The work of rehabilitation

Purpose. To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation.

Method. A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000 - 2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores.

Results. Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM.

Conclusions. The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.     

Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment

Purpose:?To assess the association between cognitive status and functional gain during a rehabilitation programme for elderly patients with hip fracture.

Method:?Prospective study in a hospital geriatric rehabilitation unit. Sixty-one consecutive patients were studied: 28 with cognitive impairment (age 87.6?±?7.2 years, Mini Mental State Examination (MMSE) score 11.25?±?5.9), 23 with possible cognitive impairment (age 83.9?±?6.8 years, MMSE 22.65?±?1.6) and 10 without cognitive impairment (age 77.6?±?7.4 years, MMSE 29.5?±?0.9). Cognitive status was assessed with the MMSE and admission and discharge functional status with the Functional Independence Measure (FIM). Functional gain was calculated by absolute FIM gain (admission FIM minus discharge FIM), relative (to maximum potential) FIM gain with the Montebello Rehabilitation Factor Score (MRFS) and analysis of covariance of the FIM (ANCOVA).

Results:?Patients without cognitive impairment had significantly higher admission FIM and discharge FIM. Cognitive status was not significantly associated with absolute functional gain. The adjusted (age, gender, sensory impairment, nutritional status, comorbidity and treatment) MRFS score of cognitively impaired patients was significantly lower (p?<?0.03). However, the functional gain related to baseline functional status (ANCOVA) was not significantly different between the groups.

Conclusions:?In spite of cognitive impairment, elderly patients with hip fracture can benefit from participation in rehabilitation programmes.     

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.     

New rehabilitation models for neurologic inpatients in Brazil

Abstract

Purpose: To describe the effects of a rehabilitation program in a neurological inpatient unit in terms of independence for activities of daily living and return to work. Method: Retrospective study with 148 adults with stroke, traumatic brain injury (TBI), spinal cord injury, and Guillain–Barré syndrome admitted as rehabilitation inpatients within a 1-year period for hospitalization at the Instituto de Reabilitação Lucy Montoro, Brazil. According to their diagnostic groups, subjects undergone semi-standardized models of intensive multidisciplinary rehabilitation for 4–6 weeks. Primary outcome measures: Functional Independence Measure (FIM?), Modified Rankin scale (Rankin), and Glasgow Outcome Scale (GOS Subjects were evaluated at admission, discharge, and 6 months after discharge. Results: Improvement in motor FIM?, Rankin and GOS was observed in all groups. Cognitive FIM? increase was less evident in TBI patients. After 6 months, 37.6% of patients were unemployed, 34% underwent outpatient rehabilitation, and 65.2% maintained gains. Conclusions: This is the first report on the effects from an inpatients rehabilitation model in Brazil. After a short intensive rehabilitation, there were motor and cognitive gains in all groups. Heterogeneity in functional gains suggests more individualized programs may be indicated. Controlled studies are required with larger samples to compare inpatient and outpatient programs.

• Implications for Rehabilitation

• The proposed brief model of rehabilitation for stroke, traumatic brain injury, spinal cord injury, and Guillain–Barre syndrome inpatients shows promising results in terms of functional improvement.

• Apparent improvements in cognitive and motor levels can be observed after 30?d of the intensive hospital-based program five times a week focusing on caregiver and patients training.

• After 6 months of discharge, more than one third of patients remained out of work, but appeared to have kept the benefits attained during hospitalization, and performed physical activities in the community as outpatients.

     

Absence of combined effects of anemia and bilateral surgical status on inpatient rehabilitation outcomes following total knee arthroplasty

Purpose.?To examine the effects of anemia on inpatient rehabilitation outcomes following unilateral and bilateral total knee arthroplasty (TKA).

Method.?This was a multicenter, retrospective study from 15 inpatient rehabilitation facilities. Patients (N?=?5421) with very low hematocrit (Hct?<30%), low Hct (30–36% women, 30–41% men), or normal Hct (>36% women, 41% men) were included. Inpatient rehabilitation occurred following TKA. Functional independence measure (FIM) scores, length of stay (LOS), itemized hospital charges, discharge destination were main outcomes.

Results.?LOS was 13% longer and hospital charges were 12.5–18.0% higher in the very low Hct than remaining groups (p?=?0.0001). The FIM score and subscores for walking, stair climbing, bathing, transfers, and dressing changes were comparable for all Hct groups for the overall score. Hct?<30% did not correspond to worse outcomes in patients with bilateral surgeries compared with unilateral surgeries; total FIM scores improved 47–53% across all Hct groups, regardless of bilateral surgical status. Discharge to home ranged 92.6–94.7% across all Hct groups (p?>?0.05).

