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.     

Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke

OBJECTIVES: To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition. DESIGN: Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period. SETTING: Free-standing urban rehabilitation hospital in the United States. PARTICIPANTS: Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria. INTERVENTION: Inpatient multidisciplinary comprehensive rehabilitation program. MAIN OUTCOME MEASURES: Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures. RESULTS: The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home. CONCLUSIONS: Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.     

Vitamin D status of patients admitted to a hospital rehabilitation unit: relationship to function and progress

OBJECTIVE: The primary objective was to determine the association between vitamin D status, baseline function, and short-term inpatient rehabilitation progress. DESIGN: This was a prospective convenience sampling of 100 patients in a tertiary general hospital rehabilitation unit (RU). The cohort comprised men and women of mixed race with a variety of diagnoses (mean age 70 yrs). Patient histories and demographic information were obtained by patient interview and chart review. Serum 25-hydroxyvitamin D (25OHD) (nmol/L) was measured on or after the day of admission. The Functional Independence Measurement (FIM) instrument, a validated survey tool, was used to measure function at admission and discharge. RESULTS: Eleven percent of the patients were overtly vitamin D deficient, with serum 25OHD concentrations <20 nmol/L. Ninety-four percent of the patients had serum 25OHD concentrations below the recommended minimum optimal concentration of 80 nmol/L. Using the Spearman rank correlation test, low serum 25OHD was weakly but significantly associated with low total FIM scores: r = 0.25 (P < 0.012) and r = 0.23 (P < 0.021) for admission and discharge total FIM score, respectively. Patients with serum 25OHD concentrations greater than the median value of 41.3 nmol/L had significantly higher FIM efficiency scores (discharge total FIM score - admission total FIM score/length of stay [LOS]) than the subgroup of patients below the median (2.0 +/- 1.1 vs. 1.6 +/- 0.9, respectively; P < or = 0.026). Serum 25OHD was not significantly correlated with FIM efficiency or the unadjusted change in total FIM score (discharge total FIM score - admission total FIM score), but it was significantly correlated with LOS (the lower the serum 25OHD concentration, the longer the LOS, and vice versa; r = -0.235, P < 0.018). Thus, the difference in FIM efficiency between patients with serum 25OHD above and below the median was the result of the significant inverse correlation between serum 25OHD and LOS; as a group, patients with serum 25OHD above the median had a 19% shorter LOS than the group with serum 25OHD below the median value (11.4 +/- 4.9 vs. 14.1 +/- 5.6 days, respectively; P = 0.005). CONCLUSIONS: Most patients in a hospital RU had a suboptimal serum 25OHD concentration, reflecting what has previously been observed in hospitalized patients in general and also the population at large. Although no specific physical deficits or attributes could be directly attributed to low serum 25OHD, the baseline functional status of RU patients, LOS, and progress attributable to inpatient rehabilitation (FIM efficiency) were favorably affected by higher serum 25OHD concentrations.     

Impact of an inpatient rehabilitation facility on functional outcome and length of stay of burn survivors

This study reviewed the use of an inpatient rehabilitation unit for burn survivors. We hypothesized that adult burn patients admitted earlier to inpatient rehabilitation have an equal or better functional outcome than those remaining in acute burn center for rehabilitation care. Functional Independence Measure (FIM) data were prospectively collected on our burn center admissions dating January 2002 to August 2003. National rehabilitation data were acquired from eRehabData and burn literature. A total of 217 adult patients survived until hospital discharge, with 21 (9.7%) discharged to inpatient rehabilitation (REHAB). REHAB had larger burn injuries, more inhalation injuries, higher incidence hand/foot burns, and longer length of stay (LOS). REHAB had lower FIM upon rehabilitation facility admission than national averages but greater FIM improvement during comparable rehabilitation LOS. Although our earlier rehabilitation admission strategy results in more frequent rehabilitation unit referrals, patients had shorter burn center LOS and greater FIM improvement compared with limited national burn patient functional outcome data currently available.     

