Racial disparities in outcomes of inpatient stroke rehabilitation

OBJECTIVE: To determine whether race is associated with outcomes of inpatient stroke rehabilitation. DESIGN: Retrospective cohort study. SETTING: A community-based inpatient rehabilitation facility. PARTICIPANTS: Poststroke patients (N=1002) admitted to a community-based inpatient rehabilitation facility between 1995 and 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional improvement at discharge from the rehabilitation facility, discharge disposition, and functional improvement at 3 months after discharge. Inpatient and follow-up data were collected from the facility's electronic patient database. We used the FIM instrument to assess functional status at admission, discharge, and follow-up. RESULTS: In multivariable models, blacks achieved less functional improvement at discharge (-1.9 FIM points, P=.02) compared with whites and, despite worse FIM scores, were more likely to be discharged to home (adjusted odds ratio=1.7; 95% confidence interval, 1.1-2.5). Although Asian-American patients did not differ from whites in terms of functional improvement at discharge or disposition, they had less improvement at 3 months following discharge (-6.3 FIM points, P=.005). CONCLUSIONS: We identified racial disparities in poststroke outcomes in a community-based inpatient rehabilitation facility. Future research in stroke rehabilitation should explore the consistency of these findings across settings and if they are confirmed, identify explanatory mediators to better inform efforts to eliminate racial disparities.     

脑卒中患者全程康复护理效果的比较

目的研究全程康复护理干预对脑卒中患者患侧肢体感觉运动功能和生活质量的影响。方法将80 例急性脑卒中患者随机分为实验组41人和对照组39人。实验组患者进行早期康复护理并持续至出院后3月,于入院时、出院时和出院后3月分别行患侧肢体感觉运动功能评估;于出院后1周和出院后3月行生活质量评定。结果康复组患者患肢运动功能(A部、B部、C部、D部、G部)明显提高,生活质量亦有明显提高,统计学检验有意义(P<0．05或P<0．01),而感觉功能、关节疼痛分值(E部、F部)经检验差异无显著意义(P>0．05)。结论全程康复护理干预可有效提高脑卒中患者患肢运动功能和生活质量。     

An observation-based intervention for stroke rehabilitation: experiences of eight individuals affected by stroke

Purpose.?To explore eight individuals’ experiences and responses to taking part in a personalised observation-based intervention for stroke rehabilitation.

Methods.?Eight participants who had experienced a cerebrovascular accident were recruited to a 16-week observation-based intervention. Participants were interviewed face-to-face to explore their responses to, and experiences of, taking part in the intervention. A list of topics, derived from the intervention process and earlier studies provided a provisional structure for the interview. All interviews were transcribed, coded and analysed using inductive content analysis to explore the impact of the observational intervention for these participants.

Results.?Three main themes emerged: physical function, behaviour change and DVD content. Lower order themes were also identified. These included: interaction with the physiotherapist; ability to complete tasks; and increased motivation to (re)engage in activities of everyday living.

Conclusion.?The findings suggest that a programme of action observation, linked to individualised and meaningful motor behaviours can provide a valid intervention for individuals affected by stroke by serving as a motivating agent to (re)engage in activities which they had believed they could not perform following their stroke. There was also evidence for positive affect on psychological wellbeing and motor function.     

脑卒中患者早期康复的预后研究

目的：探讨急性脑卒中患者早期康复治疗的重要性、安全性及其对预后的影响。方法：将６０例发病１周内的急性脑卒中患者随机分为早期康复组和对照组,每组３０例,两组一般治疗相同,早期康复组由经过专业训练的治疗师给予系统的康复训练。采用临床功能缺损评分表,简式Ｆｕｇｌ－Ｍｅｙｅｒ运动评分（ＦＭＡ）和修订的巴氏指数（ＭＢＩ）定期对两组进行康复评价。结果：临床神经功能缺损评分、ＦＭＡ评分、ＭＢＩ评价结果显示,治疗     

