Poster 29: Barriers to community integration treatment

Objective: To examine barriers to community integration treatment (CIT) among a consecutive sample of referrals. Design: A retrospective chart review of a consecutive series of referrals to CIT. Setting: CIT program for persons with brain injury. Participants: 138 consecutive referrals (n=72 nonadmitted) to CIT from January 1 to December 31, 2002. Interventions: All persons referred were evaluated by an admissions counselor and/or treatment team to determine appropriateness. Main Outcome Measures: Data comparing persons entering treatment with those not entering treatment were retrieved from summary admissions reports. Results: Persons entering treatment did not differ in age, gender, race, distance to the program, or time postinjury from persons who did not enter treatment. Common barriers to persons not entering treatment included: reliable transportation (14%), funding for treatment (8%), poor family support (6%), and awareness for relevance of treatment (14%). Conclusions: Among a sample of consecutive referrals not admitted to CIT, approximately 42% of cases were due to barriers such as reliable transportation, funding for treatment, poor family support, and education about the relevance of CIT. These data suggest points of intervention for policymakers and clinicians to decrease disability and handicap in states serving large rural populations.     

Poster 20: Community integration after traumatic brain injury

Objective: To determine the level of community integration after traumatic brain injury (TBI) and its association with clinical inpatient outcome measures. Design: The Community Integration Questionnaire (CIQ) was used to conduct telephone interviews with either the patient or a proxy who lived with the patient. Setting: Community. Participants: 77 patients with TBI who were 5 to 34 months postdischarge from an acute rehabilitation hospital. Interventions: Not applicable. Main Outcome Measure: The CIQ. Results: The CIQ total score had an inverse correlation with age (r=−.300, P<.008) and length of stay (r=−.290, P<.011). There were low but statistically significant correlations with discharge cognitive skills on the FIM™ instrument (r=.451, P<.0001), discharge FIM total score (r=.366, P<.001), and FIM efficiency (r=.367, P<.001). There were significant differences between subjects who were not currently working or attending school versus those who were. The latter group scored higher on home integration (5.6±3.0 vs 3.6±2.9), social integration (8.9±2.1 vs 6.6±2.8), productivity (5.4±0.8 vs 1.5±1.1), and CIQ total scores (20.0±3.7 vs 11.8±5.8). Conclusion: Consistent with previous findings, community integration correlated with functional outcome at discharge from rehabilitation. Patients who return to work or school exhibit better social and home integration.     

Poster 14: Cost savings of pulmonary vest therapy

Objectives: To determine cost savings from using pulmonary vest therapy to prevent hospitalizations related to pneumonia. Design: Quantitative research using before-during treatment data. Setting: 2 pediatric skilled nursing facilities for children with severe cerebral palsy (CP). Interventions: Not applicable. Main Outcome Measures: The average hospitalization for pneumonia was 5 days, 4 of which were in the intensive care unit (ICU). The daily hospitalization rates were obtained from the business offices of 3 regional hospitals with pediatric ICU units that serve our patients. Results: During our 1-year study, the number of hospitalizations was decreased by 10. The average hospitalization charge was $8225. Thus, the cost savings for 10 hospitalizations was $82,550. The cost of a vest therapy unit was $15,000 and a total of 3 units were used. The vest therapy units continue to be in use for the third year, without mechanical failure or maintenance requirements. Conclusion: In the first year alone, there was a very significant cost savings. It should be noted that these sums do not include hospital laboratory testing, pharmacy costs, or physician costs, and so significantly underestimate the actual savings.     

