Characterizing wandering behaviors in persons with traumatic brain injury residing in veterans health administration nursing homes

Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes.

Objective

To examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs).

Design

Using a cross-sectional design, logistic regression modeling was used to analyze a national database.

Setting

One hundred thirty-four NH facilities operated by the Veterans Health Administration.

Participants

NH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age.

Interventions

Not applicable.

Main Outcome Measure

Wandering.

Results

Wanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene.

Conclusions

Wandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses.     

Reliability of Rehabilitative Ultrasound Imaging of the Transversus Abdominis and Lumbar Multifidus Muscles

Koppenhaver SL, Hebert JJ, Fritz JM, Parent EC, Teyhen DS, Magel JS. Reliability of rehabilitative ultrasound imaging of the transversus abdominis and lumbar multifidus muscles.

Objectives

To evaluate the intraexaminer and interexaminer reliability of rehabilitative ultrasound imaging (RUSI) in obtaining thickness measurements of the transversus abdominis (TrA) and lumbar multifidus muscles at rest and during contractions.

Design

Single-group repeated-measures reliability study.

Setting

University and orthopedic physical therapy clinic.

Participants

A volunteer sample of adults (N=30) with current nonspecific low back pain (LBP) was examined by 2 clinicians with minimal RUSI experience.

Interventions

Not applicable.

Main Outcome Measures

Thickness measurements of the TrA and lumbar multifidus muscles at rest and during contractions were obtained by using RUSI during 2 sessions 1 to 3 days apart. Percent thickness change was calculated as thickness_contracted-thickness_rest/thickness_rest. Intraclass correlation coefficients (ICC) were used to estimate reliability.

Results

By using the mean of 2 measures, intraexaminer reliability point estimates (ICC_3,2) ranged from 0.96 to 0.99 for same-day comparisons and from 0.87 to 0.98 for between-day comparisons. Interexaminer reliability estimates (ICC_2,2) ranged from 0.88 to 0.94 for within-day comparisons and from 0.80 to 0.92 for between-day comparisons. Reliability estimates comparing measurements by the 2 examiners of the same image (ICC_2,2) ranged from 0.96 to 0.98. Reliability estimates were lower for percent thickness change measures than the corresponding single thickness measures for all conditions.

Conclusions

RUSI thickness measurements of the TrA and lumbar multifidus muscles in patients with LBP, when based on the mean of 2 measures, are highly reliable when taken by a single examiner and adequately reliable when taken by different examiners.     

A Preliminary Assessment of the Benefits of the Addition of Botulinum Toxin A to a Conventional Therapy Program on the Function of People With Longstanding Stroke

Meythaler JM, Vogtle L, Brunner RC. A preliminary assessment of the benefits of the addition of botulinum toxin A to a conventional therapy program on the function of people with longstanding stroke.

Objective

To determine if botulinum toxin type A (BTX-A) combined with therapy can facilitate improved upper-extremity (UE) functional status versus therapy alone.

Design

Double-blind randomized crossover trial.

Setting

Tertiary care outpatient rehabilitation center.

Participants

Convenience sample of 21 men and women (ages 19-80y) with stroke more than 6 months after insult who had tone greater than 3 on the Ashworth Scale for 2 joints in the involved UE.

Intervention

Subjects were consecutively recruited and randomized to a double-blind crossover trial. Subjects received either BTX-A combined with a defined therapy program or placebo injection combined with a therapy program in two 12-week sessions.

Main Outcome Measures

The primary functional outcome measure was the Motor Activity Log (MAL). Subjects were also assessed on physiologic measures including tone (Ashworth Scale), range of motion, and motor strength.

Results

Improvements were noted in the functional status of the subjects in both arms of the study as measured by the MAL. All subjects had a significant change in functional status on MAL with therapy (P<.05). The use of BTX-A combined with therapy as compared with therapy only improved the functional status of the subjects on the MAL Quality of Movement subscale (P=.0180, t test) and showed a trend toward significance in the Amount of Use subscale (P=.0605, analysis of variance). Six weeks after treatment, the BTX-A combined with therapy decreased the Ashworth score statistically (P=.0271), but the therapy alone group decreased a similar amount at 6 weeks (P=.0117), indicating that most of the physiologic tone change could be attributed to therapy. After each 12-week period, tone had largely returned to baseline (P>.05).

