Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients

OBJECTIVE: To examine how depressive symptoms, a history of depression, and cognitive functioning contribute to the prediction of rehabilitation efficiency in stroke patients. DESIGN: Consecutive admissions to an acute inpatient rehabilitation program were screened for cognitive functioning and level of depressive symptoms. History of depression was determined by family member interview. Functional status was evaluated at time of admission and discharge. Depressive symptoms, depression history, and cognitive functioning were examined as predictors of length of stay (LOS) and efficiency of utilization of rehabilitation services. SETTING: Acute inpatient rehabilitation hospital. PATIENTS: A total of 348 consecutive stroke admissions to an inpatient program were evaluated for depression and cognitive functioning, of whom 243 patients completed all aspects of the screening. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation progress, measured with the LOS efficiency measure (LOS-EFF) of the FIM instrument, and length of rehabilitation hospital stay. RESULTS: Patients with higher levels of depressive symptoms used rehabilitation services less efficiently than those with lower symptom levels but did not have longer LOSs. History of depression was associated with longer LOS and less efficient use of rehabilitation services. Cognitive impairment did not predict rehabilitation efficiency. CONCLUSIONS: The present study lends further support to the benefits of screening stroke patients at the time of rehabilitation admission for depression and history of depression. Identifying patients who have high levels of depressive symptoms and/or a previous depressive episode will allow more comprehensive assessment and rapid intervention.     

The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes

OBJECTIVE: To examine the impact of the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) on outcomes in a stroke rehabilitation program. DESIGN: An analysis was performed on a database including 945 stroke patients admitted to an inpatient stroke rehabilitation program 5 yrs before implementation of the IRF PPS and 3.5 yrs after implementation. Patients were classified with regard to stroke location (left vs. right), level of cognitive impairment, presence/absence of unilateral neglect, and level of depressive symptomatology. Functional status was evaluated at time of admission and discharge by functional independence measure (FIM). Other outcome measures included length of stay (LOS) and discharge destination. The impact of IRF PPS on LOS, progress in rehabilitation, and discharge destination was examined via univariate analyses of covariance and logistic regression. RESULTS: Patients admitted after implementation of the IRF PPS had shorter LOS but made less progress, had lower functional levels at discharge, and had higher rates of institutional discharge. CONCLUSIONS: Although associated with decreased LOS, implementation of the IRF PPS was associated with decreased functional gains, lower discharge FIM levels, and higher rates of institutional discharge. Cost savings associated with the PPS must be considered in light of these untoward outcomes.     

Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury

Weeks DL, Greer CL, Bray BS, Schwartz CR, White JR Jr. Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury.

Objective

To study whether outcomes in patients who have undergone inpatient rehabilitation for stroke, traumatic brain injury (TBI), or traumatic spinal cord injury (TSCI) differ based on antidepressant medication (ADM) use.

Design

Retrospective cohort study of 867 electronic medical records of patients receiving inpatient rehabilitation for stroke, TBI, or TSCI. Four cohorts were formed within each rehabilitation condition: patients with no history of ADM use and no indication of history of depression; patients with no history of ADM use but with a secondary diagnostic code for a depressive illness; patients with a history of ADM use prior to and during inpatient rehabilitation; and patients who began ADM therapy in inpatient rehabilitation.

Setting

Freestanding inpatient rehabilitation facility (IRF).

Participants

Patients diagnosed with stroke (n=625), TBI (n=175), and TSCI (n=67).

Interventions

Not applicable.

Main Outcome Measures

FIM, rehabilitation length of stay (LOS), deviation between actual LOS and expected LOS, and functional gain per day.

Results

In each impairment condition, patients initiating ADM therapy in inpatient rehabilitation had longer LOS than patients in the same impairment condition on ADM at IRF admission, and had significantly longer LOS than patients with no history of ADM use and no diagnosis of depression (P<.05). LOS for patients initiating ADM therapy as inpatients even exceeded LOS for patients without ADM history, but who had a diagnosis for a depressive disorder. Deviation in LOS was significantly larger in the stroke and TBI groups initiating ADM in IRF than their counterparts with no history of ADM use, illustrating that the group initiating ADM therapy in rehabilitation significantly exceeded expected LOS. Increased LOS did not translate into functional gains, and in fact, functional gain per day was lower in the group initiating ADM therapy in IRF.

