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PubMed1995

Functional outcome after rehabilitation for severe traumatic brain injury.

OBJECTIVE: (1) Define functional status at rehabilitation discharge and follow-up for patients admitted with Functional Independence Measure (FIM) of 18 after traumatic brain injury; (2) describe patterns of function measured at discharge, rehabilitation lengths of stay and costs, and disposition. DESIGN: Retrospective, descriptive study using data from the Uniform Data System for Medical Rehabilitation (UDSMR) dataset. SETTING: Acute rehabilitation hospitals and, for follow-up data, variety of settings, from community to long-term care. PATIENTS: 328 patients with rehabilitation admission FIM of 18 (principal impairment group "Brain Dysfunction, Traumatic") drawn from 5,430 TBI patients entered into the data set during 1989-1991. Excluded were 22 persons readmitted to rehab, 5 deaths, 1 case without recorded disposition, and 49 cases without ICD-9 code consistent with brain trauma. MAIN OUTCOME MEASURES: FIM scores at rehab discharge and follow-up; disposition; length of stay; cost. RESULTS: (1) Mean FIM score at discharge for the group overall (n = 328) was 53 (median = 42 with interquartile range of 18 to 87); (2) 7.6% had functional scores consistent with independence in motor areas measured by FIM; (3) 2.7% had functional scores consistent with independence in cognitive areas measured by FIM; (4) 26.1% showed no change in FIM score between admission and discharge; (5) 53% were discharged to community settings, 25% to long-term care, 11% to acute facilities, and 11% to other rehab facilities; (6) average length of stay in acute rehab was 110 days (SD = 70.9, median = 99 days, interquartile range = 57 to 153 days); (7) average rehabilitation charges (n = 322) were $110,891; (8) for those with follow-up data (n = 59), average FIM score was 79 (median, 90); 24% were in school and 5% worked in sheltered workshops. CONCLUSIONS: (1) Even the most severely disabled persons admitted to acute rehabilitation after traumatic brain injury can show a large degree of measurable functional improvement; (2) while about 25% of patients showed no measured FIM change, some showed dramatic degrees of functional recovery; (3) most common discharge setting was home (and community).

Adolescent↗
PubMed1998

Patient satisfaction and rehabilitation services.

OBJECTIVE: Despite the widespread use of patient satisfaction measures, there has been only a small amount of research and writing on the topic in rehabilitation. This article reviews selectively the large amount of literature on satisfaction in health care, examines work in rehabilitation settings, and highlights issues in patient satisfaction, given the unique circumstances of rehabilitation services. DATA SOURCES: A Medline search was made of the past 10 years using descriptors related to patient satisfaction, rehabilitation, and selected diagnostic categories. Additional sources came from references on satisfaction accumulated by the author over the past 20 years. STUDY SELECTION: Because of the voluminous literature, findings from existing reviews were emphasized, particularly those using meta-analytic methods. All articles that involved satisfaction in rehabilitation settings were included. DATA SYNTHESIS: Research in health care generally shows high levels of satisfaction. Personal aspects of care, including full communication, are the most important predictors, whereas age, education, and social status show weak relationships with rating levels. Dissatisfied patients tend to seek other providers. Higher satisfaction is associated with patient compliance and better outcomes. Levels of satisfaction are especially high in rehabilitation. CONCLUSIONS: Measures of patient satisfaction with rehabilitation should include items regarding progress and degree of return to independent living. Responses of proxies answering in place of patients should not be regarded as equivalent to patients' opinions. The field is in need of standard, validated measures appropriate for various settings.

Health Services Research↗
PubMed1998

Stroke rehabilitation: clinical predictors of resource utilization.

OBJECTIVE: To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission. DESIGN: Statistical analysis of data prospectively collected from stroke rehabilitation patients. SETTING: Large, urban, academic freestanding rehabilitation facility. PARTICIPANTS: A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation. MAIN OUTCOME MEASURES: Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD). METHODS: Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis. RESULTS: Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001). CONCLUSION: Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.