Conclusion

A focused therapy program showed the most improvement in function in this defined stroke population. BTX-A combined with a focused traditional therapy program slightly enhanced the functional status of stroke subjects beyond that obtained with therapy alone 12 weeks after injection.     

Test position and hip strength in healthy adults and people with chronic stroke

Barbic S, Brouwer B. Test position and hip strength in healthy adults and people with chronic stroke.

Objective

To determine if peak torques generated by the hip flexors and extensors are dependent on test position in healthy adults and in people with chronic stroke.

Design

Cross-sectional study.

Setting

Motor performance laboratory.

Participants

Volunteers were 10 young (20.7±1.5y), 10 older adults (62.1±7y), and 10 stroke survivors (60.6±10y) who were an average of 5 years poststroke.

Interventions

Not applicable.

Main Outcome Measures

Isokinetic (60°/s) peak concentric hip flexor and extensor torques (in Nm/kg) generated in supine and standing positions.

Results

Peak flexor torques measured in standing were generally higher than in supine (P=.018); a pattern evident in all groups, but significant only in stroke. An interaction between test position and group for hip extensor strength (P=.016) reflected 2 distinct patterns in which torques were highest in standing among the young subjects and highest in supine after stroke.

Conclusions

Isokinetic hip flexor and extensor strength measured in standing and supine are comparable in young and older healthy people. In chronic stroke, the test position may over or underestimate maximum peak torque depending on the muscle group tested, particularly on the side ipsilateral to the lesion. These findings may have implications for predicting functional ability from strength measurements.     

Relationship Among Shoulder Proprioception, Kinematics, and Pain After Stroke

Niessen MH, Veeger DH, Meskers CG, Koppe PA, Konijnenbelt MH, Janssen TW. Relationship among shoulder proprioception, kinematics, and pain after stroke.

Objective

To identify a possible relationship among chronic poststroke shoulder pain (PSSP), scapular resting pose, and shoulder proprioception.

Design

Case-control study.

Setting

Rehabilitation center.

Participants

A total of 21 inpatients with stroke and 10 healthy control subjects.

Interventions

Not applicable.

Main Outcome Measures

Orientations of both the contralateral and ipsilateral (ie, paretic and nonparetic) shoulders during rest in degrees, angular displacement (degrees) for threshold to detection of passive motion (TDPM) tests, and absolute error (degrees) for passive reproduction of joint position (PRJP) tests.

Results

The contralateral shoulder of patients with PSSP showed more scapular lateral rotation and larger TDPM and PRJP scores than both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation than control subjects, whereas their ipsilateral shoulder showed more scapular lateral rotation than both control subjects and patients with good proprioception.

Conclusions

A clear relation among affected shoulder kinematics, affected proprioception, and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateral (ie, nonparetic) shoulder because it could be used in determining the risk of developing PSSP in the contralateral (ie, paretic) shoulder.     

Incidence and Profile of Inpatient Stroke-Induced Aphasia in Ontario, Canada

Dickey L, Kagan A, Lindsay MP, Fang J, Rowland A, Black S. Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada.

Objectives

To determine the incidence rate of inpatient stroke-induced aphasia in Ontario, Canada, and to examine the demographic and clinical characteristics for stroke patients with and without aphasia.

Design

Age- and sex-specific incidence rates for aphasia in Ontario were calculated using the Ontario Stroke Audit. In addition, data collected from the Registry of the Canadian Stroke Network (RCSN) were used to determine the demographic and clinical characteristics for stroke patients with and without aphasia.

Setting

All hospitals and regional stroke centers in Ontario, Canada.

Participants

The Ontario Stroke Audit is a representative weighted sample of more than 3000 stroke inpatients admitted to emergency departments in all hospitals in Ontario within the 2004/2005 fiscal year. RCSN data included a cohort of more than 15,000 consecutive patients presenting with stroke at 12 regional stroke centers in Ontario from 2003 to 2007.

