Feasibility of Computerized Adaptive Testing for Collection of Patient-Reported Outcomes After Inpatient Rehabilitation

Objective

To evaluate the feasibility of computer adaptive testing (CAT) using an Internet or telephone interface to collect patient-reported outcomes after inpatient rehabilitation and to examine patient characteristics associated with completion of the CAT-administered measure and mode of administration.

Design

Prospective cohort study of patients contacted approximately 4 weeks after discharge from inpatient rehabilitation. Patients selected an Internet or telephone interface.

Setting

Rehabilitation hospital.

Participants

Patients (N=674) with diagnoses of neurologic, orthopedic, or medically complex conditions.

Interventions

None.

Main Outcome Measure

CAT version of the Community Participation Indicators (CAT-CPI).

Results

From an eligible pool of 3221 patients, 674 (21%) agreed to complete the CAT-CPI. Patients who agreed to complete the CAT-CPI were younger and reported slightly higher satisfaction with overall care than those who did not participate. Among these patients, 231 (34%) actually completed the CAT-CPI; 141 (61%) selected telephone administration, and 90 (39%) selected Internet administration. Decreased odds of completing the CAT-CPI were associated with black and other race; stroke, brain injury, or orthopedic and other impairments; and being a Medicaid beneficiary, whereas increased odds of completing the CAT-CPI were associated with longer length of stay and higher discharge FIM cognition measure. Decreased odds of choosing Internet administration were associated with younger age, retirement status, and being a woman, whereas increased odds of choosing Internet administration were associated with higher discharge FIM motor measure.

Conclusions

CAT administration by Internet and telephone has limited feasibility for collecting postrehabilitation outcomes for most rehabilitation patients, but it is feasible for a subset of patients. Providing alternative ways of answering questions helps assure that a larger proportion of patients will respond.     

Predictors of Functional Outcomes After Simple Decompression for Ulnar Neuropathy at the Elbow: A Multicenter Study by the SUN Study Group

Objective

To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE).

Design

Prospective cohort followed for 1 year.

Setting

Clinics.

Participants

Patients diagnosed with UNE (N=55).

Intervention

All subjects had simple decompression surgery.

Main Outcome Measures

The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow.

Results

Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9–23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9–24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, −0.38; 95% CI, −.67 to −.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, −.40; 95% CI, −.79 to −.01).

Conclusions

Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.     

Effects of Inpatient Rehabilitation in Hip and Knee Osteoarthritis: A Naturalistic Prospective Cohort Study With Intraindividual Control of Effects

Objectives

To quantify pain, function, and health-related quality of life in comparison with normative data, and to quantify intervention effects.

Design

Naturalistic cohort study without a control group. Correction of the effects observed during the intervention by those observed during waiting time prior to the intervention.

Setting

Inpatient rehabilitation clinic.

Participants

Patients with hip (n=88) and knee (n=164) osteoarthritis.

Intervention

Comprehensive, multidisciplinary inpatient rehabilitation lasting 3 weeks.

Main Outcome Measures

Medical Outcomes Study 36-Item Short-Form Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results

Four or more comorbid conditions had 45.3% of the hip and 51.8% of the knee patients on entry to and discharge from the clinic. On entry, physical health and some dimensions of psychosocial health were significantly diminished compared with population norms. At discharge, hip osteoarthritis had improved by a corrected effect size of .20 to .47 in pain, .04 to .39 in function, and −.04 to .32 in psychosocial health. Knee osteoarthritis showed a corrected effect size of .43 to .62 in pain, .19 to .51 in function, and .19 to .30 in psychosocial health. All but 1 effect in WOMAC pain and WOMAC function were higher than the minimal clinically important differences.

Conclusions

Hip and knee osteoarthritis patients admitted to the inpatient intervention were affected by a substantial burden of disease and comorbidities. Inpatient rehabilitation resulted in small to moderate, statistically significant, and clinically important improvements in pain, function, and psychosocial health.     

Interrater Reliability of Functional Status Scores for Patients Transferred From One Rehabilitation Setting to Another

Kohler F, Redmond H, Dickson H, Connolly C, Estell J. Interrater reliability of functional status scores for patients transferred from one rehabilitation setting to another.

