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PubMed2004

[Effects of three-stage rehabilitation treatment on acute cerebrovascular diseases: a prospective, randomized, controlled, multicenter study].

OBJECTIVE: To evaluate the effect of tertiary rehabilitation treatment on acute cerebrovascular diseases. METHODS: Fifteen tertiary rehabilitation networks were set up throughout the country. 1078 patients with acute cerebrovascular diseases were randomly divided into 2 groups: rehabilitation group and control group, out of which 19 patients died, 157 dropped out, and 7 successive evaluations were completed in 902 patients that. 439 of the remaining 902 patients in the rehabilitation group, 266 males and 173 females, aged 61 +/- 11, 278 cases with cerebral infarction and 161 with cerebral hemorrhage, received routine treatment and early rehabilitation for 28 days in the ward of neurology, and then went home and received community rehabilitation for 6 months or underwent specialized reinforcement training for 2 months and after that went home and received community rehabilitation for 4 months. The 463 patients in the control group, 281 males and 182 females, aged 60 +/- 11, 291 of which with cerebral infarction and 172 with cerebral hemorrhage, received only routine treatment and early rehabilitation for 28 days in the ward of neurology, and then went home to conduct rehabilitation training by themselves or their family members for 6 months. Evaluation was conducted 7 times, with National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer motor function scale, Barthel index, SF-36 scale, Lowenstein occupational therapy cognitive assessment (LOTCA), Westen aphasia battery, Hamilton depression scale, and modified Ashworth spasm scale, one week after the onset and by the ends of 1, 2, 3, 4, 5, and 6 months after the onset respectively. RESULTS: The scores of clinical neurological impairment, Fugl-Meyer scores, SF-36 scores, incidence of PSD, and modified Ashworth scores (for upper and lower limbs) were lower, and LOTCA scores and Barthel indexes were higher at different time points in the rehabilitation group than in the control group; and the differences were statistically significant since the 2nd month after the onset. By the end of the 6th month, the patients of the rehabilitation group basically re-achieved the ability of self-care in daily activities with a Barthel index of 84 +/- 33. The patients of the control group also recovered to a certain degree, however, to a smaller extent in comparison with the rehabilitation group. CONCLUSION: Tertiary rehabilitation treatment of cerebrovascular diseases is effective in improving motor function, ability of daily living activities, and quality of life and reducing the incidence rates of secondary complications.

Activities of Daily Living↗
PubMed1997

[A model of integrated partial inpatient rehabilitation].

This article deals with a new form of rehabilitation in Germany: the partly inpatient rehabilitation. This kind of rehabilitation comprises an offer for regular inpatient rehabilitation excluding overnight stay, breakfast and evening meal. In total the quasi inpatient rehabilitation is qualitatively equal to regular inpatient rehabilitation in respect of rehabilitative outcome. This new kind of rehabilitation contributes to a flexible and requirements-oriented health service in the German rehabilitation system. In this respect, "quasi inpatient rehabilitation" seems to be a valuable complement to traditional inpatient and out-patient rehabilitation, though quasi inpatient rehabilitation cannot generally replace traditional rehabilitation.

Adult↗
PubMed2005

Timing of initiation of rehabilitation after stroke.

UNLABELLED: Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke. OBJECTIVE: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. DESIGN: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. SETTING: Six U.S. inpatient rehabilitation hospitals. PARTICIPANTS: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). RESULTS: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. CONCLUSIONS: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.

Activities of Daily Living↗
PubMed2005

Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

UNLABELLED: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? OBJECTIVE: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. DESIGN: Prospective observational cohort study. SETTING: Five U.S. inpatient rehabilitation facilities. PARTICIPANTS: Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total, motor, and cognitive FIM scores and discharge destination. RESULTS: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. CONCLUSIONS: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.

Activities of Daily Living↗
PubMed2000

A taxonomy for classification of stroke rehabilitation services.

