不同年龄脑卒中患者康复结局的比较

目的分析460例脑卒中患者临床资料的分析,探讨不同年龄组患者的康复结局。方法采用回顾性研究的方法,对1994-01/2001-12北京博爱医院收治的460例首发脑卒中患者的病历进行分析、比较<60岁和≥60岁两组患者住院时间和日常生活活动(ADL)的变化。结果60岁及以上患者的ADL入院、ADL出院分别为44±24,67±22,均小于60岁以下患者55±23,78±17(t=4.8,5.4,P<0.0001);ADL增加值无差异。年龄与ADL入院、ADL出院和住院时间的相关系数r和P值分别为r=-0.31,P=0.00;r=-0.32,P=0.00;r=0.11,P=0.01。结论年龄较长的患者,入院和出院时的功能状态均较差;不同年龄的患者可获得相同程度的功能改善。年龄与ADL入院、ADL出院成负相关,与住院时间成正相关,与ADL增加不相关。     

Pattern of functional change during rehabilitation of patients with hip fracture

OBJECTIVE: To examine the rate of functional change in 2 domains, activities of daily living (ADLs) and mobility, over 2 time periods during hip fracture rehabilitation. DESIGN: Retrospective analysis of data contained in an administrative dataset. SETTING: Seventy skilled nursing facilities (SNFs). PARTICIPANTS: People (N=351) receiving rehabilitation in SNFs from March 1998 to February 2003 after hip fractures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Rate of change in scores in the ADL and mobility domains of the FIM instrument during 2 time intervals of rehabilitation. RESULTS: The rate of functional change across 2 time intervals was constant for mobility (mean change in FIM points per day, .46 vs .49), but declined in the second time period for ADLs (mean change in FIM points per day, .55 vs .41). Executive function, length of stay (LOS), and medical complexity were related to rate of change in mobility, and baseline ADLs, executive function, living setting, and LOS were related to rate of change in ADLs. There was an interaction between rehabilitation phase and baseline mobility. People with lower baseline mobility had an increased rate of change during the second interval (mean change in FIM points per day, .41 vs .55), whereas those with higher baseline mobility had a decreased rate of change (mean change in FIM points per day, .50 vs .43). CONCLUSIONS: The pattern of functional change over time differed for ADL and mobility domains, and for specific groups of patients. The results have implications for goal setting and discharge planning.     

脑卒中偏瘫患者康复疗效的评价

79例脑卒中偏瘫住院患者,接受3个月至1年以上的康复治疗,所有患者分为3组,第1组40例病程在3个月以内,第2组22例病程在4～12个月,第3组17例病程在1年以上。在康复治疗前后,患者偏瘫肢体功能评测采用上田敏标准化的偏瘫功能12级法和Barthel指数等方法。每个病人均由康复医师、护士、理学治疗士、作业治疗士,必要时语言治疗士和社会工作者组成的小组进行2～3次以上的康复评价。结果表明,在脑卒中偏瘫患者手的机能、步行能力,以及日常生活活动等方面的进步,病程在3个月以内的明显地优于病程在4～12个月和1年以上的脑卒中患者(P<0.05)。而病程在4～12个月和1年以上的两组病人之间没有显著性差异。     

Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke

Di Monaco M, Schintu S, Dotta M, Barba S, Tappero R, Gindri P. Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke.

Objective

To investigate the relationship between severity of unilateral spatial neglect (USN) and functional recovery in activities of daily living after a right-hemisphere stroke.

Design

Observational study.

Setting

Rehabilitation hospital in Italy.

Participants

We investigated 107 of 131 inpatients with right-hemisphere stroke who were consecutively admitted to our rehabilitation hospital.

Interventions

Not applicable.

Main Outcome Measures

To assess USN severity, conventional and nonconventional Behavioral Inattention Tests (BITs) were performed at admission to inpatient rehabilitation at a median of 19 days after stroke occurrence. FIM was performed both on admission to and discharge from inpatient rehabilitation to assess functional autonomy. FIM efficiency (improvement of FIM score per day of stay length) and FIM effectiveness (proportion of potential improvement achieved) were calculated.