Objective

To report the interrater reliability of FIM total score, FIM motor subscore, and FIM cognitive subscore from scoring that occurred in routine clinical practice in 2 closely linked inpatient rehabilitation services in Sydney, Australia.

Design

A natural-experiment blind clinical interrater reliability cohort study of the FIM across 2 rehabilitation units.

Setting

This study is set in 2 inpatient rehabilitation units immediately adjacent to each other in southwestern Sydney, New South Wales, Australia.

Participants

All patients (N=143) who were transferred between the 2 rehabilitation units between August 2006 and October 2007 were included in the study.

Intervention

Discharge FIMs were scored by the first unit and an admission FIM was scored independently by the second unit within a few days. The FIM scores were analyzed for agreement and systematic bias.

Main Outcome Measure

Intraclass correlation coefficients, kappa statistic, weighted kappa statistic, and Bland-Altman plots were used.

Results

There were 143 sets of scores identified. The range of differences between the 2 FIM totals was −32 to 50, between the FIM motor subscores was −22 to 43, and between the FIM cognitive subscores was −14 to 21. Bland-Altman plots demonstrated poor agreement. Few FIM totals were perfectly matched. The intraclass correlation coefficients ranged from .872 for the FIM total to .830 for the cognitive subscales. Values for kappa ranged from −.007 (FIM motor subscore) to .123 (FIM cognitive subscore). Values for weighted kappa ranged from .465 (FIM cognitive subscore) to .521 (FIM total).

Conclusions

There was no systematic scoring bias evident. Intraclass correlation coefficients were high, but tests of agreement demonstrated poor agreement. These findings have implications for the use of the FIM and any patient classification or funding system based on the FIM, especially if poor levels of agreement were found in the presence of all staff being FIM credentialed and standardization of methods of assessment. This study indicates that further investigation of agreement of both FIM totals and FIM item scores in the clinical setting is warranted.     

Rehabilitation needs of an inpatient medical oncology unit

OBJECTIVE: To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. DESIGN: Prospective cohort study. SETTING: Inpatient medical oncology unit at a Veterans Affairs hospital. PARTICIPANTS: Fifty-five patients admitted over a 6-month period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. RESULTS: On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. CONCLUSIONS: Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.     

Factors Influencing Prognosis and Functional Outcome One Year After a First-Time Stroke in a Caribbean Population

Objective

To evaluate functional outcome and quality of life 1 year poststroke in a Caribbean population.

Design

Prospective study of patients with a first hemispheric stroke admitted consecutively between December 2010 and February 2011. The patients were evaluated (1) in the emergency department, (2) when discharged from the hospital, and (3) 1 year poststroke.

Setting

A university hospital.

Participants

Of the 140 consecutive patients with stroke, 78 (42% women, 24.4% hemorrhagic stroke) were included in the study.

Interventions

None.

Main Outcome Measures

Patients were evaluated using the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), FIM, and Medical Outcomes Study 36-Item Short-Form Health Survey.

Results

The mean age of the participants was 62.1±17.7 years; 70.5% of patients had hypertension, 29.4% had diabetes, and 23.6% had chronic renal failure. At 1 year poststroke, the mortality rate was 29.4%, and the recurrence rate 2.6%. We evaluated 39 of the 55 survivors (71%). Score evolution (emergency department vs 1y later) is as follows: for the NIHSS, it was 6.2±4.9 versus 3.3±3.9 (z=−3.578; P<.001); and for the mRS score ≤2, it was 54.2% versus 66.7% (χ²=14.182; P=.25). The FIM score on discharge from the hospital versus 1 year later was 103.2±28.2 versus 101.7±31.5 (z=−1.008; P=.313). Multivariate analysis showed that aphasia, hemianopia, and incontinence significantly influenced the 1-year FIM score (P<.001). Quality of life, a patient-reported outcome measure of health-related quality of life, was significantly altered concerning vitality, role physical, and role emotional.

Conclusions

One year after a first stroke, despite significant improvement of neurologic impairment, the level of dependency did not change and quality of life was altered. Aphasia, hemianopia, and incontinence significantly influenced functional state.     

