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PubMed1999

[Experiences with ambulatory cardiologic phase II rehabilitation].

The phase II cardiac rehabilitation in Germany differs markedly from other European countries and the USA. Most of the patients enter a 3-week full residential program. In contrast we developed an outpatient phase II cardiac rehabilitation program. Since 1979 we treated more than 8,500 patients with different indications (i.e. after myocardial infarction, coronary bypass surgery, valve replacement and reconstruction). Patients with a daily commuting time over 60 minutes are not suitable for outpatient rehabilitation. Our model corresponds to the German intrahospital rehabilitation. The rehabilitation is carried out in 3 weeks offering approximately 66 hours of therapy. Groups of 8 patients with a similar level of physical capacity stay together during the rehabilitation. A comprehensive program with exercise training, physical therapy, psychological support, education in life style changes and risk factor modification has been developed. The compliance of the patients as well as the acceptance by the family are excellent. Long-lasting reduction in LDL cholesterol levels and increments in work-load capacities have been demonstrated. A high percentage of patients returned to work. Cost analysis demonstrates a reduction up to 40% in comparison to the full residential program. Therefore the outpatient phase II cardiac rehabilitation is a good alternative especially in urban areas.

Ambulatory Care↗
PubMed2004

Patient dissatisfaction: insights into the rehabilitation process.

Most patients admitted for inpatient rehabilitation find it beneficial even when there is little change in physical disability. The aim of this study was to determine the characteristics of patients who felt that they had not benefited from inpatient rehabilitation and to delineate the underlying reasons for this perception. From a database of 331 patients admitted to a neurological rehabilitation unit over a three-year period, we ascertained those with a low score (< 5) on a self-rated visual analogue scale (VAS) regarding their perception of the benefit of rehabilitation. We investigated their disability outcomes, aspects of the rehabilitation process through analysis of integrated care pathways, and from inspection of the multidisciplinary record identified specific adverse factors which might contribute to dissatisfaction. Low VAS scores were detected in 6% of patients (n = 19). These did not correlate with baseline demographic factors or disability levels, but were associated with unresolved external problems regarding community care and accommodation, and conflicts between patients and therapists. We conclude that from the patients' perspective, successful inpatient rehabilitation depends on adequate attention given to community-based issues and health care professionals recognising patients' needs. When these two conditions are not fulfilled, patients are more likely to express a lack of satisfaction with their rehabilitation.

Humans↗
PubMed2005

Team functioning and patient outcomes in stroke rehabilitation.

OBJECTIVE: To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes. DESIGN: Prospective observational study. SETTING: Veterans Administration (VA) inpatient and subacute rehabilitation units. PARTICIPANTS: Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS). RESULTS: Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness. CONCLUSIONS: Characteristics of team functioning predict selected rehabilitation outcomes.

Adult↗
PubMed2005

An exploration of central nervous system medication use and outcomes in stroke rehabilitation.

UNLABELLED: Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation. OBJECTIVE: To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables. DESIGN: Observational cohort study of post-stroke rehabilitation. SETTING: Six inpatient rehabilitation hospitals in the United States. PARTICIPANTS: Patients with moderate or severe strokes (N=919). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition, FIM score change, and rehabilitation length of stay (LOS). RESULTS: Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neuro-stimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counter-intuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation. CONCLUSIONS: There are many opportunities to enhance a stroke survivor's ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.

Activities of Daily Living↗
PubMed2006

ACRM's evolving mission: opportunities to promote rehabilitation research.

This presidential address reflects on the history and mission of the American Congress of Rehabilitation Medicine (ACRM) and considers the benefits derived from joint ownership of Archives of Physical Medicine and Rehabilitation with the American Academy of Physical Medicine and Rehabilitation (AAPM&R). Much of ACRM's history has been distinguished by collaboration with AAPM&R on essential concerns. Evolving organizational priorities have resulted in distinct association missions that have consequences for joint ownership of Archives. The journal has grown in important ways in the past 86 years from a solo editor to an editorial board and to joint ownership and sponsorship of alternating issues. The quality of Archives has improved substantially in the past decade, with an improving impact factor and an increasing number of manuscript submissions. A new contract with the publisher provides an opportunity to consider the relationship between the Congress and Archives and what kind of benefit ACRM desires it to be for its members, to the larger community of physical medicine and rehabilitation (PM&R), and to the persons with disabilities we as PM&R professionals seek to serve. Archives is well positioned to fulfill ACRM's focus on promoting rehabilitation research and facilitating information dissemination and technology transfer. An internationally respected journal is an excellent means to disseminate rehabilitation research that promotes health, independence, productivity, and quality of life for people with disabling conditions. This new chapter in the relationship between Archives and the Academy and Congress provides several opportunities for rehabilitation research leadership. More than ever, Archives provides a premier mechanism to fulfill the Congress's mission and to promote our sense of community.

