Self-Scoring Templates for Motor and Cognitive Subscales of the FIM Instrument for Persons With Spinal Cord Injury

Objective

To provide self-scoring templates for the FIM instrument's motor and cognitive scales that enable clinicians to monitor progress during rehabilitation using equal-interval Rasch-calibrated measures instead of ordinal raw scores.

Design

Secondary analysis of a prospective, observational cohort study.

Setting

Six geographically dispersed hospital-based rehabilitation centers in the United States.

Participants

Subset of consecutively enrolled individuals with new traumatic spinal cord injuries discharged from participating rehabilitation centers (N=1146).

Intervention

Not applicable.

Main Outcome Measures

Subscores of the FIM instrument, including a 13-item motor scale, a 5-item cognitive scale, an 11-item (without sphincter control items) motor scale, a 3-item transfer scale, a 6-item self-care scale, a 3-item self-care upper extremity scale, and a 3-item self-care lower extremity scale.

Results

KeyForms for the FIM instrument scales allow clinicians and investigators to estimate patients' functional status and monitor progress. In cases with no missing data, the look-up tables provide more accurate estimates of patients' functional status.

Conclusion

Clinicians can use KeyForms and look-up tables for FIM instrument subscales to monitor patients' progress and communicate improvement in equal-interval units.     

Longitudinal Analysis of Hospitalization After Spinal Cord Injury: Variation Based on Race and Ethnicity

Objective

To examine the longitudinal effects of race/ethnicity on hospitalization among adults with spinal cord injury (SCI) in the 10-year period after initial injury.

Design

Retrospective analysis of postinjury hospitalizations among non-Hispanic white, non-Hispanic African American, and Hispanic adults with SCI.

Setting

Community. Data were extracted from the 2011 National Spinal Cord Injury Model Systems database.

Participants

Patients with traumatic SCI (N= 5146; white, 3175; African American, 1396; Hispanic, 575) who received rehabilitation at one of the relevant SCI Model Systems.

Interventions

Not applicable.

Main Outcome Measures

Hospitalization, including rate of hospitalization, number of hospitalizations, and number of days hospitalized during the 12 months before the first-, fifth-, and tenth-year follow-up interviews for the SCI Model Systems.

Results

Significant differences were found in rates of hospitalization at 1 and 5 years postinjury, with participants from Hispanic backgrounds reporting lower rates than either whites or African Americans. At 10 years postinjury, no differences were noted in the rate of hospitalization between racial/ethnic groups; however, compared with whites (P=.011) and Hispanics (P=.051), African Americans with SCI had 13 and 16 more days of hospitalization, respectively. Compared with the first year postinjury, the rate of hospitalization declined over time among whites, African Americans, and Hispanics; however, for African Americans, the number of days hospitalized increased by 12 days (P=.036) at 10 years versus 5 years postinjury.

Conclusions

Racial/ethnic variation appears to exist in postinjury hospitalization for individuals with SCI, with Hispanics showing the lowest rates of hospitalization at 1 and 5 years postinjury and African Americans having a significantly higher number of days hospitalized at 10 years postinjury. Potential explanations for these variations are discussed, and recommendations are made for potential changes to policy and clinical care.     

Functional Outcomes in Traumatic Disorders of Consciousness: 5-Year Outcomes From the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems

Objective

To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation.

Design

Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research–funded Traumatic Brain Injury Model Systems (TBIMS).

Setting

Inpatient rehabilitation hospitals participating in the TBIMS program.

Participants

Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]).

Interventions

Not applicable.

Main Outcome Measures

FIM items.

Results

For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years.

Conclusions

Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.     

Employment Trajectories After Spinal Cord Injury: Results From a 5-Year Prospective Cohort Study

Objectives

To identify different employment trajectories in individuals with spinal cord injury (SCI) after discharge from initial rehabilitation and to determine predictors of different trajectories from demographic, injury, functional, and psychological characteristics.

Design

Prospective cohort study with baseline measurement at the start of active rehabilitation, a measurement at discharge, and follow-up measurements at 1, 2, and 5 years after discharge.

Setting

Eight rehabilitation centers with SCI units in The Netherlands.

