Psychosocial conditions do not affect short-term outcome of multidisciplinary rehabilitation in chronic obstructive pulmonary disease

OBJECTIVES: To characterize patients referred for pulmonary rehabilitation on a large number of psychologic and sociodemographic variables and to determine the contribution of these variables on the response to rehabilitation. DESIGN: Cross-sectional, explorative. SETTING: University hospital and outpatient clinic. PARTICIPANTS: Eighty-one consecutive patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 40%+/-16% of predicted) were included in outpatient pulmonary rehabilitation. INTERVENTION: Multidisciplinary rehabilitation program. MAIN OUTCOME MEASURES: Pulmonary function, exercise capacity (Wmax, 6-minute walk test [6MWT]), Chronic Respiratory Disease Questionnaire (CRDQ), Modified Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]) were assessed before and after 3 months rehabilitation. In addition, psychosocial adjustment, social support, marital status, mode of transportation, education, employment, and smoking status were assessed at the start of the rehabilitation. RESULTS: Rehabilitation improved exercise performance (Wmax, 6+/-12W; P<.01; 6MWT, 41+/-72 m; P<.001), quality of life (CRDQ score, 12+/-13 points; P<.001), functional status (PFSDQ-M activity score, -8+/-11 points; PFSDQ-M dyspnea score, -6+/-12 points; PFSDQ-M fatigue score, -4+/-8 points; all P<.01), HADS anxiety score (-2+/-3 points, P<.01), and HADS depression score (-3+/-3 points, P<.001). In single regression analysis, only baseline depression was weakly negatively correlated with the change in maximal workload. No other relations of initial psychologic or sociodemographic variables with outcome were observed. CONCLUSIONS: The effects of rehabilitation are not affected by baseline psychosocial factors. Patients with less favorable psychologic or sociodemographic conditions can also benefit from pulmonary rehabilitation. The multidisciplinary approach of the rehabilitation program might have contributed to this improvement.     

"Indicators of Reha-Status (IRES)"--a patient questionnaire for assessing need and success of rehabilitation]

A basic instrument is presented which enables essential parameters of rehabilitation patients' somatic, functional and psychosocial status to be brought out and data collected at a "middle level of detail" in a standardized manner, i.e. a patient questionnaire which can be used to complement medical assessment or, for example in follow-up, as a stand-alone tool. Development and testing of the instrument has been supported over the past three years by the LVA Württemberg pension insurance fund, both financially and conceptually. In the present article, questionnaire contents and structure are described, and validation findings reported, standardization on a representative sample of the resident population (n = 1848) is set out. The validation studies performed showed the instrument to be reliable, valid and sensitive, and meeting with good acceptance on the part of patients. Finally, a specifically designed computer programme is set out which facilitates questionnaire data input and basic analyses. Potential applications for the IRES questionnaire are for example seen in describing rehabilitation course and outcome, in documenting the effectiveness of rehabilitation measures (quality control), or in the framework of rehabilitation diagnosis, in particular relative to functional and psychosocial dimensions.     

An empirical structural analysis of the IRES questionnaire version 2, dependent on indication, gender and age

The patient questionnaire "Indicators of Reha Status" (IRES, Version 2) is used for assessing the need for rehabilitation and the success of rehabilitation. It is one of the most frequently used questionnaires in measuring subjective health conditions in medical rehabilitation in Germany. Based on the data of 8600 inpatient rehabilitees, the underlying structural model is examined by a confirmatory factor analysis. The model deviates in part from the original model of the questionnaire authors. The modified model was tested within 12 sub-groups. The sub-groups were divided depending on sex, age and indications (orthopaedic, cardiologic and psychosomatic) of the patients. Multi-group comparisons made between those 12 sub-groups showed specific structures within the groups of psychosomatic patients while no differences between female/male and younger/older patients were found. Furthermore, comparable structures of orthopaedic and cardiologic patients were found. Therefore the dimension values of the IRES patient questionnaire are not suited for a comparison between psychosomatic patients and patients from the somatic indications.     