Biomedical Research↗
PubMed2000

A functional diagnostic complexity index for rehabilitation medicine: measuring the influence of many diagnoses on functional independence and resource use.

OBJECTIVE: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS). DESIGN: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups. DATA: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995. RESULTS: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission. CONCLUSION: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.

Activities of Daily Living↗
PubMed2003

Early and long-term outcome of rehabilitation in stroke patients: the role of patient characteristics, time of initiation, and duration of interventions.

OBJECTIVE: To determine whether and how patient characteristics and the time of initiation and duration of rehabilitation influence early and long-term patient outcome after cerebrovascular accident. DESIGN: A cohort study. SETTING: Twenty rehabilitation hospitals and wards located throughout Italy. PARTICIPANTS: A total of 1716 stroke patients (874 men, 842 women) consecutively admitted to Italian hospital rehabilitation centers in 1997 and 1998. Patients had moderate to severe disability (FIM instrument score, < or =90). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Three negative patient outcomes were considered: death, early failure (premature, unwanted interruption of rehabilitation program; absence of any improvement at hospital discharge), and late failure in terms of severe disability (Barthel Index score, <40) or poor quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey; questionnaire score, <80) 6 months after admission. The strength of the association between the considered variables and the outcomes was calculated with the odds ratio (OR). RESULTS: The less disabled and younger patients had better survival and early and long-term outcomes. The presence of dementia and pressure ulcers on admission was associated with worse outcomes (OR for any failure or death=1.31; 95% confidence interval [CI], 1.03-1.67; OR=1.63; 95% CI, 1.12-2.37, respectively). Patients who initiated the rehabilitative procedures early (within 7d after stroke) had better long-term outcomes than did those who initiated the rehabilitation after more than 1 month (OR=2.12; 95% CI, 1.35-3.34) or from 15 to 30 days after the acute cerebrovascular event (OR=2.11; 95% CI, 1.37-3.26). CONCLUSIONS: This study's results support the idea that recovery after stroke is greatly influenced by the clinical and demographic characteristics of the patients and that early rehabilitation intervention may have a relevant role.

Activities of Daily Living↗
PubMedDate not supplied

[Prognosis of labour force participation after multidisciplinary outpatient and inpatient rehabilitation for chronic back pain].

UNLABELLED: In a one-year prospective study of patients participating in a multidisciplinary outpatient or inpatient rehabilitation program (OPR/IPR) for chronic back pain the following issues were investigated: (i) the frequency of low labour force participation (LFP), i. e., work loss due to the disease or total duration of sick leave (SL) of 6 weeks or more; (ii) prognostic indicators at the beginning of the rehabilitation program (T1) for low LFP after one year (T2); (iii) the significance of the type of rehabilitation IPR vs. OPR in relation to the identified prognostic indicators for LFP. A total of 413 patients participating in OPR (n = 299) or IPR (n = 114) for chronic back pain returned a postal questionnaire after one year. Low LFP was found in 30 % of all patients without significant differences between OPR (32 %) and IPR (25 %). Compared to the year before T1 the proportion of patients without SL between T1 and T2 increased from 12 % to 48 % after OPR, from 15 % to 47 % after IPR, respectively. In multivariate logistic regression analyses adjusted for type of rehabilitation the following prognostic indicators of T1 for low LFP were identified (p </= 0,05): SL of 6 weeks or more in the year before T1 with an odds ratio (OR) of 11.1; intended termination of employment (OR = 3.2), household income of less than 3300 DM per month (OR = 2.2); reduced social functioning (SF-36) (OR = 2.0). Regarding LFP no significance of the type of rehabilitation (IPR vs. OPR) was found in relation to the identified prognostic indicators or after adjustment for differences (i) in the characteristics of the patients at T1, and (ii) in the duration and number of single measures of the rehabilitation program. CONCLUSIONS: One year after IPR or OPR the rate of return to work is similar (about seven out of ten patients). The identified prognostic indicators may stimulate further research of the improvement of the rehabilitation processes. No evidence was found against the expansion of OPR.