Participants

People with acute SCI (N=176), aged between 18 and 60 years at baseline, who completed at least 2 follow-up measurements.

Interventions

Not applicable.

Main Outcome Measure

Employment was defined as having paid work for ≥12h/wk.

Results

Using latent class growth mixture modeling, 3 distinct employment trajectories were identified: (1) no employment group (22.2%), that is, participants without employment pre-SCI and during 5-year follow-up; (2) low employment group (56.3%), that is, participants with pre-SCI employment and a low, slightly increasing probability of employment during 5-year follow-up; and (3) steady employment group (21.6%), that is, participants with continuous employment pre-SCI and within 5-year follow-up. Predictors of steady employment versus low employment were having secondary education (odds ratio, 4.32; 95% confidence interval, 1.69–11.02) and a higher FIM motor score (odds ratio, 1.04; 95% confidence interval, 1.01–1.06) at discharge.

Conclusions

Distinct employment trajectories after SCI were identified. More than half of the individuals with SCI had a low employment trajectory, and only one-fifth of the individuals with SCI had a steady employment trajectory. Secondary education and higher functional independence level predicted steady employment.     

Medical Comorbidities in Disorders of Consciousness Patients and Their Association With Functional Outcomes

Objective

To identify, for patients in states of seriously impaired consciousness, comorbid conditions present during inpatient rehabilitation and their association with function at 1 year.

Design

Abstracted data from a prospective cross-sectional observational study with data collection occurring January 1996 through December 2007.

Setting

Four inpatient rehabilitation facilities in metropolitan areas.

Participants

The study sample of 68 participants is abstracted from a database of 157 patients remaining in states of seriously impaired consciousness for at least 28 days.

Interventions

Not applicable.

Main Outcome Measure

One-year cognitive, motor, and total FIM score.

Results

The most common medical complications during inpatient rehabilitation for the study sample are active seizures (46%), spasticity (57%), urinary tract infections (47%), and hydrocephalus with and without shunt (38%). Presence of ≥3 medical complications during inpatient rehabilitation, controlling for injury severity, is significantly (P<.05) associated with poorer total FIM and FIM motor scores 1 year after injury. The presence of hydrocephalus with and without shunt (r=−.20, −.21, −.18; P ≤.15), active seizures (r=−.31, −.22, −.42), spasticity (r=−.38, −.28, −.40), and urinary tract infections (r=−.25, −.24, −.26) were significantly (P<.10) associated with total FIM, FIM cognitive, and FIM motor scores, respectively.

Conclusions

Reported findings indicate that persons in states of seriously impaired consciousness with higher numbers of medical complications during inpatient rehabilitation are more likely to have lower functional levels 1-year postinjury. The findings indicate that persons with ≥3 medical complications during inpatient rehabilitation are at a higher risk for poorer functional outcomes at 1 year. It is, therefore, prudent to evaluate these patients for indications of these complications during inpatient rehabilitation.     

The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury

Riggins MS, Kankipati P, Oyster ML, Cooper RA, Boninger ML. The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury.

Objective

To examine quality-of-life (QOL) factors and change in mobility in individuals with traumatic spinal cord injury (SCI) 1 year after injury.

Design

Retrospective case study of National SCI Database data.

Setting

SCI Model Systems (SCIMS) sites (N=18).

Participants

Subjects (N=1826; age >18y) who presented to an SCIMS site after traumatic SCI between June 2004 and July 2009 and returned for 1-year follow-up. All subjects had FIM mobility data for both assessments.

Interventions

Not applicable.

Main Outcome Measures

Assessment of impairment based on Lower-Extremity Motor Score. Assessment of QOL based on Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire, Satisfaction With Life Scale, Self-perceived Health Status, and pain severity scores.

Results

Of the sample, 55 individuals transitioned from walking to wheelchair use within 1 year of discharge. This group had the highest number of individuals from minority groups (52.8%) and the lowest employment rate (7.3%). Compared with individuals who transitioned from wheelchair use to walking or maintained wheelchair use or ambulation, the walking-to-wheelchair transition group had significantly lower QOL scores (P<.01), including higher depression (P<.01) and higher pain severity (P<.001).