Functional recovery following rehabilitation after hemorrhagic and ischemic stroke

OBJECTIVES: To quantify recovery after rehabilitation therapy and to identify factors that predicted functional outcome in survivors of intracerebral hemorrhage (ICH) compared with cerebral infarction. DESIGN: Retrospective study of consecutive ICH and cerebral infarction admissions to a rehabilitation hospital over a 4-year period. SETTING: Free-standing urban rehabilitation hospital. PARTICIPANTS: A total of 1064 cases met the inclusion criteria (545 women, 519 men; 871 with cerebral infarction, 193 with ICH). INTERVENTIONS: Not applicable.Main Outcome Measures: Functional status was measured using the FIM trade mark instrument, recorded at admission and discharge. Recovery was quantified by the change in FIM total score (DeltaFIM total score). Outcome measures were total discharge FIM score and DeltaFIM total score. Univariate and multivariate analyses were performed. RESULTS: Total admission FIM score was higher in patients with cerebral infarction than in patients with ICH (59 vs 51, P=.0001). No difference in total discharge FIM score was present. Patients with ICH made a significantly greater recovery than those with cerebral infarction (DeltaFIM total score, 28 vs 23.3; P=.002). On multivariate analysis, younger age, longer length of stay, and admission FIM cognitive subscore independently predicted total discharge FIM and DeltaFIM total score. The severity of disability at admission, indicated by total admission FIM score, independently predicted total discharge FIM score, but not DeltaFIM total score. The ICH patients with the most severely disabling strokes had significantly greater recovery than cerebral infarction patients with stroke of similar severity. CONCLUSIONS: The patients with ICH had greater functional impairment than the cerebral infarction patients at admission, but made greater gains. Patients with the most severely disabling ICH improved more than those with cerebral infarction of comparable severity. Initial severity of disability, age, and duration of therapy best predicted functional outcome after rehabilitation.     

The effects of dehydration on rehabilitation outcomes of elderly orthopedic patients

OBJECTIVE: To study the effects of dehydration, by using the indices of prerenal azotemia and orthostasis, on the rehabilitation outcomes of elderly orthopedic patients. DESIGN: Prospective, pilot study. SETTING: Regional inpatient rehabilitation center. PARTICIPANTS: A consecutive sample of 39 patients (29 women, 10 men), ranging in age from 58 to 94 years (mean, 78y), of whom 13 had total hip replacements, 12 had total knee replacements, and 14 had hip fractures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), change in the FIM trade mark instrument score, and discharge to home. RESULTS: The mean LOS was significantly longer in the group with prerenal azotemia (n=21, 12.9+/-3.0d, t=2.49, P<.01) than in the nonazotemic group (n=18, 9.4+/-4.6d). LOS was also significantly longer in the orthostatic group (n=18, 13.7+/-3.4d, t=2.94, P<.01) than in the nonorthostatic group (n=21, 9.8+/-3.9d). Two-way analysis of variance showed a statistically significant effect on LOS for both azotemia (F=8.4, P=.006) and orthostasis (F=10.5, P=.003). A statistical interaction existed (F=4.7, P=.038), but it was more pronounced in the absence of both conditions, as opposed to the presence of both. LOS for the group with both azotemia and orthostasis was 13.6+/-2.7 days (n=10, F=4.7, P=.038), in contrast to 7.2+/-2.8 days in the group without either condition (n=10). Of the patients who had neither azotemia nor orthostasis, 100% (n=10) went home; 80% (n=8) of patients who had both conditions went home. Logistic regression analysis, however, did not show a statistically significant correlation between discharge to home and the presence of azotemia, orthostasis, or both. CONCLUSION: Prerenal azotemia and orthostasis are present in a significant number of elderly orthopedic patients and have a major effect on rehabilitation 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.     

A preliminary examination of the CMS eligibility criteria in total-joint arthroplasty

