Scoring systems to evaluate elderly patients with hip fractures

Purpose: To report about different scales and scoring systems used to evaluate elderly patient with hip fracture during the acute post-fracture phase and during post-operative rehabilitation.

Methods and results: Report of the different scales from a literature review.

Conclusions: Standard validated scales are one of the tools to perform such an evaluation process as objectively as possible and to evaluate surgical, medical and rehabilitative management in these elderly patients. These scales are only a complementary tool, and they cannot replace physical examination. However, these validated tools are probably more accurate than just clinical impression. The appropriate combination of clinical experience and these scales may well contribute to a better care of elderly patients with hip fractures.     

The use of classification models in the evaluation of CBR programmes

Classification models for community-based rehabilitation (CBR) create conceptual order in the many types of rehabilitation programmes that exist in developing countries. Several models have been developed but none of the models appears to be widely accepted or being used in the evaluation process.

Purpose. To review classification models and assess its usability.

Methods. Literature review.

Results. Sixteen documents were found describing 11 different models. These models vary from simply listing different types of CBR to multidimensional configurations encircling principles, methods and outcomes of CBR. The models are only incidentally used in the evaluation of CBR programmes. The more recent models have been used to develop, select and group indicators.

Conclusions. Classification models can indeed structure the evaluation and comparison of CBR programs that are, by nature, very different from each other. Indicators can be developed within a theoretical framework provided by the classification model. In order to be widely accepted the models should be made less complex and focus on outcomes that are meaningful for the people involved in the evaluation as well as for policymakers and researchers.     

Outpatient spinal cord injury rehabilitation: managing costs and funding in a changing health care environment

Purpose. To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

Method. Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

Results. There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

Conclusions. A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.     

Rates of access to assistive equipment and medical rehabilitation services among people with disabilities

Purpose: To determine rates of access to assistive equipment and medical rehabilitation services among people with disabilities in the US, and to determine whether health plan type is associated with rates of access to these health services.

Methods: Results were derived from a nationwide US survey sample of people with cerebral palsy, multiple sclerosis or spinal cord injury. Analyses were restricted to working-age adults ( n =500). Need for, and receipt of (1) assistive equipment in the last 12 months, and (2) rehabilitative services in the last 3 months, was determined.

Results: Over half of the sample indicated a need for assistive equipment in the last 12 months. Nearly a third of those who indicated a need did not receive assistive equipment every time it was needed. Forty per cent of the sample indicated a need for rehabilitative services in the last 3 months, and over half of those indicating a need did not receive rehabilitative services every time they were needed. Access rates did not differ appreciably between respondents covered by managed care and fee-for-service health plans.

Conclusion: Emphasis in healthcare for people with disabilities should shift from traditional acute healthcare models that focus on functional restoration, to preventive services, and maintenance of function, health and independence.     

The role of the spiritual dimension of the self as the prime determinant of health

Purpose. To present a clinical commentary on the relationship of spirituality to healthcare for those with chronic physical conditions.

Method. A spiritually based theory of self-identity was presented, based on selected literature to identify the process of health attainment for those with chronic conditions. The resultant Health Change Process Theory was then discussed in relation to relevant empirical research and the implications for rehabilitation practice were outlined.

Results. The development of a resilient, intrinsic, spiritually based concept of self was found to be pivotal to health outcomes in rehabilitation. This was then incorporated within a Health Change Process Theory to explain and predict the course followed by people with chronic disorders to achieve health.

Conclusion. The Health Change Process Theory provides an inclusive framework within which acute and chronic rehabilitation healthcare can be merged to maximise health outcomes. Nevertheless, a need remains to develop a quantitative measure of individual holistic health, based on this theory, to facilitate its use in rehabilitation practice. This paper forwards an explanation for the process that people experiencing chronic physical disabilities undergo as they achieve health. A concept of self that identifies the spiritual core as the component that determines the constancy and continuity of self as a whole which is necessary for health is presented as the basis of the rehabilitative health process.     

Quality assessment in rehabilitation centres: the indicator system 'Quality Profile'

Purpose: An indicator system for measuring the quality of rehabilitation centres ('Quality Profile' of rehabilitation centres) is presented. The implementation of the concept is explained with the aid of results regarding structural, process and outcome quality in 26 cardiac and orthopaedic rehabilitation centres.

Method: In each centre, structural, process and outcome quality, including patient and employee satisfaction, are measured. Process quality is determined by means of a peer review procedure that includes examination of 20 randomly selected cases on the basis of discharge reports and therapy plans. The medical outcome is measured by a prospective study with three measurement time points and a sample of approx. N = 200 patients per centre.