Stroke rehabilitation outcome: the Turkish experience

The objectives of this study were to examine the demographic and clinical characteristics of stroke patients admitted for inpatient rehabilitation, to study the occurrence of medical problems/complications, and to document functional outcome and possible factors influencing outcome. The mean age of this cohort (30 females, 53 males) was 58+/-12 years and the mean length of hospital stay was 45.7+/-23 days. The most common medical comorbidity was hypertension (65%), followed by heart disease (42%) and diabetes mellitus (22%). The length of hospital stay was related to the number of medical comorbidities (r=0.24, P<0.05). Almost all patients experienced several medical problems during rehabilitation stay (average 7.1 events/patient). Shoulder dysfunction (80.7%), symptomatic blood pressure fluctuations (72.3%) and psychosocial problems (57.8%) were among the most common problems. There was a statistically significant improvement in total Functional Independence Measure scores from admission to discharge (56.5 vs. 74.6), with a mean gain of 18.1. Functional Independence Measure gain was significantly correlated with onset to admission time (r=-0.21, P<0.05), length of hospital stay (r=0.50, P<0.001) and the number of previous strokes (r=-0.23, P<0.05), but not with age, onset to admission interval, comorbidities and the presence of medical problems. Discharge total Functional Independence Measure scores were significantly correlated only with the admission total Functional Independence Measure scores (r=0.72, P<0.001) and onset-admission interval (r=-0.23, P<0.05). Significant functional improvements were documented in this cohort of stroke patients after an interdisciplinary rehabilitation approach. Discharge functional status was best correlated with admission functional status. Medical problems/complications were common among patients undergoing stroke rehabilitation. In our patients, functional outcomes were not significantly influenced by the occurrence of medical problems.     

Therapy goal setting in patients with psychological stress in orthopaedic and cardiac rehabilitation

OBJECTIVES: To study goal-setting for patients with psychological stress in orthopaedic and cardiac rehabilitation centres. DESIGN: A questionnaire assessing patients' somatic, functional and psychosocial status ("IRES"-questionnaire) was administered to 3109 patients with musculoskeletal diseases and 1670 patients with cardiovascular diseases from a total of 26 rehabilitation centres at their admission and discharge. For all patients, physicians filled in the "Physician's Sheet" ("Arztbogen") that assesses patient-specific goals of therapy. RESULTS: Nearly 50 % of the patients suffered from psychological stress at their admission. Of the patients with high psychological stress (higher than in 90 % of the general population) only 11.1 % (musculoskeletal diseases) and 3.4 % (cardiovascular diseases) were diagnosed as having a mental disorder (ICD-10 diagnosis in the range of F00 - F99). High psychological stress reported by patients themselves is associated with only a small increase of goal setting in psychological therapy documented in the "Physician's Sheet". The most important factors that influence the predefinition of psychological goals of therapy are high multimorbidity, an ICD-10 diagnosis in the range of F00 - F99, low age, high motivation for rehabilitation and being a woman. However, statistically significant differences between rehabilitation centres in the predefinition of psychological goals of therapy were detected. It can be assumed that differences in concepts of therapy are responsible for this finding. CONCLUSION: The results show that physicians use the patient's self-assessments of their psychological stress only to a small extent while planning psychosocial interventions and care. The predefinition of goals in a context of "forced" consideration of patients self-assessments leads to a higher degree of consistency between patients' judgements and goal settings. It also shows a slightly higher predictive power for rehabilitation effects than the predefinition of goals of therapy without noticing patients' self-assessments. This demonstrates the usefulness of a patient-centred screening instrument for psychological stress in orthopaedic and cardiac rehabilitation.     