OBJECTIVE: To analyze inpatient rehabilitation outcomes in total-knee arthroplasty (TKA) and total-hip arthroplasty (THA) patients using the 2004 Medicare 75% rule criteria. DESIGN: This retrospective study compared outcomes in unilateral TKA (UTKA), bilateral TKA (BTKA), and THA after interdisciplinary inpatient rehabilitation (n = 867). Patients were separated into three comparison pairs: 1) UTKA or BTKA, 2) age <85 yrs or > or =85 yrs, and 3) body mass index (BMI) <50 or > or =50 kg/m. Length of stay (LOS), functional independence measure (FIM) scores (total, motor, and cognitive), hospital charges, FIM efficiency, and discharge disposition were analyzed. RESULTS: BTKA improved total FIM score more than UTKA (43 vs. 38%; P = 0.039). TKA with BMI > or =50 kg/m had similar admission and discharge FIM motor scores compared with BMI <50 kg/m (P > 0.05). TKA patients > or =85 yrs had lower admission FIM scores, longer LOS (11.3 vs. 9.4 days), and 22% higher total charges than TKA patients younger than 85 yrs (P = 0.042). THA patients > or =85 yrs had 6-10% lower total FIM, FIM motor, and FIM cognition scores and were discharged to home less frequently than younger patients (P < 0.05). Total and daily charges were 21-162% higher in THA patients with BMIs > or =50 kg/m than in THA patients with BMIs <50 kg/m (P < 0.045). CONCLUSION: All patients made functional gains during rehabilitation. However, the most costly and lengthy rehabilitation occurred in TKA patients > or =85 yrs and THA patients with BMI > or =50 kg/m.     

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.     

Effects of gender on neurologic and functional recovery after spinal cord injury

OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.     

Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact

OBJECTIVE: To investigate the characteristics, predictors, and consequences of pressure ulcers in patients with nontraumatic spinal cord injury (SCI). DESIGN: Retrospective, 3-year, case series. SETTING: Tertiary medical unit specializing in SCI rehabilitation. PARTICIPANTS: Consecutive sample of 134 adult inpatient referrals with nontraumatic SCI. Patients requiring initial rehabilitation or readmission were included. INTERVENTION: Chart review. MAIN OUTCOME MEASURES: Primary outcome measures were presence of pressure ulcers on admission to rehabilitation, incidence of new pressure ulcers developing during hospitalization, and any complications attributable to pressure ulcers during inpatient rehabilitation. Secondary objectives were to examine the predictability of risk factors for pressure ulcers, to assess the usefulness of a model previously developed for predicting pressure ulcers in patients with chronic SCI, and to estimate the effect of pressure ulcers on rehabilitation of nontraumatic SCI. RESULTS: Prevalence of pressure ulcers among admissions was 31.3% (n=42). Only 2.2% (n=3) of patients developed a new pressure ulcer after admission. The length of stay (LOS) of patients admitted with a pressure ulcer was significantly longer than that of those without a pressure ulcer (geometric mean, 62.3 d for pressure ulcer vs 28.2 d for no pressure ulcer, P=.0001). Many previously identified risk factors for pressure ulcers in SCI patients did not apply to our nontraumatic SCI patients. It is estimated that the inpatient LOS for those patients with a significant pressure ulcer was increased by 42 days. CONCLUSIONS: Pressure ulcers are a common complication for people with nontraumatic SCI who are admitted for rehabilitation, and they have a significant impact on LOS.     

Outcomes in total knee arthroplasty patients after inpatient rehabilitation: influence of age and gender

OBJECTIVES: To examine age and gender effects on outcomes after inpatient rehabilitation in primary total knee arthroplasty (TKA) and revision TKA patients. DESIGN: This retrospective, comparative study was conducted in a 50-bed, university-affiliated rehabilitation hospital. Patients included primary TKA patients (n = 286) and revision TKA patients (n = 138) placed into one of three age brackets: <60 yrs, 60-70 yrs, or >70 yrs. Measurements included length of stay (LOS), FIM scores, hospital charges, and discharge disposition location. RESULTS: FIM scores improved from admission to discharge in both primary and revision patients (P = 0.015). LOS was shorter in primary than revision patients (8.3 vs. 10.4 days, P = 0.001), and the LOS was longest in patients >70 yrs compared with those <60 or 60-70 yrs (10.6 vs. 8.7 and 8.8 days, respectively; P = 0.004). FIM efficiency was greater in primary than in revision TKA patients (3.68 vs. 2.77 points/day, P = 0.001), and greater for men than women in each age bracket regardless of TKA type (3.68 vs. 2.78 points/day, P = 0.001). Total hospital charges were lower for men than women for both TKA types ($9,656 +/- 823 vs. $11,544 +/- 1,359; P = 0.015), and were highest in patients >70 yrs of age (P = 0.015). CONCLUSIONS: Primary and revision TKA patients make improvements in functional independence during inpatient rehabilitation. Although FIM gains were similar among age and gender groupings, FIM efficiency is lowest in women. Despite similar daily hospital costs among the groups, slower progress with functional gains (decreased FIM efficiency) increases the LOS and total hospital charges, especially in older women.     