健康调查简表和脑卒中影响量表在脑卒中康复临床中应用情况的调查分析

摘要 目的：了解健康调查简表（SF-36）和脑卒中影响量表（SIS）在我国脑卒中康复临床的使用情况以及被认可程度。 方法：采用自行设计的网络问卷对国内三甲医院中从事脑卒中康复临床工作且具有一定资历的康复医师和康复治疗师进行调查。 结果：共回收有效问卷151份。SF-36和SIS在脑卒中康复中的临床使用率分别为31.13%和22.52%。同一量表在不同工作岗位的康复医师和（或）治疗师之间的使用率比较,差异无显著性意义（P>0.05）。临床对SIS的总体认可度高于SF-36（P<0.05）,主要表现在量表的测试结果对诊断疾病及制定临床方案和出院计划的帮助三个方面。 结论：SF-36和SIS在我国脑卒中康复临床的生存质量评定中尚未获得普及应用,需增强患者的全面康复意识,加强对康复医师及治疗师的规范化培训,适时对量表进行修订使其更适用于我国脑卒中患者的生存质量评定。     

脑卒中偏瘫患者早期康复效果的观察

采用随机的对照方法,比较65例脑卒中早期康复患者的近期预后和63例非康复患者的近期预后,发现早期康复组的运动功能和ADL均优于对照组(P<0.0005),且前者废用表现较轻P(<0.0005)。证明早期康复的效果是非常明显的。     

Racial disparities in stroke functional outcomes upon discharge from inpatient rehabilitation facilities

Purpose.?Analyse racial disparities in clinical outcomes after stroke in inpatient rehabilitation facilities (IRF).

Methods.?Analyses based on data from a multi-center prospective observational cohort study on inpatient stroke rehabilitation in six IRFs from across the United States. Multivariate models examined racial disparities in functional outcomes upon discharge, taking into account patient characteristics and detailed information on processes of care.

Results.?In the moderate stroke group (N?=?397), functional scores on admission were not significantly different between African-Americans and whites. In the severe stroke group (N?=?335), whites showed significantly lower functional scores at admission [Functional Independence Measurement, (FIM)], mean scores, 44 versus 49 for African-Americans, p?<?0.001). Multivariate analyses predicting discharge motor FIM score found no significant differences between African-American and white stroke patients (p?=?0.2194 and p?=?0.3547 in the moderate and severe stroke group, respectively).

Conclusion.?Controlling for patient characteristics, therapy intensity and processes of care results in non-significant differences between African-Americans and whites in motor FIM scores upon discharge. The absence of significant differences in recovery while patients were on the rehabilitation unit suggests that racial disparities in long-term functional recovery after stroke are likely to have originated before or after the inpatient rehabilitation stay.     

Assessing the impact of a home-based stroke rehabilitation programme: a cost-effectiveness study

Background: Stroke is often a severe and debilitating event that requires ongoing rehabilitation. The Community Stroke Rehabilitation Teams (CSRTs) offer home-based stroke rehabilitation to individuals for whom further therapy is unavailable or inaccessible. The objective of this study was to evaluate the cost-effectiveness of the CSRT programme compared with a “Usual Care” cohort.

Methods: We collected data on CSRT clients from January 2012 to February 2013. Comparator data were derived from a study of stroke survivors with limited access to specialised stroke rehabilitation. Literature-derived values were used to inform a long-term projection. Using Markov modelling, we projected the model for 35?years in six-month cycles. One-way, two-way, and probabilistic sensitivity analyses were performed. Results were discounted at 3% per year.

Results: Results demonstrated that the CSRT programme has a net monetary benefit (NMB) of $43,655 over Usual Care, and is both less costly and more effective (incremental cost?=??$17,255; incremental effect?=?1.65 Quality Adjusted Life Years [QALYs]). Results of the probabilistic sensitivity analysis revealed that incremental cost-effectiveness of the CSRT programme is superior in 100% of iterations when compared to Usual Care.