OBJECTIVE: To develop a taxonomy for use in measuring stroke rehabilitation services. DESIGN: A cross-sectional study using facility-level survey data and extant data files. SETTING: Veterans Administration medical centers (VAMCs). VARIABLES: (1) A list of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (2) a classification or typology of VAMCs according to the type of postacute stroke care on-site. MAIN OUTCOME MEASURES: Data sources included extant Veterans Administration (VA) computerized databases, VA central office administrative files, and 2 mailed surveys to VA rehabilitation medicine services and stroke acute care services. The rehabilitation taxonomy was derived using 2 methods that assess face and construct validity, respectively: (1) an expert panel rating, using a modified Delphi process, of the clinical importance of each of the rehabilitation characteristics; and (2) a comparison of rehabilitation characteristics across the different types of VAMCs. Variables were included in the final taxonomy if the expert panel reached consensus that the variable was clinically important, or if there were statistically significant differences in these characteristics across the different types of medical centers. RESULTS: Of 67 possible rehabilitation characteristics, a multidisciplinary expert panel reached consensus about the likely clinical importance of 21 rehabilitation characteristics, 11 of which showed statistically significant differences across different types of VAMCs. An additional 9 variables that lacked expert panel consensus differed significantly among the different medical centers. These 30 variables represent a preliminary taxonomy of key rehabilitation characteristics. Among the 20 variables that varied significantly across the different types of medical centers, 18 showed a pattern with the greatest amount of resources and organizational sophistication being found in VAMCs with rehabilitation units, followed by medical centers with geriatric units, and the least amount of resources and organizational sophistication was seen in medical centers whose postacute care services were limited to nursing home or intermediate care. CONCLUSION: Thirty rehabilitation characteristics had face validity and/or construct validity, and can be considered to represent a preliminary taxonomy for measuring stroke rehabilitation services. This study also shows that there are significant differences among hospitals in resources and organization of care deemed to be important for stroke patients.

Aged↗
PubMed2004

[Chances for advancement of outpatient rehabilitation in Germany].

Rehabilitation has a long tradition in Germany compared to other countries and is based upon a differentiated, social law foundation. Rehabilitative offers are provided as standard benefits by different social insurance schemes (pension insurance, health insurance, accident insurance, etc.) and are an independent task of care not included in acute care. A high degree of institutionalisation and specialisation are specific characteristics of rehabilitation in Germany. A country-wide network of indication specific, mostly larger institutions is available for medical rehabilitation in Germany. This emergence of centres and the location of many institutions in more rural regions give rise to the fact that rehabilitation often cannot take place close to the places of residence of those who are in need of rehabilitative offers. Until the mid-nineties, rehabilitative benefits have been performed almost exclusively on an inpatient basis, which is another characteristic of medical rehabilitation in Germany. Since then the discussion about ambulant rehabilitation has been increasing. Several initiatives are aimed at supplementing the present in-patient offers through ambulant measures. This article describes and analyses the present efforts for the development of ambulant rehabilitation. In reference to the guidelines of the BAR (Federal Rehabilitation Council) concerning ambulant medical rehabilitation, adopted by all institutions involved in 2000, the current situation and the state of implementation are discussed, and advancements necessary in the authors' view are considered.

Ambulatory Care↗
PubMed2005

Clinical and administrative outcomes during publicly-funded inpatient stroke rehabilitation based on a case-mix group classification model.

OBJECTIVES: To determine efficiency and efficacy of publicly-funded inpatient stroke rehabilitation based on a Case-Mix Group Classification Model, and to analyse the usefulness of this decisional aid in the refinement of rehabilitation services delivery needed to optimize accessibility to inpatient rehabilitation services for individuals with stroke in a publicly-funded healthcare system. DESIGN: Individuals with stroke (n=422) who received inpatient rehabilitation through the Montreal Rehabilitation Hospital Network were included in this retrospective study. Clinical (total, motor and cognitive-Functional Independence Measure (FIM) scores, percentage of discharge to community) and administrative outcomes (onset to rehabilitation interval, length of inpatient rehabilitation stay, length of stay efficiency) were measured. RESULTS: Across Case-Mix Groups, mean onset to rehabilitation days varied between 16.2 (5.7) and 32.0 (19.4) days whereas the mean length of stay fluctuated between 27.5 (13) and 77.0 (27) days. Best total (41.6 (21.4)) and motor-FIM (38.9 (19.0)) gains were observed in most severely disabled cases (114) whereas the Case-Mix Group 103 presented the best cognitive-FIM gain (5.8 (4.0)). Optimal mean total, motor and cognitive-FIM efficiency rates, found in moderately disabled stroke patients, were 0.668 (0.434), 0.634 (0.377) and 0.15 (0.136), respectively. Majority of patients returned home following rehabilitation in all Case-Mix Groups (63.6% to 96.4%) except for groups 112 and 108. CONCLUSION: Moderate to good length of stay efficiencies are observed among all Case-Mix Group following stroke rehabilitation. In fact, individuals with moderate disability present the best rate of recovery. Variations in length of stay efficiency suggest that the use of a Case-Mix Group Classification Model in stroke rehabilitation could represent an innovative approach, especially for program evaluation in publicly-funded and universal-access rehabilitation hospitals.