Conclusions.?Rehabilitation teams can expect comparable functional improvements and discharge to home in anemic and non-anemic patients with either unilateral or bilateral surgeries without hematologic correction in the rehabilitation setting, but might need an additional day to accomplish these outcomes.     

Inpatient rehabilitation following stroke: amount of therapy received and associations with functional recovery

Purpose: Canada’s Best Practice Recommendations for Stroke Care state that a minimum of one hour per day of each of the relevant core therapies be provided to patients admitted for inpatient rehabilitation. We examined whether this standard was met on a single, specialized stroke rehabilitation unit and if amount of therapy was an independent contributor to functional improvement. Methods: One-hundred and twenty-three, consecutive patients admitted to a 30-bed stroke rehabilitation program over a 6-month period with the confirmed diagnosis of stroke, were included. Workload measurement data were used to estimate the amount of therapy that patients received from core therapists during their inpatient stay. A multivariable model to predict Functional Independence Measure (FIM) gains achieved was also developed using variables that were significantly correlated with functional gain on univariate analysis. Results: On average, patients received 37 min of active therapy from both physiotherapists (PT) and occupational therapists (OT) and 13 min from speech-language pathologists per day. Admission FIM, length of stay, total OT and PT therapy time (hrs) were significantly correlated with FIM gain. In the final model, which explained 35% of the variance, admission FIM score and total amount of occupational therapy (OT) emerged as significant predictors of FIM gain. Conclusions: Patients admitted to a specialized rehabilitation unit received an average of 37 min a day engaged in therapeutic activities with both occupational and physical therapists. Although this value did not reach the standard of one hour, total amount of OT time contributed significantly to gains in FIM points during hospital stay.

Implications for Rehabilitation

• Patients on an inpatient stroke rehabilitation unit received less than the standard of one hour of physiotherapy and occupational therapy per day.

• Total amount of occupational therapy contributed significantly to gains in Functional Independence Measure points during hospital stay.

     

Masculine role variables and outcomes among men with spinal cord injury

Purpose.?Few studies have considered the impact of masculine role variables on outcome and adjustment to SCI among men. The present study examined the relations among SCI, views of masculinity, psychological adjustment, and rehabilitation outcomes among men with SCI.

Method.?The sample included 20 men with SCI receiving inpatient rehabilitation, with a mean age of 45 years. Data included demographic variables as well as Conformity to Masculine Norms Inventory (CMNI), Gender Role Conflict Scale (GRCS), Functional Independence Measure (FIM), and Satisfaction with Life Scale ratings, and change in marital status.

Results.?The findings revealed that satisfaction with life was positively related to scores on the CMNI Violence scale, FIM change from admission to discharge was positively related to the CMNI Emotional Control scale and negatively related to the CMNI Dominance scale. Change in marital status was inversely related to the CMNI Emotional Control and Primacy of Work scales and the GRCS Restricted Emotionality and Power, Success, and Competition scales.

Conclusions.?The findings show that certain aspects of the traditional masculine role (i.e., ability to modulate strong emotions) may be adaptive in the rehabilitation process, whereas other aspects (i.e., a dominant interpersonal style) may present a barrier to effective rehabilitation.     

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.

     

Clock drawing and rehabilitation outcome in hip fracture patients

Purpose.?To assess the relationship between the Clock Drawing Test (CDT) and rehabilitation outcome in hip fracture patients within normal range of the Mini Mental State Examination (MMSE).

Methods.?This retrospective study was performed in a post-acute geriatric rehabilitation centre. One hundred and forty-two patients with proximal hip fracture admitted from January 2006 to June 2008 whose MMSE scores was within normal range (>23) were enrolled in the study. The patients were divided into two groups according to CDT performance (impaired versus intact). The differences between the two groups in relation to age, gender, education level, living arrangement, pre fracture functional level, fracture type, and outcome measurements [Functional Independent Measure (FIM), motor FIM, Rate of in-hospital Improvement (RI) in FIM and motor FIM, and Length of Stay (LOS)] were assessed.