Results

Fifty-four (50.5%) of the 107 patients were affected by USN. In these 54 patients, both conventional and nonconventional BIT scores were significantly correlated with FIM scores assessed at discharge from rehabilitation: ρ values were .385 (P=.004) and .396 (P=.003), respectively. After adjustment for 7 potential confounders, including FIM scores before rehabilitation, we found a significant positive association between either conventional or nonconventional BIT scores and FIM scores after rehabilitation (r=.276, P=.047 and r=.296, P=.033, respectively), FIM efficiency (r=.315, P=.022 and r=.307, P=.025, respectively), and FIM effectiveness (r=.371, P=.006 and r=.306, P=.026, respectively).

Conclusions

Data support the independent prognostic role of USN severity assessed at admission to inpatient rehabilitation after a right-hemisphere stroke. Models aimed at predicting the functional outcome in stroke survivors may benefit from inclusion of USN severity.     

Models of rehabilitation – commonalities of interventions that work and of those that do not

Purpose.?To review models of rehabilitation and to consider factors that influence a models effectiveness or ineffectiveness.

Methods.?Narrative review, with consultation with researchers.

Results.?Whether rehabilitation works is arguably best considered from the perspective of the person with disability. Rehabilitation models can generally be considered as ‘complex interventions’ for which specific research approaches have been defined. It is more likely to be accepted by the people involved, and be more likely to work, if the complex intervention paradigm is used and if rehabilitation operates at the level of activity and participation, as defined by the WHO International Classification of Functioning, Disability and Health. Reasons for apparent ‘non-effectiveness’ of rehabilitation models are protean and can range from inadequately conceptualised health conditions, or interventions, to interference from ‘active’ control interventions, inappropriate outcome measures and, inadequate sample sizes.

Conclusion.?Many opportunities remain for future research into the effectiveness of models of rehabilitation and detection of what constitutes the crucial components.     

A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge

van den Berg-Emons RJ, Bussmann JB, Haisma JA, Sluis TA, van der Woude LH, Bergen MP, Stam HJ. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge.

Objectives

To assess the change over time in the physical activity level after a spinal cord injury (SCI), to explore its determinants, and to compare the physical activity level 1 year after discharge from the rehabilitation center with the level in able-bodied persons.

Design

Prospective cohort study. Measurements were obtained at the start of active rehabilitation, 3 months later, at discharge, 2 months after discharge, and 1 year after discharge.

Setting

Rehabilitation center in The Netherlands and the participant's home.

Participants

Persons (n=40) with SCI.

Interventions

Not applicable.

Main Outcome Measures

The physical activity level, as indicated by the duration of dynamic activities (ie, wheelchair driving, walking, cycling, noncyclic movement) per day, and the intensity of everyday activity; both were measured with an accelerometry-based activity monitor during 2 consecutive weekdays.

Results

Random coefficient analyses showed that the duration of dynamic activities and the intensity of everyday activity increased during inpatient rehabilitation at rates of 41% and 19%, respectively (P<.01). Shortly after discharge, there was a strong decline (33%; P<.001) in the duration of dynamic activities. One year after discharge, this decline was restored to the discharge level but was low in comparison with levels in able-bodied persons. The level of lesion and completeness of lesion were determinants of the change in the physical activity level after discharge.

Conclusions

The physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge, and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge.     

Clients' and workers' perceptions on clients' functional ability and need for help: home care in municipalities