Aged↗
PubMed2005

Multi-disciplinary rehabilitation for acquired brain injury in adults of working age.

BACKGROUND: Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, where older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults is not yet established, perhaps because there are different methodological challenges. OBJECTIVES: To assess the effects of multi-disciplinary rehabilitation following ABI in adults, 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected. SEARCH STRATEGY: We used a wide range of sources including: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1983-2004), PsycLIT (1967-2004), AMED, the National Research Register 2004 and ISI Science Citation Index (1981-2004). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing intervention in different settings or at different levels of intensity. Quasi-randomised and quasi-experimental designs were also included, providing they met pre-defined methodological criteria. DATA COLLECTION AND ANALYSIS: Trials were selected by two authors independently, and their methodological quality rated, again by two independent authors. A third reviewer arbitrated when disagreements could not be resolved by discussion. A 'best evidence' synthesis was performed by attributing levels of evidence, based on methodological quality. Trials were sub-divided in terms of severity of ABI and the setting and type of rehabilitation offered. MAIN RESULTS: Ten trials were identified of good methodological quality and four of lower quality. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most patients make a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there is 'strong evidence' of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there is strong evidence that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' that continued outpatient therapy can help to sustain gains made in early post-acute rehabilitation. There is 'limited evidence' that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but the studies serve to highlight the particular practical and ethical restraints on randomisation of severely affected individuals for whom there are no realistic alternatives to specialist intervention. AUTHORS' CONCLUSIONS: Problems following ABI vary; different services are required to suit the needs of patients with different problems. Patients presenting acutely to hospital with moderate to severe brain injury should be routinely followed up to assess their need for rehabilitation. Intensive intervention appears to lead to earlier gains. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation should have access to out-patient or community-based services appropriate to their needs. Those with milder brain injury benefit from follow-up, and appropriate information and advice. Not all questions in rehabilitation can be addressed by traditional research methodologies. There are important questions still to be answered and future research should employ the most appropriate methodology.

Adolescent↗
PubMed2002

[Outpatient geriatric rehabilitation - the structural and process quality of a geriatric mobile service team and a community-based outpatient center].

The trial "Outpatient Geriatric Rehabilitation (AMBRA)" has been launched to compare two outpatient rehabilitation models close to their place of residence or at home: a mobile rehabilitation team based at a geriatric hospital department and a community-based outpatient rehabilitation center run by GPs. Primary analyses concerning structural and process quality of the models are presented in this paper. They refer to medical features and factors associated with care which were assessed at the beginning of the rehabilitation procedures and during intervention. The models include 60 patients attended by the mobile rehabilitation team and 76 patients attended by the outpatient rehabilitation centre. The patients are suffering from multiple illnesses and are limited in their daily activities. Both teams co-ordinate interdisciplinary rehabilitation programs with an average of 50 therapeutic units per patient under medical supervision. The programs' focus is on physiotherapy and occupational therapy and, if indicated, on logotherapy. Psychosocial and health promotional offers are hardly integrated into the procedures. The mobile rehabilitation team on average cares for patients with better cognitive functions (Mini-Mental State Examination) but worse abilities to cope in daily life (Barthel index) than the outpatient rehabilitation team. These differences between rehabilitation groups remain significant after multivariate consideration of sociodemographic, morbidity and process factors. However, differences in mobility (Tinetti Test) can be explained by these variables. The future comparison of results of the rehabilitation programs must therefore consider the different baseline levels and determinants between both groups.

Aged↗
PubMed2005

Are we selecting the right patients for stroke rehabilitation in nursing homes?