Adult↗
PubMed2006

[Pre- and post-treatment in inpatient psychosomatic rehabilitation].

Patients who are referred to psychosomatic inpatient rehabilitation are mostly suffering from long-term illnesses. Therefore, it is necessary to take pre- and post-treatment into account. Epidemiological questions are frequency and type of pre- and post-treatment and their relation to course and outcome of rehabilitation. Pre-treatment, recommendations for follow-up treatment, and course of treatment in 1284 patients of the department of behaviour therapy and psychosomatics of the rehabilitation centre Seehof were assessed. Before admission, 75.4 % of patients had been in psychiatric treatment, and 31.3 % had received psychotherapy. The inpatient stay was significantly longer in patients with psychiatric pre-treatment and those with a combination of psychiatric treatment and psychotherapy. These patients were more often unemployed and showing an insufficient social network. Pre-treatment was unrelated to changes in the SCL-90-R, to physician ratings of therapeutic outcome or the ability to work at the end of rehabilitation. Patients pre-treated by a general practitioner, psychiatrist or psychotherapist returned to that therapeutic setting after rehabilitation. Patients only treated by general practitioners were referred to specialist treatment. These data show the need to integrate inpatient rehabilitation in long-term pre- and post-treatment. One effect of inpatient rehabilitation is to optimize treatment. This requires good communication across different areas of health care.

Adult↗
PubMed2000

Recovery from stroke: does rehabilitation counselling have a role to play?

AIMS AND OBJECTIVES: The aim of this paper is to explore the stroke literature, with particular emphasis on the management of psycho-social issues during and in the aftermath of stroke rehabilitation. Within the literature, there are a number of studies that indicate that the present 'medical/physical' approach to stroke rehabilitation may not be achieving desirable long-term psycho-social outcomes and these are considered. The studies highlight the potential effect of the human emotional and social aspects of having a stroke upon the physical and mental well-being of the person. For the person living with stroke, the ability to maintain a positive sense of direction in life as well as hold onto their, or develop a new, identity is crucial in terms of adapting to change. Holding onto one's self-worth and unity with the past and anticipating the future enhances the ability to cope and adapt in the aftermath of stroke rehabilitation. This links with the investigation into rehabilitation counselling as a potential strategy for the management of long-term psycho-social functional status following stroke. CONCLUSION: It is suggested that the medical model of stroke rehabilitation places undue emphasis on clinical diagnosis and treatment. By default, measurement of physical independence or disability that is compressed into standardized scales has arguably led to the neglect of the emotional and social consequences of stroke and a partial or inhibited view of the person. It is proposed that there is a need to develop and evaluate the effectiveness of rehabilitation counselling from short-term stroke rehabilitation through to long-term psychosocial adaptation, for this client group to provide clear evidence for service provision.

Counseling↗
PubMed2005

Psychological comorbidity in medical rehabilitation--the need for education.

PURPOSE: Prevalence of comorbid mental disorders in rehabilitation patients is high. In spite of the bio-psycho-social approach in rehabilitation, recognition and treatment rates of comorbid mental disorders during rehabilitation are low. The purpose of the study was to raise specific information about current clinical practice concerning comorbid mental disorders and training needs of rehabilitation personnel. METHOD: 435 questionnaires were sent out to medical personnel in 54 rehabilitation hospitals in south-west Germany. RESULTS: Psychologists in rehabilitation spend most of their time on counselling (45%) and group interventions (29%). Physicians and psychologists both feel highly responsible for recognizing mental disorders and motivating patients to seek aftercare. Screeners are rarely used by psychologists and physicians. Seventy-six percent of the participants would take part in specific training sessions. High training needs were stated for affective, anxiety and somatoform disorders. A specific training session for mental health in rehabilitation should last at least half a day and cover affective, anxiety and somatoform disorders. CONCLUSIONS: Taking these results into account, it is possible to put together a training program in diagnostics of comorbid mental disorders, which fits the needs of the professionals.

