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PubMed2000

Community-based service delivery in rehabilitation: the promise and the paradox.

PURPOSE: According to many researchers, rehabilitation is being prevented from developing as a distinct profession due to two major problems. First, it has been claimed that rehabilitation is in need of a professional identity and a sense of cohesion if it is to emerge as a discipline. Second, it has been recognized that there is a need for a rehabilitation framework to challenge the restorative approach that continues to dominate rehabilitation, linking it back to the medical model from which it has attempted to escape. The model of community-based rehabilitation (CBR) is offered as a model that can provide the impetus for an attitudinal shift from the restorative tradition and unite rehabilitation workers through a cohesive framework. METHOD: Unfortunately, the implementation of community-based rehabilitation in urban societies has been disappointing. The current paper is a conceptual discussion of community-based rehabilitation that explores some potential causes of this poor implementation. RESULTS: To some extent, the implementation failure of community-based rehabilitation can be attributed to the paradoxes that are inherent in its fundamental constructs-empowerment and community inclusion. These paradoxes occur at a conceptual level, a practical level and a contextual level. CONCLUSIONS: Some solutions are offered to enable the paradigm to be implemented more fully. In particular, it is suggested that there is a need to develop useful working definitions of these constructs, favourable attitudes among rehabilitation workers and a focus on community development.

Community Health Services↗
PubMed2002

Physicians' preferences and expectations in stroke rehabilitation--results of a case-based questionnaire survey.

PURPOSE: Analysis of medical decisions in the differential allocation of stroke rehabilitation programmes. METHOD: Medical specialists routinely involved in the treatment and rehabilitation of stroke patients 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 survey, in which they had to give their opinions on the individually optimal rehabilitation setting and therapies and probable outcome on the basis of case vignettes. These specialists are crucial for decision-making in rehabilitation resource allocation. RESULTS: Both allocation and prognosis did not depend only on patient but also on physician characteristics. Neurologists tended to prefer outpatient rehabilitation and expected a greater effect of rehabilitation upon ADL-function than specialists from other professions. Preferred rehabilitation setting did not influence the physicians' subjective prognosis. For patients who qualified both for in- and outpatient rehabilitation, the two settings, therapeutic potentials were considered to be equivalent. CONCLUSIONS: Differences in setting and treatment preferences between experts concerning optimal treatment cannot be resolved on the basis of available evidence. Further data are required that allow to decide which type of rehabilitation is best suited for a given patient.

Adult↗
PubMed2003

Physicians' preferences and expectations in traumatic brain injury rehabilitation--results of a case-based questionnaire survey.

PURPOSE: Analysis of medical decisions in the differential allocation of traumatic brain injury (TBI) rehabilitation programmes. METHOD: Medical specialists routinely involved in the treatment and rehabilitation of TBI patients from acute hospitals, rehabilitation centres, and the Medical Services of the Workers' Pension Insurance of Sachsen-Anhalt and Mecklenburg-Vorpommern were included in a systematic survey, in which they had to give their opinions on the individually optimal rehabilitation setting and therapies and probable outcome on the basis of case vignettes. These specialists are crucial for decision-making in rehabilitation resource allocation. RESULTS: Both allocation and prognosis depended mainly on patient characteristics. In a mixed logistic regression model, which takes into account that: (a) patient and physician characteristics may influence each other; and (b) that expert assessments might be correlated, setting preferences were related to chronicity and degree of motor and cognitive impairment, but also to the institutional background of the reviewer. Neuropsychological therapy dominated intervention recommendations, followed by physio- and occupational therapy. A comparatively great demand of psychotherapy and medicosocial assessment was recognized. Preferred rehabilitation setting did not influence the physicians' subjective prognosis. Older, chronic and motorically impaired patients were considered to profit less from rehabilitation. Physician characteristics and recommendations of either rehabilitation setting or therapies did not influence prognostic expectations. CONCLUSIONS: Physician characteristics influenced setting preferences. Preferences for type of treatment and ADL-prognosis depended on patients' variables only. Expected effects of rehabilitation were independent on rehabilitation setting and kinds of treatment.

Activities of Daily Living↗
PubMed2003

The association of rehabilitation and war.