Network of Movement and Proximity Sensors for Monitoring Upper-Extremity Motor Activity After Stroke: Proof of Principle

Objective

To test the convergent validity of an objective method, Sensor-Enabled Radio-frequency Identification System for Monitoring Arm Activity (SERSMAA), that distinguishes between functional and nonfunctional activity.

Design

Cross-sectional study.

Setting

Laboratory.

Participants

Participants (N=25) were ≥0.2 years poststroke (median, 9) with a wide range of severity of upper-extremity hemiparesis.

Interventions

Not applicable.

Main Outcome Measures

After stroke, laboratory tests of the motor capacity of the more-affected arm poorly predict spontaneous use of that arm in daily life. However, available subjective methods for measuring everyday arm use are vulnerable to self-report biases, whereas available objective methods only provide information on the amount of activity without regard to its relation with function. The SERSMAA consists of a proximity-sensor receiver on the more-affected arm and multiple units placed on objects. Functional activity is signaled when the more-affected arm is close to an object that is moved. Participants were videotaped during a laboratory simulation of an everyday activity, that is, setting a table with cups, bowls, and plates instrumented with transmitters. Observers independently coded the videos in 2-second blocks with a validated system for classifying more-affected arm activity.

Results

There was a strong correlation (r=.87, P<.001) between time that the more-affected arm was used for handling objects according to the SERSMAA and functional activity according to the observers.

Conclusions

The convergent validity of SERSMAA for measuring more-affected arm functional activity after stroke was supported in a simulation of everyday activity.     

Validity and Clinical Utility of Functional Assessments in Children With Cerebral Palsy

Objective

To examine the validity and clinical utility of functional assessments (1-minute walk test, 10-meter walk test, Timed Up & Go [TUG] test, Timed Up and Down Stairs [TUDS] test, sit-to-stand [STS] test, and lateral step-up [LSU] test).

Design

Cross-sectional study.

Setting

Four special schools for adolescents with physical disabilities.

Participants

Adolescents with spastic tetraplegia and diplegia (at levels I–III) were selected through convenience sampling (N=35; mean age, 14.97±2.03y).

Interventions

Not applicable.

Main Outcome Measures

GMFM-88 (dimensions D and E), 1-minute walk, 10-meter walk, TUG, TUDS, STS, and LSU tests. Data were analyzed using Pearson intercorrelations, multiple regression analysis, and multivariate analysis of variance (MANOVA).

Results

Significant moderate to high intercorrelations were found. Three significant positive predictors emerged (1-minute walk, 10-meter walk, and LSU) with the following regression equation: Y_{GMFM-88 (dimensions D and E)} = 5.708 + .402 × X_{1-minute walk} + .920 × X_LSU + .404 × X_{10-meter walk} The MANOVA was significant (Λ=.163, F=14.732, P<.001, η²=.596), and post hoc comparisons revealed significant differences across Gross Motor Function Classification System Expanded and Revised levels in all paired comparisons for the 1-minute walk and LSU tests. For the 10-meter walk test, significant differences were evident in the level I versus level III and level II versus level III comparisons. No significant differences were found in the 10-meter walk test between levels I and II.

Conclusions

These functional assessments (1-minute walk, LSU, and 10-meter walk tests) are simple to administer, quick, low cost, and user-friendly. Although these assessments are not a substitute for the criterion standard (GMFM-88), they may be used for a quick assessment in adolescents with cerebral palsy (levels I–III) either at school or during rehabilitation, especially when time is limited.     

Utility of the Mayo-Portland Adaptability Inventory-4 for Self-Reported Outcomes in a Military Sample With Traumatic Brain Injury

Objective

To investigate the psychometric properties of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) obtained by self-report in a large sample of active duty military personnel with traumatic brain injury (TBI).

Design

Consecutive cohort who completed the MPAI-4 as a part of a larger battery of clinical outcome measures at the time of intake to an outpatient brain injury clinic.

Setting

Medical center.

Participants

Consecutively referred sample of active duty military personnel (N=404) who suffered predominantly mild (n=355), but also moderate (n=37) and severe (n=12), TBI.

Interventions

Not applicable.