Interventions

Not applicable.

Main Outcome Measures

Presence of aphasic symptoms on admission to hospital and at discharge, age and sex, stroke type and severity, severity of disability, services received in hospital, length of stay, and discharge destination.

Results

Thirty-five percent (1131/3207) of adult patients admitted with a diagnosis of stroke in the province of Ontario during the 2004 to 2005 Ontario Stroke Audit had symptoms of aphasia at the time of discharge. This amounts to an incidence rate of 60 per 100,000 persons per year. Risk of aphasia increased significantly with age. In comparison with nonaphasic stroke patients, patients with aphasia were older, presented with more severe strokes on admission, had more severe disability, and were more frequently discharged to long-term care and/or rehabilitation (unadjusted results). Adjusting for stroke severity, age, sex, comorbidity, and stroke subtype, the presence of aphasia was found to be an independent predictor of longer hospital stays, increased use of rehabilitation services, and higher rates of thrombolytic therapy.

Conclusions

A significant number of people with stroke experience aphasia, with advancing age associated with a higher risk. The profile and patterns for stroke patients with aphasia differed significantly from those who did not experience aphasia as a residual disability after stroke, particularly in relation to service usage. Given the personal and system cost associated with aphasia, best practices in the area of stroke should include recommendations on how to best serve this population throughout the clinical pathway.     

Long-Term Pain, Fatigue, and Impairment in Neuralgic Amyotrophy

van Alfen N, van der Werf SP, van Engelen BG. Long-term pain, fatigue, and impairment in neuralgic amyotrophy.

Objectives

Recently, it has become clear that neuralgic amyotrophy (NA; idiopathic and hereditary brachial plexus neuropathy) has a less optimistic prognosis than usually assumed. To optimize treatment and management of these patients, one needs to know the residual symptoms and impairments they suffer. Therefore, the objective of this study was to describe the prevalence of pain, psychologic symptoms, fatigue, functional status, and quality of life in patients with NA.

Setting

Neurology outpatient department of an academic teaching hospital.

Participants

NA patients (N=89) were studied, and clinical details were recorded. Self-report data were on average collected 2 years after the onset of the last NA episode.

Main Outcome Measures

Pain was assessed with the McGill Pain Questionnaire, fatigue with the Checklist Individual Strength, and psychologic distress with the Symptom Checklist 90. Functional status and handicap were assessed with the modified Rankin Scale and Medical Outcomes Study 36-Item Short-Form Health Survey.

Results

Pain was usually localized in the right shoulder and upper arm, matching the clinical predilection site for paresis in NA. About a quarter to a third of the patients reported significant long-term pain and fatigue, and half to two thirds still experienced impairments in daily life. Over one third of the individual patients suffered from severe fatigue. The group did not fulfill the criteria of chronic fatigue or major psychologic distress. There was no correlation of pain or fatigue with the level of residual paresis on a Medical Research Council scale, but patients with a comorbid condition fared worse than patients without.

Conclusions

A significant number of NA patients suffer from persistent pain and fatigue, leading to impairment. Symptoms were not correlated with psychologic distress. This makes it likely that they are caused by residual shoulder or arm dysfunction but not as part of a chronic pain or fatigue syndrome in these patients.     

The Hyperemesis Impact of Symptoms Questionnaire: Development and validation of a clinical tool

Background

The Hyperemesis Impact of Symptoms Questionnaire is a clinical tool designed to assess holistically the impact of the physical and psychosocial symptoms of hyperemesis gravidarum (HG) on individuals. Its purpose is to aid planning and implementation of tailored care for women with HG. To our knowledge no similar tool exists.

Objective

To assess the validity and reliability of the HIS questionnaire.

Design

As no similar tool exists, we compared the HIS with three tools that reflect its key areas: physical impact (Pregnancy Unique Quantification of Emesis - PUQE score and markers of severity of HG), psychological impact (Hospital Anxiety and Depression Score - HADS) and social impact (SF12 quality of life score).

