Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: how guidelines change management

Purpose. To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).

Method. A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.

Results. Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.

Conclusions. Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.     

Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial

Background. The Canadian Occupational Performance Measure (COPM) is a commonly used outcome measure in rehabilitation. In this study it was adapted for very young children by deleting paid/unpaid work and household management categories and having parents act as proxies to rate child performance and their own satisfaction.

Purpose. To assess the internal consistency reliability, content and construct validity, responsiveness, and impact of half scores (20 not 10-point scale) of the adapted COPM.

Method. Parent proxies of subjects aged 2 - 8 (mean 3.9) years with spastic hemiplegic cerebral palsy (n = 41) participating in a clinical trial. There was a total of 214 occupational performance problems for analysis and an additional 56 which had used half score ratings. Internal consistency reliability and construct validity were evaluated using Cronbach alpha statistic. Proxy views explored content validity. Responsiveness was evaluated using pre-post intervention scores and a comparison with Goal Attainment Scaling scores which were assumed to be a suitable benchmark measure. The effect of half scores was assessed by two-sample t-tests.

Results. The COPM adaptations did not have a negative impact on internal consistency reliability as this was acceptable for performance (0.73) and satisfaction (0.83). The high Cronbach alpha scores indicated good construct validity. Content of occupations and rating approach was considered valid by proxies. Use of half scores did not result in significantly different performance ratings, but mean satisfaction ratings were significantly higher when half scores were used (p = 0.0001). This suggests that half scores may provide more precise proxy satisfaction ratings, but at the cost of rigour as internal consistency with satisfaction half scores was lower (0.63 vs. 0.82). Responsiveness to change in clinical status was demonstrated by significant pre-post scores and moderate correlations with goal attainment scores.

Conclusion. The adapted COPM is a psychometrically robust tool and the use of half scores is not recommended.     

Gender differences in amputation outcome

Purpose. To assess the influence of gender on the success of limb-fitting after amputation.

Methods. One-hundred and five successive in-patients admitted to an amputee rehabilitation ward were followed to assess the success of limb-fitting at discharge. The influence of demographic, clinical and social factors on the success of lower limb-fitting was assessed using linear regression analysis and group comparisons.

Results. There were 35 (33%) women in a cohort of 105 successive admissions. Men and women were comparable in terms of age, length of stay, medical comorbidity and level of amputation. Women were less likely to be successfully fitted with a prosthetic limb at discharge than men (42.9% vs 68.6%, p = 0.011), and more women lived alone (57.1% vs 38.6%, p = 0.021). Linear regression revealed that gender was an independent significant factor in the success of limb-fitting; age, level and cause of amputation, co-morbidity and length of stay were not significant factors.

Conclusions. Women were less likely to be successfully fitted with a lower limb prosthesis after amputation.     

Evaluation of patient education in spinal cord injury rehabilitation: knowledge, problem-solving and perceived importance

Purpose. Through inpatient education programmes the person with spinal cord injury (SCI) learns to understand and monitor his or her own physical, emotional and social well-being. The purpose of this study was to determine the patients' knowledge and problem-solving skills regarding SCI at admission, discharge and follow-up at 6 months after discharge; and to determine the perceived importance of each content topic included in the education programme.

Methods. A one-group repeated measures design was used to evaluate the outcomes. Knowledge was evaluated with a Multiple Choice Questionnaire (MCQ). Problem-solving ability based on participants' responses to Life Situation Scenarios relevant to each topic area was rated on a standardized four-point criterion reference scale. Perceived importance for each topic area was rated on a five-point Likert scale.

Results. Twenty-three participants completed all assessments. There was significant improvement in MCQ scores from admission to discharge (P = 0.04) and admission to follow-up (P = 0.02). For problem-solving ability, there was a trend toward improvement in all content topics with significant improvement from admission to follow-up for the topic of bowel care (P = 0.004). However, many participants continued to demonstrate poor problem-solving ability. Bowel, Bladder and Skin Care were consistently perceived as the most important education topics.

Conclusions. Improvements in knowledge do not necessarily translate to improvements in problem-solving ability even for the topics perceived as important. This may indicate the need to incorporate more active learning strategies or contextually based strategies within patient education programmes to facilitate the transfer of knowledge within life situations.     