Comorbidity↗
PubMed2004

Motor tele-rehabilitation in post-stroke patients.

PRIMARY OBJECTIVE: The advanced communication technology may allow rehabilitative interventions to patients living at home from a remote provider. We evaluated the effects of a tele-rehabilitation system for the therapy of arm motor impairments due to a stroke. RESEARCH DESIGN: Experimental observational study. METHODS AND PROCEDURES: We selected five patients suffering from mild/intermediate arm motor impairments due to a long-lasting ischaemic stroke. Two workstations were utilized, one in the patient's house and the other in the rehabilitation hospital, connected through the phone lines. A virtual reality based software allowed the patient to perform adequate motor tasks created by the physiotherapist. During performance, the patient could see not only their movement but also the correct trajectory that they had to accomplish. The feedback derived from the patient's action, its outcome, and feedback from the supervision of the physiotherapist may favour the acquisition of new motor abilities. MAIN OUTCOME MEASURES: The arm motor performance and the activities of daily living were evaluated using the Fugl-Meyer and Functional Independence Measure scale, together with the determination of the velocity and duration of 10 representative reaching movements. RESULTS: Subjects underwent the tele-rehabilitation programme for 4 weeks. The therapy significantly improved the Fugl-Meyer mean score, the mean duration and the velocity of the movements, but not the Functional Independence Measure scale score. CONCLUSIONS: These results indicated that this tele-rehabilitation system did not appear to adversely affect rehabilitation; rather it may improve arm motor deficits due to a stroke. If these evidences are further confirmed, tele-rehabilitation may represent a new home-based therapy to treat disabled people.

Activities of Daily Living↗
PubMed1991

Results of statutory rehabilitation measures in Germany.

The success of medical rehabilitation measures taken by the LVA Oberfranken and Mittelfranken in 1984 was scrutinized for 12,291 insured people. The criteria for evaluating success were the state of health of the insured persons before rehabilitation and at one month and one year afterwards. Two thirds of the insured persons were at work again one month after discharge from rehabilitation. One year after rehabilitation 14 per cent received a disablement pension. Only every second person insured who was ill before rehabilitation took up work again afterwards. Most of the insured people who were already receiving a pension before rehabilitation continued to receive their pension afterwards (86 per cent). The highest rate of inability to work and also the highest pension rate is found with insured persons suffering from an ischaemic cardiac disease. Only 33 per cent of these persons resume work after rehabilitation.

Adult↗
PubMedDate not supplied

The value of the role of the rehabilitation assistant.

This article outlines the experiences of nursing and therapy staff regarding the introduction of rehabilitation assistants. The authors discuss issues concerning a role (the rehabilitation assistant) that was created after staff identified that therapeutic input (nursing, physiotherapy, occupational therapy, speech and language therapies), which was provided from Monday to Friday, was not continued over weekend periods. A small-scale audit was carried out to assess the role and the efficacy of the rehabilitation assistant. The results demonstrate specific areas of the rehabilitative process that patients and their carers considered important. These include activities of living, general wellbeing and the patient's view towards rehabilitation over the weekend. This article demonstrates the value of the role of the rehabilitation assistant and how, together with effective multidisciplinary team working, it provides the impetus for a consistent and goal-directed rehabilitative process.

Activities of Daily Living↗
PubMed2006

Evidence-based practice and setting basic standards for stroke rehabilitation in Canada.

It is a concern that the consistency of care in stroke rehabilitation appears to vary significantly among practice settings within Canada. Based upon an evidence-based review of stroke rehabilitation, a group of physiatrists from across Canada agreed to some basic standards for stroke rehabilitation. The following standards were deemed to be critical to providing effective stroke rehabilitation care: early assessment and quick access to specialized interdisciplinary rehabilitation, appropriate intensity of therapies, availability of outpatient therapy, appropriate community supports, and careful attention to secondary prevention of stroke. Providing stroke rehabilitation care consistently within these standards remains a challenge, particularly given the potential initial costs, despite significant improvements in patient outcomes and quality of life. Nevertheless, these standards should be the expectation of stroke patients, essentially forming a stroke rehabilitation "bill of rights."

Canada↗
PubMed2001

In-hospital referral source and rehabilitation outcome of elderly stroke patients.