Conclusions

Explanations for unexpectedly long LOS in patients initiating ADM in inpatient rehabilitation focus on the potential for ADM to inhibit therapy-driven remodeling of the nervous system when initiated close in time to nervous system injury, or the possibility that untreated sequelae (eg, depressive symptoms or fatigue) were limiting progress in therapy, which triggered ADM treatment.     

Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect

OBJECTIVE: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke. DESIGN: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up. SETTING: Urban, acute inpatient rehabilitation facility. PATIENTS: Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan. MAIN OUTCOME MEASURES: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R). RESULTS: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing. CONCLUSIONS: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.     

Mobility status during inpatient rehabilitation: a comparison of patients with stroke and traumatic brain injury

OBJECTIVES: To compare the mobility status (admission and discharge status, change in status) between patients with stroke and traumatic brain injury (TBI) during inpatient rehabilitation and to determine the relationship between mobility status and outcome variables including length of stay (LOS). DESIGN: Prospective study. SETTING: Free-standing tertiary rehabilitation center. PARTICIPANTS: A total of 210 patients with stroke (n = 136) and TBI (n = 74) consecutively admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical Outcome Variable Scale (COVS), a 13-item scale of mobility status (measured on admission and discharge from inpatient rehabilitation), and rehabilitation LOS. RESULTS: With age and time since injury controlled in the model, the TBI group showed a significantly higher mobility status on admission and discharge over the stroke group, but the change (improvement) in mobility status did not differ. The admission mobility status accounted for 61% and 60% of variability of the discharge mobility status for the stroke and TBI groups, respectively. The admission mobility status accounted for 40% and 50% of the variability in rehabilitation LOS for the stroke and TBI groups, respectively. Either the admission mobility status or the physical therapist's prediction of the discharge status could be used to determine the actual discharge mobility status, although the physical therapist's predictions were more accurate than using a statistical model. CONCLUSIONS: The TBI group showed a higher mobility status at admission and discharge from inpatient rehabilitation than the stroke group; however, the rate of improvement (improvement in mobility status per day) did not differ between groups. Admission mobility status using the COVS was an excellent predictor of discharge mobility status and rehabilitation LOS in stroke and TBI patients.     

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system

BACKGROUND: Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. OBJECTIVE: The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. DESIGN: This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. SUBJECTS: The study included 55,438 stroke patients. MEASURES: Study measures were LOS, functional status at discharge, and community discharge. RESULTS: The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05). CONCLUSIONS: While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.     

Prevalence of post-stroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation

PURPOSE: (1). To examine the prevalence of depressive symptoms and operationally defined depressive disorder (major depression) in an Irish sample of subjects undergoing inpatient rehabilitation following their first stroke. (2). To investigate factors predictive of depression following stroke. (3). To examine the relationship between post-stroke depression and outcome following inpatient rehabilitation. METHODS: Fifty consecutive patients meeting inclusion criteria who were admitted for inpatient rehabilitation to a specialised unit following their first stroke were prospectively studied. Inclusion criteria: first stroke 3 - 12 months previously, lesion identified on CT or MRI, age 18 - 65 years, at least some sensory/motor impairment, no pre-existing disabling condition and Barthel Index score > 14 prior to stroke. Mood (Center for Epidemiologic Studies Depression scale, Hamilton Depression Rating Scale, DSM-IV diagnostic criteria for Major Depressive Disorder), Cognition (Mini-Mental State Examination) and Disability (Barthel Index, Rankin Disability Scale) were assessed one week after admission (baseline) and again after 2 months of rehabilitation. Outcome was measured as effectiveness of rehabilitation (Shah et al., 1990) and length of inpatient stay (LOS). RESULTS: 10/50 (20%) of the sample met criteria for major depressive disorder on admission. The best predictor of depression was gender, with females having a two-fold higher rate of both subjectively reported and objectively rated depressive symptoms. Depression was unrelated to baseline Barthel Disability, side of lesion or previous psychiatric history. The best predictor of effectiveness of rehabilitation was baseline Barthel Disability score. Depression did not predict either effectiveness or LOS. CONCLUSION: (1). Major depression is common in subjects undergoing rehabilitation following their first stroke. (2). Females appear to be especially at risk, possibly reflecting an increased general risk of depression. (3). Depression in our sample was not related to functional disability following stroke or early functional outcome following rehabilitation.     

Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation

OBJECTIVE: To determine the prevalence of venous thromboembolic disease (VTED) and impact on functional outcome in patients with major lower-extremity (LE) amputation admitted to an inpatient rehabilitation unit. DESIGN: Retrospective medical records review. SETTING: Acute inpatient rehabilitation unit in a tertiary, urban academic medical center. PARTICIPANTS: Fifty consecutive patients admitted to an acute inpatient rehabilitation unit after a major LE amputation. Participants were screened at rehabilitation admission for LE deep vein thrombosis using duplex ultrasonography. INTERVENTIONS: Not applicable.Main outcome measures VTED incidence, FIM instrument, total rehabilitation charges, and length of stay (LOS). RESULTS: Six of 50 patients (12%) had evidence of VTED. The VTED cohort had significantly lower admission and discharge FIM scores than the no-VTED cohort (admission FIM score, 57.2 vs 76.0; discharge FIM score, 66.0 vs 90.1, respectively; P< or =.02). Subjects with VTED had a longer rehabilitation LOS (22.8d vs 13.9d, respectively; P=.02) and higher total rehabilitation charges (28,314 US dollars vs 17,724 US dollars, respectively; P<.05). CONCLUSIONS: In this study, VTED prevalence after LE amputation in a rehabilitation setting was 12%. Subjects with VTED had lower admission and discharge functional status, longer LOS, and higher hospital charges. The utility of screening duplex ultrasound examinations at rehabilitation admission remains unclear.     

Prevalence of post-stroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation

Purpose:?(1) To examine the prevalence of depressive symptoms and operationally defined depressive disorder (major depression) in an Irish sample of subjects undergoing inpatient rehabilitation following their first stroke. (2) To investigate factors predictive of depression following stroke. (3) To examine the relationship between post-stroke depression and outcome following inpatient rehabilitation.

Methods:?Fifty consecutive patients meeting inclusion criteria who were admitted for inpatient rehabilitation to a specialised unit following their first stroke were prospectively studied. Inclusion criteria: first stroke 3?–?12 months previously, lesion identified on CT or MRI, age 18?–?65 years, at least some sensory/motor impairment, no pre-existing disabling condition and Barthel Index score >?14 prior to stroke. Mood (Center for Epidemiologic Studies Depression scale, Hamilton Depression Rating Scale, DSM-IV diagnostic criteria for Major Depressive Disorder), Cognition (Mini-Mental State Examination) and Disability (Barthel Index, Rankin Disability Scale) were assessed one week after admission (baseline) and again after 2 months of rehabilitation. Outcome was measured as effectiveness of rehabilitation (Shah et al., 1990) and length of inpatient stay (LOS).

Results:?10/50 (20%) of the sample met criteria for major depressive disorder on admission. The best predictor of depression was gender, with females having a two-fold higher rate of both subjectively reported and objectively rated depressive symptoms. Depression was unrelated to baseline Barthel Disability, side of lesion or previous psychiatric history. The best predictor of effectiveness of rehabilitation was baseline Barthel Disability score. Depression did not predict either effectiveness or LOS.

Conclusion:?(1) Major depression is common in subjects undergoing rehabilitation following their first stroke. (2) Females appear to be especially at risk, possibly reflecting an increased general risk of depression. (3) Depression in our sample was not related to functional disability following stroke or early functional outcome following rehabilitation.     

Potential impact of the new medicare prospective payment system on reimbursement for traumatic brain injury inpatient rehabilitation

OBJECTIVE: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation. DESIGN: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria. SETTING: Fourteen urban rehabilitation facilities throughout the United States. PARTICIPANTS: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes. RESULTS: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients. CONCLUSIONS: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.     