OBJECTIVE: To examine the effect of stroke rehabilitation in the nursing home on community discharge rates and functional status among patients stratified by propensity to receive rehabilitation. DESIGN: Retrospective cohort. SETTING: Medicaid-certified nursing homes (N=945) in Ohio. PARTICIPANTS: Patients with stroke (N=2013) admitted to an Ohio nursing home. INTERVENTION: Rehabilitation therapy services. MAIN OUTCOME MEASURES: The propensity to receive rehabilitation, used to adjust for selection bias, was calculated for each patient by using a logistic regression model. Community discharge and change in functional status, measured by using a crosswalk to the FIM instrument, were determined 3 months after admission. RESULTS: By 3 months after admission, 36.9% of the patients were discharged to the community, 16.6% had died, and 46.5% remained in the nursing home. The overall effect of rehabilitation on community discharge (relative risk [RR]=1.58; 95% confidence interval [CI], 1.33-1.85) was not homogeneous across subgroups stratified by propensity to receive rehabilitation. Patients less likely to receive rehabilitation, as measured by a lower propensity score, had a significant benefit in terms of community discharge (RR=1.65; 95% CI, 1.35-1.97), but those more likely to receive services did not (RR=1.21; 95% CI, 0.87-1.56). Among long-term nursing home residents, rehabilitation services were not associated with improved functional status. CONCLUSIONS: With respect to community discharge, patients who were less likely to receive rehabilitation therapy appear to receive greater benefit from rehabilitation services than those who were more likely to receive rehabilitation. This finding raises concerns about current selection practices for rehabilitation services. Research is needed to identify the patients most likely to benefit, especially in the present fiscally constrained reimbursement environment.

Aged↗
PubMed2000

Outcome indicators for stroke: application of an algorithm treatment across the continuum of postacute rehabilitation services.

OBJECTIVE: To determine the feasibility and utility of applying a case-mix adjusted algorithm for treatment across the continuum of stroke rehabilitation. DESIGN: Implementation of a clinical algorithm developed through national expert panels to standardize rehabilitation assessment and treatment of veterans with stroke. Stroke patients were stratified into initial severity groups using FIM instrument-Function Related Groups (FIM-FRG) classifications and were followed up from first rehabilitation referral to completion of all active restorative functional goals. FIM-FRG assignments were used to establish case-mix adjusted outcome indicators for the continuum of rehabilitation services. SETTING: Rehabilitation services in medical and surgical units, intermediate care units, inpatient rehabilitation bed units, and outpatient settings in 10 participating Veterans Affairs (VA) medical centers. PATIENTS: Stroke patients (n = 421) who received rehabilitation in the 10 participating VA centers. MAIN OUTCOME MEASURES: Patients' functional gains, length of treatment (LOT), functional status at discharge, LOT efficiency, costs, cost efficiency, and disposition location. RESULTS: Two hundred twenty-three patients began rehabilitation while in acute medical or surgical units, 171 in inpatient rehabilitation units, 24 in intermediate care, and the remainder while in other settings. With cases compiled across all settings, average total rehabilitation costs for patients in the lowest FRG class (most severe disabilities) were more than twice those for patients assigned to the highest FRG class (least severe disabilities). FIM gains were greatest in the subset of younger stroke patients with the most severe disabilities. CONCLUSIONS: Implementing a standard algorithm of rehabilitation care that includes outcome indicators adjusted to patients' disability severity is feasible. The algorithm's utility is evident because it encompasses rehabilitation care provided across the full continuum, promotes access to care by advocating assessment of all stroke patients, encourages early initiation of treatment, and promotes a smooth transition though various levels of care while encouraging cost containment.

Aged↗
PubMed2002

Interruptions to amputee rehabilitation.

