patients.     

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury

Vickery CD, Sherer M, Nick TG, Nakase-Richardson R, Corrigan JD, Hammond F, Macciocchi S, Ripley DL, Sander A. Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury.

Objective

To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI).

Design

Prospective cohort study.

Setting

Acute inpatient TBI rehabilitation.

Participants

Participants were 1748 persons with TBI.

Interventions

Not applicable.

Main Outcome Measures

Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation.

Results

Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS.

Conclusions

The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.