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 20: Effects of a cognitive training program on outcomes in extended acute inpatient medical rehabilitation for patients with cardiac disease

Objectives: To test the hypotheses that (1) a structured learning environment and computer-based cognitive training will improve cognition in elderly, extended acute (phase 1B) medical inpatients admitted for deconditioning secondary to cardiac disease, who demonstrate cognitive deficits on admission; and (2) a change in cognition will lead to improved functional outcomes. Design: Experimental, prospective, randomized, single-factor, pretest-posttest design. Setting: Phase 1B inpatient medical rehabilitation unit using a multidisciplinary approach. Participants: 50 patients (47 completed the study) admitted to a phase 1B inpatient medical rehabilitation unit who met study inclusion criteria (Mini-Mental State Examination score, <25; >1wk length of stay [LOS], cardiac diagnosis) were randomly assigned to a cognitive training group (experimental, n=25) or standard treatment (control, n=22) group. Interventions: Groups received 3 to 6 hours of daily standard therapy. The experimental group also received computer-based cognitive training sessions 3 times/wk, 20 min/session, and a morning and evening group session designed to improve memory and organization skills. Main Outcome Measures: For hypothesis 1, cognitive portion of the FIM™ instrument. For hypothesis 2, LOS, falls, number of home services on discharge, discharge placement, total and motor FIM scores, and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results: There were no significant differences in baseline characteristics. The experimental group showed a significantly greater percentage improvement for the cognitive portion of the FIM (23.6%±18.4% vs 11.8%±17.2%, P=.035). LOS, falls, home services, discharge placement, total FIM, motor FIM, and 7 of 8 of the SF-36 subscales did not differ between the groups. The control group showed a significantly greater percentage improvement on the physical functioning subscale of the SF-36 (130.0%±67.1% vs 83.3%±66.5%, P=.008). Conclusions: The structured learning environment and computer-based training program showed improvements in cognition, as measured by the cognitive portion of the FIM. However, there were no differences in functional outcomes.     

Poster 17: Is length of stay associated with spinal cord injury functional outcome at discharge from acute rehabilitation?

Objective: To determine whether rehabilitation length of stay (LOS) is associated with discharge motor function for persons with spinal cord injury (SCI). Design: Longitudinal. Setting: Spinal Cord Injury Model Systems center. Participants: 920 persons with traumatic, complete SCI enrolled in the Spinal Cord Injury National Database, with levels of injury (LOI) at C5, C6, C7, and T1-5; and inpatient rehabilitation discharge dates between 1989 and 1992 (“early”) and 1999 and 2002 (“late”). Interventions: Not applicable. Main Outcome Measures: FIM™ instrument at rehabilitation discharge. Results: For all LOI groups, the late group had a LOS shorter than the early group, with the largest difference in the C7 group: 107 days (early) versus 59 days (late). FIM motor scores at rehabilitation discharge also differed significantly for the C5, C7, and T1-5 LOI groups. For each of these LOIs, the late group was discharged with lower FIM motor scores; the largest difference was again noted for the C7 group, which had FIM motor scores of 51.9 (early) versus 40.7 (late). Conclusions: Decreased inpatient rehabilitation LOS was associated with decreased function at rehabilitation discharge. Persons with C7-level SCI were the most affected group; this group had the largest decrease in LOS and motor FIM score.     

Abstract 20: Rehabilitation outcome for patients requiring percutaneous endoscopic gastrostomy after stroke: a case-matched control study.