The relationship between mean flow velocity and functional and neurologic parameters of ischemic stroke patients undergoing rehabilitation

OBJECTIVE: To investigate the correlation between mean flow velocity (MFV) as measured by transcranial Doppler ultrasonography (TCD) and functional and neurologic impairment during inpatient rehabilitation after acute stroke. DESIGN: Prospective study comparing results of rehabilitation in patients with different TCD findings. SETTING: Acute neurologic rehabilitation department. PARTICIPANTS: Twenty-four consecutive patients admitted to a rehabilitation center with a diagnosis of a first ischemic stroke in the middle cerebral artery (MCA) territory. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Impairment as measured with the National Institutes of Health Stroke Scale (NIHSS) and disability as assessed with the FIM instrument. RESULTS: Normative or high blood-flow velocity in the MCA of the damaged hemisphere was associated on admission with higher FIM and lower NIHSS scores during 2 months of hospitalization. Absent or low flow velocity correlated with much worse functional and neurologic outcome, especially after 1 and 2 months of inpatient rehabilitation. Statistical correlation was found between MFV in the MCA of the damaged hemisphere, measured by admission TCD, and FIM score on admission and 1 month later. NIHSS scores during hospitalization also correlated with MFV in the MCA of the damaged hemisphere on admission and after 1 month. MFV in the MCA of the undamaged hemisphere 1 month after admission correlated negatively with FIM scores during inpatient rehabilitation. CONCLUSIONS: Our data showed a correlation between blood-flow velocity in the MCA of both hemispheres and the parameters of functional and neurologic status at different stages of acute inpatient rehabilitation after first ischemic stroke in MCA territory. Cerebral blood flow as measured by TCD can be an additional tool for monitoring the rehabilitation process after stroke.     

Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect

OBJECTIVE: To evaluate the impact of unilateral spatial neglect (USN) on the rehabilitation outcome and long-term functioning in activities of daily living (ADL) and instrumental ADL (IADL) of right hemisphere damaged (RHD) stroke patients. DESIGN: Assessments of sensory-motor and cognitive impairment and of functional disability were conducted upon admission to rehabilitation, upon discharge from the rehabilitation hospital, and 6 months after discharge, up to a year postonset. SETTING: The Loewenstein Rehabilitation Hospital, which receives patients from all general hospitals in Israel. PATIENTS: Forty consecutive admissions of adult right-handed patients with a first, single, right hemispheric stroke proven by computed tomography. Based on their total score in the Behavioral Inattention Test for neglect, patients were divided into two groups: 19 with neglect (USN+) and 21 without neglect (USN-). OUTCOME MEASURES: Functional Independence Measure, for ADL; The Rabideau Kitchen Evaluation, for IADL. RESULTS: Impairment and disability levels of RHD patients with and without USN were clearly differentiated. Neglect is associated with lower performance on measures of impairment (sensory-motor and cognitive), as well as on measures of disability in ADL and IADL. Differences were significant in all testing periods. The recovery pattern of USN+ patients is slower and more attenuated. In both groups, most improvement occurs in the first 5 months after onset. USN is the major predictor of rehabilitation outcome from admission to follow-up. CONCLUSIONS: The significance of neglect as a major source of stroke-related long-term disability justifies further research efforts to develop appropriate therapeutic modalities for this complex, multifactorial syndrome.     

Time to rehabilitation admission and associated outcomes for patients with traumatic brain injury

OBJECTIVE: To examine the association between time from injury to rehabilitation admission and outcomes for patients with traumatic brain injuries (TBIs). DESIGN: Retrospective chart review. SETTING: One hundred-bed inpatient rehabilitation facility with a 20-bed brain injury unit. PARTICIPANTS: Patients with TBIs discharged from initial inpatient rehabilitation between 2003 and 2004 (N=158). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcomes examined were functional independence at discharge (motor, cognitive, total FIM scores), rehabilitation length of stay (LOS), and rehabilitation cost. RESULTS: Significant linear trends were observed for time to admission and motor FIM scores, total FIM scores, rehabilitation LOS, and cost. All linear regression models contained time to admission as a significant predictor of rehabilitation outcomes. Over half of the variability in outcomes was explained by predictors including time to admission and case-mix group or individual FIM scores with the exception of discharge motor FIM score, for which only 45% of the variability was explained. CONCLUSIONS: Patients who progress to rehabilitation earlier do better functionally and have lower costs and shorter LOSs. Furthermore, the time to rehabilitation admission is easily calculated and could be used by rehabilitation providers in adjunct with admission FIM scores to estimate resource utilization.     

