Functional reach: does it really measure dynamic balance?

BACKGROUND: Functional reach (FR) is a new clinical measurement intended to assess dynamic balance. The purposes of this study were (1) to measure the mean FR distance in healthy elders compared with individuals with known balance impairments, (2) to analyze the extent to which FR measures dynamic balance, and (3) to describe movement strategies used during FR. METHODS: Thirteen healthy elders and 15 individuals with vestibular hypofunction (VH) were tested during FR and free gait. Whole body kinematic and kinetic data including the center of gravity (CG) and center of pressure (CP) using 11 body segments and two force plates, respectively, were collected. RESULTS: There was no difference in FR distance between healthy elders and individuals with VH. FR distance was not correlated to lateral stability measures, but was related to anterior-posterior postural control measures of FR (r = .69 to .84) in both groups. Although FR distance strongly correlated with maximum moment arm during FR in both groups, the correlations were not as strong when the subjects were then classified by movement strategy. The mean moment arm during FR was significantly less than that of free gait. CONCLUSIONS: These data suggest FR does not measure dynamic balance; healthy elders and balance-impaired individuals with vestibular dysfunction attained the same FR distance and did so without increasing the moment arm during or at the end of FR. Recording the strategy used during FR, however, may provide other valuable information necessary in addressing balance control. Clinical implications of assessing movement strategy are discussed.     

Health-related quality of life after stroke: does response shift occur in self-perceived physical function?

Barclay-Goddard R, Lix LM, Tate R, Weinberg L, Mayo NE. Health-related quality of life after stroke: does response shift occur in self-perceived physical function?

Objective

To determine whether response shift (a change in the self-perceived meaning of health-related quality of life [HRQL]) was present in a model of physical function over time poststroke.

Design

Secondary data analysis of a longitudinal observational study.

Setting

Community.

Participants

A consecutive sample of stroke survivors (N=677) at 1, 3, 6, and 12 months poststroke was included. Sixty-seven individuals were approached, but refused. Sixty-seven percent completed the study at 12 months. Mean age was 68 years; 45% of the participants were women.

Interventions

Not applicable.

Main Outcomes Measures

The Medical Outcomes Study 36-Item Short-Form Health Survey, Euroqol, Stroke Impact Scale, Preference-Based Stroke Index, and the Health Utilities Index.

Results

Structural equation modeling was used to identify response shift. A chi-square difference test between constrained and unconstrained longitudinal models suggested the presence of response shift in the data. Reprioritization response shift, a change in relative importance of domains, was observed for physical activites. Recalibration response shift, a change in internal standards of measurement, was observed in physical activities, stairs, walking, and hand function.

Conclusions

Response shift has implications for the measurement of change in physical function. Measures that focus on difficulty in task performance may be sensitive to response shift, resulting in a change in perceived HRQL over time. This has implications for choosing self-perceived or performance-based measures to detect change in physical function.     

Hospice care for patients with dementia: does volume make a difference?

Using the repository of 2005 Family Evaluation of Hospice Care data, this study examined whether bereaved family members report higher quality of care when hospices care for greater vs. lesser proportions of dementia patients. This organization-level analysis included 396 hospices meeting the study's eligibility criteria. Using hospice percentages of the "proportion of decedents with dementia," categories representing the lower three, the fourth and highest quintile values were created (i.e., <13%, > or =13%-19%, and > or =19%). Analyses were stratified by for-profit vs. not-for-profit because preliminary analyses showed differential associations by profit status. In for-profit hospices, hospices with the highest vs. lowest proportion of dementia patients (> or =19% vs. <13%) had significantly lower unmet pain needs (-1.7%, 95% confidence interval [CI] -3.1%, -0.2%). However, for both profit groups, caring for > or =19% dementia decedents (vs. <13%) was associated with a lower proportion of "excellent" care ratings (-2.3%, 95% CI -4.5%, -0.2%). Statistically significant associations between higher volume and better ratings were not observed for the remaining (six) outcomes, although this trend was found more among for-profit hospices. Thus, profit status appears to modify the association between volume of dementia care and care ratings. Further study is needed to understand the nonintuitive negative association between higher volume and lower satisfaction. This study emphasizes the need for examination of quality outcomes by profit status.     

Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

Berlowitz DR, Hoenig H, Cowper DC, Duncan PW, Vogel WB. Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

Objectives

To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures—the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)—in how well they predict these outcomes.

Design

Inception cohort of patients followed for 6 months.

Setting

Department of Veterans Affairs (VA) hospitals.

Participants

A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database.

Interventions

Not applicable.

Main Outcome Measures

Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score.

Results

During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R² values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R² of .111 for change in FIM score.

Conclusions

Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.     

Recovery from stroke: does rehabilitation counselling have a role to play?