Nonrandomized studies of rehabilitation for traumatic brain injury: can they determine effectiveness?

OBJECTIVE: To examine the feasibility of investigating rehabilitation effectiveness for traumatic brain injury (TBI) with a nonrandomized design. DESIGN: Observational cohort with confounder control by regression methodology. SETTING: Level I trauma center. PARTICIPANTS: Consecutive series of 365 individuals with TBI discharged to inpatient rehabilitation or home (78% follow-up). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Glasgow Outcome Scale (GOS), Sickness Impact Profile (SIP), Burden Inventory, and Perceived Quality of Life (PQOL). The predictors of interest: discharge to comprehensive inpatient rehabilitation or home and inpatient rehabilitation length of stay (LOS). RESULTS: Discharge to rehabilitation was associated with poorer functioning on the GOS (P=.03) and SIP (P=.57), an increase on the Burden Inventory (P=.14), and improved PQOL (P=.20). Similar results were found for longer lengths of inpatient rehabilitation. CONCLUSIONS: The results appear to be because of a confounding effect rather than rehabilitation. The study design could not control for confounding that resulted from unmeasured or difficult to measure aspects of the clinical decisions for discharge placement and rehabilitation LOS. Furthermore, typical severity indices were inadequate to control for injury severity and recovery. Matching designs that investigate TBI rehabilitation are also at risk for inadequate confounder control.     

Nontraumatic spinal cord injury: an Italian survey

OBJECTIVE: To describe the demographic and clinical characteristics and the clinical course of patients with nontraumatic spinal cord injury (SCI). DESIGN: A multicenter prospective study. SETTING: Thirty-two rehabilitation centers in several Italian regions. PARTICIPANTS: Patients with nontraumatic SCI (N=330) on first admission (February 1, 1997-January 31, 1999) to rehabilitation centers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Indicators of rehabilitation process quality were efficient bladder and bowel management. The indica-tor of neurologic recovery was improvement in American Spinal Injury Association Impairment Scale (AIS) level at discharge. The indicator of rehabilitation outcome was return home. Length of stay (LOS) was also measured as an indicator of the care process. RESULTS: Of the 330 patients, 30% exhibited an improvement in AIS classification at discharge, and 73% returned home. In multivariate analysis, a longer LOS was associated with vascular etiology, complete lesions, residence outside the district of the rehabilitation center, and presence of clinical complications. Neurologic improvement was related to incompleteness of the lesion and longer LOS. Factors predicting a return home were married status, incompleteness of lesion, clinical improvement, efficient bowel and bladder management, absence of pressure ulcers, and longer LOS. CONCLUSIONS: Patients showed long waiting times between diagnosis and initiation of rehabilitation, a good chance of improvement on the AIS, and low rates of home returns.     

Inpatient rehabilitation outcome after hip fracture surgery in elderly patients: a prospective cohort study of 946 patients

OBJECTIVE: To identify the factors associated with inpatient rehabilitation outcome after surgical repair of hip fracture in elderly patients. DESIGN: A noninterventional prospective cohort study. SETTING: Geriatric inpatient rehabilitation center in a tertiary university medical center in southern Israel. PARTICIPANTS: Patients (N=946) aged 65 years of age or older who were hospitalized for rehabilitation after surgery for hip fracture. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional studies by the FIM instrument and a broad spectrum of clinical, demographic, and social variables. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the percentage change in the FIM score during the course of rehabilitation in relation to the severity of the functional impairment at its inception. RESULTS: Eight variables were significantly and independently associated with rehabilitation outcome. Prefracture FIM scale (standardized regression coefficient in multiple regression [beta]=.261, P<.001), serum albumin at discharge (beta=.222, P<.001), Folstein Mini-Mental State Examination (beta=.174, P<.001), visual impairment (beta=-.089, P=.002), dyspnea at mild exertion (New York Heart Association class III) (beta=-.080, P=.005), age (beta=-.080, P=.007), poststroke motor impairment (beta=-.072, P=.011), and decreased serum folic acid (beta=-.055, P=.047). The total percentage of the explained variance of the primary rehabilitation outcome measure accounted for by these 8 variables (adjusted R(2)) was 31.9%. CONCLUSIONS: The outcome of rehabilitation of elderly patients after surgical repair of hip fracture is associated with 4 clinical and nutritional correctable parameters. The other 4 variables that are associated with the process cannot be corrected but may help predict outcomes and adjust expectations.     

Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation

OBJECTIVE: To retrospectively examine the effects of sex and age on the inpatient rehabilitation outcomes of patients after total hip arthroplasty (THA). DESIGN: Exploratory, retrospective study. SETTING: A university-affiliated rehabilitation hospital. PARTICIPANTS: Male and female THA patients (N=332) were stratified into age brackets (<65y, 65-84y, >or=85y). All patients completed interdisciplinary inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), FIM instrument scores, FIM efficiency (FIM/LOS), hospital costs, and discharge disposition location were collected by chart review. RESULTS: Regardless of age, women had lower FIM scores at admission and discharge than men (P<.05). FIM efficiency was 22% to 53% lower for women in primary THA and 16% to 85% lower in revision THA than men (P=.001). Women accrued higher total hospital charges than men (13,099 dollars vs 11,141 dollars; P<.05), and were discharged home less frequently than men (84.4% vs 90.9%; P<.05). Admission FIM scores were 10.6% and 8.9% lower and discharge FIM scores were 7.3% and 9.2% lower in patients 85 years or older than those less than 65 or 65 to 84 years (P<.01). FIM efficiency was 25% to 38% higher in patients less than 85 years than those 85 years and older (P=.015), and 37% higher in men than women (P=.001). Patients 85 years and older were discharged less frequently to home than patients less than 85 years (P<.05). CONCLUSIONS: All patients made functional improvement after inpatient rehabilitation, but women and patients 85 years and older had longer LOS and lower FIM efficiency, incurred greater hospital charges, and were less likely to be discharged to home than men and younger counterparts.     

FIM量表在外伤性颅脑损伤患者康复疗效评价中的应用

目的 :运用功能独立性评价量表 (FIM )评价外伤性颅脑损伤 (TBI)患者的康复治疗疗效 ,比较闭合性颅脑损伤 (CBI)和开放性颅脑损伤 (OBI)患者的临床特点和康复治疗的效果。方法 :79例TBI患者中 ,5 7例为CBI、2 2例为OBI。运用FIM量表评价两组患者康复治疗前后的功能情况 ,统计患者的入院天数 ,计算FIM效率。结果 :CBI和OBI患者入院时的FIM总评分分别为 81.5 1和 73.0 9;出院时FIM总评分分别为 115 .0 4和 117.77,两组平均增加 4 1%和 5 3%。两组患者康复治疗前后FIM各项评分自身相比有非常显著差异 (P <0 .0 0 1) ,但两组之间相比无显著差异。两组患者的FIM效率分别为 1.99分 /天和 1.71分 /天。结论 :康复治疗可有效改善TBI(无论是CBI还是OBI)患者的功能情况。康复治疗应强调早期和综合性治疗     

Do preinjury alcohol problems predict poorer rehabilitation progress in persons with spinal cord injury?

OBJECTIVE: To determine whether a history of alcohol-related problems is associated with inpatient rehabilitation progress. DESIGN: Cross-sectional cohort survey. SETTING: Acute inpatient rehabilitation program in a level I trauma center. PARTICIPANTS: Seventy-six of 104 consecutive patients with spinal cord injury (SCI) who met inclusion criteria and had completed interviews and functional outcome data. Participants were on average 38 years old; 84% were white, and 86% were men. Forty-two percent had tetraplegia and 39% had a history of problem drinking. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument admission, discharge, and efficiency scores as well as rehabilitation length of stay (LOS). RESULTS: The group with a history of problem drinking had significantly lower FIM admission, discharge, and efficiency scores and longer rehabilitation LOS. After controlling for potential confounding factors, a history of problem drinking accounted for a significant proportion of the variance in FIM efficiency scores. CONCLUSIONS: A history of problem drinking may be a risk factor for poorer rehabilitation progress among patients with SCI. They may be more costly to rehabilitate and may be discharged before attaining an adequate level of independence. Despite this, the current rehabilitation prospective payment system does not recognize this common comorbid condition.