Objective: To test the hypothesis that percutaneous endoscopic gastrostomy (PEG) placement, while signaling an increased risk of medical complications and death, allows survivors to achieve functional recovery and home discharge rates similar to those of case-matched controls. Design: Retrospective case-matched control study. Setting: Acute stroke rehabilitation inpatient unit. Participants: 364 patients admitted for stroke rehabilitation, 182 with PEG tubes in place and 182 case controls without PEG were matched at the time of admission for sex, age, FIM™ instrument score (mean, 2.5), and interval poststroke (mean, 1.5d). Interventions: Not applicable. Main Outcome Measures: Outcomes of interest were change in FIM scores, length of rehabilitation hospital stay, need for intercurrent transfer back to the acute hospital, final discharge destination, and survival status. All data were recorded concurrently in a computerized stroke rehabilitation data bank by rehabilitation team members unaware of the study hypothesis. Statistical analyses were as follows: the Student t test for linear data, Mann-Whitney U test for ordinal data, the chi-square test for categorical data. Variances are provided as mean ± SEM. Results: Outcomes for the 2 groups, PEG versus controls, respectively, were as follows: change in FIM scores from admission to discharge (17.3±1.3 vs 20.5±1.2, P=.07); length of rehabilitation hospital stay (45.4±1.8d vs 44.1±1.5d, P=.57); need for intercurrent transfer back to the acute hospital (51/182 vs 22/182, P=.0001); final discharge destination home/institutional care (92/74 vs 97/80, P=.91); and survival status dead/alive (16/166 vs 5/177, P=.01). Conclusions: Patients who require PEG placement are at increased risk for medical complications and death. Those who survive, however, show similar functional recovery and rate of home discharge as case-matched controls.     

Abstract 23: Selective serotonin reuptake inhibitors in acute ischemic stroke patients during inpatient rehabilitation

Objective: To examine the safety of selective serotonin reuptake inhibitor (SSRI) antidepressants after stroke and their effect on rehabilitation. Design: Chart review study. Setting: Community-based rehabilitation hospital. Participants: 147 ischemic stroke survivors admitted between August 1, 2001 and May 31, 2002. Interventions: Not applicable. Main Outcome Measures: Evidence of SSRI-related adverse events and FIM™ instrument score. Results: 85 patients received an SSRI for depressive symptoms. +SSRI and −SSRI patients did not differ in age, gender, length of stay (LOS) in the acute care hospital (9.5±7.6d vs 8.2±5.9d, P=.065), or change FIM score (22.1±13.2 vs 20.5±16.2, P=0.5). +SSRI patients had longer LOS in rehabilitation (20.1±9.1d vs 13.7±8.0d, P<.0001), lower FIM score at admission (55.6±20.7 vs 73.8±20.2, P<.0001), and lower FIM efficiency (1.2±1.0 vs 1.8±1.5, P=.01). 16 +SSRI (18.8%) and 6 −SSRI (9.7%) patients experienced 1 or more bleeding episodes, most commonly: gastrointestinal bleed (including occult bleeding), bleeding from a recently inserted gastrostomy tube or pacemaker, nose bleeds, hematuria, or easy bruising. Only 1 +SSRI and 1 −SSRI patient with bleeding required acute medical care. No hemorrhagic transformations of ischemic strokes were noted. Altered mental status occurred in 2 +SSRI and 6 −SSRI patients. Worsening neurologic symptoms occurred only in 4 −SSRI patients. All patients with abnormal bleeding received ≥1 anticoagulant or antiplatelet agents (n=21) or had recently undergone a surgical procedure (renal stent placement, n=1). Conclusions: Bleeding complications were more common in +SSRI patients despite equivalent anticoagulant and antiplatelet treatment, emphasizing the importance of monitoring for bleeding complications during SSRI treatment. +SSRI patients experienced a similar improvement in FIM score, but had lower FIM efficiency, possibly reflecting the underlying effect of depressive symptoms.     

Poster 17: Functional outcome for asian americans at a traumatic brain injury model systems center

