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.     

The work of rehabilitation

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

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

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

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

Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period.

Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine.

Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 ± 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 ± 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low.

Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

Performance of activities of daily living in multiple sclerosis

Purpose: To assess the performance of activities of daily living (ADL) in individuals with moderate to severe multiple sclerosis (MS).

Method: A total of 12 men and 32 women with MS (Expanded Disability Status Scale, EDSS, 6.0 - 8.5) were studied. The performance of personal ADL (P-ADL) and instrumental ADL (I-ADL) was assessed with the Functional Independence Measure (FIM) and the Assessment of Motor and Process Skills (AMPS).

Results: Twenty-four of the 44 individuals were rated dependent in P-ADL by the FIM motor score, mainly due to limitations in some areas of self-care and in transfers and locomotion. Only three individuals were rated dependent by the FIM cognitive score, indicating no or little cognitive disability. Two thirds of the individuals who were rated independent/modified independent in P-ADL by the FIM were rated dependent in I-ADL by the AMPS. Only the FIM motor score was significantly related to the EDSS score, indicating that ADL performance and disease severity is weakly related.

Conclusions: Moderate to severe MS reduces the ability to perform both P-ADL and I-ADL. An individual with MS can be independent in P-ADL but still unable to perform I-ADL satisfactorily. Assessments of both P-ADL and I-ADL are advocated to evaluate ADL performance in order to implement appropriate management strategies for individuals with MS.     

Recovery from unilateral neglect after right-hemisphere stroke

Purpose: To show the recovery process for different forms of unilateral neglect (UN)—including personal neglect and neglect of far space—in relationship to impairment, disability, cognition and mood.

Method: Patients were tested at 2 - 4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

Results: Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

Conclusions: For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.     

Long-term outcomes after moderate to severe traumatic brain injury

Objective: This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI).

Design: Retrospective cohort study.

Setting and subjects: We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury.

Main outcome measures: Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services.

Results: Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living.

Conclusion: Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.     

Evaluation of a 5-level functional independence measure in a longitudinal study of elderly stroke survivors

Purpose: The aim of the present study was to evaluate a modified 5-level Functional Independence Measure (FIM), by using the assessments from a longitudinal study of elderly stroke survivors.

Method: One hundred and seventy-three patients were followed longitudinally. Firstly, the 7-level FIM™ was used at 0 - 3 days, 3 weeks, and 3 months and then after 1 year following acute stroke. The data, in total 8996 assessments, were presented on the item level. Secondly, the data were recoded with the help of a modified 5-level FIM according to the cut-off levels suggested in a previous study of the same target group. Two registered occupational therapists did the assessments in the patients' natural environment, i.e., in their own homes or in different kinds of assisted living. The data were obtained both by interviews and with the help observations, when the occupational therapist asked the patients to perform specific activities.

Results: The assessments on all four occasions were found to polarise when using the 7-level FIM™, and the intermediate levels of assistance were more seldom used. After the assessment data were recoded with the modified 5-level FIM, it was shown that it was easier to follow the process of activity by using an instrument with fewer levels. A modified 5-level FIM had enough levels to ensure sensitivity and was easier to handle when evaluating performance of daily activities in a large population study.

Conclusions: A modified 5-level FIM can be useful in large population studies and most likely increase reliability without losing in sensitivity.     

An evaluation of aftercare following discharge from a specialist in-patient rehabilitation service

Purpose: To evaluate the aftercare of patients discharged from specialist rehabilitation unit with respect to use of equipment and follow-up by therapy and care services and to assess change in dependency and care needs.

Design: Cross-sectional survey of a consecutive cohort of patients discharged from a regional rehabilitation unit with reference to the British Society of Rehabilitation Medicine (BSRM) standards for rehabilitation services.