Conclusions: The study shows that CSRT model of care is cost-effective, and should be considered when evaluating potential stroke rehabilitation delivery methods.

• Implications for Rehabilitation

• Ongoing rehabilitation following stroke is imperative for optimal recovery.

• Home-based specialised stroke rehabilitation may be an option for individuals for whom ongoing rehabilitation is unavailable or inaccessible.

• The results of this study demonstrated that home-based rehabilitation is a cost-effective means of providing ongoing rehabilitation to individuals who have experienced a stroke.

     

Patient-specific functional electrical stimulation strategy based on muscle synergy and walking posture analysis for gait rehabilitation of stroke patients

ObjectiveTo evaluate a novel multi-channel functional electrical stimulation (FES) rehabilitation method based on the evaluation of patient-specific walking dysfunction.MethodsThis study investigated a novel multi-channel FES-based rehabilitation method that analysed the patient’s muscle synergy and walking posture. A patient-specific FES profile was produced in the pre-evaluation stage by comparing the muscle synergy and walking posture of the patient with those of healthy control subjects. During the rehabilitation phase, this profile was used to determine an appropriate FES pulse width and amplitude for stimulating the patient’s muscles as they walked across a flat surface.ResultsTwo stroke patients with hemiplegic symptoms participated in a clinical evaluation of the proposed method involving a 4-week course of rehabilitation. An evaluation of the rehabilitation results based on a comparison of the pre- and post-rehabilitation muscle synergy and walking posture revealed that the rehabilitation enhanced the muscle synergy similarity between the patients and healthy control subjects and their quantitative walking performance, as measured by a 10-m walk test and walking speed, by up to 23.38% and 30.00%, respectively.ConclusionThese results indicated that the proposed rehabilitation method improved walking ability by improving muscle coordination and adequately supporting weakened muscles in stroke patients.     

运动想象疗法在脑卒中康复中的应用现状

综述运动想象(MI)的概念、机制以及在脑卒中康复的应用现状。目前MI的研究虽多,但各研究的治疗方案并无统一标准,仍需大样本、多中心的随机对照临床研究,以验证并形成一套规范化的治疗方案。现有研究将运动想象在社区护理中进行应用和强化的较少。     

Predicting employment outcomes of rehabilitation clients with orthopedic disabilities: A CHAID analysis

Purpose.?To examine demographic and service factors affecting employment outcomes of people with orthopedic disabilities in public vocational rehabilitation programs in the United States.

Method.?The sample included 74,861 persons (55% men and 45% women) with disabilities involving the limbs or spinal column who were closed either as rehabilitated or not rehabilitated by their state-run vocational rehabilitation agencies in the fiscal year 2001. Mean age of participants was 41.4 years (SD?=?11.2). The dependent variable is employment outcomes. The predictor variables include a set of personal history variables and rehabilitation service variables.

Results.?The chi-squared automatic interaction detector (CHAID) analysis indicated that job placement services significantly enhanced competitive employment outcomes but were significantly underutilized (only 25% of the clients received this service). Physical restoration and assistive technology services along with support services such as counseling also contributed to positive employment outcomes. Importantly, clients who received general assistance, supplementary security income, and/or social security disability insurance benefits had a significant lower competitive employment rates (45%) than clients without such work disincentives (60%).

Conclusion.?The data mining approach (i.e., CHAID analysis) provided detailed information and insight about interactions among demographic variables, service patterns, and competitive employment rates through the segmentation of the sample into mutually exclusive homogeneous subgroups.     