The aim of the study was to compare clients' and named home care (HC) workers' perceptions of clients' functional ability (FA) and need for help and to analyse which client- and municipality-related factors are associated with perceptions of client's FA. The total of 686 Finnish HC clients was interviewed in 2001. Further, the questionnaire was sent to 686 HC workers. FA was assessed by activities of daily living (ADL), which included both basic/physical (PADL) and instrumental (IADL) activities. The association between client's FA and municipality-related variables was analysed by using hierarchical logistic regression models. The findings indicated that clients' and HC-workers' perceptions about what the clients were able to do were similar in the PADL functions, but perceptions differed when it comes to the IADL functions for mobility and in climbing stairs. A smaller proportion of clients compared with HC workers assessed themselves to be in need of help in all ADL functions. Use of home help and bathing services increased the probability of belonging to the 'poor' FA class while living alone and small size of municipality decreased the probability. The study indicates that although clients and workers assessed client's FA fairly similarly, there were major differences in perceptions concerning clients' needs for help in ADL functions. Clients' and workers' shared view of need for help forms a basis for high-quality care. Therefore, the perception of both the clients and workers must be taken into account when planning care and services. There was also variation in clients' FA between municipalities, although only the size of municipality had some association with the variation. The probability that clients with a lower FA are cared for in HC is higher if the clients live in large- rather than small-sized municipalities. This may reflect a better mix of services and resources in large-sized municipalities.     

康复训练对脑血栓形成偏瘫患者功能恢复的影响

以４０例急性期，恢复早期脑血栓形成偏瘫患者为研究对象，随机分为康复组和对照组，康复组运用神经促通技术，循序进行康复训练，心理疏导和适度的ＡＤＬ训练，功能评定采用Ｌｉｎｄｍａｒｋ感觉运动功能评定表和ＢａｒｔｈｅｌＡＤＬ指数，结果为３周后，康复组主动运动功能，快速运动变换能力，姿位转换及平衡功能明显提高，与康复前及对照组间差异显著；腕，手功能，行走能力与对照组无显著差异，ＡＤＬ指数提高，与对照组间存在     

Occupational therapy for complex inpatients with stroke: identification of occupational needs in post-acute rehabilitation setting

Purpose: Inpatients admitted to rehabilitation express needs not linked to disease causing hospitalization.

This observational cross-sectional study identifies features and occupational needs of complex inpatients during rehabilitation, focusing on function and ability, regardless of diagnosis.

Method: This study included sixteen adult inpatients with stroke, deemed complex according to Rehabilitation Complexity Scale-Extended, at admission to Rehabilitation ward (from July 2014 to February 2015). Patients with primary psychiatric disorders, language barriers, cognitive or severe communication deficits were excluded. Upon admission, a multidisciplinary team collected data on general health, independence in daily activities (Modified Barthel Index), fatigue (Fatigue Severity Scale), resistance to sitting and ability to perform instrumental activities (Instrumental Activities of Daily Living). The occupational therapist identified occupational needs according to Canadian Occupational Performance Measure.

Results: Inpatients enrolled in this study were dependent in basic ADL, limited in instrumental ADL and easily fatigable. Their occupational needs related to self-care (75%) and, to a lesser extent, productivity (15%) and leisure (10%). According to inpatients, rehabilitation process should firstly address self-care needs, followed by productivity and leisure problems.

Conclusions: Despite small sample size, this study described patterns of occupational needs in complex inpatients with stroke. These results will be implemented in client-centered rehabilitation programs to be tested in a phase-two trial. [NCT02173197]

• Implications for Rehabilitation

• Priority occupational needs of complex inpatients with stroke during rehabilitation are focused on self-care area.

• Productivity and leisure problems also arise in early post-acute phase.

• Client-centered rehabilitation programs should firstly address self-care needs and, later on, they should also focus on the recovery of family and social roles.

     

Inpatient rehabilitation following burn injury: patient demographics and functional outcomes

OBJECTIVE: To identify demographic characteristics of burn patients referred for inpatient rehabilitation, the benefits of rehabilitation in this population, and factors that influence functional outcome. DESIGN: Retrospective chart review. SETTING: Free-standing rehabilitation hospital. PARTICIPANTS: Patients (N=129) admitted for inpatient rehabilitation after a burn injury. INTERVENTION: Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURES: Demographic data and the FIM instrument on admission and discharge for all patients. RESULTS: Linear measures of functional status derived by Rasch analysis of the FIM showed significant improvements from admission to discharge for all patients. There was no correlation between total body surface area (TBSA), premorbid psychiatric alcohol or drug abuse history, and change between admission and discharge FIM score. There was a significant correlation between TBSA burn and age and between TBSA and length of stay. CONCLUSIONS: Burn patients referred for inpatient rehabilitation are either older or have large TBSA burns. All patients made significant functional improvements and consequently inpatient rehabilitation can be considered an important component of care after a burn injury.     