PURPOSE: To examine the assumed association of war and the development of rehabilitation through a review of the pertinent literature. METHODS: Search in the Medline databases from 1942-2002 for papers that described the impact of war on rehabilitation services and their practice, and the study of the relevant identified reports. The following search terms were used: history of rehabilitation, medicine and war, rehabilitation and war, rehabilitation of war casualties. RESULTS: In WWI physical and occupational therapy became adjuncts in the treatment of military orthopaedic casualties, artificial limb services were set-up and workshops and factories for vocational rehabilitation were created. During WWII further developments occurred, mainly in the field of amputation of limbs and spinal cord injuries. Additional advances took place in all armed conflicts after WWII, particularly in the field of brain injury. CONCLUSION: The literature review indicates that the assumed association of rehabilitation and war is correct. Rehabilitation services have developed partly in association with war and the experience of rehabilitating war casualties supplied valuable principles and practices to rehabilitation medicine enriching the specialty and contributing to the health care systems of the involved countries.

Asia↗
PubMed2005

Rehabilitation in HIV/AIDS: development of an expanded conceptual framework.

In industrialized countries where HIV infection is becoming a chronic, episodic condition, rehabilitation services have the potential to play an expanded role for people living with HIV/AIDS (PLHAs). However, little is known about rehabilitation in the context of HIV. This paper documents the development of an enhanced, multidisciplinary conceptual framework of rehabilitation in the context of HIV, using the perceptions of PLHAs and rehabilitation professionals. Rehabilitation, broadly defined, is a dynamic process that includes all prevention and/or treatment activities and/or services that address body impairments, activity limitations and participation restrictions for an individual. The framework was developed through broad consultation and interviews with thirteen key informants. Themes that emerged from analysis of interviews related to concepts of rehabilitation in the context of HIV, rehabilitation professionals' roles in the context of HIV, and barriers to access and delivery of rehabilitation services. While there was some variation, key informants generally viewed rehabilitation as a goal-oriented and client-centered process with the potential to impact a range of life domains. Themes were presented to members of a national advisory committee (including PLHAs and health care providers), who produced the foundation of the HIV rehabilitation framework. The framework uses the perspective of the person living with HIV/AIDS, and includes individual life domains that may be affected by HIV, drawing and expanding upon the World Health Organization's (WHO's) International Classification of Functioning, Disability and Health.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people.

BACKGROUND: Hospitals are under pressure from admissions of increasing numbers of older people. Older people may suffer unnecessary activity limitation after acute illnesses through lack of appropriate rehabilitation. OBJECTIVE: To evaluate an early discharge and rehabilitation service for older people. DESIGN: A randomised controlled trial comparing an early discharge and rehabilitation with standard hospital aftercare. Outcome measures assessed at 3 and 12 months were the Barthel Index, Nottingham Extended Activities of Daily Living and EuroQol (for patients) the General Health Questionnaire (for patients and carers). Use of services over 12 months was recorded. An interview study of patients and staff was conducted. SETTING AND INTERVENTION: The early discharge and rehabilitation service offered a home-based rehabilitation and care programme for up to 4 weeks. PARTICIPANTS: 370 hospitalised older medical and surgical patients were included in the randomised controlled trial. Twenty patients and 11 staff were interviewed. RESULTS: Subjects in the early discharge rehabilitation service group used fewer days in hospital at 3 months (mean difference 9, median difference 4 days, 95% CI of median difference 2-8). At 3 months the early discharge and rehabilitation service patients had better Barthel scores (mean difference 1.2, 95% CI 0.4-1.9), Nottingham Extended Activities of Daily Living kitchen scores (mean difference 1.2, 95% CI 0.2-2.3), Nottingham Extended Activities of Daily Living domestic scores (mean difference 1.1, 95% CI 0.2-2.0) and General Health Questionnaire scores (mean difference 2.4, 95% CI 0.7-4.1). Significant Nottingham Extended Activities of Daily Living domestic and General Health Questionnaire benefits remained at 12 months. The early discharge and rehabilitation service carers had better General Health Questionnaire scores at 3 months (mean difference 2.0, 95% CI 0.1-3.8). The interviews suggested that the early discharge and rehabilitation service was patient-centred, set clear goals, worked as a team, and considered physical, psychological, social and environmental issues. It was found to be highly satisfactory. CONCLUSIONS: Some older people can be discharged from hospital sooner, with better health outcomes using a well-staffed and organised patient-centred early discharge service providing rehabilitation.