Ulm Scientific Rehabilitation Research Group--"building blocks in rehabilitation"

The Rehabilitation Research Network of Ulm on "Bausteine der Reha" consists of several departments of the University of Ulm, and various rehabilitation hospitals and cooperates with a pension insurance institute (LVA Wuerttemberg). The aim of this interdisciplinary approach is to evaluate process and outcome of rehabilitation measures considering specific clinical and rehabilitative questions with main emphasis on epidemiological and economic aspects. The Rehabilitation Research Nétwork of Ulm is subdivided into clinical projects and cross-sectional subjects. The clinical studies deal with cardiovascular and neurological rehabilitation and rehabilitation in disorders of the musculoskeletal system. The cross-sectional topics contain special fields such as biometry, health economics, epidemiology and occupational rehabilitation. All participating institutions have access to a central database with uniform structure of the data.     

Physical functioning and quality of life after cancer rehabilitation

In order to overcome cancer-related problems and to improve quality of life, an intensive multi-focus rehabilitation programme for cancer patients was developed. We hypothesised that this six-week intensive rehabilitation programme would result in physiological improvements and improvement in quality of life. Thirty-four patients with cancer-related physical and psychosocial problems were the subjects of a prospective observational study. A six-week intensive multi-focus rehabilitation programme consisted of four components: individual exercise, sports, psycho-education, and information. Measurements (symptom-limited bicycle ergometry performance, muscle force and quality of life [RAND-36, RSCL, MFI]) were performed before (T0) and after six weeks of rehabilitation (T1). After the intensive rehabilitation programme, statistically significant improvements were found in symptom-limited bicycle ergometry performance, muscle force, and several domains of the RAND-36, RSCL and MFI. The six-week intensive multi-focus rehabilitation programme had immediate beneficial effects on physiological variables, on quality of life and on fatigue.     

Influence of admission functional status on functional change after stroke rehabilitation

OBJECTIVE: To determine whether the admission functional score influences the functional change after stroke rehabilitation. DESIGN: Two hundred forty-three patients who had received the Functional Independence Measure (FIM) assessment at admission and at discharge were enrolled in the study. The patients were stratified into three groups according to their FIM total scores at admission, i.e., < or =36, 37 to 72, and > or =73. RESULTS: The Scheffé's multiple comparison test showed that patients with FIM total scores of > or =73 at admission were significantly younger (58 +/- 11 [SD] yr) than those who had scores of 37 to 72 (64 +/- 11 yr) or < or =36 (66 +/- 12 yr). Patients with FIM total scores of 37 to 72 at admission showed significantly higher FIM gain (37 +/- 15) compared with those patients who had scores of > or =73 (20 +/- 10) or < or =36 (29 +/- 23). CONCLUSION: The functional levels of affected patients at admission stratified by the FIM scale roughly predict the degree of functional gain after rehabilitation in survivors with a first episode of ischemic stroke. Moderately affected patients will benefit from intensive rehabilitation. These findings may be useful for rehabilitation triage.     

A pilot randomized controlled trial to evaluate the benefit of the cardiac rehabilitation paradigm for the non-acute ischaemic stroke population