Early and intensive rehabilitation predicts good functional outcomes in patients admitted to the stroke intensive care unit

Purpose.?Earlier and more intense rehabilitation benefit stroke patients. Yet, studies have caution intensive therapy during acute brain injury. This study examined the rehabilitation commencement time and intensity as predictors of functional outcomes in acute stroke patients admitted to the stroke intensive care unit (ICU).

Method.?Sociodemographic, medical, rehabilitative and functional data were collected on 154 acute stroke patients. Regression analyses were used to identify predictors for the basic activities of daily living (Barthel Index, BI) and the walking ability at discharge.

Result.?Rehabilitation commencement time and intensity significantly predicted the BI score at discharge after adjusting for initial severity (National Institute of Health Stroke Scale, NIHSS) and age (p?<?0.05). For the walking function at discharge, only the rehabilitation intensity was a significant predictor after adjusting for initial severity and age (p?<?0.05). Furthermore, with increasing rehabilitation intensity, patients with severe stroke benefited more than those with moderate stroke.

Conclusion.?Rehabilitation commencement time and intensity, after adjusting for admission functional status and severity of stroke, remained to be important predictors of stroke functional outcomes. This study supported the recommendation to commence rehabilitation early and intensively and provided evidence that this claim can be extended to acute stroke patients admitted to an ICU.     

早期康复教育对脊髓损伤患者日常生活活动能力及功能独立性的影响

目的探讨早期康复教育介入早期康复训练对脊髓损伤患者日常生活活动能力(ADL)及功能独立性的影响。方法将76例脊髓损伤患者随机分成康复教育组和对照组,康复教育组在进行早期康复训练前进行科学的康复教育,而对照组只做康复训练。用Barthel指数和功能独立性评定法(FIM)对两组患者在入院和出院时各评定1次。结果出院时康复教育组和对照组的Barthel指数和FIM评分分别是81.16±10.56、99.86±11.23和68.42±11.55、89.95±10.64,两组患者的功能均有提高,但康复教育组功能改善程度高于对照组,差异有统计学意义(P0.01)。结论早期康复教育介入早期康复训练对脊髓损伤患者功能恢复有积极意义。     

影响脑卒中患者日常生活活动能力预后的相关因素分析

目的：探讨脑卒中偏瘫患者治疗前后影响日常生活活动（ADL）能力的相关因素。方法：选择可能对脑卒中患者临床预后有影响的因素，以入院康复治疗1个月后改良Barthel指数为标准，进行回顾性和多因素分析。入选病例为17例脑卒中偏瘫患者。结果：康复治疗1个月后患者的ADL能力主要与治疗前的ADL能力呈正相关。与年龄、发病天数、肺部感染、尿路感染、关节挛缩等呈负相关。结论：并发症的发生是脑卒中患者ADL能力恢复的主要影响因素。提示要积极预防并发症，并对患者的家属和护理人员进行康复护理教育。同时强调早期康复治疗对于促进脑卒中患者ADL能力的恢复是十分重要的。     

Poor functional status immediately after discharge from an intensive care unit

Purpose.?To evaluate the functional status of patients within the first week of discharge from an intensive care unit (ICU), and to identify predictors and explanatory factors of functional status.

Methods.?A prospective, observational, cohort study was conducted with consecutive ICU patients who had stayed in a mixed, closed-format, university-level ICU for longer than 48 h.

Results.?Between 3 and 7 days of discharge from the ICU, functional status (as primary outcome), walking ability, muscle strength, and sensory and cognitive functioning were assessed in 69 survivors. The overall functional status was poor (median Barthel Index 6). In their ability to perform basic activities of daily living, 67% percent were severely dependent, 15% were moderately dependent, and 9% were slightly dependent on other people. Independent walking was impossible for 73% of participants, grip strength was reduced for 50%, and 30% had cognitive impairments. Duration of ventilation was associated with functional status after ICU discharge. Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU.