Activities of Daily Living↗
PubMed2001

Nontraumatic vs. traumatic spinal cord injury: a rehabilitation outcome comparison.

OBJECTIVE: Nontraumatic spinal cord injury (SCI) represents a significant proportion of individuals admitted for SCI rehabilitation; however, there is limited literature regarding their outcomes. As our society continues to age and nontraumatic injuries present with greater frequency, further studies in this area will become increasingly relevant. The objective of this study was to compare outcomes of patients with nontraumatic SCI with those with traumatic SCI after inpatient rehabilitation. DESIGN: A longitudinal study with matched block design was used comparing 86 patients with nontraumatic SCI admitted to a SCI rehabilitation unit and 86 patients with traumatic SCI admitted to regional model SCI centers, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. Main outcome measures included acute and rehabilitation hospital length of stay, FIM scores, FIM change, FIM efficiency, rehabilitation charges, and discharge-to-home rates. RESULTS: Results indicate that when compared with traumatic SCI, patients with nontraumatic SCI had a significantly (P < 0.01) shorter rehabilitation length of stay (22.38 vs. 41.35 days) and lower discharge FIM scores (57.3 vs. 65.6), FIM change (18.6 vs. 31.0), and rehabilitation charges ($25,050 vs. $64,570). No statistical differences were found in acute care length of stay, admission FIM scores, FIM efficiency, and community discharge rates. CONCLUSIONS: The findings indicate that patients with nontraumatic SCI can achieve rates of functional gains and community discharge comparable with traumatic SCI. Whereas patients with traumatic SCI achieved greater overall functional improvement, patients with nontraumatic SCI had shorter rehabilitation length of stay and lower rehabilitation charges. These findings have important implications for the interdisciplinary rehabilitation process in the overall management and outcome of individuals with nontraumatic SCI.

Activities of Daily Living↗
PubMed2006

Informal stroke rehabilitation: what do Thai caregivers perform?

Our aim was to explore the informal rehabilitation activities performed by Thai caregivers for stroke survivors at home. Twenty primary informal caregivers were individually interviewed, using semi-structured questions developed by researchers, to investigate the informal rehabilitation activities provided for the stroke survivors at their homes. All interviews were audiotape recorded and some pictures of rehabilitation activities were taken during data collection. The data collected underwent content analysis. Findings revealed three major categories of rehabilitation activities - biological, psychological and social rehabilitation. Biological rehabilitation was the most frequently undertaken by all Thai caregivers. Several methods were used to rehabilitate the stroke survivors in each category, based on the scientific background and cultural beliefs of the caregivers and survivors. In conclusion, informal caregivers always have in mind all activities, thus providing a holistic approach for informal rehabilitation. This plays a very significant role in minimizing residual disabilities, preventing related complications and sustaining the well-being of stroke survivors. Health professionals should motivate caregivers of stroke survivors to maintain informal rehabilitation activity at home. Additionally, health care providers should be concerned about the coordination between institutional and informal rehabilitation in order to better optimize the quality of care provided at home.

Adaptation, Psychological↗
PubMed1999

Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited.

OBJECTIVE: To identify factors associated with the uptake of cardiac rehabilitation following acute myocardial infarction. DESIGN: Retrospective analysis using multivariate logistic regression modelling. SETTING: Two large teaching hospitals in Nottingham. PATIENTS: Cohorts of patients admitted with acute myocardial infarction in 1992 and 1996. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Factors in multivariate analysis found to be associated with attendance at cardiac rehabilitation. Use of secondary prevention in those who were and were not invited and those who did and did not attend cardiac rehabilitation. RESULTS: 58% of all patients were offered cardiac rehabilitation. Attendance rates were 60% in 1992 and 74% in 1996. Invitations were more likely to be offered to younger patients, those who had received thrombolysis, and to patients admitted to one of the two Nottingham hospitals. Use of secondary prevention was only 48% in 1992 but this increased to 80% in 1996. Patients not receiving secondary prevention were less likely to be invited to cardiac rehabilitation. Social deprivation was the only factor significantly associated with poor uptake of cardiac rehabilitation in both years. There was no difference in the use of secondary prevention between those who did and did not attend cardiac rehabilitation. CONCLUSION: Those invited to attend a cardiac rehabilitation programme are likely to be in a good prognosis group, comprising those who are young and have received thrombolysis. Those at greatest risk, particularly patients from socially deprived areas, seem to be missing out on the potential benefits of cardiac rehabilitation. High risk patients should be specifically targeted to ensure that they are invited to, and encouraged to, attend a programme of cardiac rehabilitation.