Poster 9: Motivating, game-based stroke rehabilitation: a pilot study

Objective: To determine the efficacy and reactions of stroke patient to a game-based rehabilitation modality for more affected upper limbs. Design: Case series. Setting: Outpatient rehabilitation clinic. Participants: 4 persons with stroke (3 men; mean age, 60.0±4.9y; age range, 56-66y; mean time since stroke, 84.3mo; range, 10-264mo). Interventions: Each patient received thirteen 30-minute training sessions using the gaming device. Each session required participation in electronic table tennis using the more affected hand as the joystick, thus forcing use of the more affected limb. Instantaneous kinesthetic and force feedback was available via participation. Main Outcome Measures: Wolf Motor Function Test (WMFT) and patient interviews before and after intervention. Results: After the intervention, patients exhibited decreased median time to complete WMFT tasks (−5.3s), decreased mean time to perform WMFT tasks (−19.7s), and improved performance ratings as assessed by an objective rater. Interviews revealed high satisfaction and motivation; they also revealed that motor improvement had a high carryover to valued activities. Conclusions: This approach appears to be an efficacious, motivating, and enjoyable modality deserving of additional research. A larger, multicenter trial is planned.     

Poster 27: Acute rehabilitation: comparison of functional outcomes of liver transplant and stroke patients

Objectives: To determine the functional outcomes of liver transplant patients with acute rehabilitation and to compare outcomes with those of stroke patients. Design: Retrospective study. Setting: Acute rehabilitation unit in a university hospital. Participants: Inpatient charts of 13 liver transplant patients and 13 stroke patients were reviewed. Interventions: The charts of 13 patients who underwent inpatient rehabilitation after liver transplants were reviewed to assess their functional gains. Their functional progress was measured on the FIM™ instrument at admission, weekly, and at discharge. Progress was compared with 13 age-matched stroke patients. Main Outcome Measures: FIM efficiency ratio of liver transplant patients was obtained by dividing the total FIM gain by the length of stay (LOS). This ratio was compared with that of the stroke patients. Results: The average age of the liver transplant patients was 56 years and that of the stroke patients was 55 years. The average admission FIM scores for transplant patients was 50 and discharge FIM scores was 76, compared with 51 and 72, respectively, for the stroke patients. The average LOS of the transplant patients was 20 days; it was 21 days for the stroke patients. The efficiency ratio was 1.35 for transplant patients and 1.33 for the stroke patients. The Student t test, with 24 degrees of freedom, showed no statistically significant differences between the liver transplant and stroke patients for their average admission and discharge FIM scores and efficiency ratios. There was also no significant difference in the average LOS. Conclusion: Patients with liver transplants made functional gains similar to those of stroke patients of similar age.     

Poster 35: High-resolution electroencephalography and reorganization of posterior cortical potentials

Objective: To test whether reorganization after spinal cord lesions is “unfavorable” because of a takeover of cortical areas representing weak or paralyzed muscles. Design: Randomized study of electroencephalograms. Setting: Spinal cord research laboratory. Participants: 16 patients with spinal cord lesions and 10 normal controls. Interventions: Subjects were instructed in moving their right middle or index fingers. The fingers were also moved in a similar manner by an operator. Voluntary movement was monitored by electromyography. Main Outcome Measures: Movement-related cortical potentials and passive movements. Results: Posterior cortical reorganization represented reinforcement of residual motor pathways from somatosensory cortex (S1) to the spinal cord, and facilitated rehabilitation. Conclusion: Motor potentials can be generated by active and passive measurements of the fingers. Reorganization of somatosensory cortex is important in deriving potentials from proprioceptive input and creating the necessary templates to activate the motor networks and electroencephalographic activity.     