Results.?Discharge FIM score and motor FIM scores were significantly lower for the impaired CDT group (89?±?13.7 vs. 94.9?±?11.6, p?=?0.007; 61.6?±?11.1 vs. 65.7?±?9.6, p?=?0.022 respectively); LOS was significantly longer (28.2?±?7.9 vs. 25.3?±?8.5, p?=?0.033) and rates of improvement in FIM and motor FIM were significantly slower (0.62?±?0.35 vs. 0.77?±?0.45, p?=?0.036; 0.61?±?0.34 vs. 0.75?±?0.42, p?=?0.033, respectively). Nevertheless, FIM and motor FIM scores changes were similar in both CDT groups. Following adjustment for age, LOS of patients with impaired CDT was significantly longer (p?=?.027).

Conclusions.?The CDT may assist the multidisciplinary team in identifying hip fracture patients whose MMSE scores are within the normal range, but yet need a longer training period to extract their rehabilitation potential.     

Predicting length of stay in patients admitted to stroke rehabilitation with high levels of functional independence

Purpose.?In Ontario, stroke patients with relatively mild functional deficits are admitted to inpatient rehabilitation programmes. Despite apparently minor impairments, many of these patients remain in rehabilitation for prolonged periods of time. The objective of the present study is to identify variables that predict length of stay (LOS) within this population of high functioning stroke patients.

Methods.?Stroke patients with Functional Independence Measure (FIM?) scores?≥100 admitted to a specialised inpatient rehabilitation programme in Ontario, Canada, from April 2005 to March 2008 were included in this study. Data from the National Rehabilitation Reporting System and chart review were used. Associations with LOS were examined among 25 potential predictor variables using bivariate correlations. Significantly correlated (p <0.002) variables were entered into a multiple linear regression.

Results.?Twenty-four percent (n == 134) of patients admitted during the study period were identified as presenting with mild functional deficits. These patients had a mean admission age of 63.5 (SD 14.6) years, a mean admission FIM score of 109.9 (SD 6.6) and a mean LOS of 22.3 (SD 10.5) days. FIM motor and cognitive subscale scores, Mini Mental State Exam scores and five single items assessing orientation, financial independence, and verbal, written and auditory communication ability were significantly correlated with LOS. The regression model, which included all eight variables, explained 60%% of the variance associated with LOS (r == 0.80).

Conclusions.?For patients admitted to stroke rehabilitation programmes with mild functional impairment, 60%% of the variance in LOS can be explained by a small number of variables indicative of deficits in the areas of motor function, cognition and communication.     

The role of patient demographics and clinical presentation in predicting discharge placement after inpatient stroke rehabilitation: analysis of a large,US data base

Purpose: To determine whether functional ability at admission and demographics predict discharge placement after inpatient rehabilitation for older adults recovering from stroke. Method: In this retrospective study, we examined records of 31,910 adults 65 years of age and older who were admitted for inpatient rehabilitation post-stroke. Binary logistic regression was used with the outcome of placement and potential predictors of the admission Functional Independence Measure (FIM) score, age, sex and marital status. Results: The average admission FIM was 60.0 out of 126; the average FIM at discharge was 84.8. The mean age was 77.7?±?7.3 years, 57% were female and 52.5% were not married. More than three quarters of the patients were discharged to home. Odds ratios (ORs) with 95% confidence intervals (CIs) showed that patients with a FIM score below the mean of our sample (OR = 5.8, CI = 5.5–6.2), older than the mean age of our sample (OR = 1.6, CI = 1.5–1.7), and who were not married (OR = 1.9, CI = 1.8–2.0) (p-values <0.001) were more likely to be discharged to residential care. Sex was not predictive of placement. Conclusion: The admission FIM was an important predictor of discharge placement after rehabilitation in older adults. Age and marital status were also significant predictors of discharge placement. Sex was not a significant predictor.

Implications for Rehabilitation

• Functional ability, age and marital status are significant predictors of discharge placement after stroke rehabilitation.

• Those who have lower admission Functional Independence Measure scores, are older, and are not married are more likely to be discharged to residential care than their counterparts who return home.

• Sex is not a significant predictor of discharge placement after stroke rehabilitation.

• To anticipate discharge placement after inpatient rehabilitation, the clinician should consider the age and marital support system of the patient, as well as the functional presentation at admission.

     

Validation of the Middlesex Elderly Assessment of Mental State (MEAMS) as a cognitive screening test in patients with acquired brain injury in Turkey

Purpose. Assessment of cognitive impairment with a valid cognitive screening tool is essential in neurorehabilitation. The aim of this study was to test the reliability and validity of the Turkish-adapted version of the Middlesex Elderly Assessment of Mental State (MEAMS) among acquired brain injury patients in Turkey.