Objective: To compare the demographics and functional outcome for Asian Americans and whites treated at a Traumatic Brain Injury Model Systems (TBIMS) center. Design: Prospective, single-center trial. Participants: 30 Asian Americans and 133 whites admitted to a TBIMS center between February 1989 and July 2000. Subjects had to meet all the criteria to be entered into the Traumatic Brain Injury National Database. Interventions: Not applicable. Main Outcome Measures: All information was collected at the time of acute admission as well as at rehabilitation admission and discharge. Demographic data (gender, age), preinjury characteristics (prior employment, level of education, drug use), Glasgow Coma Scale (GCS), and outcome scales (Disability Rating Scale [DRS], FIM™ instrument) were obtained. Results: Most Asians (67%) and whites (74%) were men. More Asians were either students (20% vs 7%) or homemakers (10% vs 1%) preinjury. The average age at the time of injury was 30.7 years for Asians and 39.3 years for whites. Average admission GCS score was 9.1 for Asians and 10.5 for whites. Prior traumatic brain injury (TBI) requiring hospitalization was 7% for Asians and 21% for whites. The mean DRS change score ± SD was 8.5±4.5 for Asians and 6.8±4.3 for whites. Conclusion: Preinjury employment status differed between Asians and whites, with more Asians being students or homemakers. The history of TBI was significantly lower for Asians than whites. Asians were generally younger at the time of injury. DRS change was slightly better for Asians. There were no other statistically significant differences between both groups in DRS or FIM scores.     

Abstract 22: Acute neuroradiograhic predictors of rehabiliation costs.

Objective: To examine acute neuroradiographic and injury predictors of rehabilitation costs in a large traumatic brain injury (TBI) population. Design: Multiple regression-based within-group design. Setting: Urban university-based neurotrauma center and rehabilitation hospital. Participants: 293 persons presenting to a level 1 trauma center with a primary diagnosis of moderate or severe TBI who required inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measures: Multiple variables derived from demographics, injury characteristics, ratings of various computed tomography (CT) scan indicators of neuropathology, and charges for rehabilitation services. Results: Several key variables that are predictive of rehabilitation outcome (including age, cause of injury, admission Glasgow Coma Scale [GCS] score) and several CT-derived neuroradiographic variables were entered into a multiple regression model to predict the total dollar charges for all rehabilitation services. The variables that emerged as statistically significant were (in order of amount of variance accounted for in the predictive model: presence of subarachnoid hemorrhage (SAH) (F change=17.89; P<.0001), admission GCS total score (F change=13.59; P<.0001), presence of frontal lobe contusion (F change=8.26; P<.004), presence of left parietal contusion (F change=7.15; P<.008), presence of right epidural hemorrhage (F change=4.51; P=.035), and presence of a punctate hemorrhage (F change=4.89; P=.028). Conclusions: Charges for TBI rehabilitation are an important consideration. The ability to predict the relative cost of rehabilitation can facilitate planning and may be helpful in more accurately determining the allocation of resources. The presence of SAH was an important predictor of charges and may reflect a risk factor for secondary brain injury not captured by other measures.     

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.     

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.     

Presentation 4: Intensive medical intervention and pulmonary rehabilitation of patients with advanced restrictive lung disease

Objective: To examine the benefits of an inpatient pulmonary rehabilitation program on patients with advanced interstitial lung disease (ILD). Design: Prospective cohort study. Repeated measures with experimental interventions and control group over a 2-year period. Setting: In- and outpatient pulmonary rehabilitation program in a hospital-based academic center. Participants: A total of 80 patients with the diagnosis of advanced ILD—40 consecutive patients (mean age, 45.7y) admitted for inpatient pulmonary rehabilitation with the diagnosis of advanced ILD and 40 patients (mean age, 48.1y) with the diagnosis of advanced ILD who did not receive inpatient rehabilitation services. Intervention: Patients with advanced ILD were offered inpatient pulmonary rehabilitation. Patients admitted for inpatient pulmonary rehabilitation received services as defined by the American Association of Cardiovascular and Pulmonary Rehabilitation. Main Outcome Measures: Pulmonary vital capacity, diffusion capacity, FIM™ instrument, 6-minute walk, and St. George’s Questionnaire. All measures were collected at the time of eligibility for admission to rehabilitation. Subsequent measures were collected in the inpatient program (experimental group) on discharge. The same measures were collected from patients (control group) who were not admitted for rehabilitation at the same time interval. Results: Analysis of covariance was used to test for group differences in mean change after adjusting for initial status. Improvements in all outcome measures were found in patients with ILD who received inpatient pulmonary rehabilitation services. These patients had improved vital capacity (P≤.001), FIM score (P≤.001), St. George’s Questionnaire score (P≤.001), 6-minute walk score (P≤.001), and diffusion capacity (P=.009). Conclusion: Pulmonary rehabilitation of patients with advanced ILD results in statistically significant improvement in pulmonary physiology, physical functioning, and quality of life.     