Adult↗
PubMed2007

The determinants of successful in-hospital rehabilitation in people aged 90 years and older.

BACKGROUND/OBJECTIVES: The very elderly constitute a subgroup of elderly who may respond differently than the younger elderly to medical intervention. This possibility has not previously been investigated. Our study investigates whether successful rehabilitation of the very elderly is possible within the current processes of care and also whether factors that help predict successful rehabilitation in all age elderly are applicable to the oldest old. METHODS: A retrospective case note analysis of all very elderly people (>or=90 years old) treated within in-patient elderly person rehabilitation facilities at the Northern General Hospital, Sheffield. Potential predictive factors analysed: Barthel index, main presenting illness, number of co-morbid conditions, number of regular prescribed medications, abbreviated mental test score, prior formal social services input, previous hospital admission within 1 year and serum albumin (g/l). Outcome measures reflecting success of rehabilitation: duration of rehabilitation (days), discharge destination to the same ('good outcome') or increased ('poor outcome') level of social and/or nursing care, readmission to hospital within 30 days of discharge and death during rehabilitation or within 120 days of discharge. RESULTS: Of 230 nonagenarians admitted to inpatient elderly rehabilitation 47% required no increase in social support following their admission and 76% of those admitted from their own home were able to return there. Barthel index and the number of co-morbid conditions were the most influential predictors of success, with Barthel index predicting length of stay (p < 0.001), discharge destination (p < 0.001) and in-hospital mortality (p < 0.01) and co-morbidity predicting readmission to hospital (p = 0.05), in-hospital mortality (p = 0.04) and survival (p = 0.05). On multi-variate analysis all other predictive factors analysed, except for presenting illness, were associated with at least one outcome measure (p < 0.05). CONCLUSION: Successful inpatient rehabilitation of the very elderly is possible. Factors that predict the success of rehabilitation of nonagenarians are similar to those associated with success in the younger elderly. The factors that most broadly predict success are Barthel index and the number of co-morbid conditions identified at admission to rehabilitation. Main presenting illness did not emerge as a predictor within this group.

Accidental Falls↗
PubMed1998

[The "rehabilitation sciences" promotional emphasis--a promotional program and its implementation].

The German Federal Research Ministry and the German pension insurance have set up a special funding programme for medical rehabilitation research. Eight regional research networks with about 70 projects receive funds for a first three year period. Rehabilitation experts from several countries selected the promising networks and studies from more than 100 proposals. In these networks medical and social scientists from universities and other research units cooperate with rehabilitation centers and pension insurance institutes in order to combine forces for the development of German rehabilitation science. The programme aims at improving the research structures and at tackling the major challenges of medical rehabilitation research. The following subjects represent the main fields of the ongoing research: a) etiology, course and prognosis of chronic diseases and their consequences to rehabilitation, b) diagnostics in rehabilitation, c) evaluation and improvement of rehabilitation therapy, d) the patient's perspective in rehabilitation and e) rehabilitation system research. As yet funding is limited to the year 2001. Further support of the networks will depend on the results of a thorough evaluation of the progress of their research and their structural perspective.

Cost-Benefit Analysis↗
PubMed1999

[Current developments in ambulatory rehabilitation].