OBJECTIVES: To determine the frequency of interruptions to inpatient amputee rehabilitation, and to identify the causes, risk factors, and consequences of these interruptions. DESIGN: Retrospective cohort study. SETTING: Inpatient amputee rehabilitation service. PATIENTS: A total of 254 consecutive patients admitted within 90 days of amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient age, gender, comorbid medical conditions, amputation type(s), days from amputation to admission, admission Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) score, rehabilitation length of stay (LOS), whether a prosthesis was fabricated, discharge destination, discharge Houghton Scale score, discharge 2-minute walk test, and discharge SF-36 score. RESULTS: Interruptions occurred in 76 patients (30%). Impaired stump healing caused 46 (18%) interruptions and acute medical illness caused 26 (10%); 4 (2%) interruptions were because of other causes. Higher incidence of interruption was associated with female gender, peripheral vascular disease, and decreased days from amputation to rehabilitation. The majority of patients with interruptions (60/76, 79%) returned to complete rehabilitation. Patients with interruptions had significantly longer rehabilitation LOS (48.5 vs 37.0d, P<.001), but functional outcome measures at rehabilitation discharge were similar between those patients who returned to complete rehabilitation after interruption and those patients without interruption. CONCLUSIONS: Interruptions to amputee rehabilitation are common and result in longer rehabilitation LOS but do not adversely affect rehabilitation outcomes in those who are able to return to complete rehabilitation. No subgroup of patients with exceptionally high incidence of interruption could be identified.

Amputees↗
PubMed2005

[Significance of the chronic fatigue syndrome in rehabilitation medicine--status and perspectives].

It appears that from a clinical point of view chronic exhaustion or fatigue is an important factor in rehabilitation. This is, however, first of all a phenomenon that can be described as a function in accordance with the International Classification of Functioning, Disability and Health (JCF), caused by chronic illnesses or chronic excessive stress. The clinical and sociomedical ranking of chronic fatigue or exhaustion in respect of rehabilitation was discussed in the framework of a Workshop at the 12th Rehabilitation Science Colloquium, 2003 from the viewpoints of psychiatric rehabilitation, methodology, sociology and practical rehabilitation, and conclusions for future research were drawn. The definition of chronic fatigue is first of all mainly based on the feeling of chronic tiredness but also on phenomena of disturbed concentration, physical discomfort, headache and disorders of "drive" and mood. A psychiatric diagnosis linked with symptoms of chronic fatigue is neurasthenia, which is arrived at according to precisely defined criteria. Depressive disorder is one of the most important differential diagnoses in this sphere. Examinations by general practitioners revealed that about 90 % of the patients who had been diagnosed as suffering from psychovegetative disorders completely agreed with the diagnosis of neurasthenia. Neurasthenia resulted more often in work disability periods than disorders of somatisation and other psychosomatic diagnoses. Basing on the "IRES" scale "vital exhaustion", singular of even serious changes become evident in about 50 % to 90 % of the patients undergoing rehabilitation, depending on their individual range of indications. As was to be expected, the majority of pathologic findings concerns patients undergoing psychosomatic rehabilitation, since in such cases there is an overlapping with symptoms of psychosomatic diseases. It is, however, remarkable that also in somatically oriented orthopaedic rehabilitation symptoms of fatigue are seen in up to 50 % of the patients. Preliminary studies have shown that these symptoms can be definitely ameliorated within the rehabilitation framework, although pathological signs are still abundantly apparent in follow-up examinations. Markedly severe degrees of "vital exhaustion" and "vocational exhaustion" are also seen in rheumatology patients undergoing somatic rehabilitation. This agrees with case history details related by many female and male patients. Hence, it appears necessary to adapt rehabilitative intervention to both the psychovegetative and the medical behavioural aspects of this symptom. Scientific classification of the entire sphere of chronic fatigue in respect of rehabilitation requires classification of the relevant functions within the ICF framework. To this end it would be necessary to conduct patient inquiries within cross-sectional studies on the one hand and, on the other, a systematic consensus process among experts would have to be used for allocation to the relevant functions. This is the basis for development of suitable assessment tools for use in prospective studies in order to systematically evaluate the impact on functions and especially their effects on activities and participation.

Disability Evaluation↗
PubMed2000

Use of healthcare, impact on family caregivers and patient satisfaction of rehabilitation at home after stroke in southwest Stockholm.