Can the results 6 months after anterior cervical decompression and fusion identify patients who will have remaining deficit at long-term?

Purpose. There is no knowledge if short-term outcome in patients after anterior cervical decompression and fusion (ACDF) can be used to identify which patients have remaining deficit in long term. This study investigates if 6-month outcome with a broad assessment after ACDF with a cervical intervertebral fusion cage can be a guide for the 3-years outcome.

Method. A prospective study. Questions about background data, pain, numbness, neck specific disability, distress, sick leave, health, symptom satisfaction and effect of and satisfaction with surgery were asked 28 patients 3 years after ACDF. Measurements have earlier been obtained before and 6 and 12 months after ACDF.

Results. Compared with the results before surgery patients had improved in pain intensity (p = 0.001), neck pain (0.001), numbness (p = 0.02) and were more 'satisfied' with having their neck problems (p = 0.01). Except for a worsening in expectations of surgery fulfilled (p = 0.04) there were no significant differences between 6-month and 3-year outcome. Three years after ACDF about two-thirds of the patients had remaining deficit with regard to pain intensity, Neck Disability Index, Distress and Risk Assessment Method and general health. According to the parameters studied 50 - 78% of those who at the 6-month follow-up were without deficit were still healthy at the 3-year follow-up. For patients with deficit at 6-month follow-up, still 83 - 100% had deficit 3 years after surgery.

Conclusions. Despite a rather small study obtained the stability of 6-month and 3-year results indicates that short-term results might be sufficient for evaluating effects of the treatment. Since the patients in this study clearly demonstrate broad problems array of development of more structured multi-professional rehabilitation models including exercises which improve neck muscle strength, endurance and proprioception need to be introduced.     

Gait in the early days after total knee and hip arthroplasty: a comparison

Purpose. To evaluate whether gait after Total Knee Arthroplasty (TKA) is different from gait after Total Hip Arthroplasty (THA) in the early days following surgical intervention.

Method. The gait was studied in water, thus exploiting its buoyancy force. Twenty consecutive patients underwent TKA and twenty consecutive patients underwent THA. The mean age was 70.2 years (SD 6.9). Twenty age-matched volunteers were the control group.

Results. At the beginning TKA and THA patients had the same speed and the same step length. At day 15 there was a speed difference in favour of THA patients (t = - 2.245, df 38, p = 0.031). Likewise, the step length was longer in THA patients (t = -2.293 df 38, p = 0.027). In contrast to TKA patients, THA patients were unbalanced, having a longer stance phase on the non-operated leg and a longer swing on the contralateral one.

Conclusions. Gait strategies were completely different after TKA and THA interventions. TKA patients were balanced over their feet and they appeared more cautious and more concerned about gait quality than moving quickly. By contrast, THA patients were unbalanced, having a longer stance phase on the non-operated leg and a longer swing on the contralateral one. However, their speed gain was higher.     

Perceptual-motor coordination in persons with mild intellectual disability

Background. There is limited experimental evidence to support the view that individuals with intellectual disabilities (ID) have a deficit in motor control. This work is a first attempt to evaluate their motor coordination.

Purpose. The study assessed the relationship between cognitive ability and sensorimotor integration. The clinical hypothesis is that adults with ID fall below non-ID adults in motor skills that involve hand-eye coordination.

Method. A group of 42 adults with ID (ID group) was compared to 48 age-matched typical adults (TA) using a mixed experimental design ('Task' as the within-subjects factor and 'Group' as the between-subjects factor). Participants performed the following tests twice: Box-and-Blocks, 25-Grooved-Pegboard, Stick Catching and overhead Beanbag-Throw. Pearson correlations and ANOVAs were used to test the hypothesis (p ≤ 0.05).

Results. As expected, TA outperformed the ID group in all tests regardless of the hand used during for the assessment. However, TA individuals scored significantly better with one hand (i.e., the preferred and dominant hand) as opposed to persons with ID, who exhibited no hand preference. Test-retest correlations among the first and second assessment scores yielded moderate-strong coefficients, depending on the type of test (Box-and-Blocks = 0.92 and 0.96, 25-Grooved-Pegboard = 0.69 and 0.83, Stick-Catching = 0.88 and 0.94, Beanbag-Throw = 0.58 and 0.91 for ID and TA, respectively).