Up to now, the majority of rehabilitative measures in Germany has been performed in inpatient programmes. In the past 10 years discussions have increased about extending a flexible scheme involving outpatient, inpatient and partially inpatient rehabilitation benefits. Some concepts in outpatient rehabilitation were already developed as well by the Federal Rehabilitation Council as by various rehabilitation providers. Concept requirements include the principles of holism, interdisciplinarity, goal-oriented rehabilitation and team-work of rehabilitation staff. The arguments in favour of extended outpatient rehabilitation are being faced with many questions and uncertainty about future needs, differential indication criteria and effectiveness. In order to answer these questions pilot projects accompanied by scientists are being conducted for different indication fields. Preliminary findings of the scientific studies indicate that the inpatient rehabilitation model gains more acceptance than the partially inpatient type. The studies on the whole show that partially inpatient populations differ from inpatient ones on various variables. Considering these limitations in comparability, there is a tendency for partially inpatient rehabilitation to yield similar results as inpatient measures. Additionally, it is important to accurately identify the indication.

Ambulatory Care↗
PubMed1999

[LVA Rheinland-Pfalz Model Project of day care rehabilitation: initial results].

A study is carried out to examine a demonstration project for partial hospitalization rehabilitation of patients of the pension insurance scheme of Rhineland-Palatinate (LVA Rheinland-Pfalz) using a parallel design. In four centers for the rehabilitation of musculoskeletal diseases the patients are assessed at the beginning and at the end of rehabilitation as well as six and twelve months post using the IRES questionnaire, a phycisians' questionnaire for the documentation of medical parameters, an instrument for client satisfaction and additional questionnaires. In addition the treatment and the costs on the side of the pension insurance agency are examined. Partial hospitalization rehabilitation clients are compared to inpatient ones from three rehabilitation hospitals. Preliminary analyses of patient self-report data show a strong similarity of inpatient and partial hospitalization clients as far as admission parameters, rehabilitation treatment, perception of rehabilitation and its effects are concerned. These results indicate that the pension insurance schemes' concept of interdisciplinary rehabilitation can be realized in partial hospitalization rehabilitation centers as well, achieving an outcome very similar to inpatient rehabilitation.

Adult↗
PubMed1999

[Medical rehabilitation in long-term disability].

UNLABELLED: Based on data from a prospective observational cohort study the following article attempts to answer two key questions of rehabilitation research in Germany: (1) What are the utilization rates of rehabilitation measures in patients with long-term work-incapacity due to low-back pain? (2) In this group of patients: does participation in rehabilitation programs correlate with return to work? Patients with long-term work-incapacity due to low-back pain report a severely impaired health status (measured by FFbH, SF-36, numeric rating scale for pain intensity) which calls for comprehensive medical treatment and rehabilitation. 40.5% of study patients received first time medical rehabilitation between three months and one year after the beginning of long-term work-incapacity, 20.5% between one year and two years after the beginning of long-term work-incapacity. These figures were not influenced by age. Considering the severity of impairment we judge these rates as being quite low. There was no positive correlation found between utilization of medical rehabilitation measures or any other medical treatment and return to work. A positive correlation was observed for utilization of first time medical rehabilitation between three months to one year after the beginning of long-term work-incapacity and functional capacity. This effect was demonstrable for patients 50 years of age or younger. CONCLUSIONS: (1) In our cohort utilization of medical rehabilitation measures in patients with low-back pain and long-term work-incapacity is quite low. This suggests a considerable amount of underutilization. (2) In order to avoid underutilization the process of accessing medical rehabilitation within the German health care system should be critically reviewed. (3) In the given context of high unemployment rates and the German early pensioning system the use of "return to work" as the main criterion to judge effectiveness of rehabilitation measures remains debatable.

Adult↗
PubMed2003

A rationale and training agenda for rehabilitation informatics: roadmap for an emerging discipline.

Decreased length of inpatient rehabilitation stay, greater long-term injury survival rates, broader access to information technologies, and the growing role of the Internet create potential for new models of rehabilitation that are more community- and person-centered rather than historically hospital- and provider-centered services. In recent years, information-based rehabilitation technologies have grown rapidly, expanding the possibilities for numerous interventions to promote independent living. These programs have centered primarily on providing rehabilitation health services over a distance ("telerehabilitation"). Telerehabilitation can be conceived as part of a broader approach that includes elements of direct rehabilitation services, service coordination, community resources, and information relay between numerous individuals, service providers, and community members ("rehabilitation informatics"). Because of the complexity of these information types and sectors, this broader conceptual approach of rehabilitation informatics borrows heavily from fields such as adaptive computing, robotics, computer networking, and high-level systems programming. As such, innovation in rehabilitation informatics will require new models of training that span these domains. This paper proposes a rationale for the new field of rehabilitation informatics, and offers a multidisciplinary training model for the next generation of rehabilitation informaticians.