Aged↗
PubMed1999

Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions.

A comprehensive review of the medical literature from 1950 to 1998 revealed 79 articles examining associations between rehabilitation interventions and functional outcome after stroke. This body of literature was critically analyzed, using established techniques, to reveal factors that were consistently associated with functional outcome after stroke. The following rehabilitation interventions after stroke appear to have a strong relationship with improved functional outcome at hospital discharge and follow-up: increased functional skills on admission to rehabilitation, early initiation of rehabilitation services, and rehabilitation in an interdisciplinary versus multidisciplinary setting. The following rehabilitation interventions after stroke appear to have a weak relationship with improved functional outcome at hospital discharge and follow-up: use of specialized types of therapy services and greater intensity of therapy services. The current literature is too limited to allow an assessment of the relationship of the following factors after stroke and functional outcome: specific types of non-inpatient rehabilitation services.

Ambulatory Care↗
PubMed2005

Seeking evidence of rehabilitation in nephrology nursing.

Individuals with renal failure experience many varied and complex alterations in their health status. As a consequence, rehabilitation is an important aspect of their care. However, until recently, rehabilitation has not been explicit in the published nephrology nursing literature. This paper addresses that deficit through an examination of Australian nephrology nursing competency standards for evidence of rehabilitation. Recent Australian research about rehabilitation nursing practice was used as a guiding definition of rehabilitation. A systematic examination of these documents revealed evidence of rehabilitative practices embedded in the nephrology nursing competency standards' domains of empowerment and clinical problem solving. These findings add support for the belief that rehabilitation is a philosophy that all nurses can apply in their practice.

Australia↗
PubMed2002

The role of the nurse in cardiac rehabilitation programmes.

Cardiac rehabilitation programmes are intended to enhance the effect of acute treatment actions and to prevent risk factors, thus leading to an improvement in the patient's well being and recovery. Accordingly, all cardiac rehabilitation activities do not take place at the same time, which is the reason why the nurse's role changes in character over time. The aim of this paper is, therefore, to highlight the role of the nurse in cardiac rehabilitation programmes. The nurse's multiple roles in cardiac rehabilitation have a 'spider in the web-like' character and, depending on the phase of the patient's recovery, he/she acts as a container, a counsellor, a coach and an educator. To implement a successful cardiac rehabilitation, the nurse needs to have improved evaluation tools in clinical practice as well as to be self-critical and serve as a good role model. Finally, the cardiac rehabilitation nurse has to have a four-fold comprehensive perspective of the cardiac rehabilitation concept; an impact perspective, a timing perspective, a lifespan perspective, and a personal perspective.

Attitude of Health Personnel↗
PubMed2000

Prediction of functional outcome after spinal cord injury: a task for the rehabilitation team and the patient.

STUDY DESIGN: Descriptive analysis of data gathered in an information system. OBJECTIVES: To explore the predictions of professionals and patients regarding functional outcome after spinal cord injury related to the final results after inpatient rehabilitation, in order to make prognostics of rehabilitation outcome more successful and enlarge the role of the patient in selecting realistic rehabilitation goals. METHODS: Data from 55 patients with spinal cord injury admitted to the rehabilitation centre. Expectations of the rehabilitation team and the patients regarding future independence in performing six daily activities were compared to the functional results at discharge. The results of patients with different level and extent of lesion were analyzed. RESULTS: In 52% of all performed skills, independence was achieved at discharge. Professionals and patients made similar predictions. If they both expected independence after rehabilitation. 90% of the skills were performed independently at discharge. If they both did not expect independence only 3% of the functional results were positive. Of all combined predictions 64% was correct. Correct predictions were most often found regarding self-care skills of patients with paraplegia and regarding mobility of patients with complete lesions. Prediction of self-care outcome of patients with tetraplegia is far more complicated. There was a considerable variation in predictions of mobility potential, especially regarding patients with incomplete lesions. If the team and patients agreed upon expected independence in mobility skills of these patients, the final results were mostly positive. CONCLUSIONS: Prediction of functional outcome after spinal cord injury was most successful if the expectations of the team and patients were combined. Prognosis of self-care outcome of patients with paraplegia and mobility potential of patients with complete spinal cord lesions was usually clear at admission. However, selection of realistic goals concerning self-care skills of patients with tetraplegia and mobility skills of patients with incomplete lesions is far more complicated. Gradual adjustment of objectives is needed during the rehabilitation process in close collaboration between the professionals and the patients.