Subjects and methodology: Fifty-three subjects with neurological disability were discharged during a 15-month period. Structured interviews conducted by telephone with the patient (n = 22) or carer (n = 31) between 8 and 21 (mean 15) months after discharge. Dependency and care needs were assessed using the Northwick Park Dependency Score (NPDS) and Care Needs Assessment (NPCNA)

Results: Approximately half the patients improved in dependency and care needs between discharge and follow-up, but a quarter deteriorated. Fifty-one (96%) were referred for continuing therapy of which 39% expressed dissatisfaction. There was a significant relationship between inadequate therapy follow-up and increased dependency (Chi Squared p = 0.002). However, where care packages were revised downwards this generally reflected improvement in independence and therefore reduced need. Fourteen (26%) discontinued use of equipment early after discharge since they found it unacceptable or unhelpful. Seventeen (38%) of this population experienced late seizures.

Conclusions: Specialist rehabilitation in this group of severely disabled brain injured patients with complex needs can result in sustained improvement of function with resultant reduced care needs. However, appropriately skilled community-based services are required to maintain and build on the benefits, and are currently lacking in many districts. In particular, psychological support was notably absent. A possible relationship between late onset seizures and the use of anti-depressant medication requires further exploration, which is currently underway.     

Leisure-time physical activity and secondary conditions in women with physical disabilities

Purpose: To examine the relationship between secondary conditions and leisure-time physical activity participation (LTPA) in women with physical disabilities.

Method: A survey was conducted in a metropolitan urban USA area of women (n = 170) with physical disabilities including MS, CP, polio, arthritis, TBI, and CVA among others and aged 21 - 65 years. Outcome measures were LTPA, secondary conditions (numbers and severity), and functional status.

Results: Respondents experienced 11.99 ( ± 6.05) secondary conditions in the past year, self-rated their severity as 'moderate problems', and reported moderate levels of functional impairment. LTPA participation (excluding calisthenics/exercise) was reported to be 2.90 ( ± 5.12) times/week with 39.4% reporting no participation. After controlling for the interaction between severity of secondary conditions and functional status, the secondary conditions of physical deconditioning and isolation were significantly and inversely related to LTPA participation (r = - 0.164, p = 0.036; r = - 0.156, p = 0.045, respectively).

Conclusion: Reported secondary conditions of physical deconditioning and isolation are inversely related to the ability of moderately impaired women with physical disabilities to participate in LTPA when functional status was controlled and should be considered in efforts to increase involvement in this health promoting behaviour.     

Effects of surface electrical stimulation on the muscle-tendon junction of spastic gastrocnemius in stroke patients

Purpose: The purpose of this study was to explore the effects of spasticity suppression by surface electrical stimulation (ES) on the muscle-tendon junction of spastic gastrocnemius muscles in stroke.

Methods: Twenty-four neurologically stable stroke patients (aged 41 - 69 years, 12 - 35 months post-stroke), with spasticity graded 2 or 3 on the modified Ashworth scale, were recruited and divided into two groups. In the ES group, each patient received 20 min of surface ES once daily, 6 days per week for 1 month. In the control group, ES was used with stimulation intensity kept at zero. To evaluate the therapeutic effect, the modified Ashworth scale, Fmax/Mmax ratio, H-reflex latency, H-reflex recovery curve, and the 10-m walking time were tested before and after the 1-month treatment.

Results: In the ES group, the modified Ashworth Scale showed a trend toward reduced spasticity after 1 month of treatment. The Fmax/Mmax ratio decreased from 8.10% ± 4.84% to 4.00% ± 1.36%; the H-reflex latency increased from 28.87 ± 2.45 ms to 29.40 ± 2.57 ms; the H-reflex recovery curves indicated a downward shift; and the 10-metre walking time significantly decreased after ES. In the control group, none of the measures showed a statistically significant change.

Conclusions: In the study, we demonstrated a way to suppress spasticity at a metameric site and to increase walking speed effectively by applying surface ES on the muscle-tendon junction of spastic gastrocnemius muscles.     