Aims and objectives: The aim of this paper is to explore the stroke literature, with particular emphasis on the management of psycho-social issues during and in the aftermath of stroke rehabilitation. Within the literature, there are a number of studies that indicate that the present 'medical physical' approach to stroke rehabilitation may not be achieving desirable long-term psycho-social outcomes and these are considered. The studies highlight the potential effect of the human emotional and social aspects of having a stroke upon the physical and mental well-being of the person. For the person living with stroke, the ability to maintain a positive sense of direction in life as well as hold onto their, or develop a new, identity is crucial in terms of adapting to change. Holding onto one's self-worth and unity with the past and anticipating the future enhances the ability to cope and adapt in the aftermath of stroke rehabilitation. This links with the investigation into rehabilitation counselling as a potential strategy for the management of long-term psycho-social functional status following stroke. Conclusion: It is suggested that the medical model of stroke rehabilitation places undue emphasis on clinical diagnosis and treatment. By default, measurement of physical independence or disability that is compressed into standardized scales has arguably led to the neglect of the emotional and social consequences of stroke and a partial or inhibited view of the person. It is proposed that there is a need to develop and evaluate the effectiveness of rehabilitation counselling from short-term stroke rehabilitation through to long-term psycho-social adaptation,for this client group to provide clear evidence for service provision.     

Testing the ‘teachable moment’ premise: does physical activity increase in the early survivorship phase?

Purpose

Little is known about objectively measured physical activity during the early survivorship period. This study measured physical activity, fatigue, and quality of life (QOL) in breast cancer patients over the first year after completion of chemotherapy and compared results to a matched non-cancer group.

Methods

Data was obtained from 24 breast cancer subjects (mean ± SD) 50.9?±?12.8 years at time points of 6 weeks, 6 months and 1 year after completion of adjuvant chemotherapy and from 20 matched women. The following variables were assessed, physical activity (RT3 accelerometer and International Physical Activity Questionnaire), quality-of-life (EORTC QLQ C-30) and fatigue (Brief Fatigue Inventory).

Results

At 6 weeks after completion of chemotherapy, high levels of sedentary behaviour were found (6.8?±?1.9 h sedentary per day), which did not improve, and was no different to the comparison group (6.5?±?1.4 h). Less light activity was performed in the cancer cohort compared to the comparison group (p?=?0.003). Body mass index (BMI) increased significantly in the cancer cohort (p?=?0.015) and 1 year after chemotherapy finished only 13 % (n?=?3) had a BMI <25, while the comparable value was 45 % (n?=?9) in the non-cancer group. The QOL domain of cognitive function improved over the first 6 months (p?=?0.034) but physical functioning declined (p?=?0.008) over this time period. Fatigue did not change, and at the 1-year time point, 38 % of the cancer patients (n?=?11) reported high levels of fatigue.

Conclusion

This study highlighted the unchanging sedentary behaviour and weight gain of breast cancer survivors during the first year after completion of chemotherapy, which may inform rehabilitation models in this population.     

Changes in stroke volume induced by passive leg raising in spontaneously breathing patients: comparison between echocardiography and Vigileo?/FloTrac? device

Introduction  

Passive leg raising (PLR) is a simple reversible maneuver that mimics rapid fluid loading and increases cardiac preload. The effects of this endogenous volume expansion on stroke volume enable the testing of fluid responsiveness with accuracy in spontaneously breathing patients. However, this maneuver requires the determination of stroke volume with a fast-response device, because the hemodynamic changes may be transient. The Vigileo™ monitor (Vigileo™; Flotrac™; Edwards Lifesciences, Irvine, CA, USA) analyzes systemic arterial pressure wave and allows continuous stroke volume monitoring. The aims of this study were (i) to compare changes in stroke volume induced by passive leg raising measured with the Vigileo™ device and with transthoracic echocardiography and (ii) to compare their ability to predict fluid responsiveness.     

Prone position delays the progression of ventilator-induced lung injury in rats: does lung strain distribution play a role?

OBJECTIVE: To investigate if prone position delays the progression of experimental ventilator-induced lung injury, possibly due to a more homogeneous distribution of strain within lung parenchyma. DESIGN: Prospective, randomized, controlled trial. SETTING: Animal laboratory of a university hospital. SUBJECTS: Thirty-five Sprague Dawley male rats (weight 257 +/- 45 g). INTERVENTIONS: Mechanical ventilation in either supine or prone position and computed tomography scan analysis. MEASUREMENTS:: Animals were ventilated in supine (n = 15) or prone (n = 15) position until a similar ventilator-induced lung injury was reached. To do so, experiments were interrupted when respiratory system elastance was 150% of baseline. Ventilator-induced lung injury was assessed as lung wet-to-dry ratio and histology. Time to reach lung injury was considered as a main outcome measure. In five additional animals, computed tomography scans (GE Light Speed QX/I, thickness 1.25 mm, interval 0.6 mm, 100 MA, 100 Kv) were randomly taken at end-expiration and end-inspiration in both positions, and quantitative analysis was performed. Data are shown as mean +/- sd. MEASUREMENTS AND MAIN RESULTS: Similar ventilator-induced lung injury was reached (respiratory system elastance, wet-to-dry ratio, and histology). The time taken to achieve the target ventilator-induced lung injury was longer with prone position (73 +/- 37 mins vs. 112 +/- 42, supine vs. prone, p = .011). Computed tomography scan analysis performed before lung injury revealed that at end-expiration, the lung was wider in prone position (p = .004) and somewhat shorter (p = .09), despite similar lung volumes (p = .455). Lung density along the vertical axis increased significantly only in supine position (p = .002). Lung strain was greater in supine as opposed to prone position (width strain, 7.8 +/- 1.8% vs. 5.6 +/- 0.9, supine vs. prone, p = .029). CONCLUSIONS: Prone position delays the progression of ventilator-induced lung injury. Computed tomography scan analysis suggests that a more homogeneous distribution of strain may be implicated in the protective role of prone position against ventilator-induced lung injury.