Activities of Daily Living↗
PubMed2005

Rehabilitation of spinal cord injury in France: a nationwide multicentre study of incidence and regional disparities.

STUDY DESIGN: Multicentre retrospective 1-year survey during 2000. OBJECTIVES: To describe the network of physical medicine and rehabilitation units in France that care for people with traumatic spinal cord injuries (SCI), and secondly, to evaluate the incidence of SCI persons who have postinjury rehabilitation care. SETTING: Every rehabilitation unit involved in rehabilitation of SCI patients in metropolitan France. METHODS: During the first phase of the survey, a questionnaire was used to list the rehabilitation units that treat SCI people among a total of 380 centres. An additional survey was then carried out on a sample of 30 units that did not answer this questionnaire. In the second phase, the units involved were asked about the number of SCI patients received for a first rehabilitation stay during the year 2000 and their demographic and clinical characteristics. The incidence was calculated on the basis of the population census in metropolitan France aged 15 years, above. RESULTS: Of the 275 respondent units, 148 declared that they treat SCI people on a regular or occasional basis. The survey on the sample of 30 randomly selected nonrespondents enabled us to estimate that 10% of the 105 nonrespondent units were concerned. Among the 148 units contributing to the study, 131 identified all the SCI patients received during the year 2000. After a series of adjustments, an extrapolation for all of metropolitan France leads to an annual incidence of 19.4 SCI persons per million inhabitants, or 934 new cases per year. CONCLUSION: This is the first nationwide survey aiming to estimate the incidence of SCI patients in France. The finding is based on the incidence of SCI persons treated in rehabilitation units. It therefore concerns the incidence of patients who will remain severely disabled.

Female↗
PubMedDate not supplied

Home rehabilitation for older adults with fractured hips: how many will take part?

Rehabilitation at home is a new 'technology' which has been promoted as an efficient alternative to hospital rehabilitation for older patients with conditions such as fractured hip. In Australia, no formal description of elderly patients with fractured hips likely to be eligible for home rehabilitation has been made and the acceptability of such services is unclear. Using information obtained prospectively from a consecutive sample of 188 patients with a fractured hip we describe the characteristics of older adults who were eligible for a trial examining home versus hospital rehabilitation. While staff assessed 36% of patients as eligible, only 20% were both eligible and agreeable. Reasons for refusal to participate included a preference for inpatient rehabilitation (26%), family reluctance (26%) and anxiety regarding the ability to manage at home (16%). Our results suggest that home rehabilitation is suitable for the least disabled group but is still unacceptable to many elderly patients and their families. As the population ages and hip fractures increase, home rehabilitation in its current form will have little impact on future bed needs.

Aged↗
PubMed2002

Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital.

OBJECTIVES: To evaluate the effect of medical indicators of health status on functional gain during rehabilitation of frail older patients. DESIGN: Observational study. SETTING: A hospital geriatric rehabilitation department (Catholic University of Rome). PARTICIPANTS: Two hundred forty-four older patients admitted consecutively for rehabilitation after acute illnesses between March 1999 and June 2000. MEASUREMENTS: Patients were evaluated with the Minimum Data Set for Post-Acute Care (MDS-PAC) assessment form soon after the admission and every 2 weeks thereafter. Two summary scales based on MDS-PAC items are designed to describe the performance in personal activities of daily living (ADLs) and the level of cognitive function (Cognitive Performance Scale). To identify predictors of functional recovery, we constructed a multiple logistic regression model having as a dependent variable the improvement of one or more points in the ADL scale. RESULTS: Patients aged 85 and older with cognitive or sensory impairment were less likely to significantly improve physical functioning after an intensive rehabilitation program. However, the cognitive impairment was the only "negative" factor that remained significant in a multivariable model (odds ratio = 0.36, 95% confidence interval = 0.14-0.92) after adjusting for several potential negative predictors. CONCLUSIONS: The results of the present study document that severe cognitive impairment may be considered a negative predictor of functional recovery after a period of intensive rehabilitation. However, the effectiveness of such a rehabilitation program in patients with dementia is controversial. Additional studies are necessary to better clarify the effect of cognitive impairment on the potential recovery of the older subjects after a period of rehabilitation and whether this is influenced by different pathologies.