OBJECTIVE: To evaluate risk factor reduction and health-related quality of life following a 10-week cardiac rehabilitation programme in non-acute ischaemic stroke subjects. DESIGN: Single-blinded randomized control trial.SETTING: Outpatient rehabilitation.SUBJECTS: Forty-eight community-dwelling ischaemic stroke patients (38 independently mobile, 9 requiring assistance, 1 non-ambulatory) were randomly assigned to intervention or control groups by concealed allocation.INTERVENTION: The trial consisted of a 10-week schedule with measures taken at weeks 1 and 10. Both groups continued usual care (excluding aerobic exercise); intervention subjects attended 16 cycle ergometry sessions of aerobic-training intensity and two stress-management classes.MAIN OUTCOME MEASURES: Cardiac risk score (CRS); VO(2) (mL O(2)/kg per minute) and Borg Rate of Perceived Exertion (RPE) assessed during a standardized ergometry test; Hospital Anxiety and Depression Scale (HADS); Frenchay Activity Index; Fasting Lipid Profiles and Resting Blood Pressure.RESULTS: Group comparison with independent t-tests showed significantly greater improvement at follow-up by intervention subjects than controls in VO(2) (intervention 10.6 +/-1.6 to 12.0 +/- 2.2, control 11.1 +/-1.8 to 11.1 +/-1.9 t=4.734, P<0.001) and CRS (intervention 13.4 +/-10.1 to 12.4 +/-10.5, control 9.4 +/-6.7 to 15.0 +/-6.1 t=-2.537, P<0.05). RPE rating decreased in intervention subjects (13.4 +/-12.2 to 12.4 +/-2.0) and increased in controls (13.8 +/-1.8 to 14.4 +/-1.6); Mann-Whitney U (U = 173.5, P<0.05). Within-group comparison showed significant decrease in the HADS depression subscale in the intervention group alone (5.1 +/-3.4 to 3.0 +/-2.8) (Wilcoxon signed ranks test Z=-3.278, P<0.001).CONCLUSION: Preliminary findings suggest non-acute ischaemic stroke patients can improve their cardiovascular fitness and reduce their CRS with a cardiac rehabilitation programme. The intervention was associated with improvement in self-reported depression.     

Vitamin D deficiency and osteoporosis in rehabilitation inpatients

OBJECTIVE: To determine vitamin D status and bone mineral density (BMD) in patients admitted to a subacute rehabilitation facility. DESIGN: Cross-sectional cohort study. SETTING: Subacute rehabilitation facility. PARTICIPANTS: Fifty-three community-dwelling patients admitted from June through February 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: BMD, 25-hydroxyvitamin D (25[OH]D), C-telopeptide (CTX), osteocalcin, and dietary milk intake. RESULTS: Prevalence of vitamin D deficiency (25[OH]D <20 ng/mL) was 49.1%, while a total of 83% of patients were either vitamin D deficient or insufficient (25[OH]D <30 ng/mL). The prevalence of osteopenia (T score, <-1) was 52.8%; osteoporosis (T score, <-2.5) was 17.0%. CTX (bone resorption marker) was elevated in 60.4% of patients. Osteocalcin (bone formation marker) was elevated in 13.2% of patients. Measurements of bone resorption and formation positively correlated (R2 = .22) indicating increased bone remodeling. CONCLUSIONS: Vitamin D deficiency and osteopenia and osteoporosis were highly prevalent in patients admitted for rehabilitation. Elevated bone resorption and remodeling were evident. This could be due to vitamin D deficiency that should be corrected before antiresorptive therapy is considered. The study emphasizes the need for vigilance for vitamin D status and BMD testing in patients admitted to rehabilitation facilities.     

The effect of cardiac rehabilitation on recovery of heart rate over one minute after exercise in patients with coronary artery bypass graft surgery

OBJECTIVE: To evaluate the effects of cardiac rehabilitation on the recovery of heart rate over 1 min after peak exercise of patients who received coronary artery bypass graft (CABG) surgery. DESIGN: Thirty subjects who received CABG surgery were randomly assigned to enter or not enter a cardiac rehabilitation exercise programme (cardiac rehabilitation n = 15; control group n = 15). SETTING: Outpatient cardiac rehabilitation centre in a national medical hospital. INTERVENTIONS: Patients assigned to the cardiac rehabilitation group received 36 sessions of the exercise programme, three times a week, with the intensity designed to achieve an individual 60-85% peak heart rate in cardiopulmonary exercise test. Patients assigned to the control group did not get further advice about a specific exercise programme. MAIN OUTCOME MEASURES: Resting heart rate and recovery of heart rate over 1 min after a peak exercise test at discharge and three months later were collected. The heart rates were analysed with computer-recorded electrocardiogram. RESULTS: At follow-up, the 15 patients in the cardiac rehabilitation group had a significantly lower resting heart rate (77.46+/-9.49 versus 92.31+/-10.18 bpm; p<0.001) and a significantly higher recovery of heart rate over 1 min (16.38+/-6.32 versus 11.38+4.81 bpm; p = 0.03) compared with the control group. There were also significant reductions in resting heart rates (cardiac rehabilitation p < 0.001; control p = 0.05) and improvements in recovery on heart rate over 1 min (cardiac rehabilitation p < 0.001; control p = 0.001) compared with baseline measurements in both the cardiac rehabilitation and control groups. CONCLUSION: Cardiac rehabilitation had a positive effect on the improvement of recovery on heart rate over 1 min in patients with coronary artery disease who received CABG surgery.     