Conclusion.?In the first week after discharge from the ICU, the majority of the patients had substantial functional disabilities in activities of daily living. These disabilities were more severe in patients who experienced ventilation for a longer period of time. There is a need for prospective studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge.     

Exploring functional outcomes and allied health staffing levels in an inpatient paediatric rehabilitation unit

Purpose: This study provides data from a paediatric tertiary hospital on the length of stay, functional improvement and allied health workload for children and adolescents on active inpatient rehabilitation programs.

Methods: An audit was conducted of records of patients managed through an inpatient rehabilitation program at a 359 bed tertiary children’s hospital in Brisbane, Australia between December 2014 and December 2015. Data relating to diagnosis, length of stay, functional change, occasions of allied health service and hours of patient attributable allied health professional time were collected.

Results: Data on 94 children and adolescents with a total of 102 rehabilitation episodes of care were sourced. The greatest average length of stay was for the “Stroke” group. The highest average allied health professional contact hours were for the “Brain Dysfunction – Traumatic” group. The greatest average functional change was observed in the “Brain Dysfunction- Traumatic group.” Physiotherapy accounted for the largest proportion of allied health professional service time, with an average of 32% of total time.

Conclusions: This review from a tertiary hospital-based inpatient paediatric rehabilitation service provides information regarding the length of stay, functional change and allied health workload for children and adolescents on active inpatient rehabilitation programs. As expected, total and rehabilitation episode length of stay, functional improvement and allied health contact and input varied according to diagnostic groups. This information is likely to be of value to other Paediatric Rehabilitation Medicine inpatient units when developing staffing for services and benchmarking service delivery.

• Implications for Rehabilitation

• Paediatric Rehabilitation Medicine supports children and adolescents to achieve the highest level possible of physical, cognitive, psychological and social functioning following accident or injury.

• There are little data in the literature to inform the optimal allied health staffing levels required for intensive inpatient multidisciplinary for children and adolescents suffering acquired neurological impairments.

• Data from this tertiary hospital-based paediatric inpatient rehabilitation program provide information on the length of stay, functional improvement and allied health professional contact for patients across broad diagnostic groupings.

• This information is useful for other paediatric rehabilitation services when planning for allied health staffing in service development.

     

Mobility and functional outcomes after femoral neck fracture surgery in elderly patients: a comparison between hemiarthroplasty and internal fixation

Purpose.?To find out whether patients with femoral neck fracture treated with hemiarthroplasty differ from those treated with internal fixation regarding functional outcome, walking ability, pain or short-term mortality.

Method.?Sixty-six patients aged 64 years or more with femoral neck fracture were included in a prospective non-randomised trial with two equal-sized groups recruited consecutively within each group. All patients were treated operatively and encouraged to pursue an active rehabilitation. They were reviewed at admission, before discharge and 3 months after surgery. Assessments included demographic data, length of hospitalisation, post-operative medical complications, activities of daily living, walking ability, pain and mortality.

Results.?There were no significant differences between the two groups in terms of age, gender, ability to walk, functional status or at admission. The patients treated with hemiarthroplasty had a longer total hospital stay due to longer waiting time to operation. They started to walk sooner after operation and walked better during hospitalisation. Their walking distance at discharge was longer; their improvement in functional independence, as measured by the Functional Independence Measure, was also higher, but this difference was not statistically significant. Observed mortality in the hemiarthroplasty group was lower.

Conclusion.?A longer follow-up would be necessary to determine whether the preferable outcomes of hemiarthroplasty persist in the long-term.     