Setting

A large regional referral, women and children's hospital in the North West of England.

Participants

The HIS was evaluated on 50 women admitted to hospital with HG and 50 women recruited from ante-natal clinic without severe nausea and vomiting of pregnancy and with an uncomplicated pregnancy.

Results

Good criterion validity was demonstrated by strong significant correlations with all three scores (PUQE, r = 0.75, p < 0.001, HADS, depression r = 0.76, p < 0.001, and SF12, mental component r = −0.65, p < 0.001). The HIS showed good internal consistency, Cronbach alpha 0.87, split half 0.80.

Conclusions

There is evidence for the validity and reliability of the HIS to assess the impact of the physical and psychosocial symptoms of HG. Further research is currently underway to establish the clinical utility of the HIS questionnaire in the care of women hospitalised with HG.     

The effectiveness of a multidisciplinary pain management programme managing chronic pain on pain perceptions, health-related quality of life and stages of change—A non-randomized controlled study

Background

Cognitive behavioural therapy (CBT) has been useful in the treatment of chronic pain conditions for many years. Given the increasing number of persons with chronic pain and associated psychosocial problems, the development and implementation of effective interventions based on CBT is warranted.

Objectives

The aim of this study is to evaluate the effects of a multidisciplinary pain management programme on health-related quality of life (HRQL), as measured by the Short Form Health Survey (SF-36), pain perception as measured by the Brief Pain Inventory (BPI), and readiness-to-change as measured by the Pain Stages of Change Questionnaire (PSOCQ).

Design

A pretest-post-test quasi-experimental design, with waiting list controls and baseline and post-test measures, was used.

Setting

The study was conducted in the rehabilitation unit of a university hospital.

Participants

Of 117 people suffering from chronic pain, 113 completed the 8-week multidisciplinary pain management programme. The patients were consecutive referrals. Inclusion criteria were: adults (18-67 years), pain lasting over 6 months, motivation and no ongoing litigation. Exclusion criteria were affected by major mental disorders or major medical conditions requiring treatment.

Methods

The intervention was based on a cognitive behavioural approach. Therapeutic dialogues and training, combined with physical activity, were provided to a fixed plan, including homework. The programme has several features that directly address psychosocial aspects of chronic pain. Statistical and clinical significance are considered.

Results

The findings suggest that this programme has the potential to improve HRQL, reduce pain intensity and interference, and contribute to improvement in readiness-to-change. Statistically significant results are supplemented by results showing their clinical significance.

Conclusions

Improvements in HRQL, pain-related disability, and readiness-to-change suggest that the vicious cycle of chronic pain may be alleviated by our programme. As we see it, effective treatment results are about identifying and addressing the important and changeable influences maintaining pain problems such as acceptance, understanding the mind-body connection and self-management. Although further research is needed to evaluate the effectiveness of this work, such group approaches appear to represent a feasible treatment option for many patients with chronic pain.     

Stand up and be counted: measuring time spent upright after hip fracture and comparison with community dwelling older people

Objectives

Following hip fracture, the amount of time an individual spends on their feet (‘uptime’) may be an important marker of recovery. Using an automated device that measured uptime (Uptimer), we aimed to: (1) compare hip fracture patients’ uptime with age- and gender-matched community dwelling older people; (2) identify whether uptime changed during the transition from hospital to home; and (3) examine the relationship between uptime and existing functional measures.

Design

Prospective, observational study.

Setting

Rehabilitation hospital and community.

Participants

Patients undergoing rehabilitation after hip fracture surgery who aimed to return home at the end of rehabilitation, and age- and gender-matched community dwellers.

Interventions

Patients received standard care.

Main outcome measures

Uptime over 24 hours was measured on three occasions in hip fracture patients: 1 week before, 1 day before and 1 week after discharge home. Uptime over 24 hours was measured once in age- and gender-matched community dwelling older people. Functional mobility, self-reported activity, pain, mood and endurance were also assessed.