Main Outcome Measure

MPAI-4

Results

Initial factor analysis suggested 2 salient dimensions. In subsequent analysis, the ratio of the first and second eigenvalues (6.84:1) and parallel analysis indicated sufficient unidimensionality in 26 retained items. Iterative Rasch analysis resulted in the rescaling of the measure and the removal of 5 additional items for poor fit. The items of the final 21-item Mayo-Portland Adaptability Inventory-military were locally independent, demonstrated monotonically increasing responses, adequately fit the item response model, and permitted the identification of nearly 5 statistically distinct levels of disability in the study population. Slight mistargeting of the population resulted in the global outcome, as measured by the Mayo-Portland Adaptability Inventory-military, tending to be less reflective of very mild levels of disability.

Conclusions

These data collected in a relatively large sample of active duty service members with TBI provide insight into the ability of patients to self-report functional impairment and the distinct effects of military deployment on outcome, providing important guidance for the meaningful measurement of outcome in this population.     

Functional Outcomes After Limb-Salvage Surgery and Endoprosthetic Reconstruction With an Expandable Prosthesis: A Report of 4 Cases

Beebe K, Song KJ, Ross E, Tuy B, Patterson F, Benevenia J. Functional outcomes after limb-salvage surgery and endoprosthetic reconstruction with an expandable prosthesis: a report of 4 cases.

Objective

To determine the functional outcomes of skeletally immature patients after replacement of the femur and tibia performed by using noninvasive expandable endoprostheses.

Design

Case series.

Setting

A hospital-based ambulatory care center.

Participants

Pediatric patients (N=4) with primary bone tumors of the distal femur and proximal tibia who underwent surgical replacement performed by using the Repiphysis noninvasive expandable endoprosthesis (Wright Medical Technology, Memphis, TN).

Interventions

Wide resection of bone sarcoma and placement of expandable endoprosthesis.

Main Outcome Measures

Musculoskeletal Tumor Society (MSTS) scores were assessed at the beginning of the study and at each follow-up visit. Medical Outcomes Study 36-Item Short-Form Health Survey, Version 2 (SF-36); gait; sit-to-stand transition; and range of motion (ROM) were assessed at an average follow-up of 31.5 months.

Results

At an average of 31.5 months postoperative, the SF-36 physical component summary scores lagged behind the national mean, whereas the mental component summary scores were satisfactory. MSTS scores indicated low levels of pain and supports use with high emotional acceptance and walking ability but persisting difficulties with function and gait. Patients also showed altered patterns of sit-to-stand transition including decreased peak vertical force in the operated limb and increased center of mass momentum in a shorter amount of time. Parts of gait functioning were found to be decreased, including gait velocity, stride length, and cadence. Some patients displayed alternate weight-bearing strategies that accompanied increased double-limb support and stance phase during walking. ROM and strength were diminished at both the hip and knee joints in the operated limb and in the nonoperated limb.

Conclusions

Reconstruction with a noninvasive expandable endoprosthesis produces satisfactory functional outcomes in pediatric patients with primary tumors of the bone. Patients in our study displayed some persisting physical difficulties including decreased ROM and strength and altered gait and sit-to-stand patterns, yet they maintained high levels of emotional acceptance and coping.     

Predicting Home and Community Walking Activity in People With Stroke

Fulk GD, Reynolds C, Mondal S, Deutsch JE. Predicting home and community walking activity in people with stroke.

Objective

To determine the ability of the 6-minute walk test (6MWT) and other commonly used clinical outcome measures to predict home and community walking activity in high-functioning people with stroke.

Design

Cross-sectional.

Setting

Outpatient physical therapy clinic.

Participants

Participants (N=32) with chronic stroke (n=19; >6mo poststroke) with self-selected gait speed (GS) faster than .40m/s and age-matched healthy participants (n=13).

Interventions

Not applicable.

Main Outcome Measures

Independent variables: 6MWT, self-selected GS, Berg Balance Scale (BBS), lower extremity motor section of the Fugl-Meyer Assessment, and Stroke Impact Scale. Dependent variable: average steps taken per day during a 7-day period, measured using an accelerometer.

Results

6MWT, self-selected GS, and BBS were moderately related to home and community walking activity. The 6MWT was the only predictor of average steps taken per day; it explained 46% of the variance in steps per day.

Conclusions

The 6MWT is a useful outcome measure in higher functioning people with stroke to guide intervention and assess community walking activity.