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.     

Presentation 2: Outcomes and reimbursement of inpatient rehabilitation services for medicare beneficiaries with stroke and hip fracture

Objective: To assess whether outcomes and reimbursement differ for Medicare beneficiaries with a stroke or hip fracture when beneficiaries are treated in an inpatient rehabilitation facility (IRF)- versus a skilled nursing facility (SNF)-based rehabilitation program. Design: Retrospective cohort study in which patients’ clinical outcome data and Medicare payment data were linked. Setting: Inpatient rehabilitation facilities and skilled nursing facility-based rehabilitation programs from across the United States. Participants: 29,793 Medicare beneficiaries with hip fracture and 58,724 beneficiaries with stroke who were treated in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. Interventions: Not applicable. Main Outcomes Measures: Discharge destination after the rehabilitation stay and discharge FIM™ instrument motor ratings after adjustment for various patient- and facility-level characteristics; Medicare Part A reimbursement stratified by case-mix group (CMG). Results: Among older patients with hip fracture in CMGs 701 to 703 (age range, 83-102y) and all patients in CMGs 704 and 705, those treated in IRFs were less likely to return to the community. Adjusted odds ratios ranged from .73 (95% CI, .63-.84) to .82 (95% CI, .68-.98). For younger patients in CMGs 701 to 703 (age range, 24-82y), the proportion of patients discharged to the community was equivalent. Discharge functional status for patients with hip fracture did not differ clinically. Across all CMGs, the IRF Medicare Part A payments were higher than SNF payments by 54% to 73%. For all patients with stroke in CMGs 101 to 107, and younger patients in CMGs 108 to 114 (age range, 26-77y), those treated in IRFs were more likely to return to the community. Adjusted odds ratios ranged from 1.42 (95% CI, 1.15-1.74) to 1.61 (95% CI, 1.22-2.11). The functional status of patients in CMGs 101 to 107 did not differ clinically, but for patients in CMGs 108 to 114, those treated in IRFs achieved more independence by discharge (raw FIM motor ratings were higher by 4.9 and 2.3 units for patients <78y and >77y, respectively). Across all CMGs, the IRF Medicare Part A payments were higher than SNF payments by 79% to 117%. Conclusion: Patients with hip fracture achieved equal or better outcomes in SNF-based rehabilitation programs at a lower cost. Patients with stroke achieved better outcomes when treated in IRFs at a higher cost.     

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     

Relationship between strength, balance, and swallowing deficits and outcome after traumatic brain injury: a multicenter analysis

OBJECTIVE: To examine the relation among strength, balance, and swallowing deficits, as measured on rehabilitation admission, and functional outcome at discharge and 1 year after traumatic brain injury (TBI). DESIGN: Multicenter analysis of consecutive admissions to designated Traumatic Brain Injury Model Systems (TBIMS) facilities. SETTING: Seventeen TBIMS centers. PARTICIPANTS: Adults and children older than 16 years of age with TBI (N=2363) enrolled in the national database from January 1989 to November 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Transfers, locomotion, stairs, lower-body dressing, grooming, bathing, upper-body dressing, toileting, and eating as measured by the FIM instrument at acute rehabilitation discharge and at 1 year after TBI. RESULTS: Lower-extremity strength less than 3/5 on admission to acute rehabilitation was associated with increased need for assistance in locomotion, transfers, and lower-body dressing and less than 3/5 upper-extremity strength was associated with the need for assistance in self-care at rehabilitation discharge and at 1 year postinjury. Similar relations were found between impaired swallowing and assistance with eating, grossly impaired dynamic sitting, or standing balance and assistance with locomotion, transfers, eating, and self-care at rehabilitation discharge and at 1 year after TBI. CONCLUSIONS: Assessments of physical strength, swallowing ability, and dynamic balance on acute rehabilitation admission are helpful as screening tests in predicting the need for assistance of another person for mobility and self-care at rehabilitation discharge. This association remains strong at 1 year after TBI. By using this information, clinicians should initiate therapeutic interventions that optimize rehabilitation of the identified impairments and should make necessary arrangement for the patient's anticipated postdischarge needs. Further studies are necessary to delineate the amount of unique variance that these early physical examination findings contribute to outcome prediction.     