Results

Thirteen hip fracture patients (mean age 80.4 years) and 13 community dwelling participants completed testing. Once home, hip fracture patients spent 3.4 hours/day (25th, 75th percentiles 2.8, 5.2) upright, while community dwelling healthy older people were upright for 6.5 hours/day (6.1, 8.7). A trend for uptime to increase between hospital and home was observed. Hip fracture uptime at home correlated significantly with self-reported activity, functional mobility and gait endurance (P < 0.05).

Conclusions

This study highlighted uptime limitations of hip fracture patients at home. We discuss possible future directions for research using the Uptimer.     

Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases

Gonzalez-Fernandez M, Kuhlemeier KV, Palmer JB. Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases.

Objectives

To determine whether the proportion of patients with stroke experiencing dysphagia differs among racial groups and whether this relation can be explained by stroke type or severity.

Design

Case-control study using California's Medical Information Reporting and New York's Statewide Planning and Research Cooperative System databases for 2002. Cases had primary diagnosis of cerebrovascular disease (International Classification of Disease, 9th Revision [ICD-9] codes 430-438.9, excluding transient [435-435.9] and late-effects [438-438.9]), and self-identified race was white, black, or Asian. Two comparison groups were selected: (1) Parkinson's disease (ICD-9 codes 332-332.1) and (2) oral cancer (ICD-9 codes 141-149).

Setting

Inpatient admissions in the respective states.

Participants

Cases with primary diagnosis of cerebrovascular disease whose self-identified race was white, black, or Asian.

Interventions

Not applicable.

Main Outcome Measure

Dysphagia, defined by ICD-9 codes 787.2 (dysphagia), 507.0 (aspiration pneumonia), or presence of a feeding tube in the absence of a diagnosis of coma (Current Procedural Terminology codes 432.46 or 437.50 without ICD-9 code 780.01).

Results

In the stroke group, the adjusted odds ratio (OR) with 95% confidence interval (CI) for dysphagia was significantly higher for Asians than whites in New York (OR=1.64; 95% CI, 1.50-1.79) and California (OR=1.69; 95% CI, 1.34-2.13). The adjusted OR was slightly but significantly higher for blacks than whites in New York (OR=1.15; 95% CI, 1.03-1.28), but not in California (OR=1.08; 95% CI, 0.97-1.19). No statistically significant differences among racial groups were found in patients with Parkinson's disease or oral cancer. Other factors strongly associated with dysphagia included hemiplegia (OR=2.19; 95% CI, 2.07-2.32) and aphasia (OR=1.97; 95% CI, 1.83-2.11).

Conclusions

Asians were more likely to have dysphagia after stroke. This association was statistically significant after adjusting for age, sex, stroke severity indicators, comorbidities, and stroke type.     

Differential Performance of SF-36 Items in Healthy Adults With and Without Functional Limitations

Horner-Johnson W, Krahn GL, Suzuki R, Peterson JJ, Roid G, Hall T, the RRTC Expert Panel on Health Measurement. Differential performance of SF-36 items in healthy adults with and without functional limitations.

Objective

To determine whether Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) items show differential item functioning among healthy adults with various types of functional limitations as compared with a healthy sample with no identified limitations.

Design

Survey responses were analyzed by using partial correlations.

Setting

General community.

Participants

Participants (N=206) included (1) adults with spinal cord injury (SCI), (2) adults who were deaf or hard of hearing, (3) adults who were legally blind, (4) adults with psychiatric or emotional conditions, and (5) adults with no reported functional limitations. Participants were screened to ensure the absence of substantial health problems.

Interventions

Not applicable.

Main Outcome Measure

SF-36.

Results

Partial correlations showed a significant negative correlation, indicating differential item functioning (ie, apparent bias) for people with SCI on all 10 SF-36 Physical Functioning items. For people who were blind, 5 items showed a significant negative correlation. Two items had significant negative correlations for the deaf/hard-of-hearing group. One item showed significant negative performance for people with mental health conditions.

Conclusions

Our data indicated a possibility for measurement bias caused by the blending of health and function concepts in the SF-36.     