Masculine role variables and outcomes among men with spinal cord injury

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

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

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

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

The influence of severe malnutrition on rehabilitation in patients with severe head injury

Objective: The purpose of the study was to evaluate the consequences of severe malnutrition in patients with severe head injury during rehabilitation.

Patients and methods: The data were collected from medical records of patients admitted to the neurorehabilitation unit over the last 5 years. Twenty of 1850 patients had severe malnutrion, the body mass index (BMI) of these patients were under 15 (10 - 14) kg/m². The majority of patients suffered traumatic brain damage (17/20). Thirteen patients arrived with percutaneous endoscopic gastrotomy /PEG, three nasogastric tube in 3 cases we placed PEG. The nutritional strategy included a high-calorie diet, by means of bolus feeding five times during the day, continuous feeding during the night; the daily intake target being more than 2500 kcal.

Results: During rehabilitation treatment the majority of patients (13/20) revealed weight gain with a rate of 0.5 - 2 kg/week. The following complications were treated during the rehabilitation phase: 20 pressure sores, 20 contractures, 11 urinal infections, 6 cases of pneumonia, 2 of purulent bronchitis, 6 of sepsis, 1 penoscrotal abscess, epidydymitis, and 1 case of purulent arthritis. The patients required total assistance at the time of admission. At discharge 10 patients remained completely dependent, 6 patients needed minimal assistance, and 4 patients could perform daily activities independently. The average length of stay in our unit was 78/6 - 150/days.

Conclusion: Patients with head injury suffering from severe malnutrition exhibit serious complications at the time of admission as well as during rehabilitation treatment. The patients were very difficult to mobilize. The length of stay at the rehabilitation unit was 28 days longer when complicated by malnutrition, than head injuries showing normal nutritional status. These findings underline the importance of adequate nutrition in patients with head injury in both the acute ward and in the rehabilitation unit.     

Reintegrating space and object representations in patients with hemispatial neglect: two case studies

Purpose: This article examines the effectiveness of differentiated rehabilitation programmes for patients with two distinct types of hemispatial neglect: body-centred and object-focused. We hypothesized that patients with body-centred neglect would respond to motor-control programmes designed for patients with limb apraxia, while those with object-focused neglect would require visually oriented therapy.

Material and methods: The article describes the rehabilitation of two patients treated by the authors 6 - 9 months after right-hemisphere infarct. Both showed significant left-sided hemispatial neglect: body-centred in one case (patient BC), object-focused in the other (patient OF). A modified AB - BA experimental design was used, where A represents visual training, and B is spatio-motor training. For patient BC, the sequence was A - B; for patient OF, B - A. Neglect was measured using standard tests for neglect and the analysis of drawings made during therapy by both patients.

Results: As hypothesized, patient BC showed no progress after conclusion of programme A, while after programme B she showed virtually no lingering neglect. In the case of patient OF, the results were exactly reversed.

Conclusions:  Body-centred neglect is essentially a defect in space formation, while object-focused neglect is a disorder of object formation. The patients described here both benefited from neuropsychological therapy for neglect, but not from the same programme.     

Learning to eat after radiation therapy for throat cancer

Purpose: The initial purpose was to find more expedient ways for learning to eat for personal rehabilitation. The secondary purposes were to inform other radiation therapy patients and to inform clinicians and therapists involved in rehabilitation of throat cancer patients.

Method: This is an account of personal experiences of the author who is a throat cancer survivor. This rehabilitation engineer, and his social worker wife, systematically sought and found more effective ways for learning to eat again.

Results: More effective approaches for discovering, preparing, presenting and consuming food by recovering throat cancer patients were identified.

Conclusion: The rehabilitation process for patients with radiation damage to the throat can be enhanced through simple methods and dedicated efforts of the patients themselves.     

Quality assessment in rehabilitation centres: the indicator system 'Quality Profile'

Purpose: An indicator system for measuring the quality of rehabilitation centres ('Quality Profile' of rehabilitation centres) is presented. The implementation of the concept is explained with the aid of results regarding structural, process and outcome quality in 26 cardiac and orthopaedic rehabilitation centres.