Conclusions

Individuals with SCI who transitioned from walking at discharge to wheelchair use within 1 year had low QOL factors, including high pain and depression scores. Rehabilitation professionals should consider encouraging marginal ambulators to work toward functional independence from a wheelchair, rather than primary ambulation during acute inpatient rehabilitation.     

Cluster Analysis of Vulnerable Groups in Acute Traumatic Brain Injury Rehabilitation

Objective

To analyze the complex relation between various social indicators that contribute to socioeconomic status and health care barriers.

Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury

Stenson KW, Deutsch A, Heinemann AW, Chen D. Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury.

Objective

To examine the effect of obesity on change in FIM self-care and mobility ratings and community discharge for patients with traumatic spinal cord injury (SCI).

Design

Retrospective cohort study analyzing National Model Systems SCI Database data.

Setting

Fourteen Model Systems SCI programs.

Participants

Patients (N=1524) with a new traumatic SCI discharged from Model Systems rehabilitation centers between October 2006 and October 2009.

Interventions

None.

Main Outcome Measures

Change in FIM self-care and mobility ratings, discharge destination. Separate analyses were conducted by neurologic category: paraplegia incomplete, paraplegia complete, tetraplegia incomplete, and tetraplegia complete.

Results

Of all patients with traumatic SCI, approximately 25% were obese at admission. Patients who were obese were more likely to be married and slightly older than nonobese patients. In patients with paraplegia incomplete, obese patients had lower FIM self-care (−1.9; 95% confidence interval [CI], −3.4 to −.4) and mobility score gains (−1.5; 95% CI, −2.9 to −.1) than normal-weight patients. For patients with paraplegia complete, obese patients had significantly lower self-care (−2.2; 95% CI, −3.5 to −.8) and mobility score gains (−2.7; 95% CI, −3.9 to −1.5). For patients with tetraplegia incomplete and tetraplegia complete, FIM self-care and mobility ratings for obese patients were not significantly different from ratings for normal-weight patients. Within each neurologic category, the percentage of patients discharged to the community was not significantly different for nonobese and obese patients.

Conclusions

Obesity appears to be a barrier to meeting self-care and mobility functional goals for patients with paraplegia in inpatient SCI rehabilitation.     

Effect of Body Mass Index on Stroke Rehabilitation

Objective

To investigate the association between body mass index (BMI) and the functional progress of patients with stroke, admitted to a rehabilitation hospital.

Design

A retrospective cohort study.

Setting

A freestanding university rehabilitation hospital stroke unit.

Participants

All patients (N=819) admitted to the stroke unit of a rehabilitation hospital during the study.

Interventions

Not applicable.

Main Outcome Measures

The primary study outcome measure was the FIM efficiency of patients by BMI category.

Results

For the 819 patients admitted during the observation period, BMI was compared with FIM score changes per day (FIM efficiency). After adjusting for age and sex, the FIM efficiency differed by BMI. The underweight group had the lowest FIM efficiency, followed by the obese and normal-weight subgroups. The overweight group had the highest FIM efficiency (P=.05) when compared with the obese subgroup.

Conclusions

Among patients admitted to an acute rehabilitation hospital for stroke rehabilitation, overweight patients had better functional progress than did patients in the other weight categories.     

Inpatient Stroke Rehabilitation Lengths of Stay in Canada Derived From the National Rehabilitation Reporting System, 2008 and 2009

Objective

To determine rehabilitation length of stay (LOS) for patients with stroke in Canada, and to evaluate which factors contribute to variations in LOS.

Design

A retrospective cohort study of Canadians rehabilitating from stroke using medical, functional, and sociodemographic variables extracted from the Canadian Institute for Health Information's National Rehabilitation Reporting System.

Setting

Canadian rehabilitation hospitals providing stroke rehabilitation services.

Participants

Patients with stroke (N=11,983) admitted to rehabilitation hospitals from January 2008 through December 2009.

Interventions

None.

Main Outcome Measures

Rehabilitation LOSs were calculated nationally and regionally. Regression models incorporating sociodemographic and clinical measures were constructed to test their effect on LOS.