Curriculum↗
PubMed2004

[Comparative assessment of rehabilitation centres].

Comparative quality analyses of rehabilitation centres are required by the legislators and are the focus of the external Quality Assurance plans presently implemented. However, they are also highly relevant for internal Quality Management models (e.g. for the result criteria of the EFQM model). To control for confounders of rehabilitation success that cannot be influenced by the rehabilitation centre (e.g. age, co-morbidity), and thus to permit fair comparisons of clinics, regression analysis risk adjustment procedures are primarily used in the literature. The present paper explains the use of so-called Hierarchical Linear Models (HLMs) using example of data of N = 2.044 patients undergoing rehabilitation following hip and knee operations from the Quality Assurance programme of the statutory health insurance funds (QA-Reha-procedure). This procedure has the advantages of: a) taking into account the multi-level structure of the comparison problem; b) permitting the inclusion of predictors at the rehabilitation centre level; and c) permitting the modelling of variation in regression coefficients over the centres. The data presented show that the differences in achieved rehabilitation outcome among the rehabilitation centres - after control of the confounders by means of HLMs tend to be slight. In addition to patient-related predictors of rehabilitation outcome (baseline somatic, functional, psychosocial status, co-morbidity, rehabilitation motivation, gender, age), the mean functional disability of the patients in the centre is shown to be a confounder at the clinic level. In this respect, a centre that has little experience with severely affected rehabilitation patients achieves on average lesser effects on somatic, functional, and psychosocial levels.

Germany↗
PubMed1978

Cancer rehabilitation: assessment of need, development, and evaluation of a model of care.

A sample of 805 cancer patients, comparable to but not identical with a national study, was screened to identify: rehabilitation problems encountered at different cancer sites; the need for rehabilitation services; and gaps in the delivery of rehabilitation care. Significant numbers of rehabilitation problems were found that could be improved by rehabilitation care. Psychologic problems were commonly encountered and seemed more severe in patients with physical disabilities; these patients have to make adjustments to both life-threatening disease and to a disabling condition. The findings suggest a need for psychosocial support services on any oncology service; where cancer is associated with significant physical disability, a comprehensive rehabilitation team with psychologic management capability is often needed. Primary barriers to optimal delivery of rehabilitation care are the lack of identification of patient problems and/or lack of appropriate referral by physicians unfamiliar with the concept of rehabilitation. Health care financial support for the patients in the sample came primarily from private insurance, Medicare and Medicaid; financial support from the patient's family held up well even in the advanced stages of the disease. A model of rehabilitation care delivery was established and implemented, with the result being that gaps and barriers to rehabilitation service delivery disappeared rapidly.

Activities of Daily Living↗
PubMedDate not supplied

[Responsibilities and goals of a rehabilitation clinical in the present and future].

Rehabilitation its an important part of the management of patients with chronic rheumatic diseases and it aims to improve or supervene physical or psycho-social disability and handicap. With regard to the fluctuating course of chronic inflammatory rheumatic diseases, a universal concept of rehabilitation always includes the curative aspect of treatment. Based on the legal and organizational premises for rehabilitation, the problems of access, usage, management and of continuous treatment are critically reviewed. The important tasks in rehabilitation of patients with rheumatic diseases by rehabilitation clinics are education and informing of patients about their disease, including the outcome, possible treatments, self management and coping strategies as well as functional therapy of disorders of the locomotor system. In addition, the adaptation of medical and physical treatment, advice and help with regard to work and occupation, and planning of continuing rehabilitative interventions are important activities of rehabilitation clinics. In the future, an improved integration of rehabilitation within concepts of medical and social support, progress in quality of structuring and processing activities in rehabilitation clinics, and the expansion of ambulant rehabilitation to facilitate continuous support has to promoted.

Activities of Daily Living↗