Poster 36: Neuropsychiatric symptoms in patients with traumatic brain injury: 2 years postdischarge

Objective: To assess the prevalence of neuropsychiatric symptoms in traumatic brain injury (TBI) 2 years postdischarge from inpatient rehabilitation and its associated caregiver distress. Design: Follow-up study. Setting: Inpatient acute rehabilitation hospital and community. Participants: 39 consecutive patients with TBI. Interventions: Not applicable. Main Outcome Measure: The Neuropsychiatric Inventory. Results: Neuropsychiatric symptoms were present in 75% of our sample 2 years postdischarge from acute rehabilitation. Among these symptoms, the most frequently encountered were: irritability, 48.7%; depression, 43.6%; appetite and eating changes, 25.6%; night-time and sleep behavior, 23.1%; apathy, 20.5%; anxiety, 17.9%; agitation and aggression, 17.9%; and disinhibition, 10.3%. The least frequently observed behaviors included: hallucinations, 5.1%; euphoria and elation, 2.6%; and delusions, 0%. At 2-year follow-up, anxiety, agitation and aggression, apathy, and irritability caused the most emotional distress to the caregivers, while hallucination and euphoria caused the least. Conclusions: Neuropsychiatric symptoms are prevalent in patients with TBI after discharge from acute rehabilitation. These symptoms are associated with significant caregiver distress. These findings further support the continued need for adequate psychologic assessment and possible intervention postdischarge.     

Abstract 21: Treadmill with partial body-weight support versus conventional gait training after stroke.

Objective: To test the hypothesis that stroke patients treated with treadmill training and partial body-weight support walk faster 90 days after stroke than patients treated with conventional gait training. Design: Block randomized, 2 treatment arm trial. Outcome measurement was performed blind to treatment group. Setting: Inpatient rehabilitation hospital. Participants: 83 patients randomized to the treadmill (n=42) or conventional (n=41) treatments within 30 days of stroke. Patients were stratified by initial walking speed (0, >0, <.25, ≥.25m/s) and stroke location (cortical, subcortical). Eligible patients had first stroke, hemiparesis, required at least contact guard to walk, and were not ataxic. Interventions: Subjects received 12 once-daily 30-minute treatments over a 3-week period and received equal study treatment time in addition to their normal therapy. Treadmill subjects started treatment with average unweighting of 30% body weight and treadmill speed set at 1.1 miles/h. Conventional treatment included standing, walking, sit to stand, standing with activity, and walking with activity. Main Outcome Measure: The primary outcome was velocity 90 days after stroke. Secondary outcomes included 6-minute walk distance, FIM™ instrument mobility subscale score, National Institutes of Health Stroke Scale score, Fugl-Meyer Assessment leg motor score, and Tinetti score. Results: All demographic, medical, and other risk factors showed no difference except for mean age (treadmill group, 69.4±10.6y vs conventional group, 62.0±12.9y). 90-day walking speed did not differ significantly (treadmill group, .71±.50m/s vs conventional group, .83±.50m/s), nor was there a difference in change in walking speed between initial measurement and 90 days. There was no significant difference in the 6-minute walk distance at 90 days or in any of the other secondary outcomes. Conclusions: Both treatment groups made improvements in walking velocity and clinical measures during rehabilitation, but treadmill training with partial body-weight support conferred no additional benefit compared with conventional training. Age may be a contributing factor to the results.     

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.