Results

The median stroke rehabilitation LOSs was 35 days (quartiles: 20d, 54d). LOSs varied regionally within Canada. A multivariable regression model including age, FIM motor function scores at admission, and geographic region explained 20% of the variation in LOSs. Modeling these data using a Function-Related Groups case-mix model explained 16% of the variation in LOSs.

Conclusions

FIM motor function scores at admission along with age and geographic region best predicted rehabilitation LOS. These variables explained 20% of the variation in LOSs. Despite regional differences in LOSs, patient characteristics were similar between regions. Other nonpatient factors not captured in these data may contribute to a greater extent in determining stroke rehabilitation LOS.     

Additive Effect of Age on Disability for Individuals With Spinal Cord Injuries

Objective

To examine the additive effect of age on disability for adults with spinal cord injury (SCI).

Design

Prospective cohort study.

Setting

SCI Model Systems.

Participants

Individuals with SCI (median age at injury, 32y; range, 6–88y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia.

Interventions

Not applicable.

Main Outcome Measures

The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI.

Results

When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant (P=.07). Age at the time of SCI was significantly associated with motor FIM (F_1,238=22.49, P<.001). Two sensitivity analyses found significant interactions for both age × time (P=.03, P=.02) and age × time-square (P=.01, P=.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years.

Conclusions

These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.     

Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation

Yokoyama O, Sakuma F, Itoh R, Sashika H. Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation.

Objective

To compare outcomes, complications, and therapy intensity of inpatient rehabilitation in patients with paraplegia caused by spinal cord injury associated with aortic aneurysm repair (SCI-AA) versus patients with traumatic spinal cord injury (SCI).

Design

Case-controlled study.

Setting

SCI unit in a rehabilitation center.

Participants

Seventeen patients with SCI-AA and 17 patients with traumatic SCI.

Intervention

Standard rehabilitation therapy for SCI.

Main Outcome Measures

Length of stay (LOS) in acute and rehabilitation hospitals; FIM instrument scores; FIM change; FIM efficiency; complications; therapy intensity; and ambulatory state and return to community at discharge.

Results

No significant differences were noted in acute and rehabilitation LOS and admission FIM scores. Discharge FIM scores, FIM change, and FIM efficiencies were significantly lower in the SCI-AA group, which had many complications related to AA and SCI. Intensity of rehabilitation sports therapy in the SCI-AA group was significantly lower than that of the traumatic SCI group, but total therapy intensity did not differ significantly. Both had similar rates of return to ambulatory state and discharge to the community.

Conclusions

SCI-AA patients had many complications that interfered with rehabilitation therapy, and could not achieve functional gains comparable to those with traumatic SCI. However, both groups achieved comparable success with return to ambulatory state and discharge to the community.     

Disparities in bystander CPR provision and survival from out-of-hospital cardiac arrest according to neighborhood ethnicity

Study objective

We aimed to determine if there are differences in bystander cardiopulmonary resuscitation (BCPR) provision and survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) occurring in Hispanic neighborhoods in Arizona.

Methods

We analyzed a prospectively collected, statewide Utstein-compliant OHCA database between January 1, 2010, and December 31, 2012. Cases of OHCA were geocoded to determine their census tract of event location, and their neighborhood main ethnicity was assigned using census data. Neighborhoods were classified as “Hispanic” or “non-Hispanic white” when the percentage of residents in the census tract was 80% or more.

Results

Among the 6637 geocoded adult OHCA victims during the study period, 4821 cases were included in this analysis, after excluding 1816 cases due to incident location, traumatic cause, or because the arrest occurred after emergency medical service arrival. In OHCAs occurring at Hispanic neighborhoods as compared with non-Hispanic white neighborhoods, the provision of BCPR (28.6% vs 43.8%; P < .001) and initially monitored shockable rhythm (17.3% vs 25.7%; P < .006) was significantly less frequent. Survival to hospital discharge was significantly lower in Hispanic neighborhoods than in non-Hispanic white neighborhoods (4.9% vs 10.8%; P = .013). The adjusted odds ratio (OR) of Hispanic neighborhood for BCPR provision (OR, 0.62; 95% confidence interval, 0.44-0.89) was lower as compared with non-Hispanic white neighborhoods.