Pain in persons with postpolio syndrome: frequency, intensity, and impact

Stoelb BL, Carter GT, Abresch RT, Purekal S, McDonald CM, Jensen MP. Pain in persons with postpolio syndrome: frequency, intensity, and impact.

Objective

To describe the frequency, intensity, and impact of pain in persons with postpoliomyelitis syndrome (PPS).

Design

Retrospective, cross-sectional survey.

Setting

Community-based survey.

Participants

Convenience sample of people with PPS.

Interventions

Not applicable.

Main Outcome Measures

Overall intensity and duration of pain, pain sites, pain interference, pain treatments, and relief provided by pain treatments.

Results

A total of 91% (n=57) of the study participants (N=63) reported pain. The most frequently reported pain sites were the shoulders, lower back, legs, and hips. Participants reported pain intensity to be the greatest in the knees, legs, wrists, lower back, and head. Pain interfered most with sleep and with activities requiring a high level of musculoskeletal involvement. Respondents also reported pain problems that were more severe than those of the general population and than those of a sample of people with multiple sclerosis. Many treatments had been tried previously for pain, but continued use of treatments was reported by relatively few participants at the time of the survey.

Conclusions

The findings indicate that pain is a persistent and common problem in persons with PPS, highlighting the need for effective and accessible pain treatments for this population.     

Prevalence and impact on quality of life of lower urinary tract symptoms among a sample of employed women in Taipei: A questionnaire survey

Background

Previous studies about the prevalence and impact of lower urinary tract symptoms (LUTS) were focused on urinary incontinence or overactive bladder in the general population. Little research has been focused on the role that the workplace has in employed women's experiences with LUTS or the impact of LUTS on their health-related quality of life (HRQL).

Objectives

To estimate the prevalence of LUTS among employed female nurses in Taipei and to compare the HRQL for nurses with and without LUTS.

Design

This study was a cross-sectional, questionnaire survey.

Settings

Three medical centers and five regional hospitals in Taipei were selected randomly.

Participants

In the selected hospitals, 1065 female nurses were selected randomly. Data analyses were based on 907 usable surveys. All participants were native Taiwanese; most of the female nurses were 26-35 years of age (mean = 31.02, SD = 6.32), had normal body mass index, and had never given birth. Most nurses’ bladder habits were poor or very poor and their personal habits of fluid consumption at work were inadequate.

Methods

Data were collected using the Taiwan Nurse Bladder Survey and the Short Form 36 Taiwan version. Chi-square tests were used to compare the prevalence rates of different LUTS for nurses in different age groups. Student's t-tests were conducted to compare the mean scores of HRQL for nurses with and without LUTS.

Results

Based on 907 usable surveys, 590 (65.0%) experienced at least one type of LUTS. The prevalence for different LUTS ranged from 8.0% to 46.5%. Nurses who reported LUTS also reported lower HRQL, more so on physical health than mental health, than nurses who did not report LUTS.

Conclusions

Although most of the nurses in this study were young (≦35 years) and nulliparous, LUTS were common among this group. The high prevalence rate of LUTS leads to concerns about nurses’ possible dysfunctional voiding patterns and possible effects of working environment and poor bladder and personal habits on LUTS. Study results showed a possible negative impact of LUTS on nurses’ physical health. Designing a continence-related education program for this group is essential for delivering information about LUTS prevention and management.     

HealthSouth's Inpatient Rehabilitation Facilities: How Does Their Performance Compare With Other For-Profit and Nonprofit Inpatient Rehabilitation Facilities?

McCue MJ, Thompson JM. HealthSouth's inpatient rehabilitation facilities: how does their performance compare with other for-profit and nonprofit inpatient rehabilitation facilities?

Objectives

To assess the financial and operational differences in freestanding inpatient rehabilitation facilities (IRFs) that are operated by HealthSouth Corporation relative to other for-profit and nonprofit system-affiliated ownership groups. Since 2003, when it faced fraud charges and financial penalties, HealthSouth has experienced new management and refocused its business strategy. Because HealthSouth is the largest provider of freestanding IRF services, it is important to understand how their performance may differ relative to other ownership groups.