Method: In each centre, structural, process and outcome quality, including patient and employee satisfaction, are measured. Process quality is determined by means of a peer review procedure that includes examination of 20 randomly selected cases on the basis of discharge reports and therapy plans. The medical outcome is measured by a prospective study with three measurement time points and a sample of approx. N = 200 patients per centre.

Results: Overall, the level of quality of the medical rehabilitation in the institutions participating in the study must be considered high. However, on almost all quality dimensions, even after a risk adjustment there are clear differences between centres, which point to the usefulness of benchmarking analyses and the need for improvements in quality in some centres.

Conclusions: The indicator system presented is a starting-point for comprehensive, comparative measurement of the quality of in-patient rehabilitation centres that, with regard to its principles, also appears applicable to other areas of health care.     

The value of the Rehabilitation Activities Profile (RAP) as a quality sub-system in rehabilitation medicine

Purpose: To determine whether interdisciplinary team care, using the Rehabilitation Activities Profile (RAP) as a team tool, results in a better rehabilitation outcome.

Method: A multilevel prospective cohort study, with a controlled before and after design. Eighteen rehabilitation teams in eight rehabilitation centres in the Netherlands and Belgium participated. Based on the level of implementation of the RAP, we compared three study groups. Consecutive adult patients (n = 933) with stroke, amputation of the lower limb, spinal cord injury, multiple sclerosis, or other neuromuscular disorders, were followed during inpatient or outpatient rehabilitation. Main outcome measures were Barthel Index, RAP-CPM (sum score of the domains communication, personal care and mobility), Nottingham Health Profile (NHP), length of rehabilitation (LOR) and discharge destination (home vs elsewhere).

Results: Overall results show that scores on the Barthel Index, the RAP-CPM and the NHP improved, on average, by 18.4%, 12.7%, and 6.7%, respectively. However, treatment from a rehabilitation team that uses the RAP was associated with a significantly lower Barthel score, and small, non-significant effects on the RAP-CPM and the NHP. Partial use of the RAP resulted in non-significant, lower scores on these measures. With respect to discharge destination and LOR, there were also no significant differences between the three study groups, with the exception of a shorter outpatient rehabilitation period for the group in which partial use was made of the RAP.

Conclusion: The RAP, at the current level of implementation, does not improve rehabilitation outcome.     

Psychometric validation of a subjective well-being measure for people with spinal cord injuries

Purpose: The researchers examined the factorial validity and the concurrent validity of the Sense of Well-Being Inventory (SWBI) based on a sample of Canadians with spinal cord injuries (SCI) in the community.

Method: One hundred thirty-two participants were recruited from the Alberta, Saskatchewan, Nova Scotia, and Manitoba chapters of the Canadian Paraplegic Association. Mean age of participants was 45.82 years (SD = 15.67), and 77% were men. The participants were asked to complete a research packet containing a demographic questionnaire, the SWBI, and the brief version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF).

Results: Factor analysis yield four factors (Psychological Well-Being, Financial Well-Being, Social and Family Well-Being, and Physical Well-Being) similar to the original SWBI. In addition, the SWBI factors in the present study correlated moderately well with the corresponding factors in the WHOQOL-BREF and with demographic variables appropriate to the respective subscale.

Conclusions: The factorial validity and the concurrent validity of the SWBI were generally supported. The SWBI, as a subjective well-being measure developed specifically to relate to disability and rehabilitation, appears useful for use with people with SCI in the community.     

Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

Purpose: The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study.

Method: Twenty-seven inpatients following stroke (mean age = 67 years, range = 40 - 80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with 'Upper Arm Function', 'Hand Movements', and 'Advanced Hand Activities' items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS.

Results: All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbach's alpha of 0.83 which did not benefit from removal of any items.

Conclusions: The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.