Assessments in Australian stroke rehabilitation units: a systematic review of the post-stroke validity of the most frequently used

Purpose.?In Australia, stroke is the leading cause of adult disability. For most stroke survivors, the recovery process is challenging, and in the first few weeks their recovery is supported with stroke rehabilitation services. Stroke clinicians are expected to apply an evidence-based approach to stroke rehabilitation and, in turn, use standardised and validated assessments to monitor stroke recovery. In 2008, the National Stroke Foundation conducted the first national audit of Australia's post acute stroke rehabilitation services and findings identified a vast array of assessments being used by clinicians. This study undertook a sub-analysis of the audit's assessment tools data with the aim of making clinically relevant recommendations concerning the validity of the most frequently selected assessments.

Method.?Data reduction ranked the most frequently selected assessments across a series of sub-categories. A serial systematic review of relevant literature using Medline and the Cumulative Index to Nursing and Allied Health Literature identified post-stroke validity ranking.

Results.?The study found that standardised and non-standardised assessments are currently in use in stroke rehabilitation. It recommends further research in the sub-categories of strength, visual acuity, dysphagia, continence and nutrition and found strengths in the sub-categories of balance and mobility, upper limb function and mood.

Conclusions.?This is the first study to map national usage of post-stroke assessments and review that usage against the evidence. It generates new knowledge concerning what assessments we currently use post stroke, what we should be using and makes some practical post stroke clinical recommendations.     

Predicting goal achievement during stroke rehabilitation for Medicare beneficiaries

Abstract

Purpose: Few studies have investigated the ability of treatment teams to predict functional improvement and whether an association between predicted goals and discharge function in patients with stroke exists. This study investigated goal prediction during stroke rehabilitation delivered in inpatient rehabilitation facilities (IRF) and the factors associated with goal prediction. Methods: A serial, cross-sectional design analyzing the Medicare IRF Patient Assessment Instrument dataset. The sample included 179?479 admissions for stroke aged over 65 years in 968 IRFs. Generalized estimating equations (GEE) controlled for facility cluster effects were used for analysis of time trends for length of stay (LOS), predicted Functional Independence Measure (FIM) scores, discharge FIM scores and predicted-discharge difference FIM scores (goal FIM scores minus discharge FIM scores). GEE models were employed to determine the correlation between predicted FIM and discharge FIM scores and factors associated with goal achievement. Results: Mean LOS, predicted FIM scores and discharge FIM scores decreased 1.8?d, 2.2 points and 3.6 points, respectively, while predicted-discharge difference FIM scores increased 1.3 points. Discharge goals were not met 78.9% of the time. After controlling for patient characteristics, each predicted FIM point was associated with 0.6 discharge FIM points (p?<?0.0001). Factors associated with not meeting or exceeding goals were: age (odds ratio; OR?=?0.997), African Americans (OR?=?0.905), number of comorbidities (OR?=?0.970), number of complications (OR?=?0.932) and right brain stroke (OR?=?0.869). Factors associated with meeting or exceeding goals were: LOS (OR?=?1.03), admission FIM score (OR?=?1.02) and females (OR?=?1.05). Conclusions: Trends for lower goals and lower discharge function occurred over time. A correlation existed between predicted FIM scores and discharge FIM scores. Patient factors were associated with goal achievement.

• Implications for Rehabilitation

• Using the Functional Independence Measure, rehabilitation teams set lower goals for stroke rehabilitation in inpatient rehabilitation facilities during first 5.5 years of the IRF-PAI dataset.

• Discharge FIM scores also trended lower and fell at faster rate than goal FIM scores.

• Teams’ goal FIM scores averaged nearly 12 points higher than discharge FIM scores, and over 75% of patients did not reach goals for the rehabilitation stay.

• Factors associated with meeting or exceeding goals were: length of stay, admission FIM scores and being a female. Factors associated with not meeting or exceeding goals were: age, number of comorbidities and complications, having a right-brain stroke and being African American.