Results: Overall, the level of quality of the medical rehabilitation in the institutions participating in the study must be considered high. However, on almost all quality dimensions, even after a risk adjustment there are clear differences between centres, which point to the usefulness of benchmarking analyses and the need for improvements in quality in some centres.

Conclusions: The indicator system presented is a starting-point for comprehensive, comparative measurement of the quality of in-patient rehabilitation centres that, with regard to its principles, also appears applicable to other areas of health care.     

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.     

Some ethical issues in community-based rehabilitation initiatives in developing countries

Purpose : This commentary provides both theoretical and practical insights into the concept of community-based rehabilitation (CBR) and its application in developing countries. In doing so it explores current practices in CBR and the debate surrounding them, namely the ethical question and how this may impact on future CBR. The main argument in this account is that disability is a development issue; with widespread poverty, inequality and violation of human rights, and should be addressed within the broader context of community development which may include strategies such as CBR.

Method : A review and analysis of recent literature on CBR has been conducted including the review of a number of empirical research documents from various CBR initiatives in developing countries.

Results : CBR has increasingly been under scrutiny in terms of the extent to which these have succeeded in delivering rehabilitation services to those in need in the community as well as the permitted level of participation and control of disabled people over the rehabilitation process. Many programmes have been unsustainable and it has been difficult to evaluate their full usefulness to disabled people. These issues raise an ethical question about CBR being an appropriate strategy for the rehabilitation of people with impairments in developing countries.

Conclusion : This background emphasizes that new directions in CBR need to be put in place in order to maximize the realization of the ultimate goal: the greatest participation for disabled people in all spheres of life. Effective rehabilitation programmes should allow people with disability to have greater control in the nature of their rehabilitation and that the role of professionals and other stakeholders is one of allies and resources in the rehabilitation process. Moreover, the participation of community members in the rehabilitation policy should be assured.     

Paediatric traumatic brain injury in South Africa: some thoughts and considerations

Purpose: This paper endeavours to describe the socio-political and economic backdrop to the assessment and management of traumatic brain injury (TBI) in children in South Africa.

Outcomes: The argument put forward is that huge disparities in socio-economic status, diverse socio-cultural influences, and widely differing educational systems and educational attainment which characterize the country's population, render the management of TBI different from approaches adopted in developed countries. The main causes of TBI can be attributed to the high rates of violence in the country, as well as an inordinately high incidence of motor vehicle accidents. Compensation through existing national legislative and insurance agencies is unavailable to most of the population, and markedly insufficient in many cases. The access to medical care and rehabilitation is inadequate for the majority of South African children, although there are valiant efforts on the part of professionals working within the primary health care model to provide the support to the children and their families not offered by existing educational and school structures.

Conclusion: The impact of the HIV/AIDS pandemic on the clinical picture of children and their families is profound and guides many of the decisions that are made by health care professionals. Given this bleak scenario, a re-focus on the strengths of existing structures and the creation of new possibilities is suggested as a positive and constructive approach to prevention, rehabilitation, and education.     

Conservative management of neuromuscular scoliosis: personal experience and review of literature

Purpose. The principles of conservative management of neuromuscular scoliosis in childhood and adolescence are presented.

Methods. Analysis of personal experience and literature review. The topic is discussed separately for patients with flaccid or spastic paresis.

Results. These demonstrate that conservative management might be proposed for patients with neuromuscular scoliosis in many clinical situations. In spastic disorders, it maintains the symmetry around the hip joints. Bracing is technically difficult and often is not tolerated well by cerebral palsy children. In patients with flaccid paresis, the fitting and the use of brace is easier than in spastic patients. The flexibility of the spinal curvature is more important. Functional benefits of conservative management of neuromuscular scoliosis comprise stable sitting, easier use of upper limbs, discharge of the abdomen from the collapsing trunk, increased diaphragm excursion, and, not always, prevention of curve progression.

Conclusions. Specific natural history and multiple medical problems associated with the disease make the treatment of children with neuromuscular scoliosis an extremely complex issue, best addressed when a team approach is applied. Continuously improving techniques of conservative management, comprising bracing and physiotherapy, together with correctly timed surgery incorporated in the process of rehabilitation, provide the optimal care for patients.     

Return to work following traumatic brain injury: trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 - 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach - medical and psychosocial - eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.     