A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay

OBJECTIVE: To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI). DESIGN: Retrospective collaborative study. SETTING: Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems (TBIMS) centers. PARTICIPANTS: A sample of 273 older patients (> or =55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included. INTERVENTION: Inpatient interdisciplinary brain injury rehabilitation. MAIN OUTCOME MEASURES: Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition. RESULTS: One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients. CONCLUSIONS: Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.     

Awareness of disabilities in stroke rehabilitation--a clinical trial

Purpose : To investigate the frequency of unawareness of disabilities after stroke during the rehabilitation stage, the relationship of unawareness with neuroanatomical variables, and the impact of unawareness on functional outcomes.

Method : Sixty consecutive patients (36 with right, 24 with left hemisphere damage) admitted to rehabilitation hospital with a first, single, unilateral stroke were evaluated at admission, discharge and at 1-year post onset of stroke. Unawareness of disabilities was operationally defined as the discrepancy between therapist and patient's rating on the motor scale of the functional independence measure (FIM). Functional outcomes included FIM, instrumental activities of daily living (IADL) scale, activity card sort (ACS) and safety rating scale.

Results : Unawareness of disabilities was found in 44/60 patients at admission and 24/57 at discharge. There was no significant difference between the hemisphere groups in the frequency of unawareness at both times. Discharge unawareness in the right hemisphere group was significantly associated with lesions in the frontal and temporal lobes, and with lesion size. Unawareness in the left hemisphere damaged group was not associated with any neuroanatomical variables. A negative impact of unawareness at admission on functional outcomeswas not found, but it was found that unawareness at discharge was a negative predictor of activity level (ACS score) at follow up, after controlling for the severity of initial disability level.

Conclusions : Unawareness of disabilities is a significant issue in stroke rehabilitation. Unawareness that persists to discharge from rehabilitation correlates with neuroanatomical variables in right hemisphere damaged patients, and is a negative predictor for some rehabilitation outcomes at follow-up.     

Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation.

OBJECTIVE: To compare outcomes of patients with neoplastic spinal cord compression (SCC) to outcomes of patients with traumatic spinal cord injury (SCI) after inpatient rehabilitation. DESIGN: A comparison between patients with a diagnosis of neoplastic SCC admitted to an SCI rehabilitation unit and patients with a diagnosis of traumatic SCI admitted to the regional Model Spinal Cord Injury Centers over a 5-year period, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. SETTING: Tertiary university medical centers. PATIENTS: Twenty-nine patients with neoplastic SCC and 29 patients with SCI of traumatic etiology who met standard rehabilitation admission criteria. MAIN OUTCOME MEASURES: Acute and rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, and discharge rates to home. RESULTS: Patients with neoplastic SCC had a significantly (p < .01) shorter rehabilitation LOS than those with traumatic SCI (25.17 vs 57.46 days). No statistical significance was found in acute care LOS. Motor FIM scores on admission were higher in the neoplastic group, but discharge FIM scores and FIM change were significantly lower. Both groups had similar FIM efficiencies and community discharges. CONCLUSIONS: Patients with neoplastic SCC can achieve rates of functional gain comparable to those of their counterparts with traumatic SCI. While patients with traumatic SCI achieve greater functional improvement, patients with neoplastic SCC have a shorter rehabilitation LOS and can achieve comparable success with discharge to the community.     