Activities of Daily Living↗
PubMed2002

Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome.

OBJECTIVE: To assess whether, and to what extent, cognitive outcome relates to overall functional outcome among elderly stroke patients. DESIGN: Nonconcurrent prospective study. SETTING: Geriatric rehabilitation division at a large, urban, academic, freestanding hospital in Israel. PARTICIPANTS: Three hundred thirty-six patients aged 60 years and older admitted consecutively for rehabilitation after first acute stroke. Inclusion criteria were met by 315 patients, who were included in the final analysis. Average age was 75.3 years. The stroke was right sided in 44.1%. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The motor subscale of the FIM instrument assessed functional status. Absolute functional gain was determined by the FIM motor gain. Relative functional gain was calculated according to the Montebello Rehabilitation Factor Score. Cognitive status was assessed with the Mini-Mental State Examination (MMSE) and the FIM cognitive subscale. RESULTS: FIM scores increased significantly during rehabilitation, mainly due to improvement in motor functioning. A strong association was found between the cognitive scales (r=.853, P<.001). Better rehabilitation outcomes were observed in patients with higher admission cognitive status, adjusting for the effect of age, sex, onset to admission interval, length of stay, and severity of stroke (odds ratio = 2.0; 95% confidence interval, 1.5-2.5). CONCLUSIONS: Impaired cognitive status at admission negatively affects the rehabilitation outcome of elderly stroke patients. The utility of routinely using a cognitive test for all patients before admission to rehabilitation, preferably the MMSE, is emphasized. The time, cost, and effort involved in performing such a test are negligible, and the potential benefits are considerable.

Activities of Daily Living↗
PubMed2002

Exploring qualified nurses' perceptions of the relevance of education in preparation for their role in rehabilitation.

The increasing importance of rehabilitation in the health sector and the nurses' critical role therein make it essential that nurses have the right skills and knowledge to work effectively in rehabilitation settings. Drawing from a wider qualitative investigation of the role of the nurse within the multi-professional rehabilitation team, gaps in the skills and knowledge of qualified nurses working in rehabilitation settings are presented and ways to address them are proposed. Both pre- and post-registration education were found wanting. Only one third of nurses thought, in retrospect, that their pre-registration education had provided them with adequate skills and knowledge for their role in rehabilitation. A need for greater focus on rehabilitation per se and associated clinical skills was identified. Whilst post-registration education was highly valued, substantial difficulties accessing relevant courses were noted. In-service training and ad hoc learning 'from experience' and colleagues formed additional ways to develop hands-on skills. Benefits of better education included enhancing confidence, promoting inter-professional equality and improving client care. Potential ways to address some of these concerns included: adoption of a 'thread and module' approach and dedicated rehabilitation student placements, a nationally recognized multi-professional post-registration course, and an integration of work based learning with formal educational provision.

Attitude of Health Personnel↗
PubMed2000

[Orthopedic traumatologic rehabilitation--a superfluous anachronism?].