Validation of an adapted falls efficacy scale in older rehabilitation patients

Büla CJ, Martin E, Rochat S, Piot-Ziegler C. Validation of an adapted Falls Efficacy Scale in older rehabilitation patients.

Objective

To determine the psychometric properties of an adapted version of the Falls Efficacy Scale (FES) in older rehabilitation patients.

Design

Cross-sectional survey.

Setting

Postacute rehabilitation facility in Switzerland.

Participants

Seventy elderly persons aged 65 years and older receiving postacute, inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

FES questions asked about subject’s confidence (range, 0 [none]-10 [full]) in performing 12 activities of daily living (ADLs) without falling. Construct validity was assessed using correlation with measures of physical (basic ADLs [BADLs]), cognitive (Mini-Mental State Examination [MMSE]), affective (15-item Geriatric Depression Scale [GDS]), and mobility (Performance Oriented Mobility Assessment [POMA]) performance. Predictive validity was assessed using the length of rehabilitation stay as the outcome. To determine test-retest reliability, FES administration was repeated in a random subsample (n=20) within 72 hours.

Results

FES scores ranged from 10 to 120 (mean, 88.7±26.5). Internal consistency was optimal (Cronbach α=.90), and item-to-total correlations were all significant, ranging from .56 (toilet use) to .82 (reaching into closets). Test-retest reliability was high (intraclass correlation coefficient, .97; 95% confidence interval, .95−.99; P<.001). Subjects reporting a fall in the previous year had lower FES scores than nonfallers (85.0±25.2 vs 94.4±27.9, P=.054). The FES correlated with POMA (Spearman ρ=.40, P<.001), MMSE (ρ=.37, P=.001), BADL (ρ=.43, P<.001), and GDS (ρ=−.53, P<.001) scores. These relationships remained significant in multivariable analysis for BADLs and GDS, confirming FES construct validity. There was a significant inverse relationship between FES score and the length of rehabilitation stay, independent of sociodemographic, functional, cognitive, and fall status.

Conclusions

This adapted FES is reliable and valid in older patients undergoing postacute rehabilitation. The independent association between poor falls efficacy and increased length of stay has not been previously described and needs further investigations.     

Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training

OBJECTIVE: To determine the prevalence of hostility symptoms in young patients with coronary artery disease (CAD), the associated risk factor profile in these patients, and the effects of a formal phase 2 cardiac rehabilitation and exercise training program. PATIENTS AND METHODS: Our study included consecutive CAD patients referred for cardiac rehabilitation from May 1999 through December 2000. At baseline and after rehabilitation, behavioral factors and quality of life were assessed by validated questionnaires, and standard CAD risk factors were measured, including exercise capacity. We specifically evaluated detailed data for young patients. RESULTS: A total of 500 patients were included in the study. Hostility scores were 2.5 times higher (P<.001) in the 81 young patients (< 50 years; mean +/- SD age, 45 +/- 5 years) than in the 268 elderly patients (> or = 65 years; mean +/- SD age, 70 +/- 4 years), and the prevalence of hostility symptoms was 3.5 times higher in young patients (28% vs 8%; P<.001). Young patients with hostility symptoms also had more adverse CAD risk profiles, including higher total cholesterol levels, triglyceride levels, total cholesterol/high-density lipoprotein cholesterol ratios, fasting glucose levels, and glycosylated hemoglobin levels and lower quality-of-life scores compared with young patients with low hostility scores. After cardiac rehabilitation, young patients with hostility symptoms had marked improvements in CAD risk factors, behavioral characteristics (including hostility), and quality of life, and a nearly 50% (P=.005) reduction in the prevalence of hostility symptoms occurred. CONCLUSIONS: Young CAD patients have a high prevalence of hostility symptoms and adverse CAD risk profiles. Reducing hostility symptoms and other parameters of psychological distress in young CAD patients should be emphasized, and the potential benefits of cardiac rehabilitation programs in the secondary prevention of CAD should be highlighted.     