Conclusions

In Arizona, OHCA patients in Hispanic neighborhoods received BCPR less frequently and had a lower survival to hospital discharge rate than those in non-Hispanic white neighborhoods. Public health efforts to attenuate this disparity are needed.     

Functional Recovery After Severe Traumatic Brain Injury: An Individual Growth Curve Approach

Objective

To examine person, injury, and treatment characteristics associated with recovery trajectories of people with severe traumatic brain injury (TBI) during inpatient rehabilitation.

Design

Observational prospective longitudinal study.

Setting

TBI rehabilitation units.

Participants

Adults (N=206) with severe nonpenetrating TBI admitted directly to inpatient rehabilitation from acute care. Participants were excluded for prior disability and intentional etiology of injury.

Interventions

Naturally occurring treatments delivered within comprehensive multidisciplinary teams were recorded daily in 15-minute units provided to patients and family members, separately.

Main Outcome Measures

Motor and cognitive FIM were measured on admission, discharge, and every 2 weeks in between and were analyzed with individual growth curve methodology.

Results

Inpatient recovery was best modeled with linear, cubic, and quadratic components: relatively steep recovery was followed by deceleration of improvement, which attenuated prior to discharge. Slower recovery was associated with older age, longer coma, and interruptions to rehabilitation. Patients admitted at lower functional levels received more treatment, and more treatment was associated with slower recovery, presumably because treatment was allocated according to need. Therefore, effects of treatment on outcome could not be disentangled from effects of case mix factors.

Conclusions

FIM gain during inpatient recovery from severe TBI is not a linear process. In observational studies, the specific effects of treatment on rehabilitation outcomes are difficult to separate from case mix factors that are associated with both outcome and allocation of treatment.     

Cognition in Patients With Burn Injury in the Inpatient Rehabilitation Population

Objective

To analyze potential cognitive impairment in patients with burn injury in the inpatient rehabilitation population.

Design

Rehabilitation patients with burn injury were compared with the following impairment groups: spinal cord injury, amputation, polytrauma and multiple fractures, and hip replacement. Differences between the groups were calculated for each cognitive subscale item and total cognitive FIM. Patients with burn injury were compared with the other groups using a bivariate linear regression model. A multivariable linear regression model was used to determine whether differences in cognition existed after adjusting for covariates (eg, sociodemographic factors, facility factors, medical complications) based on previous studies.

Setting

Inpatient rehabilitation facilities.

Participants

Data from Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury (N=5347) were compared with other rehabilitation populations (N=668,816).

Interventions

Not applicable.

Main Outcome Measures

Comparison of total cognitive FIM scores and subscales (memory, verbal comprehension, verbal expression, social interaction, problem solving) for patients with burn injury versus other rehabilitation populations.

Results

Adults with burn injuries had an average total cognitive FIM score ± SD of 26.8±7.0 compared with an average FIM score ± SD of 28.7±6.0 for the other groups combined (P<.001). The subscale with the greatest difference between those with burn injury and the other groups was memory (5.1±1.7 compared with 5.6±1.5, P<.001). These differences persisted after adjustment for covariates.

Conclusions

Adults with burn injury have worse cognitive FIM scores than other rehabilitation populations. Future research is needed to determine the impact of this comorbidity on patient outcomes and potential interventions for these deficits.     

Measurement Properties of the Spinal Cord Injury-Functional Index (SCI-FI) Short Forms

Objective

To evaluate the psychometric properties of the Spinal Cord Injury-Functional Index (SCI-FI) short forms (basic mobility, self-care, fine motor, ambulation, manual wheelchair, and power wheelchair) based on internal consistency; correlations between short forms banks, full item bank forms, and a 10-item computer adaptive test version; magnitude of ceiling and floor effects; and test information functions.

Design

Cross-sectional cohort study.

Setting

Six rehabilitation hospitals in the United States.

Participants

Individuals with traumatic spinal cord injury (N=855) recruited from 6 national Spinal Cord Injury Model Systems facilities.

Interventions

Not applicable.

Main Outcome Measures

SCI-FI full item bank, 10-item computer adaptive test, and parallel short form scores.