     

脑卒中患者康复护理研究进展

脑卒中是一种常见病、多发病。康复训练的早期介入在保持患者社会适应性方面具有重要意义。本文对脑卒中患者早期康复的意义、目标、康复介入时间、康复护理内容、注意事项等进行综述。     

家庭康复护理对脑卒中家庭护理者护理能力的影响

目的 研究家庭康复护理干预对脑卒中家庭护理者护理能力的影响。方法 采用以社区为基础的对照试验研究。将60名社区脑卒中家庭主要护理者按其患者随机分组分别进入干预组和对照组,各30人。培训社区护士根据“脑卒中家庭康复护理干预方案”实施干预,于1、3个月时对护理者进行各项护理能力评定。结果 干预组护理者各项护理能力提高较对照组显著,统计学检验差异有显著意义(P=0．00)。结论 家庭康复护理干预可有效提高脑卒中家庭护理者的护理能力。     

多功能锤叩击穴位对中风康复的影响

目的 探讨患者使用按摩锤叩击穴位对脑卒中早期康复疗效的影响.方法 将80例脑卒中患者随机分成治疗组和对照组各40例,对照组给予脑卒中常规护理,治疗组增加按摩锤穴位叩击.每周对两组患者进行运动功能及日常生活能力的评定,将所得数据运用SPSS 10.0统计软件进行数据分析.结果 在给予干预措施25 d后,治疗组、对照组间肢体运动功能和神经功能恢复比较,差异有统计学意义(P<0.01),治疗组各项指标均显著优于对照组.结论 患者使用按摩锤叩击穴位,能明显改善肢体运动功能,提高生活质量.     

康复干预时间对脑卒中偏瘫患者预后的影响

目的：探讨康复干预时间对脑卒中偏瘫患者预后的影响。方法：９３例脑卒中偏瘫患者依康复介入时间不同分为超早期组（病后７天之内开始康复,４７例）和早期组（病后７～２９天开始康复,４６例）,全部患者在病情稳定,生命体征平稳后,按早期康复程序进行床边训练,每天１次,每次３０ｍｉｎ,其余时间由患者家属帮助练习。结果：治疗前两组资料可比,经平均３５天治疗后,两组运动功能、平衡功能、ＡＤＬ及继发性损伤均无显著性差     

Friedman家庭评估模式在康复期脑卒中患者社区护理中的应用

目的探讨Friedman家庭评估模式在康复期脑卒中患者家庭康复中的应用效果。方法采用以家庭为基础的对照试验研究。将80例出院的脑卒中恢复期患者按出院先后顺序随机分为观察组和对照组,各40例。观察组采用Friedman家庭评估模式为指导的家庭康复护理干预。对照组采用常规的出院随访。结果观察组患者在运动功能、日常生活活动能力、生活质量方面均较对照组提高显著,差异有显著意义（P〈0．05）。结论应用Friedman家庭评估模式进行家庭护理干预可有效提高恢复期脑卒中患者的居家康复效果。     

早期康复对脑卒中患者功能活动能力的影响

采用FIM量表对68例急性脑卒中患者功能活动能力进行临床对照研究。两组患者在病后3月时的功能活动能力均有不同程度的改善，但康复组优于对照组（P＜0．001），在恢复独立功能活动者中，康复组16例（47．06％），对照组4例（11．76％）。研究结果表明，早期康复干预有助于脑卒中患者独立功能活动能力的恢复；患者在病后1月内，FIM评定为72．25±20．96分考，经早期康复治疗有可能达到功能活动独立。     

综合康复治疗对脑卒中饮食障碍患者的影响

目的:探讨综合康复治疗和护理对脑卒中饮食障碍患者的影响.方法:将150例脑卒中饮食障碍患者分成常规药物组、功能训练组、低频组、电针组、综合组各30例,给予相应治疗,观察各组治疗前、后饮食障碍的改善情况.结果:经康复治疗14d、28d后评估,综合组较常规药物组、功能训练组、低频组、电针组饮食功能的改善更显著(P＜0.05,P＜0.01).结论:在常规药物治疗的基础上,辅以吞咽功能训练、冰刺激、低频电刺激、电针刺激等综合康复措施是治疗脑卒中饮食障碍的最佳方案.