Functional outcome in stroke patients with atrial fibrillation

OBJECTIVES: To identify the prevalence of atrial fibrillation (AF) in a sample of stroke patients and to evaluate the impact of AF on patient clinical characteristics and functional outcome. DESIGN: A retrospective case-comparison study. SETTING: University-affiliated rehabilitation centers. PARTICIPANTS: One hundred ninety-six of 231 consecutive stroke patients admitted to inpatient rehabilitation units were evaluated during the rehabilitation period. MAIN OUTCOME MEASURES: Characteristics of cerebral lesions, patient demographic features, disease duration, length of hospital stay (LOS), risk factors for stroke, and functional status at admission and at discharge were assessed and compared in patients with and without AF. Functional Independence Measure (FIM) and Adapted Patient Evaluation Conference System (APECS) were used to evaluate functional status. RESULTS: AF was diagnosed in 41 (20.1%) patients. Patients who had AF were more likely to have ischemic cerebral lesions. There were no significant differences between the AF and non-AF groups with regard to mean age, LOS, and disease duration. Ischemic and valvular heart disease were more common in patients with AF. Based on FIM and APECS scores, both initial and discharge disability were more severe in patients with AF. In a multivariate model, AF was a negative prognostic factor for functional outcome in stroke patients. CONCLUSION: AF is not only associated with increased risk of stroke, but also with markedly greater disability in stroke patients. Factors such as size and type of cerebral lesions, stroke severity, comorbid conditions, and impact of AF on systemic and cerebral circulation can influence stroke recovery.     

The role of unilateral spatial neglect in rehabilitation of right brain-damaged ischemic stroke patients: a matched comparison

OBJECTIVE: To assess the specific influence of unilateral spatial neglect (USN) on rehabilitation outcome. DESIGN: A case-control study in consecutive stroke inpatients. SETTING: Rehabilitation hospital. PATIENTS: One hundred seventy-eight patients with sequelae of first stroke, enrolled in homogeneous subgroups, matched for age (within 1yr) and onset admission interval (within 3d), and difference because of the presence of USN, evaluated by a specific neuropsychologic battery. INTERVENTIONS: All patients received physical rehabilitation: physiotherapy for 60 minutes twice a day (once on Saturday), 6 days a week, within 24 hours of admission. USN-positive (USN(+)) patients received specific treatment of 5, 1-hour sessions per week, for 8 consecutive weeks: (1) visual scanning, (2) reading and copying, (3) copying of line drawings on a dot matrix, and (4) describing a scene. Patients were assessed with neurologic (Canadian Neurological Scale), neuropsychiatric (Hamilton Depression Rating Scale), neuroradiologic, and functional (Barthel Index, Rivermead Mobility Index [RMI]) examinations. MAIN OUTCOME MEASURES: Length of stay, efficiency (average daily increase in Barthel Index), effectiveness (amount of potential improvement achieved during rehabilitation) of treatment and percentage of low- and high-response patients calculated on the Barthel Index and the RMI, and percentage of urinary incontinence and return home were evaluated. Odds ratios (ORs) of dropouts and of low and high therapeutic response were also quantified. RESULTS: Compared with USN-negative patients, USN(+) patients had significantly more severe baseline neurologic and functional status at admission, less effectiveness and efficiency on activities of daily living (ADLs) and mobility, a higher percentage of low responders, longer hospitalization, a higher percentage of persistent incontinence at discharge (20.5% vs 4.9%), and a lower percentage of high responders and patients returning home. The presence of USN was incompatible with a high therapeutic response, for both ADLs (OR= 2.94, 95% confidence interval [CI]= 1.05-8.20; b +/- standard error = 1.08 +/- .52, p< .05), and mobility (OR = 7.16, 95% CI = 2.78-18.44; b = 1.97 +/- .52, p < .001) and was a relevant prognostic factor for institutional discharge (OR = 5.62, 95% CI = 1.63-19.38; b = 1.73 +/-.63, p < .01, accuracy 88.41%). CONCLUSIONS: The results of this study provide further strong evidence of the relationship between USN and disability in right brain-damaged patients and of its unfavorable impact on rehabilitation, despite the cognitive training performed by all USN(+) patients.     

A functional diagnostic complexity index for rehabilitation medicine: measuring the influence of many diagnoses on functional independence and resource use

OBJECTIVE: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS). DESIGN: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups. DATA: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995. RESULTS: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission. CONCLUSION: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.