Results

The SCI-FI short forms (with separate versions for individuals with paraplegia and tetraplegia) demonstrate very good internal consistency, group-level reliability, excellent correlations between short forms and scores based on the total item bank, and minimal ceiling and floor effects (except ceiling effects for persons with paraplegia on self-care, fine motor, and power wheelchair ability and floor effects for persons with tetraplegia on self-care, fine motor, and manual wheelchair ability). The test information functions are acceptable across the range of scores where most persons in the sample performed.

Conclusions

Clinicians and researchers should consider the SCI-FI short forms when computer adaptive testing is not feasible.     

An exploratory analysis of functional staging using an item response theory approach

Tao W, Haley SM, Coster WJ, Ni P, Jette AM. An exploratory analysis of functional staging using an item response theory approach.

Objectives

To develop and explore the feasibility of a functional staging system (defined as the process of assigning subjects, according to predetermined standards, into a set of hierarchic levels with regard to their functioning performance in mobility, daily activities, and cognitive skills) based on item response theory (IRT) methods using short forms of the Activity Measure for Post-Acute Care (AM-PAC) and to compare the criterion validity and sensitivity of the IRT-based staging system to a non-IRT-based staging system developed for the FIM instrument.

Design

Prospective, longitudinal cohort study of patients interviewed at hospital discharge and 1, 6, and 12 months after inpatient rehabilitation.

Setting

Follow-up interviews conducted in patients' homes.

Participants

Convenience sample of 516 patients (47% men; sample mean age, 68.3y) at baseline (retention at the final follow-up, 65%) with neurologic, lower-extremity orthopedic, or complex medical conditions.

Interventions

Not applicable.

Main Outcome Measures

AM-PAC basic mobility, daily activity, and applied cognitive activity stages; FIM executive control, mobility, activities of daily living, and sphincter stages. Stages refer to the hierarchic levels assigned to patients' functioning performances.

Results

We were able to define IRT-based staging definitions and create meaningful cut scores based on the 3 AM-PAC short forms. The IRT stages correlated as well or better to the criterion items than the FIM stages. Both the IRT-based stages and the FIM stages were sensitive to changes throughout the 6-month follow-up period. The FIM stages were more sensitive in detecting changes between baseline and 1-month follow-up visits. The AM-PAC stages were more discriminant in the follow-up visits.

Conclusions

An IRT-based staging approach appeared feasible and effective in classifying patients throughout long-term follow-up. Although these stages were developed from short forms, this staging methodology could also be applied to improve the meaning of scores generated from IRT-based computerized adaptive testing in future work.     

Activity Limitations Experienced by People With Stroke Who Receive Inpatient Rehabilitation: Differences Between 2001, 2005, and 2011

Objective

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

Design

A multicenter observational study of 3 periods.

Setting

Inpatient rehabilitation units (N=15).

Participants

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

Interventions

Not applicable.

Main Outcome Measures

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

Results

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

Conclusions

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.     

Rehabilitation Outcomes of Stroke Patients With and Without Diabetes

Objective

To investigate the relation of diabetes comorbidity and the rehabilitation outcomes of patients with stroke.

Design

Secondary data analysis.

Setting

Inpatient rehabilitation facilities.

Participants

Patients with stroke (N=35,243) who received inpatient rehabilitation in 2004 through 2008.

Interventions

None.

Main Outcome Measures

FIM, length of stay, and discharge destination.

Results

Mean age ± SD of the sample was 71.0±13.2 years. The percent of the sample of Medicare beneficiaries was 53.8%, whereas 46.2% had other sources of funding. Of the patients in the sample, 34.5% had a comorbidity of diabetes, with 17.2% classified as tier-eligible and 82.8% as nontier eligible. Findings included that patients in this sample with diabetes were admitted for rehabilitation services at a younger age than those without diabetes and support previous studies in which tier-eligible diabetes comorbidities moderated by patient age were found to be significant predictors of stroke rehabilitation outcomes. Furthermore, similar findings remained regardless of payer source.

Conclusions

This study provides additional evidence that diabetes as a comorbidity is significantly related to stroke rehabilitation outcome, but the relation is moderated by patient age.