To date, there is no data regarding the association of patient in-hospital referral source and stroke rehabilitation outcomes. The objective of the present study was to investigate the possible relation between in-hospital referring source, whether directly from an emergency ward (EW) or indirectly through a general medical ward (GMW), and the functional outcomes achieved during rehabilitation of such stroke patients. This retrospective observational study included 315 consecutive patients, admitted for rehabilitation following the onset of acute stroke. We compared those referred directly to us from the EW, with others referred from GMWs. Functional status was assessed by Functional Independence Measure method (FIM). Functional outcome was determined by total FIM gain (efficacy) and daily FIM gain (efficiency), both absolute and relative (to potential). The two study groups were similar in terms of age, gender, and diagnosis. FIM admission scores were higher at admission in patients admitted directly from the EW, compared with those referred from GMWs (72.5 +/- 27.5 and 62.7 +/- 25.6, respectively) but similar at discharge (77.4 +/- 28.8 and 80.7 +/- 32.5, respectively). Length of stay (LOS) in the GMW group was longer as compared to the EW group. Efficacy was significantly associated with being married, younger age, hemiplegia, and admission scores between 40-60. Both absolute and relative efficacy and efficiency rates of rehabilitation were significantly lower among patients referred from the EW. We conclude that in-hospital referral source is associated with different rehabilitation outcomes in stroke patients. Direct admission of stroke patients from the EW is associated with lower rehabilitation efficacy and efficiency rates, compared with those admitted from GMWs. The findings support the implementation of different selection methods, underscoring the need of both clinicians and administrators to consider the in-hospital referral source as a potential factor associated with stroke rehabilitation outcome.

Adult↗
PubMed1979

Training in rehabilitation: basics needs and considerations.

Rehabilitation is an integral part of medicine. It includes physical therapy, occupational therapy, speech therapy. It involves nurses, social workers, clinical and educational psychologists. It also involves resettlement into the community and to work. Each patient, whether temporarily or permanently disabled, requires a comprehensive service to meet all his needs at the appropriate time. Although there are some multidisciplinary teams providing comprehensive rehabilitation services the needs are so wide and complex that many patients do not achieve optimum rehabilitation. Most doctors believe that the best rehabilitation stems from high standards of general medical care, but many patients require care and counselling extending into social and community aspects of their lives. The clinician must be trained to understand these needs and accept the responsibility for, at least, initiating appropriate rehabilitation and resettlement procedures and thus reducing clinical and social morbidity. Rehabilitation is more than the practice of special techniques. Most therapists can contribute considerably by the assessment of potential functional capability and by exploiting residual capability by alternative techniques of activity, or the use of aids and appliances. The behavioural aspects of response to illness or injury and the patterns of recovery thus determined need to be more clearly understood and the rehabilitation programme reappraised in the light of the knowledge.

Comprehensive Health Care↗
PubMed1977

[Rehabilitation of rheumatoid arthritis and ankylosing spondylitis: a study of the pre-requisites (author's transl)].

Rheumatoid arthritis/chronic polyarthritis and ankylosing spondylitis belong to the most common inflammatory rheumatic diseases. Owing to their progressive character they can result in morphological and functional defective conditions making rehabilitation procedures necessary. In contrast to other diseases calling for rehabilitation treatment the rehabilitation of these two diseases is in the majority of cases a life-long process, during which a change in rehabilitation goals and procedures is not seldom. Hence, rehabilitation is a dynamic process which requires flexible adjustment. A positive rehabilitation outcome is dependent upon the following factors: (1) the patient's disease (duration, stage, type of affection, progression, inflammatory and immunological activity, general condition and drug tolerance), (2) the patient's personality (age, intelligence, motivation), (3) the patient's home and vocational environments. In addition to technical pre-requisites, which are also important, the following medical ones have to be outlined: early diagnosis and initiation of therapy and the availability of a comprehensive treatment programme embracing drug, surgical, physical and balneological therapies, also as an in-patient. A further pre-requisite is the high rheumatological qualification of the responsible physician, who must maintain good contacts with the other members of the rehabilitation team. In the long run, this qualification can only be achieved with the provision of adequate training programmes, and if rheumatology is accepted as an independent discipline.

Arthritis, Rheumatoid↗