In orthopaedic-traumatologic rehabilitation, muscular atrophies, joint contractures, bone loss and other restrictions of the locomotor system can be prevented or at least diminished. After an operation in particular, decreases in physical capacity of the locomotor and cardiopulmonary systems are common, which can be countered by special training therapies. Therefore, an effective rehabilitation programme is necessary including specific therapy forms and training concepts based on scientific findings in sports medicine, performance physiology and training sciences, in orthopaedics and traumatology as well as further medical disciplines. Determination of the load on the locomotor system and examination of cardiopulmonary capacity are important basic elements of rehabilitation training. Rehabilitation should include intense muscular and regular endurance training where loads must be tuned to the patient's individual capacity. Overuse syndromes can be avoided by planning regeneration breaks between training units and by continuously controlling the individual parameters of the patient. The costs of intense rehabilitation may at first seem high; however, one year after an operation the financial expenditures in those patients who did not receive intense rehabilitation exceeded all costs incurred for an operation and additional rehabilitation.

Cost-Benefit Analysis↗
PubMed2002

[Can the classification of patients for phase B, C and D of neurological rehabilitation be done by FIM(tm) scores?].

The classification of patients for phase B, C and D of neurological rehabilitation follows the suggestions of the Bundesarbeitsgemeinschaft für Rehabilitation (BAR) based on defined clinical criteria and on neurological rehabilitation assessment. The focus of this study is to define the intervals of the complete FIM(tm)-index, intervals covered empirically as well as by evaluations of physicians, that permit utmost accuracy in assigning patients to phase B, C and D of neurological rehabilitation. Therefore, data records of 3686 patients from 4 neurological rehabilitation centres were evaluated. The patients' functional autonomy was classified by FIM(tm) on admission, in intervals of 14 days and at discharge, at the same time all patients in addition were assigned to phases B, C or D by the rehabilitation centre physicians. Statistical analysis of a total of 11,247 links of the phase classifications and FIM-indexes at 6 measurement points showed that correct correlation to phase B, C and D could be obtained on average in 79 to 89 % of the cases, based on the assumption that 18 - 36 points of the FIM-index assign to phase B, 37 - 90 points to phase C and 91 - 126 points to phase D. Discrimination between phases B and C could be obtained accurately in an average of 84 %, discrimination between phases C and D in an average of 89 %. Conformance of the FIM-intervals with TAR-based groups of care efforts compared to the evaluation by physicians indicate that the FIM(tm) represents the need for care with greater validity. If assignment to phases B, C and D would have been done on the basis of the FIM-index instead of evaluation by a physician, 8,9 % fewer patients would on admission have been classified for phase C but, instead, 4,5 % more patients for phase B and 4,4 % for phase D. In case of using the FIM-intervals for classification, 12,1 % more phase B patients could have changed to phases C or D. Of the phase C cases, 17,7 % could have been transferred to phase D before discharge. The number of phase D patients would have remained unchanged comparing admission and discharge. FIM-orientated classification for the phases of neurological rehabilitation offers considerable advantages: operationalized criteria, possibility of statistical evaluation, objectiveness, reliability, validity, reproducibility of the decisions, sensitivity to change, prognostic sensitivity, and suitability as an instrument for internal and external quality assurance.

Activities of Daily Living↗
PubMedDate not supplied

[Outpatient and inpatient orthopaedic rehabilitation--results of a study comparing outcome and costs].

This article presents main results of a study comparing outcome and costs of various all-day outpatient and inpatient orthopaedic rehabilitation forms. The results were obtained within the scope of a comprehensive evaluation programme commissioned by the federation of health (VdAK) and pension insurance institutes (VDR). The purpose of this evaluation was to examine the quality of different types of various rehabilitation care. The outcome comparison comprises a longitudinal follow-up of various somatic, psychosocial und occupational reintegration parameters up to one year after rehabilitation as well as outcome assessments from the perspective of patients and physicians in rehabilitation centres and general practice. The costs are estimated on the basis of data from health and pension insurance funds. The results show extensive corresponding of results und assessments in the different forms of rehabilitation care for comparable patient groups. There are no indications of poorer care quality in outpatient rehabilitation, while economic analyses show better cost effectiveness in outpatient treatment by comparability of treatment, patients, and results. Results suggest that outpatient care, offered in the same quality as in the examined rehabilitation centres, is an alternative or complement to inpatient care at least for those patients, who can be treated in both the outpatient and inpatient setting.