Poster 27: Pressure ulcer history and spinal cord injury

Objective: To identify risk and protective factors associated with a history of recurrent pressure ulcers after spinal cord injury (SCI). Design: Cross-sectional. Setting: Large southeastern US specialty hospital. Participants: 826 nonambulatory adults with traumatic SCI of at least 5 years in duration. Interventions: Not applicable. Main Outcome Measures: Outcomes included current pressure ulcers, pressure ulcers within the past years, days adversely impacted by pressure ulcers, pressure ulcer surgeries, and pressure ulcer history (recurrent vs nonrecurrent). Results: 69% failed to report recurrent pressure ulcers, whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year (18% could not be classified). Logistic regression identified several general protective behaviors for recurrent pressure ulcers (eg, lifestyle, exercise, diet), none of which included those generally recommended during inpatient rehabilitation to prevent pressure ulcers (eg, skin checks, weight shifts). Fewer risk behaviors were associated with pressure ulcer history, although several proxy variables were related to pressure ulcer history. Conclusions: Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period of time (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A general healthy lifestyle appears to be strongly associated with an absence of recurrent pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated.     

Poster 31: Value of a fitness program after completion of rehabilitation therapy poststroke

Objective: To assess the value of a fitness program after completion of formal stroke rehabilitation. Design: Randomized, controlled, prospective study. Setting: Community wellness center. Participants: 39 subjects with stroke randomly assigned to immediate (n=20) versus deferred treatment (n=19). Interventions: The immediate group (IG) was enrolled in a 12-week exercise program. The deferred group (DG) was deferred from the exercise program for 12 weeks. Main Outcome Measures: Fugl-Meyer motor and balance subscores, 2- and 6-minute timed walk tests, FIM™ instrument, number of falls, number of hospitalizations, Mini-Mental State Examination, Beck Depression Scale, Community Integration Questionnaire, and Burke Handicap Scores were obtained at baseline and at 12 weeks postenrollment. Results: Preliminary analysis showed that the change in Fugl-Meyer motor score from baseline to 12 weeks was the only significant outcome variable (IG score ± SEM, 5.3±1.5 vs DG score, −1.7±2.1; P=.01). Subject dropouts differed significantly between the 2 groups (1 in IG, 6 in DG; χ²=4.0, P=.04). Conclusions: Structured exercise after completion of formal stroke rehabilitation has a significant effect on impairment. Subject dropouts in the DG indicated the strength of patient demand for a structured exercise program.     

Poster 2: Postural control in elderly women with knee osteoarthritis

Objective: To examine the effect of painful knee osteoarthritis on baseline balance and the relationship between balance measures and clinical measures. Design: Cross-sectional, observational, and controlled study. Setting: Sports medicine laboratory. Participants: 22 healthy women and 26 women with unilateral knee pain (age range, 60-80y). Interventions: Not applicable. Main Outcome Measures: Outcome measures included 6 force platform measures, ambulatory and transfer knee-pain intensity score (visual analog scale [VAS]), and disease burden (Kellgren-Lawrence score). The force platform measures obtained using the Balance Master System, which included weight-bearing symmetry, sway, and movement time during performing 6 tasks: weight bearing and squat, unilateral stance with eyes open, rhythmic weight shift, sit to stand, tandem walk, and step up and over. Results: On-axis velocity (deg/s) and directional control (%) in front and back rhythmic weight shift, and rising index (% body weight) in sit to stand were lower in women with unilateral knee pain (P<.05). Center of gravity (COG) sway velocity (deg/s) during unilateral stance in painful legs was greater than that in subjects’ other legs. The weight of women with unilateral knee pain loaded less on the painful side during 30° and 60° squats and during sit to stand (P<.05). Movement time during step up and over on the painful side was longer than that on the pain-free side (P<.05). Ambulatory knee-pain intensity (VAS) had a linear relationship with the movement time during step up and over on the painful side (r=.42). Conclusion: Avoidance of pain associated with limb loading and decline in postural control ability were demonstrated in elderly women with unilateral knee pain. Based on these results, further studies should be carried out to correlate the avoidance and decline with the falls in patients with painful knee osteoarthritis.     