Methods. Some 155 patients with acquired brain injury admitted for rehabilitation were assessed by the adapted version of MEAMS at admission and discharge. Reliability was tested by internal consistency, intra-class correlation coefficient (ICC) and person separation index; internal construct validity by Rasch analysis; external construct validity by associations with physical and cognitive disability (FIM); and responsiveness by Effect Size.

Results. Reliability was found to be good with Cronbach's α of 0.82 at both admission and discharge; and likewise an ICC of 0.80. Person separation index was 0.813. Internal construct validity was good by fit of the data to the Rasch model (mean item fit ?0.178; SD 1.019). Items were substantially free of differential item functioning. External construct validity was confirmed by expected associations with physical and cognitive disability. Effect size was 0.42 compared with 0.22 for cognitive FIM.

Conclusion. The reliability and validity of the Turkish version of MEAMS as a cognitive impairment screening tool in acquired brain injury has been demonstrated.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose.?To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method.?One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results.?The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions.?Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

Development and validation of the Italian version of the Spinal Cord Independence Measure III

Purpose.?To provide a translation and cultural adaptation of the Spinal Cord Independence Measure version III scale for Italy (i-SCIM3) and to validate this version of the scale.

Method.?i-SCIM3 was developed involving a forward–backward translation and administered to patients with spinal cord lesions (SCL) admitted to two centers. Two raters for each center evaluated patients at admission and discharge. Psychometric testing included reliability by internal consistency (Cronbach's α) and test–retest reliability. The validity of i-SCIM3 was assessed by comparing it with the Italian version of Functional Independence Measure? (FIM?).

Results.?One hundred three adult patients with SCL (84 males) with a mean age of 50.33?±?15.35 years were recruited. Seventy-four patients were paraplegic and 29 patients were tetraplegic. The median time elapsed between the two evaluations was 77.5 days (interquartile range, 53–144 days). Internal consistency, inter-rater reliability, and test–retest reliability were satisfactory overall, showing values higher than 0.90. The validity of i-SCIM3 was confirmed by the close correlation with FIM results both at admission and discharge (r?=?0.91, p?<?0.01). The sensitivity to change of i-SCIM3 was similar to that of FIM.

Conclusion.?i-SCIM3 was found to be a consistent, reliable, and valid scale for use in the clinical setting. It is the first validated scale in Italian for patients with SCL.     

Functional outcome of ischemic stroke: A comparative study of diabetic and non-diabetic patients

Background and purpose. Diabetes is associated with more ischemic strokes and diabetic patients have up to a three-fold increased risk for suffering a stroke, compared with non-diabetics. The aim of this study is to evaluate whether diabetes mellitus may also affect the functional outcome of patients with acute ischemic stroke, undergoing post-acute care rehabilitation.

Methods. A retrospective charts analysis of consecutive older patients with acute ischemic stroke admitted for rehabilitation at a tertiary hospital with post-acute care geriatric rehabilitation wards. Functional outcome of diabetics and non-diabetics was assessed by the Functional Independence Measurement scale (FIM?) at admission and discharge. Data were analysed by t-tests, Pearson correlation, and Chi-square test, as well as by linear regression analysis.

Results. A total number of 527 patients were admitted, of whom 39% were diabetics. Compared with non-diabetics, diabetic stroke patients were slightly younger (p = 0.0001) but had similar admission FIM scores. FIM gain parameters (total FIM gain, motor FIM gain, daily total and motor FIM gains) upon discharge were similar in both groups. A linear regression analysis showed that higher MMSE scores (β = 0.08; p = 0.01) and higher admission total FIM scores (β = 0.87; p < 0.001) predicted higher total FIM scores upon discharge. Diabetes mellitus was not interrelated, whatsoever, with better total FIM scores upon discharge (β = ?0.03; p = 0.27).

Conclusions. The findings suggest that there is no difference in the functional outcome of diabetic and non-diabetic patients, presenting for rehabilitation after acute ischemic stroke. Diabetes should not be considered as adversely affecting rehabilitation of such patients.     