A comparison of regular rehabilitation and regular rehabilitation with supported treadmill ambulation training for acute stroke patients

The purpose of this pilot study was to compare differences in motor recovery between regular rehabilitation (REG), and regular rehabilitation with supported treadmill ambulation training (STAT) using the performance on a bicycle exercise test and the locomotor scale of the Functional Independence Measure (FIM-L). Twelve patients with acute strokes were randomly assigned to either REG or STAT for 2 to 3 weeks. The STAT group received daily gait training utilizing a treadmill with partial support of body weight. After intervention, the STAT group had higher oxygen consumption (11.34+/-0.88 vs 8.32+/-0.88 ml/kg/min, p=0.039), total workload (58.75+/-7.09 vs 45.42+/-7.09 watts, p=ns), and total time pedaling the bike (288.91+/-30.61 vs 211.42+/-30.61 s, p=ns) compared to the REG group. The FIM-L scores were not different for the two groups. This pilot study suggests that the STAT intervention is a promising technique for acute stroke rehabilitation, and that future studies with larger sample sizes are warranted to establish the effectiveness of this intervention.     

社区干预对精神分裂症患者康复的影响对照研究

目的 探讨社区干预对社区精神分裂症患者康复的影响. 方法 抽取我院青杠林社区服务站43例精神分裂症患者设为干预组,抽取相邻的雷公滩服务站41例精神分裂症患者设为对照组.两组患者均接受专科医院的电话和其他方式的随访活动.干预组同时接受社区系统康复干预,观察1 a.于干预前及干预6个月、1 a末采用简明精神病评定量表、阳性症状量表、阴性症状量表、社会功能缺陷筛选量表评定两组康复效果,统计两组患者干预前后的服药依从率及复发率. 结果 两组患者入组时各量表评分均无显著性差异（P均＞0.05）,干预后干预组各量表评分均显著低于干预前（P＜0.05或0.01）,并显著低于对照组（P＜0.05或0.01）;服药依从率干预组显著高于对照组（χ2=8.71,P＜0.01）;1 a复发率干预组显著低于对照组（χ2=11.11,P＜0.01）. 结论 社区干预可显著提高精神分裂症患者的服药依从性,进一步改善残留症状,降低复发率,促进患者的全面康复.     

Low-volume exercise rehabilitation improves functional capacity and self-reported functional status of dialysis patients

OBJECTIVE: The purpose of this study was to examine the effects of a program of low-volume exercise rehabilitation on the functional capacity and self-reported functional status of nonanemic dialysis patients. DESIGN: This was a controlled study in a clinical setting with a repeated measures design. Functional capacity and functional status were assessed before and after 12 wk of exercise rehabilitation or 12 wk of normal activity for two groups of dialysis patients. RESULTS: Mixed-model repeated measures analysis of variance revealed significant group by time interactions characterized by improvements for the exercise rehabilitation group alone in total walk, stair-climb, and stair-descent times of 15+/-5.8%, 22+/-11%, and 18+/-12% respectively. Self-reported walking speed, walking impairment-leg weakness, and walking impairment-shortness of breath were also observed to improve significantly for the exercise rehabilitation group alone by 15+/-13%, 25+/-11%, and 28+/-16%, respectively. CONCLUSION: Low-volume exercise rehabilitation can improve activity of daily living-related functional capacity and self-reported functional status of nonanemic dialysis patients.