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.     

Vocational rehabilitation acceptance in the USA: controlling for education, type of major disability, severity of disability and socioeconomic status

Purpose: The aim of the study was to investigate whether there were differences in acceptance rates for VR services among African Americans, White Americans, Native American or Alaskan Natives, and Asian or Pacific Islanders with disabilities in the USA?

Method: The study was based on a population 599 444 customers who sought VR or Bureau of Visual Service Agency services in the USA from 1 October, 1997, through 30 September, 1998. The subsample of customers with no missing values on the variables under investigation included African Americans (n = 13 287), White Americans (n = 38 048), Native American or Alaskan Natives (n = 599), and Asian or Pacific Islanders (n = 596). The chi-square test of homogeneity of proportions was the test statistic. The final random subsample included African Americans (n = 300), White Americans (n = 300) Native American or Alaskan Natives (n = 300), and Asian or Pacific Islanders (n = 300) was drawn from the population of VR customers in the USA.

Results: The study supports the hypothesis that African Americans were more likely to be found ineligible for VR services, while Asian or Pacific Islanders were more likely to be accepted for VR services.

Conclusion: While discovering that African Americans are more likely to be rejected for VR services was not surprising, discovering that Asians or Pacific Islanders are more likely to be accepted for VR services than African Americans was unexpected, given that past VR acceptance research adduced that White Americans, not Asian or Pacific Islanders, are more likely to be accepted for VR services when compared to African Americans with disabilities. While a preponderance of VR research indicates that White Americans are more likely to be accepted for VR services than African Americans, it was also unexpected that White Americans were not statistically significant when education, type of major disability, disability severity, and SES were controlled.     

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.     

Development and validation of AIMFREE: Accessibility Instruments Measuring Fitness and Recreation Environments

Purpose: The purpose of this study was to develop and validate a series of 16 survey instruments measuring fitness and recreation accessibility, collectively referred to as AIMFREE (Accessibility Instruments Measuring Fitness and Recreation Environments). General domains of assessment included the built environment, equipment, programmes, policies, and training and behaviour.

Methods: Fitness and recreation professionals (n = 35) assessed fitness centres/swimming pools (n = 35) in nine regions across the US. Rasch analysis was used to assess the psychometric properties of the instrument.

Results: The AIMFREE evidenced adequate to good fit to the Rasch model and adequate to good internal consistency (r = 0.70 - 0.90). Test-retest reliability ranged from 0.70 (entrance areas) to 0.97 (swimming pools). Analysis of differential item functioning indicated that item calibrations generally did not differ significantly between urban and suburban environments.

Conclusion: The AIMFREE instruments demonstrated adequate to good fit to the Rasch model with several of the subscales demonstrating well to excellent separation of facility accessibility.     

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.     

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.     

Predictors of long-term participation after stroke

Purpose: (1) To explore factors that predict long-term participation after stroke (2 - 4 years after discharge from rehabilitation), and (2) to determine factors that predict both short- and long-term participation.

Methods: Biopsychosocial data of people who had had a stroke were measured at discharge from an intensive rehabilitation unit using valid instruments. Six months later (n = 102) as well as 2 - 4 years later (n = 66), social participation of the survivors was measured in their living environments. Participation was estimated with the Assessment of Life Habits (LIFE-H), which includes 12 categories of daily activities and social roles.

Results: From mutivariate regression analyses, the best predictors of long-term participation after stroke appear to be age, comorbidity, motor coordination, upper extremity ability and affect. Age, comorbidity, affect and lower extremity coordination are the best predictors of participation after stroke at both measurement times.

Conclusions: With the exception of age, these factors may be positively modified and thus warrant special attention in rehabilitation interventions.     

Comparison of clinical test and questionnaires for the evaluation of upper limb prosthetic use in children

Purpose: The aim of the present study was to find out if there was a correlation between an observational clinical test and a questionnaire for the evaluation of upper limb prosthetic use in children and to determine which one was better and easier to use in clinical practice.

Method: Twenty children who were patients of the children's prosthetic clinic at the Rehabilitation Institute in Ljubljana, Slovenia, and had a functional prosthesis were included in the study. The age appropriate subtest of the University of New Brunswick Test of Prosthetic Function (the UNB test) was assessed by an occupational therapist. Parents completed either the Child Amputee Prosthetics Project-Functional Status Inventory for Preschool children (CAPP-FSIP) or the Child Amputee Prosthetics Project-Functional Status Inventory (CAPP-FSI), depending on which was appropriate for the child's age. Information was limited to the upper extremity items.

Results: We found a significant correlation between UNB spontaneity and skill score (r = 0.956, p = 0.000) and also between the parental CAPP score and UNB test (UNB spontaneity—CAPP activities r = 0.634, p = 0.003; UNB spontaneity—CAPP prosthetic use r = 0.542, p = 0.014, UNB skill—CAPP activities r = 0.559, p = 0.010, UNB skill—CAPP prosthetic use r = 0.597, p = 0.005).

Conclusions: We concluded that both instruments can be used for assessing upper limb prosthetic use in children but neither is an optimal choice.     

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.     

Using the theory of planned behaviour to develop an assessment of attitudes and beliefs towards prosthetic use in amputees

Purpose: To develop a questionnaire based on the theory of planned behaviour (TPB) to predict prosthetic use.

Method: In part one, 31 amputees over 50 years of age with peripheral arterial disease completed attitude items containing 27 bipolar adjectives and open-ended questions on behavioural, normative and control beliefs relating to using the prosthesis. Academic, clinical and patient experts (n = 12) identified bipolar adjectives with best face validity. In part two, 15 amputees completed three behavioural format questions relating to prosthetic use and were asked to indicate the easiest to answer.