The potential for utilizing inter-limb coupling in the rehabilitation of upper limb motor disability due to unilateral brain injury

Purpose. Symmetry tendencies in human movement have generally been regarded as a constraint to upper limb motor performance. However, several recent studies have suggested that this phenomenon might be utilized in the rehabilitation of individuals with motor disability due to unilateral brain injury. In this paper the efficacy of such a rehabilitative approach is explored by reviewing: (i) examples of symmetry tendencies in healthy individuals, (ii) the potential neurophysiological mechanisms responsible for inter-limb coupling, and (iii) recent studies which have directly assessed the effects of inter-limb coupling on individuals with unilateral brain injury.

Method. A thorough review of current published evidence was conducted utilizing various electronic search engines (Medline, PreMedline, Embase and Cinahl). Studies included those that focused on symmetry tendencies and/or inter-limb coupling in the upper limbs with a particular emphasis placed on studies of individuals with unilateral brain injury.

Results. Based on the current literature it seems that motor function of the affected upper limb in individuals with unilateral brain injury can be improved through a rehabilitation approach that incorporates inter-limb coupling.

Conclusion. This approach should be considered as an adjunct to more common rehabilitation strategies with future research aimed at determining the most effective means of employing this paradigm.     

Reliability and construct validity of the client-centred rehabilitation questionnaire

Purpose. A key component in assessing the performance of rehabilitation services is the client's perspective. The purpose of this paper is to report on the development of a publicly available measure of client-centred rehabilitation (CCRQ) that can be used for discriminative and evaluative purposes.

Method. Mixed qualitatative and quantitative methods were used. Phase 1: Identification of seven domains of client-centred rehabilitation based on a literature review, focus groups with clients, and review by content experts. Phase 2: Item generation for the seven conceptually derived subscales and cognitive interviews with inpatient rehabilitation patients. Phase 3: Psychometric testing for internal reliability, test-retest reliability and discriminative construct validity using data from a mailed, self-administered survey to 1568 patients discharged from two large inpatient rehabilitation facilities.

Results. The seven conceptually derived subscales all have strong internal (0.72 - 0.87) and test-retest reliability (0.74 - 0.85). Discriminative construct validity is demonstrated by the ability of subscales to identify significant differences between programs within two rehabilitation facilities.

Conclusions. The results for the reliability and validity of this measure support its value for use in clinical and quality improvement work as well as research.     

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.     

Religious views of the 'medical' rehabilitation model: a pilot qualitative study

Purpose: To explore the religious beliefs that patients may bring to the rehabilitation process, and the hypothesis that these beliefs may diverge from the medical model of rehabilitation.

Methods: Qualitative semi-structured interviews with representatives of six major religions—Islam, Buddhism, Christianity, Judaism, Sikhism, and Hinduism. Representatives were either health care professionals or religious leaders, all with an interest in how their religion approached health issues.

Results: There were three recurrent themes in the interviews: religious explanations for injury and illness; beliefs about recovery; religious duties of care towards family members. The Buddhist, Sikh, and Hindu interviewees described beliefs about karma—unfortunate events happening due to a person's former deeds. Fatalistic ideas, involving God having control over an individual's recovery, were expressed by the Muslim, Jewish, and Christian interviewees. All interviewees expressed the fundamental importance of a family's religious duty of care towards ill or injured relatives, and all expressed some views that were compatible with the medical model of rehabilitation.

Conclusions: Religious beliefs may both diverge from and resonate with the medical rehabilitation model. Understanding these beliefs may be valuable in facilitating the rehabilitation of diverse religious groups.     

Work physical therapy and rehabilitation ergonomics: a review and discussion of the scope of the areas

Purpose. There has been a recent development of the work physical therapy area in Brazil. The relationship between work physical therapy and rehabilitation ergonomics needs to be highlighted to avoid segregation and fragmentation of these complementary fields. For these reasons, the purpose of this article was to review and clarify the scope of the areas of work physical therapy and rehabilitation ergonomics.

Method. The available literature discussing the roles of the areas of interest was critically reviewed.

Results. Both areas are concerned with workers' health and safety and they complement each other.

Conclusions. Work physical therapy can be considered as rehabilitation ergonomics practiced by physical therapists with their specific interests. Hopefully, this paper will contribute to further interaction between the areas of work physical therapy and rehabilitation ergonomics not only in Brazil but worldwide. This may contribute to improved occupational disability prevention and rehabilitation.     

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

Methods: Design: A prospective observational cohort study and a cross-sectional study.

Setting: University hospital in the Netherlands.

Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.