Abstract 4: Acupuncture analgesia and electromyography

Objectives: To evaluate the analgesic effect of a simple acupuncture protocol with needle electromyography and to validate independently a telescopic sham acupuncture needle. Design: Randomized, double-blinded, controlled study. Setting: University-based electrodiagnostics laboratory. Participants: 38 subjects referred for electrodiagnostic evaluation. Intervention: Before the electromyographic examination, an independent provider applied either real acupuncture needles or telescopic sham needles to the acupuncture points Large Intestine 4 and Liver 3 bilaterally. Main Outcome Measures: 100-mm visual analog scale (VAS) of the subjects’ pain before electromyography as well as pain and unpleasantness related to electromyography after 3 muscles were examined. Subjects were also asked if they thought they had received true acupuncture or sham needles. Pretest pain was subtracted from electromyography-related pain to give a measurement of pain attributable to the electromyography. Results: 21 subjects were randomized to the treatment group and 17 to the sham group. The subjects in the two treatment arms did not differ by age (P=0.9) or gender (P=0.4). The pain attributable to electromyography in the treatment group (mean, −5.38±27.6) was significantly less than the pain attributable to electromyography in the control group (mean, 11.3±17.3) (P=.037; 95% CI, −32.3 to −1.1) The percentage of subjects who thought they had received real needles in the acupuncture group (67%) did not differ from the proportion in the control group (53%) (Fisher exact test, P=.51). Conclusion: Acupuncture may represent an effective form of analgesia for electromyography. This is the first study of which we are aware that independently validates the telescopic sham acupuncture needle as an effective control.     

Poster 1: Pulmonary vest therapy to prevent pneumonias in quadriplegic cerebral palsy

Objectives: To extend our previous observations (J Am Med Directors Assn 2002;3:318-21) on the effectiveness of high-frequency chest wall oscillation vest therapy, with the Advanced Respiratory vest, for preventing pneumonias. Design: Quantitative research using before-during treatment data. Setting: 2 pediatric skilled nursing facilities for children with severe cerebral palsy (CP). Participants: 11 subjects (6 men, 5 women), with severely quadriplegic CP and frequent pulmonary infections, were identified (age range, 1-28y; median, 17y). All were fed by gastrostomy tube; 9 had a tracheostomy; and 6 had epilepsy. Interventions: Not applicable. Main Outcome Measures: Data were collected for the 12 months prior to initiation of vest therapy and for the 12 months of vest therapy. Results: The number of pneumonias decreased from 52 to 27 per year (P<.05). The number of hospitalizations due to pneumonia decreased from 13 to 3 (P<.05). The frequency of effective suctioning of pulmonary secretions was significantly increased (P<.001) and the frequency of seizures decreased (P<.05). Conclusion: Vest therapy resulted in a statistically significant reduction in the incidences of pneumonias, number of hospitalizations for pneumonia, and seizure frequency. Vest therapy was tolerated well, without side effects.     

Poster 31: Community-acquired pneumonia in veterans with spinal cord injury

Objective: To describe the characteristics of community-acquired pneumonia (CAP) in persons with spinal cord injury (SCI) and how management is related to outcomes. Design: Cross-sectional retrospective review of administrative and clinical data. Setting: Department of Veterans Affairs (VA) facilities, and for substudy, 3 VA SCI centers (October 1998-September 2000). Participants: Veterans with SCI: 260 inpatients with CAP; in the substudy, 41 inpatients and outpatients with CAP from 3 sites. Interventions: Not applicable. Main Outcome Measures: Percentage of patients with an etiologic diagnosis, mortality rate, mean length of stay (LOS), and number and types of procedures and treatments. Results: Of the 260 inpatients with SCI identified from administrative data with CAP, only 24% had an etiologic diagnosis. Etiologic diagnosis was not associated with mortality after adjusting for several factors (OR=1.38; CI, 0.45-4.20), however, it was associated with an increase in LOS (P=.024). For the substudy, almost 75% of the 41 patients were hospitalized (mean LOS=16.3d) and 3 patients died. Most received chest radiographs (85%), but up to 54% did not receive other tests standard for management of CAP during the first day of care (eg, blood cultures, CHEM 7). Of the 16 patients with sputum cultures, an organism was identified in 44% through microbiology testing. Over 90% received antibiotics within 24 hours of admission. Conclusions: Many patients do not receive the minimum recommended testing. Empiric treatment appears to have been the predominant type of management used in this population. Further research to assess the relationship between clinical characteristics and management with patient outcomes is     