“疏经通络操”对恢复期脑卒中患者运动康复的影响研究

目的探讨"疏经通络操"对恢复期脑卒中患者康复的疗效。方法将108例恢复期脑卒中患者按入院先后顺序分成观察组(52例)和对照组(56例)。两组患者在入院后均接受神经内科常规药物治疗,对照组按常规进行治疗及康复护理,观察组在常规治疗及康复护理的基础上采用自创"疏经通络操"进行康复锻练。两组患者入院后第3天及第2个月、第6个月各评价FMA(运动功能)和Barthel指数一次。结果康复护理后两组FMA、Barthel指数均比康复前好转,且6个月后观察组运动功能评分、生活自理能力较对照组改善更明显,差异有统计学意义(P0.01)。Logistic回归方程显示,不吸烟者脑卒中好转的情况是吸烟患者的20.41倍;而文化程度和参加本研究治疗方案是脑卒中好转情况的保护性因素,也就是说文化程度每升高一级,脑卒中好转的情况就增加2.135倍,参加该治疗方案的患者脑卒中好转的情况是未参加患者的3.729倍;其他各因素在本研究中差异均无统计学意义(P0.05)。结论疏经通络操可促进脑卒中患者康复效果,提高其生活质量。     

Predictors of basic and instrumental activities of daily living performance in persons receiving rehabilitation services

OBJECTIVE: To examine the relations among cognitive and emotional function and other patient impairment and demographic variables and the performance of daily activities. DESIGN: Cohort. SETTING: Acute inpatient rehabilitation, skilled nursing facilities, home care, and outpatient clinics. PARTICIPANTS: Adults (N=534) receiving services for neurologic (32.3%), lower-extremity orthopedic (42.7%), or complex medical (24.9%) conditions. Mean age was 63.8 years; 55% were women; 88.6% were white; and the time since condition onset ranged from 0.2 to 3.9 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activity Measure for Post-Acute Care: applied cognitive, personal care and instrumental, and physical and movement scales; Mental Health Inventory-5 (MHI-5); and patient-identified problems (vision, grasp). RESULTS: Path analyses resulted in good model fit both for the total sample and 3 patient subgroups (chi(2) test, P>.05; comparative fit index >.95). There was a significant (P<.05) direct relation between the applied cognitive, grasp, and personal care and instrumental variables in all patient groups. There were also significant indirect relations between the MHI-5, visual impairment, and grasp problems with the personal care and instrumental scale through an association with the applied cognitive scale. Strength and significance of associations between age, sex, and physical and movement and personal care and instrumental scales varied more across patient groups. The model R(2) for the personal care and instrumental scale for the total sample was .60, with R(2) values of .10, .72, and .62 for the lower-extremity orthopedic, neurologic, and complex medical groups, respectively. CONCLUSIONS: Results suggest that variations in cognitive function, along with visual impairment and lower perceived well-being are associated with a patient's ability to complete daily activities. Rehabilitation professionals should consider cognitive and emotional factors as well as physical performance when planning treatment programs to restore daily activity function.     

Effect of short-duration,limited rehabilitation on maintenance of the activities of daily living in patients with acute phase of COVID-19

[Purpose] To determine whether short-duration, limited rehabilitation is effective in patients with COVID-19. [Participants and Methods] Single-center, retrospective, observational study. Thirty-six inpatients were classified into the three groups: a close contact (CC) group with a negative polymerase chain reaction (PCR) test (n=14); a PCR–positive (PP) group (n=15); and a PCR–positive and transfer (PT) group with severe COVID-19 patients who were transferred to an acute care hospital for treatment and then returned to our hospital (n=7). Short-duration, limited rehabilitation was provided to the CC and PP groups in isolated rooms by a therapist wearing full personal protective equipment, and we assessed the changes in their activities of daily living. [Results] The patients’ clinical characteristics at baseline were similar among the three groups. Functional Independence Measure scores in the CC, PP, and PT groups were not different at baseline (69 ± 29, 53 ± 26, and 63 ± 32), but differed after control of COVID-19 (63 ± 25, 47 ± 24, and 32 ± 19). Multivariate regression analysis showed that the implementation of a customized self-exercise program and the Mini Nutritional Assessment Short-Form at baseline were independently associated with Functional Independence Measure score after control of COVID-19. [Conclusion] These results suggest that even short-duration, limited rehabilitation may be effective for preventing decreases in activities of daily living in patients with COVID-19.