Discussion. Difficulties in the integration of perceptual information into motor action may result in inadequate solutions to daily motor problems. As it stems from our results, intellectual disability relates to inability to integrate visual inputs and hand movements. In people with mild ID such inability is observed using both hands (i.e., they show no hand preferences). Poor perceptual-motor coordination might have a functional significance in that it may lead to exclusion from vocational and recreational activities, and a decreasing competence of ADL. Assessing coordination in adults with ID may contribute to understanding the nature of the ID condition and may encourage an early rehabilitation.     

Force production and EMG activity of neck muscles in adolescent headache

Purpose. This study compared the maximal force, EMG/force ratio and co-activation characteristics of the neck-shoulder muscles between 30 adolescents with migraine-type headache, 29 with tension-type headache, and 30 headache-free controls.

Method. Force was measured with surface electromyography (EMG) from the cervical erector spinae (CES), the sternocleidomastoid (SCM) and trapezius muscles during the maximal isometric neck flexion, neck extension and shoulder flexion.

Results. Girls with migraine-type headache had higher EMG/force ratios between the EMG of the left agonist SCM muscle and the corresponding maximal neck flexion (p = 0.030) and neck rotation force to the right side (p = 0.024) than the girls with tension-type headache. Migrainous girls had more co-activation of right antagonist CES muscle during maximal neck flexion force than the girls without headache (p = 0.015). Neck force production showed no significant differences between girls. Girls with tension-type headache displayed lower left shoulder flexion force than girls with migraine-type headache (p = 0.005) or with no headache (p = 0.005). In boys, no significant differences were observed.

Conclusions. Girls with tension-type headache and migraine-type headache have differences in neuromuscular function in the neck-shoulder muscles. The data amplify our knowledge of the neck-shoulder muscle dysfunction in adolescent headache, and may encourage the use of specific rehabilitation methods in the management of different types of headache.     

A pilot study of a web-based physical activity motivational program for adults with physical disabilities

Purpose. Develop, deliver, and assess the efficacy of a 4-week web-based leisure-time physical activity (LTPA) motivational program based on the Transtheoretical Model and tailored to inactive adults with physical disabilities.

Method. This was a pilot-based study incorporating a true experimental design with one treatment and one control group. The intervention program was delivered on the web and was based on the constructs of the Transtheoretical Model. From the 151 individuals who completed the LTPA standardized questionnaire at baseline, 75 people participated in the 1-month post-test assessment.

Results. The results of the analysis confirmed the pretest LTPA scores as the study covariate for the post-test assessment (F (1,72) = 16.06, p = 0.001, η² = 0.18). Based on the one-way ANCOVA, there were no statistically significant differences in LTPA scores between the treatment and control groups at post-test. However, the corresponding effect size and variance explained by the treatment approached a moderate level of significance (d = 0.34 and η² = 0.04).

Conclusions. Although conclusive statements about program effectiveness cannot be secured, several 'lessons learned' from this project may be 'key factors' for program improvement. Given the pilot nature of the study and the limited resources for program development and monitoring, continued examination of such motivational materials and delivery mechanisms for people with physical disabilities appear warranted.     

Reduction of disability after stroke is a more informative predictor of long-time survival than initial disability status

Purpose. Few studies have evaluated the roles of reducing disability after stroke in predicting survival. This study aimed to investigate the effects of improvement in the Barthel Index (BI) and other prognostic factors on survival in patients with first-time noncardioembolic ischemic stroke.

Method. BI effectiveness was defined as the improvement of BI between initial stroke (within 3 days) and 2 months after stroke. Cox regression analysis and Kaplan-Meier methods were used to evaluate the predictive roles of various prognostic factors.

Results. A total of 111 patients were enrolled. Mean age at the time of stroke was 68 (±11.2) years. Median follow-up time was 77.4 months. Mean initial BI was 36.1 (±28.5) and mean BI effectiveness was 46.9 ± 29.0. Overall, 55 deaths (49.5%) of the cohort were ascertained. The BI effectiveness had significant effects on long-time survival while initial BI was not a significant predictor. Higher BI effectiveness led to lower risk of mortality (hazard ratio = 0.44, 95% CI 0.24 - 0.80, p = 0.007). Elder age was correlated with poor survival (overall p = 0.006). Subjects in the eldest age group (≧70 years) showed a significant elevated risk for death (hazard ratio = 3.42, 95% CI 1.18 - 9.92). There was a trend indicating that the smaller the lesion size, the more favourable the prognosis (overall p = 0.057).