Ambulatory Care↗
PubMedDate not supplied

[Structural and procedural quality of different orthopaedic rehabilitation settings: A comparison].

In addition to outcome quality, the quality of structure and process is an essential parameter for health care. In the context of a study comparing the outcome and costs of inpatient and different outpatient rehabilitation settings, the structural and procedural quality of the participating rehabilitation facilities were examined as well. Data were collected using questionnaires, interviews, treatment plans and visitations of the rehabilitation facilities. The analyses show a great correspondence of structural and procedural quality between the different rehabilitation settings. Particularly the data gathered by questionnaires show few differences. Points of significant difference include the more extensive equipment and the more favorable personnel key with regard to physicians in the inpatient clinics and the outpatient settings within these clinics. The outpatient rehabilitation facilities outside of rehabilitation clinics are characterized by a stronger accentuation of functional therapy, in particular physiotherapy and sports therapy. Functional therapy is of greater importance in the self-concept of the outpatient rehabilitation facilities and is also applied there more often.

Ambulatory Care↗
PubMed2003

[Efficacy of inpatient rehabilitation for chronic back pain in Germany: a systematic review 1980-2001].

BACKGROUND: Chronic back pain has a high personal impact, is frequent and of outstanding economical relevance. Analysis of the international literature indicates strong or moderate evidence for the effectiveness of multimodal multidisciplinary team care of chronic back pain. Our review aims at a complete review and critical appraisal of German studies of inpatient medical rehabilitation. METHODS: We conducted a systematic search for relevant German studies (1/1980 - 6/2001) using electronic data bases, manual search of congress abstracts and postal questionnaires of 712 German rehabilitation clinics. Relevant studies were categorized according to the recommendation of the Cochrane Back Review Group. For all studies, aims, participants, type of intervention, evaluation time, main outcomes and results were extracted and tabulated. The effect size for 6 central outcome parameters (pain intensity, functional status, catastrophizing, depression, vitality, days on sickness leave) were calculated using pre-post comparisons and were integrated into short and long term weighted means of intra-group effect sizes. RESULTS: 30 studies, both controlled and uncontrolled, report a multitude of positive changes with inpatient rehabilitation treatment. Improvements included both somatic and psychological parameters. However, methodological quality was often poor; only three studies fulfilled the criteria for high quality. Comparison of meta analyses of German and international studies indicates partly good agreement (e. g. changes in pain intensity), partly discrepancies (e. g. functional ability in daily activities). Taken together, inpatient rehabilitation treatment for chronic low back pain in Germany appears to be of low to moderate efficacy. DISCUSSION AND CONCLUSIONS: In the era of evidence based medicine, inpatient rehabilitation has to show its usefulness, necessity and efficiency as any other type of health care. For the German system of inpatient rehabilitation of chronic back pain available evidence is not conclusive, due to a lack of randomised controlled studies. The prevailing design of observational cohort studies has severe limitations in proving a causal relationship between outcomes and intervention. The international literature however provides more valid evidence in favour of the multimodal multidisciplinary intervention in chronic back pain. Under the assumption of a "class effect" of medical rehabilitation the German data seem to corroborate the conclusions drawn from international studies.

Germany↗
PubMed2003

[Findings on gender differences in the quality of care in cardiac rehabilitation: are women discriminated against?].

Questions and results concerning the quality of cardiac rehabilitation are discussed, and the outcomes of a study on 104 female and 206 male patients suffering from first coronary events are reported. No gender differences were found as far as rehabilitation utilization or rehabilitation programs are concerned. Rehabilitation programs and medicinal therapy were the same in women and men. Satisfaction with the in-hospital rehabilitation was slightly higher in women, but there were no gender differences in the preferences for cardiac rehabilitation features. Gender in Germany seems not a relevant variable in cardiac rehabilitation. Further questions for research on gender differences are discussed.

Adult↗