Design

We used the Mann-Whitney U test to assess differences in median values for financial and operational variables of HealthSouth-owned IRFs compared with other for-profit system IRFs and nonprofit system IRFs.

Setting

System-affiliated freestanding IRFs in the United States.

Participants

Sixty-four HealthSouth IRFs, 18 nonprofit system-affiliated IRFs, and 18 for-profit system-affiliated IRFs.

Interventions

Not applicable.

Main Outcome Measures

Net patient revenue per adjusted discharge, operating expense per adjusted discharge, salary expense per full-time equivalent, and cash flow margin.

Results

HealthSouth IRFs had significantly lower net patient revenue per adjusted discharge and operating expense per adjusted discharge; however, its cash flow margin was significantly higher than other comparison groups. HealthSouth IRFs treated a higher case mix of patients relative to these comparison groups.

Conclusions

The financial and operating performance of HealthSouth IRFs is stronger than other ownership groups. Strong cash flow will enable HealthSouth to pay down long-term debt.     

Minimizing pre- and post-defibrillation pauses increases the likelihood of return of spontaneous circulation (ROSC)

Background

The three-phase model of ventricular fibrillation (VF) arrest suggests a period of compressions to “prime” the heart prior to defibrillation attempts. In addition, post-shock compressions may increase the likelihood of return of spontaneous circulation (ROSC). The optimal intervals for shock delivery following cessation of compressions (pre-shock interval) and resumption of compressions following a shock (post-shock interval) remain unclear.

Objective

To define optimal pre- and post-defibrillation compression pauses for out-of-hospital cardiac arrest (OOHCA).

Methods

All patients suffering OOHCA from VF were identified over a 1-month period. Defibrillator data were abstracted and analyzed using the combination of ECG, impedance, and audio recording. Receiver-operator curve (ROC) analysis was used to define the optimal pre- and post-shock compression intervals. Multiple logistic regression analysis was used to quantify the relationship between these intervals and ROSC. Covariates included cumulative number of defibrillation attempts, intubation status, and administration of epinephrine in the immediate pre-shock compression cycle. Cluster adjustment was performed due to the possibility of multiple defibrillation attempts for each patient.

Results

A total of 36 patients with 96 defibrillation attempts were included. The ROC analysis identified an optimal pre-shock interval of <3 s and an optimal post-shock interval of <6 s. Increased likelihood of ROSC was observed with a pre-shock interval <3 s (adjusted OR 6.7, 95% CI 2.0-22.3, p = 0.002) and a post-shock interval of <6 s (adjusted OR 10.7, 95% CI 2.8-41.4, p = 0.001). Likelihood of ROSC was substantially increased with the optimization of both pre- and post-shock intervals (adjusted OR 13.1, 95% CI 3.4-49.9, p < 0.001).

Conclusions

Decreasing pre- and post-shock compression intervals increases the likelihood of ROSC in OOHCA from VF.     

Ambulatory oxygen therapy assessment: a comparative study of incremental shuttle and 6-minute walking tests

Background

Walking tests, such as the incremental shuttle walk test (ISWT) and the 6-minute walk test (6MWT), are recommended in the assessment of ambulatory oxygen for patients with chronic obstructive pulmonary disease (COPD). However, there is no evidence that these tests can be used interchangeably.

Objectives

To compare the ISWT and the 6MWT in COPD patients in terms of indication for ambulatory oxygen therapy.

Design

Crossover design.

Setting

Patients attended as outpatients.

Participants

Fifty patients with stable COPD (31 males; age 67 years, range 43 to 83 years); mean forced expiratory volume in 1 second 1.2 l [standard deviation (SD) 0.6 l] and 48.6% predicted (SD 23.4%).

Intervention

Patients performed both the ISWT and the 6MWT whilst breathing air. Breathlessness (Borg scale), percutaneous arterial oxygen saturation (SpO₂) and heart rate were measured before and after both tests.

Main outcome measures

Post-test SpO₂ and change from baseline.