Conclusions. BI effectiveness in the first 2 months after first-time noncardioembolic stroke was more informative than initial disability status for predicting long-time mortality. It highlights the potential benefit in maximizing functional performance in patients with stroke.     

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.     

Can children with developmental coordination disorder adapt to task constraints when catching two-handed?

Purpose. To compare the nature and extent of inter and intralimb coupling during two-handed catching and the effect of manipulating task constraints in children with Developmental Coordination Disorder (DCD) and their typically developing peers (AMC).

Method. Twenty children aged 7 - 10 years, ten with DCD and 10 AMC attempted to catch a ball ten times in condition 1 (C1), ball to the midline; condition 2 (C2), ball to the left shoulder and condition 3 (C3), ball to the right shoulder. Both 3D kinematic data and video data were collected.

Results. Children with DCD caught fewer balls than the AMC children, regardless of age or condition (p ≤ 0.001). Children with DCD demonstrated a higher degree of linkage between limbs in C1 and a lower degree of between limb coupling in C2 and C3 when compared to the AMC (p ≤ 0.05). Differences between the AMC7 - 8 and AMC9 - 10 group were found with respect to interlimb coupling.

Conclusions. The influence of manipulating task constraints and the individual nature of children with DCD must be considered by those involved in rehabilitation. By doing so, children with DCD may search for appropriate motor solutions to many functional movement tasks required for everyday life.     

Functional status in 5 to 7-year-old children with Down syndrome in relation to motor ability and performance mental ability

Purpose. To examine the contribution of motor ability and 'performance' mental ability on functional skills in children with Down syndrome (DS).

Method. A structural equation modelling approach was used to test the relation between motor ability, performance mental ability and functional status. Functional status was assessed with the Pediatric Evaluation Disability Inventory (PEDI), motor ability with the Movement Assessment Battery for Children (M-ABC), and performance mental ability was assessed with the Gross-Form Board (GFB). Sixty-five children with DS, selected by the Dutch Down Syndrome Foundation, were asked to participate in the study. Data were analysed with the programme AMOS using the Bollen-Stine bootstrap method. Chi² and NFI index were used as goodness-of-fit indices.

Results. The fit of the model was good (χ² 4 = 1.35, p = 0.85; and NFI = 0.99). 'Functional status' explained 70% of the variance in the model. Standardized regression weights indicated that motor ability was a far better predictor of functional status of children with DS than performance mental ability (0.96 vs. 0.17).

Conclusions. Limitations in functional activities of 5 to 7-year-old children with Down syndrome seem to be more related to the level of motor ability than to the level of performance mental ability.     

Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: An observational study

Purpose. Understanding the relationship between the motor impairments and their impact on physical activity will allow rehabilitation after stroke to be based on scientific principles. The aims of this study were to determine: (i) the relative contribution of weakness and spasticity to contracture, and (ii) the relative contribution of all three impairments to limitations in physical activity during the first 12 months after stroke.

Method. This longitudinal observational study charted the evolution of weakness (loss of maximal force), spasticity (stretch-evoked EMG) and contracture (loss of joint range) of the elbow flexors and limitations in upper limb activity (Motor Assessment Scale) for a year after stroke in 27 subjects who had suffered a first stroke. Spasticity was measured as abnormal reflex activity, weakness was measured as loss of maximum isometric torque, contracture was measured as the difference in range of motion between the affected and intact side, and limitations in physical activity were measured on a clinical scale.

Results. The major independent contributors to contracture were spasticity for the first four months after stroke (p = 0.0001 - 0.10) and weakness thereafter (p = 0.01 - 0.05). However, the major and only independent contributor to limitations in physical activity throughout the year was weakness (p = 0.0001 - 0.05).

Conclusions. For the first time, from a longitudinal study, the findings show that spasticity can cause contracture after stroke, consistent with the prevailing clinical view. However, weakness is the main contributor to activity limitations.     

Recovery from disability after stroke as a target for a behavioural intervention: results of a randomized controlled trial

Purpose. Disability following stroke is highly prevalent and is predicted by psychological variables such as control cognitions and emotions, in addition to clinical variables. This study evaluated the effectiveness of a workbook-based intervention, designed to change cognitions about control, in improving outcomes for patients and their carers.