We previously conducted a randomized controlled trial in which early supported discharge from the Department of Neurology at Huddinge Hospital in southwest Stockholm with continuity of rehabilitation at home (n = 41) was compared to routine rehabilitation services (n = 40) for moderately disabled selected stroke patients. No statistical significant differences were found in patient outcome at 3 or 6 months, but a moderately positive effect in the home rehabilitation group was suggested. In the present study we evaluated resource utilization of health and social care, impact on family caregivers during 6 months after acute stroke and patient satisfaction. A 50% reduction in total hospitalization (initial and recurrent) was observed, from 30 days in the routine rehabilitation group to 15 days in the home rehabilitation group (p < 0.001). After discharge, the mean number of home visits in the home rehabilitation group was 12. In total, the routine rehabilitation group had a higher frequency of therapy contacts and daycare in outpatient care. Seventy-eight percent received help from a family caregiver in activities of daily living, yet only 15% had formal home help service. No major differences were found in use of home help service or impact on family caregivers in the form of time devoted to helping the patient or subjective well-being of spouses as per Sickness Impact Profile. Patient satisfaction was in favour of the home rehabilitation group, but a significant difference was only found in active participation in rehabilitation programme planning. In conclusion, early supported discharge with continuity of rehabilitation at home, using goal-directed functional activities based on the patient's personal interests, should be the rehabilitation service of choice for moderately disabled stroke patients fulfilling certain criteria, provided that further evaluation during the first year after stroke reveals no great changes in outcome or resource use. More research into the effectiveness and cost implications of early supported discharge with continuity of rehabilitation at home is needed in other parts of Sweden and in other countries before it can be asserted that the conclusions drawn from this study are applicable elsewhere.

Activities of Daily Living↗
PubMed2001

Physicians' estimates of rehabilitation requirements after stroke and traumatic brain injury--a questionnaire survey in East Germany.

PURPOSE: The provision of rehabilitation services is organized differently in Germany than most other countries, with large indication-specific in-patient centres. This study is aimed at the rehabilitative knowledge of physicians who initiate and conduct rehabilitation in Germany. METHODS: Medical specialists routinely involved in the treatment and rehabilitation of patients with stroke and traumatic brain injury (TBI) from acute hospitals, rehabilitation centres, and the Medical Services of the Workers' Pension Funds of Sachsen-Anhalt and Mecklenburg-Vorpommern were included in a systematic questionnaire survey aiming at the rehabilitation requirements of patients under their care or evaluation. These specialists are crucial for decision-making in rehabilitation ressource allocation. RESULTS: According to these experts, rehabilitation requirements for stroke and TBI patients are dominated by deficits in motor functions and daily-living. They are aware that TBI rehabilitation includes a greater focus on memory functions, problem-solving and attention, and in stroke on language functions. According to the surveyed specialists, the present system of medical rehabilitation in Germany covers the requirements of stroke and TBI patients only partially. Deficits are identified in out-patient and day clinic rehabilitation. CONCLUSIONS: Although the knowledge of rehabilitation requirements is adequate in general, its large ranges reflect the necessity for further analysis. The opinions of the surveyed specialists reflect their respective professional setting. Advantages and disadvantages of the German system require further investigation.

Activities of Daily Living↗
PubMed1990

Characteristics of cost outliers who did not benefit from stroke rehabilitation.

The purpose of this paper is twofold: 1) to identify stroke patients who generated substantial charges during inpatient rehabilitation, but did not seem to benefit from that experience and 2) to identify factors that can predict which patients will fall into this group using only variables known at admission to rehabilitation. High cost stroke patients during inpatient medical rehabilitation are examined to determine how they differ from low cost patients and to identify a subset who did not appear to benefit from rehabilitation. This paper is based on longitudinal charge data involving 73 former stroke rehabilitation patients discharged from three Boston area rehabilitation facilities in 1984. Medical charges are presented on initial acute and rehabilitation inpatient stays and on care received in the 12 months after discharge. Among these 73 stroke patients, charges for inpatient medical rehabilitation amounted to nearly 1.8 million dollars, excluding physician fees and out-of-pocket expenses. Of this total, 57.6% was accured by only 33% of the patients. Fourteen patients, who were both rehabilitation cost outliers and apparent rehabilitation "failures," were identified. Rehabilitation charges for these 14 amounted to $673,232 or 37.5% of the total rehabilitation charges for all 73 patients.

Adult↗
PubMed1995

Musculoskeletal disability, employment, and rehabilitation.