Characteristics and functional outcomes of brain injury caused by physical assault in Canada: a population-based study from an inpatient rehabilitation setting

Abstract

Purpose: To investigate the characteristics and inpatient rehabilitation outcomes of persons who sustained a traumatic brain injury (TBI) resulting from physical assault – a form of intentional TBI – and compare these outcomes to those of persons with TBI resulting from other aetiologies. Method: A prospective population-based cohort study using inpatient rehabilitation data from Canadian population-based administrative databases for the fiscal years 2001–2006. Outcome measures were measures of functional independence (motor and cognitive), as measured by the FIM? Instrument, and discharge destinations. Results: Characteristics associated with intentional TBI were being male, younger in age and unemployed; living alone and having a greater likelihood of alcohol/drug abuse prior to admission. The intentional TBI group showed poorer total functional gains at discharge from inpatient rehabilitation. Multivariate regression analyses showed that persons with intentional injury were less likely to be discharged home. Conclusions: Persons with TBI from physical assault are a distinct clinical group in Canadian inpatient rehabilitation settings. These findings can support clinicians in determining proper assessment, management, discharge planning and post-rehabilitation care that target specific needs of persons with TBI resulting from physical assault.

• Implications for Rehabilitation

• Clinicians should have appropriate training to properly assess the mental health status of this patient group.

• Inpatient rehabilitation facilities should be prepared to provide services targeting psychosocial, substance abuse and interpersonal relationship issues to persons with a TBI from physical assault while patients are still within a hospital setting.

• Follow-up clinical care and community support services are warranted for those with intentional TBIs, including provision of occupational rehabilitation services, such as vocational rehabilitation.

• The discharge team should be responsible for ensuring appropriate discharge to community in the absence of family or other advocates on behalf of the patient.

     

Functional outcomes and quality of life in patients with brain tumors: a preliminary report.

OBJECTIVES: To determine the relationship between functional outcome and quality of life (QOL) in patients with brain tumors receiving inpatient rehabilitation, and to assess the sensitivity of 4 assessment tools in measuring changes in that population. DESIGN: Prospective study using longitudinal data collected from consecutively admitted patients. SETTING: Acute inpatient rehabilitation unit. PARTICIPANTS: Ten patients with primary brain tumors admitted to an acute inpatient rehabilitation unit. INTERVENTIONS: Patients participated in an inpatient interdisciplinary rehabilitation program that used the following disciplines: occupational therapy, rehabilitation therapy, recreational therapy, speech therapy, physical therapy, rehabilitation nursing and case management. MAIN OUTCOME MEASURES: The FIM instrument, Disability Rating Scale (DRS), Karnofsky Performance Status Scale (KPS), Functional Assessment of Cancer Therapy-Brain (FACT-BR). RESULTS: Improvement in total functional outcome was indicated by all 3 functional measures (FIM: F = 46.84, p < .05; DRS: F = 19.25, p < .05; KPS: F = 10.11, p < .05). Significant improvements were found between admission and discharge scores for the FIM and DRS. The KPS revealed significant improvement between admission and 3-month follow-up scores. All admission and discharge functional scales (FIM, DRS, KPS) correlated significantly with each other. No significant change was noted in the FACT-BR between admission and discharge scores, but FACT-BR scores did improve at 1- and 3-months postdischarge relative to admission. The FIM, KPS, and DRS did not show significant correlation with the FACT-BR. Ninety percent of patients were initially discharged to a home environment. CONCLUSION: Although patients make functional gains during and after inpatient rehabilitation, gains in QOL are not significant until 1 month postdischarge. QOL does not appear to correlate well with functional outcomes. Further, the KPS is less sensitive than the FIM and DRS in detecting change in functional status.     

Responsiveness of functional health status measures frequently used in stroke research

Purpose. To compare the responsiveness of several functional health status measures frequently used in stroke research, namely the Barthel Index (BI), Functional Independence Measure (FIM), Frenchay Activities Index (FAI) and Stroke-Adapted Sickness Impact Profile 30 (SA-SIP 30).

Method. Patients with a first-ever supratentorial stroke admitted for inpatient rehabilitation were included. Complete datasets for 163 patients were available for analysis. Floor/ceiling effects and responsiveness, quantified by effect sizes, were studied for the periods between rehabilitation admission and six months post stroke (subacute phase) and between six and 12 months post stroke (chronic phase).

Results. Effect sizes in the subacute phase were similar and were classified as large for the BI, FIM total and FIM motor score. The FIM cognitive score showed a considerable ceiling effect and had the smallest effect size in the subacute phase. In the chronic phase, the FAI and SA-SIP 30 detected the most changes and had moderate effect sizes.

Conclusions. BI, FIM total and FIM motor score, FAI and SA-SIP 30 were responsive measures. We recommend the use of the BI in the subacute phase and the use of the FAI and SA-SIP 30 in the chronic phase, especially for the stroke rehabilitation population.     

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.