Method. At discharge, stroke patients were randomly allocated (with their carers) to a 5-week intervention (n = 103) or control (normal care: n = 100). The main outcome (at 6 months) was recovery from disability using a performance measure, with distress and satisfaction as additional outcomes.

Results. The intervention group showed significantly better disability recovery, allowing for initial levels of disability, than those in the control group, F(1,201) = 5.61, p = 0.019. Groups did not differ in distress or satisfaction with care for patients or carers. The only psychological process variable improved by the intervention was Confidence in Recovery but this did not mediate the effects on recovery.

Conclusions. A large proportion of intervention participants did not complete the workbook tasks. This was perhaps associated with the fairly low level of personal contact with workbook providers. The modest success of this intervention suggests that it may be possible to develop effective behavioural interventions to enhance recovery from disability in stroke patients.     

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

Purpose. To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

Method. This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7-24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

Results. Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

Conclusions. The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.     

Material handling performance of patients with chronic low back pain during functional capacity evaluation: a comparison between three countries

Purpose. Functional Capacity Evaluations (FCEs) are batteries of tests designed to measure patients' ability to perform work-related activities. Although FCEs are used worldwide, it is unknown how patients' performances compare between countries or settings. This study was performed to explore similarities and differences in FCE performance of patients with chronic low back pain (CLBP) between three international settings that utilize the same FCE protocol.

Methods. Standardized FCEs were performed on three cohorts of patients with CLBP: A sample from an outpatient rehabilitation context in The Netherlands (n = 121), a Canadian sample in a Worker's Compensation context (n = 273), and a Swiss sample in an inpatient rehabilitation context (n = 170). Patients were undergoing FCE as part of their usual clinical care. Means and standard deviations of maximum performance on the FCE material handling items were calculated and differences compared using ANOVA. Multivariable linear regression was used to determine the relationship between country of origin and FCE performance while controlling for potential confounders including, age, sex, duration of back pain problems, and self-reported pain and disability ratings.

Results. Compared to the Dutch sample, the mean performance of patients in the Canadian and Swiss samples was consistently lower on all FCE items. This association remained statistically significant after controlling for potential confounders.

Conclusions. Considerable differences were observed between settings in maximum weight handled on the various FCE items. Future FCE research should examine the effects of a number of potentially influential factors, including variability in evaluator judgements across settings, the evaluator-patient interaction and patients' expectations of the influence of FCE results on disability compensation.     

Referral of patients with neuromuscular disease to occupational therapy, physical therapy and speech therapy: usual practice versus multidisciplinary advice

Purpose. To compare the volume of occupational therapy (OT), physical therapy (PT) and speech therapy (ST) as currently received by patients with neuromuscular diseases with the volume of OT, PT and ST recommended by a multidisciplinary team.

Method. The use of OT, PT and ST was studied retrospectively and prospectively in a reference group (n = 106) receiving usual care and in an intervention group (n = 102) receiving advice based on multidisciplinary assessments. A cost analysis was made and the implementation of the advice was evaluated at 6 months.

Intervention. Multidisciplinary assessments consisted of a single consultation by OT, PT and ST each, followed by a multidisciplinary meeting and integrated advice.

Outcome variables. Volume (frequency times duration) of therapy, relative over- and underuse of therapy and costs of therapy and intervention.

Results. Compared to the multidisciplinary advice, there was 40% underuse of OT among patients with neuromuscular disease. For PT, there was 32% overuse and 22% underuse; for ST, there was neither over- nor underuse. Some 40% of patients received once-only advice regarding ST compared to 27% regarding OT and 19% regarding PT. The costs of the multidisciplinary advice were estimated at €245 per patient. If fully implemented, our multidisciplinary approach would result in a mean cost savings of €85.20 per patient. The recommended therapy had, however, been implemented only partially at 6 months follow-up.

Conclusions. Some patients with a neuromuscular disease do not receive any form of allied healthcare, whereas they should. Among patients with neuromuscular disease who do receive some form of allied healthcare, quite a few receive these treatments for too long periods of time. Ways need to be developed to improve implementation of the multidisciplinary advice and to obtain a more favourable balance between its costs and benefits.