OBJECTIVE: To determine which, if any, baseline social and disease characteristics can be used to identify persons with musculoskeletal disabilities accepted for state-federal vocational rehabilitation services who are most likely to return to work. METHODS: A database of case closures from the Alabama Vocational Rehabilitation Service was analyzed using segmentation modelling. This included all persons (n = 4093) with musculoskeletal disability who were accepted by the Alabama Vocational Rehabilitation Agency in 1987-91. Demographics, income, type of disability, severity of disability, medical insurance, similar benefits, benefit status, and referral source were independent variables. Outcome (dependent) variable was work status at end of agency services. RESULTS: Overall, 71% of persons with arthritis and musculoskeletal disorders who were accepted for vocational rehabilitation services in 1987-91 returned to work at the end of agency services. Segmentation modelling created a tree in which certain baseline characteristics formed subgroups with differing rates of successful rehabilitation. Social Security Disability Insurance (SSDI) status was the single best predictor of rehabilitation. Seventy-three percent of nonbeneficiaries were rehabilitated compared to 55% of beneficiaries (p < 0.00001). For non-SSDI beneficiaries, education level > or = grade 12 was associated with better rehabilitation outcome (p < 0.00001). SSDI beneficiaries with nonback disorders fared better than those with back disorders (p < 0.05). Disease severity, assessed by Federal Special Programs criteria, was not associated with rehabilitation outcome at any level of the tree. CONCLUSION: Simple baseline social and disease characteristics can be used to identify groups of persons accepted for vocational rehabilitation services with musculoskeletal disability with differing rates of vocational rehabilitation. Disability benefit status and education level are important predictors of return to work after agency services. These findings can lead to the development of strategies to improve the efficacy of vocational rehabilitation services.

Adult↗
PubMed2001

[Inpatient rehabilitation improves implementation of therapeutic guidelines for secondary prevention in patients with coronary heart disease].

In Germany, measures for secondary prevention in patients with coronary artery disease are poorly utilized. We therefore investigated whether a cardiac in-hospital rehabilitation and education program may enhance the implementation of respective guidelines in patients with severe coronary artery disease (CAD). Specifically, we developed a case-control design in siblings with severe CAD in order to achieve optimal matching for patients with or without participation in the rehabilitation program. By the screening of more than 200,000 patient charts in 15 cardiac rehabilitation clinics, we identified 1500 families in which at least two siblings suffered from severe coronary artery disease. In 268 such sibling pairs, siblings were discordant with respect to participation in a 3-4 week cardiac in-hospital rehabilitation program. The coronary risk profile was studied, first, retrospectively at the time of hospitalization for acute MI or revascularization procedures and, secondly, prospectively at the time of follow-up (on average 5.2 years later). At the time of the acute cardiac event, both groups showed an equal risk factor distribution suggesting appropriate matching. However, at follow-up the number of individuals taking antihypertensive medication and displaying effective antihypertensive treatment (< or = 140/90 mmHg) was significantly higher in the rehabilitation group (92.2 vs. 82.1%, p < 0.01; 59.7 vs. 37.2%). Accordingly, rehabilitation siblings presented with significantly lower systolic (137 +/- 1 vs. 145 +/- 1 mmHg; p < 0.01) and diastolic blood pressure (82 +/- 1 vs. 85 +/- 1 mmHg; p < 0.01). The utilization of CSE inhibitors was also significantly higher in siblings participating in the rehabilitation program (57.5 vs. 43.1%; p < 0.01), leading to significantly lower blood lipid levels in these siblings (total cholesterol 225 +/- 3 vs. 236 +/- 3 mg/dL, p < 0.01; LDL cholesterol 148 +/- 3 vs. 158 +/- 3 mg/dL, p < 0.01). Moreover, participation in the cardiac rehabilitation stimulated markedly more smokers to quit (80.8 vs. 57.6%, p < 0.01). Additionally, there was a strong temporal trend from 1997 until 2000 towards improved control of arterial hypertension in rehabilitation siblings. In parallel, the utilization of CSE inhibitors increased over time and LDL cholesterol decreased. These favorable temporal trends were also observed in siblings not participating in the rehabilitation program, however, to a lesser extent. Taken together, in the last four years, the implementation of secondary preventive strategies in patients with cardiac disease improved. Siblings who participated in a rehabilitation program displayed a better control of cardiovascular risk factors as compared to those not participating in such a program. Thus, an in-hospital cardiac rehabilitation program may successfully encourage the implementation of measures for secondary prevention and enhance the treatment of coronary risk factors.

Aged↗