Results

The mean change in saturation was −4.6% (SD 6.2%) and −2.8% (SD 5.3%) after the ISWT and the 6WMT, respectively. Using Bland and Altman plots, the limits of agreement for difference in change in SpO₂ (%) between the two tests were wide (−8.1 to 11.6) and clinically relevant. Sixteen patients (32%) and 13 patients (26%) met the criteria for ambulatory oxygen with the ISWT and the 6MWT, respectively (P = 0.32).

Conclusions

This study found a wide variation between differences in exercise oxygen desaturation after the ISWT compared with the 6MWT, supporting the premise that these tests should not be used interchangeably in the assessment of ambulatory oxygen for COPD patients.     

Patients With Chronic Disabling Occupational Musculoskeletal Disorder Failing to Complete Functional Restoration: Analysis of Treatment-Resistant Personality Characteristics

Howard KJ, Mayer TG, Theodore BR, Gatchel RJ. Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: analysis of treatment-resistant personality characteristics.

Objective

To identify the risk factors for noncompletion of a functional restoration program for patients with chronic disabling occupational musculoskeletal disorders.

Design

Prospective cohort study.

Setting

Consecutive patients undergoing functional restoration treatment in a regional rehabilitation referral center.

Participants

A sample of 3052 consecutive patients, classified as either completers (n=2367) or noncompleters (n=685), who entered a functional restoration program.

Interventions

Not applicable.

Main Outcome Measures

The measures used included medical evaluations, demographic data, Diagnostic and Statistical Manual of Mental Disorders psychiatric diagnoses, the Minnesota Multiphasic Personality Inventory, and validated questionnaires evaluating pain, depression, and occupational factors.

Results

The findings revealed that patients who did not complete the program had a longer duration of total disability between injury and admission to treatment (completers=20mo vs noncompleters=13mo; P<.001). Furthermore, patients who were opioid-dependent were 1.5 times more likely to drop out of rehabilitation, and patients diagnosed with a socially problematic Cluster B Personality Disorder were 1.6 times more likely to drop out.

Conclusions

Although some risk factors associated with program noncompletion may be addressed in treatment, socially maladaptive personality disorders, long-neglected disability, and chronic opioid dependence are the major barriers to successful treatment completion. The patients identified with personality disorders may display resistance to treatment and may be difficult for the treatment staff to deal with. Early recognition of these treatment-resistant personality characteristics in the functional restoration process may assist the treatment team in developing more effective strategies to help this dysfunctional group.     

Relatives' Criticism Influences Adjustment and Outcome After Traumatic Brain Injury

Weddell RA. Relatives' criticism influences adjustment and outcome after traumatic brain injury.

Objectives

To apply some of the methods developed to study the effects of relatives' expressed emotion (EE) on psychiatric relapse rates and to test the prediction that relatives' criticism and psychiatric distress would be associated with outcome and emotional distress after traumatic brain injury (TBI).

Design

Retrospective cohort design with correlational analyses of quantitative and qualitative measures of TBI outcomes.

Setting

The author interviewed participants in the hospital. The research assistant interviewed close relatives at home.

Participants

Participants and relatives (N=78) were interviewed 34.3±15.2 months (mean ± SD) after a severe TBI.

Interventions

None.

Main Outcome Measures

Dependent variables in a series of hierarchical linear regression models were participants' scores on the Zung Depression Scale, Spielberger Trait Anxiety Inventory, State-Trait Anger Expression Inventory, an Anger Towards Relative questionnaire constructed for this study, and Extended Glasgow Outcome Scores. Participant-independent variables were social class, posttraumatic amnesia, Wechsler Memory Scale-Delayed Recall score, WAIS-R intelligence quotient, and a short version of the Smell Identification Test. Relative independent variables were the number of critical comments directed toward participants in the interview and psychiatric distress as measured by the General Health Questionnaire.

Results

The contributions of variance associated with relative independent variables (predominantly criticism) were significant in stage 2 of most hierarchical regression analyses after the adjustments for variance associated with participant independent variables made in stage 1.

Conclusions

Future application of EE research methods is warranted. If the present results are replicated, then evidence-based family interventions developed by EE researchers to reduce criticism might also improve TBI outcomes.