Results: Following the completion of the attitude items by the amputees and the expert panel review, 5 items remained (Cronbach's alpha = 0.87) with corrected item-total correlations ranging from 0.43 to 0.83. Modal behavioural beliefs concerned mobility (46.5%), independence (25.6%) and participation restrictions (16.3%), normative beliefs concerned family (33.3%), NHS staff (31.7%), friends (19.1%) and other patients (15.9%) and control beliefs concerned stairs (21.1%), slippery/rough surfaces (28.9%), disabled facilities (54.8%) and people helping (22.6%). In relation to part 2, an exact numerical report of hours and days of prosthetic use was found easiest to answer (73%).

Conclusions: Based on this qualitative and quantitative development work, the questionnaire contains five attitude items, six behavioural, eight normative, eight control belief items and two self-report questions of the behaviour.     

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

Purpose: The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

Method: The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa = 0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

Results: The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

Conclusions: A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.     

Rehabilitation following hip fracture surgery: a comparative study of females and males

Purpose: To compare patient, fracture and rehabilitation variables between male and female patients during the rehabilitation period immediately following surgical repair of hip fracture (HF).

Methods: A prospective cohort study was conducted in a rehabilitation geriatric ward in a tertiary university hospital in southern Israel. The study group consisted of 808 elderly patients, 65 years of age or older, selected for hospitalized rehabilitation following surgery for HF. The measurements included functional studies by the Functional Independence Measure (FIM™) scale, mental status by Folstein Minimental Test and Clock Drawing Test, Geriatric Depression Screening Scale (GDS), demographic and social parameters, laboratory tests, length of rehabilitation, complications and mortality during rehabilitation.

Results: Six hundred and fourteen patients (76%) were women and 194 (24%) were men. The mean age ( ± SD) of the women was 78.4 ± 7.1 years and of the men was 77.8 ± 7.5 (NS). There were no significant differences between women and men in terms of the anatomic site of the fracture or the type of surgery, the complication rate or mortality during rehabilitation, the length of time needed for rehabilitation, the framework to which the patient was discharged, FIM values before the HF, on admission and at the end of rehabilitation, or the difference between FIM scores at these last two points in time.

Conclusions: In selected elderly patients with HF gender does not affect variables associated with hip fracture, the rehabilitation process immediately following the fracture, or the results of rehabilitation.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction. Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims: To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods. 20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results. Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion. Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions. Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

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.     

Electrical stimulation of denervated muscles

Purpose: In this report, the 3-year rehabilitation of a 43-year-old male patient, who have pelvic 'open book' fracture, urinary bladder and urethral injury, lumbosacral plexus avulsion trauma and right lower extremity monoparesis is explained.

Method: Rehabilitation of these injuries is absolutely essential to ensure optimal functional recovery. But the value of electrical stimulation for denervated muscle is not proven and its application to gain what may only be a small benefit is often not justified.

Conclusions: With this case I emphasize that electrical stimulation and appropriate exercise programme in denervated protected muscle fibers activity for 3 years and rehabilitation should be continued.     

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.     

Effects of counsellor race on racial stereotypes of rehabilitation counselling clients

Purpose: This study investigated perceptions of European American, African American, and Asian American rehabilitation graduate students in rehabilitation counselling by assessing their clinical impressions of African American, European American, and Asian American clients. This investigation is a continuation of several studies investigating clinical perceptions and client race.

Method: Rehabilitation graduate students in rehabilitation counselling participating in this study were randomly assigned to one of three groups and were asked to review case materials for a client portrayed either as African American, European American, or Asian American. In pursuit of the main effect of client race, three separate MANOVA analyses were conducted: one for African American graduate students in rehabilitation counselling, one for Asian American graduate students in rehabilitation counselling, and one for European American graduate students in rehabilitation counselling.

Results: Contrary to previous findings from comparable research, MANOVA results did not reveal a significant main effect of bias by European American, Asian American, and African American graduate students in rehabilitation counselling against any of the three groups.

Conclusions: Understanding of the conditions in which racial biases and subsequent judgmental errors are likely to occur (or not occur) should allow clinicians to recognise tendencies for their assessments to be influenced by client characteristics that elicit stereotypes and thereby to make more accurate judgements.     

The efficacy of a work-station intervention programme to improve functional ability and flexibility in ageing clients with Cerebral Palsy: a pilot study

Purpose: Health care workers associated with the long-term care of ageing clients with Cerebral Palsy have reported on the adverse effects of less active daily activity programmes with resultant decreased functional mobility. While the negative effects of ageing have been reported in these clients, programmes have not been implemented to determine whether these adverse changes can be reversed or prevented. The efficacy of a work-station intervention programme to improve functional ability and flexibility in ageing clients with cerebral palsy was investigated.

Method: A clinical intervention study using repeated measures (pre/post-intervention and at follow-up) to evaluate efficacy was undertaken. Twenty-two clients with Cerebral Palsy participated in a twice-weekly work-station programme delivered over 8 weeks. The Physical Mobility Scale items, two upper limb function measures, range limitation of hip and knee extension and gleno-humeral movement were assessed.

Results: Results showed a significant improvement that was retained at follow-up in functional but not flexibility measures.

Conclusion: The efficacy of a work-station exercise programme for ageing clients with Cerebral Palsy was demonstrated. Evidence was provided that the PMS is effective in showing level of dependency for these clients.     

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

Methods: Design: A prospective observational cohort study and a cross-sectional study.

Setting: University hospital in the Netherlands.

Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.