Poster 21: Postacute mortality after moderate to severe traumatic brain injury

Objective: To establish very long term mortality rates and predictors of mortality for persons after moderate to severe traumatic brain injury (TBI) in adults. Design: A retrospective cohort study design. Setting: A large inpatient rehabilitation hospital in Pennsylvania. Participants: Consecutive records of persons with moderate to severe TBI who were discharged from the hospital in the years 1974-1984, 1988, and 1989 (N=642). Interventions: Not applicable. Main Outcome Measures: Eligible participants were traced and mortality was ascertained up to 24 years postinjury. Results: Poisson regression analyses revealed at least a 2-fold increased risk for mortality in relation to the general population. Preinjury characteristics and levels of disability at discharge from inpatient rehabilitation were among the strongest predictors of mortality. Conclusions: Using rigorous methodology, this study quantifies the increased risk for premature death in the postacute TBI population after a moderate to severe head injury and has clinical relevance for the prevention of premature death.     

Poster 29: Functional outcomes of liver transplant patients treated in an acute rehabilitation setting

Objective: To determine associations between categorical and continuous variables that characterize liver transplant patients and outcome variables measuring resource utilization and functional gains during inpatient rehabilitation. Design: Retrospective review. Setting: Inpatient acute rehabilitation unit and community follow-up. Participants: 13 liver transplant patients undergoing initial acute rehabilitation. Interventions: ≥3h/d of acute multidisciplinary rehabilitation treatment. Main Outcome Measures: Rasch-converted FIM™ instrument scores, and categorical and continuous clinical variables. Results: Patients of a mean age of 52±12.35 years were admitted at a mean of 34.77±18.27 days after transplant. 9 of 13 patients were discharged to a residential setting, with mean rehabilitation length of stay (LOS) of 15.9±13.1 days. The median hospital charge was $21,500 (range, $7137-$107,568). These patients had a mean Model for End-Stage Liver Disease (MELD) score of 24.17±11.26 and serum ammonia averaged 104.46±73.08μmol/L. The Wilcoxon signed-rank assessment of paired t tests for differences between time points (admission, discharge, follow-up) showed that motor scores (P<.001) improved for all timed comparisons, but cognitive scores did not improve (P<.99). Motor function at admission correlated with hypoalbuminemia (Spearman P=.01), while cognitive function correlated with low levels of total protein (Spearman P=.014) and low globulin (Spearman P=.059). Despite this, these patients did not differ in the degree of cognitive or motor gains across their stay. Subgroups characterized by other clinical characteristics (eg, alcoholism, gender, cigarette use, diabetes) did not differ in rehabilitation outcomes, although LOS varied by group. Conclusion: Patients with end-stage liver disease are among the most medically complex and debilitated in the hospital. Despite this, we found that liver transplantation patients demonstrated significant reduction in motor disabilities when rehabilitation was provided in an inpatient rehabilitation unit setting. Cognition did not improve during the study period.     

Abstract 2: Efficacy of epidural steroid injections

Objectives: To test the efficacy of epidural steroid injections (ESIs) for the relief of radicular-, facet joint-, and lumbar stenosis-related pain 3 months postinjections and to demonstrate whether the presence of litigation and smoking influenced the response to treatment. Design: Prospective survey. Setting: Community-based hospital. Participants: 300 patients who received steroid injections for radicular-, facet joint-, and lumbar stenosis-related pain. Interventions: All participants had clinical and diagnostic evidence of lumbar radiculopathy, spinal stenosis, or facet pain. Each was then treated with a series of ESIs. Each patient filled out a preinjection survey to determine the duration and distribution of their pain. A 10-point analog pain scale determined their pre-injection pain. Factors also evaluated were the etiology of pain, the presence of a lawsuit, and if the patient was a habitual smoker. At 3 months postinjection, each participant received a survey to rate their current pain and declare other interventions such as physical therapy and surgery. Main Outcome Measures: Percentage of participants who received pain relief from their ESIs and specifically which etiology of back pain showed a better response. Results: 3 months after ESIs, approximately 80% of patients had a decrease in their symptoms by 2 or more points on the 10-point analog pain scale. Patients who experienced the most pain relief were those with radicular or stenotic symptoms, nonsmoking, or without concomitant litigation. Conclusion: Steroid injections for back pain of radicular or stenotic nature (not facet), especially for nonsmokers or those without litigation, are an effective means of treating low back pain (LBP) in the first 3 months. This study will be followed by a 6 month and 12 month survey to determine the long-term efficacy of steroid injections for LBP.     

Poster 19: Upper-body function and other health outcomes in breast cancer survivors

Objective: To research the relationship among upper-body function and patient characteristics, type of breast cancer treatment, and emotional health among breast cancer survivors participating in a trial of nurse case management. Design: Prospective, randomized controlled trial. Setting: Patients were recruited from 60 surgeons in 13 community and 2 public hospitals in southeast Texas from November 1, 1993, to October 31, 1996. Participants: Women (N=335) with newly diagnosed breast cancer, who were at least 65 years old in community hospitals or at least 60 years old in public hospitals. Intervention: Receipt of nurse case management services. Main Outcome Measures: Upper-extremity range of motion (ROM) and emotional health (depression, anxiety, life satisfaction, mood) at 2 and 12 months after breast cancer diagnosis. Results: 55% of patients who received nurse case management demonstrated full ROM at 2 months in contrast to 40% for the control group (P=.025). Controlling for nurse case management status, women treated with mastectomy were less likely to have full ROM at 2 months compared with women treated with breast-conserving surgery plus radiation (44% vs 74%, P<.003). At 12 months, African-American women were less likely to have full ROM than white women (66% vs 81%, P=.40). Full ROM was significantly associated (P<.05) with all measures of positive emotional health at both time periods. Conclusion: Women with nurse case management had significantly better upper-body function at 2 months after diagnosis compared with women without case management. The type of breast surgery and race were risk factors for decreased arm mobility at 2 months and 12 months. Full ROM was associated with better emotional health at both time periods.     

Poster 4: Comparative efficacy of 3 in-hospital rehabilitation programs on knee flexion after total knee arthroplasty: a randomized controlled trial

Objective: To compare the efficacy of 3 in-hospital rehabilitation programs with and without continuous passive motion (CPM) on knee flexion after a primary total knee arthroplasty (TKA). Design: Randomized controlled trial. Setting: Acute care hospital. Patients: 81 patients who underwent a TKA for a diagnosis of osteoarthritis were randomly assigned to 3 groups immediately after TKA: group I: conventional rehabilitation (CONV) only (n=27); group II: CONV and CPM 35min/d (n=26); and group III: CONV and CPM 2h/d (n=28). Interventions: Rehabilitation programs began the day after TKA and continued once a day until discharge. All patients were evaluated twice: before TKA and 7 to 8 days after. Main Outcome Measure: The primary measure was active knee flexion as measured with a manual goniometer in seated position by a physical therapist blinded to the study. Results: Patients’ baseline characteristics were similar. No difference between groups was found for knee flexion after intervention (ANOVA, P=.33; 95% CI of group differences: groups I-II: −5.8° to 9.2°; groups I-III: −10.3° to 4.5°; groups II-III: −12.1° to 2.9°). Conclusion: Our results did not support the use of CPM, as applied in this study, during the acute phase of rehabilitation after TKA.