Comparison of Rehabilitation Outcomes for Long Term Neurological Conditions: A Cohort Analysis of the Australian Rehabilitation Outcomes Centre Dataset for Adults of Working Age

Predictive Validity of Motor Assessment Scale on Poststroke Discharge Destination

Background: Stroke frequently leads to hospital admission and subsequent rehabilitation in order to overcome poststroke sequelae, such as motor impairments. Efficient planning of the steps following hospital admission includes early prediction of whether the patient can be discharged home or not. Early assessment of motor performance in patients with stroke-induced motor deficits may be able to function as a predictor of discharge destination but is less explored. Objective: The primary objective was to assess the predictive validity of the Motor Assessment Scale (MAS) on discharge destination both regarding total score and regarding subscores (transfer-mobility items and upper extremity items). Design: The study was designed as a prospective cohort study. Subjects: Thirty-seven consecutively recruited patients with stroke are the subjects of the study. Methods: Logistic regression model was used to calculate the odds of being discharged to own home upon hospital admittance. The predictive ability was examined with a receiving operator characteristic (ROC) curve, and cut-points from the curve were employed in Cox regression. Results: A one-unit higher score on the total MAS significantly increased the odds of being discharged home upon hospital admittance (odds ratio (OR) 1.14, 95% CI 1.04-1.25). The same pattern was observed with the summed items of 1-5 and 6-8. The total MAS showed sensitivity of 91.7% and specificity of 68.0%. Patients having a total MAS score ≥ 24 were 17 times more likely to be discharged home (HR 17.64, 95% CI 2.23-139.57) compared to patients with a lower score. Conclusion: Motor function measured by the MAS can be applied as a predictor of discharge destination upon hospital admission after stroke in Danish setting.

Responsiveness of the International Classification of Functioning, Disability And Health (ICF) Clinical Functioning Information Tool (ClinFIT) in Routine Clinical Practice in an Australian Inpatient Rehabilitation Setting

OBJECTIVE

To examine the responsiveness of the International Classification of Functioning, Disability and Health (ICF) Clinical Functioning Information Tool (ClinFIT) in routine clinical practice in an Australian context.

METHODS

A prospective observational study with consecutive recruitment of inpatients at a tertiary rehabilitation facility. The assessments were at admission (T0), discharge (T1) and 3-month postdischarge (T2), using the following questionnaires: ClinFIT, Functional Independence Measure (FIM) and European Quality of Life (EQ-5D-5L). Extension Indices (EI) were calculated for the ClinFIT set, and responsiveness measured as a change in scores over time. The association between FIM and ClinFIT scores was explored.

RESULTS

Participants (n = 91, mean age 66.8±13.0 years, 52% male, 48% following stroke) reported ≥ 1 issue related to ClinFIT categories. ClinFIT total raw scores improved significantly across all health conditions compared with T0 (median (interquartile range): 196 (110, 228)) at both T1: 69 (37, 110); p < 0.001 and T2: 46.5 (20.8, 77); p < 0.001, with a medium effect size (r = 0.61 for both). There were significant changes in EI in the entire ClinFIT set from T0 to T1, and from T0 to T2 (p < 0.001 for both), with small to medium effect sizes. Analyses confirmed significant correlation in improvements between ClinFIT and FIM scores.

CONCLUSION

ClinFIT is useful in evaluating patient functioning and can detect changes in functioning over time and across different health conditions.

Rehabilitation interventions after traumatic brain injury: a scoping review

PURPOSE

To (1) identify interventional research topics in traumatic brain injury (TBI) rehabilitation, (2) describe potential knowledge gaps, and (3) uncover further needs for interventional TBI rehabilitation research for patients and families.

METHOD

We searched three databases (2006-2019) and screened 1552 non-duplicate articles. Titles and abstracts were screened for relevance, yielding 754 articles for full-text review. Of these, 425 were included, as relevant to the purpose of the scoping review.

FINDINGS

Among articles on TBI rehabilitation, the majority (71.8%) applied quantitative methodology; of these only 19.7% were randomized controlled trials. Severe TBI was described more often than mild/moderate TBI populations. Hospital vs community/home rehabilitation was 55.1% vs 37.2%; rehabilitation at workplace/school was described in only 4.5% articles, while in 7.2% the setting was undisclosed. Of 83 articles describing work/education, only 14 were in a work/school context. An additional focus in the work/education articles was activities of daily living (n = 28), cognition (n = 33) and emotions (n = 23), few targeted family or network.

CONCLUSION

The main attention of interventional TBI rehabilitation studies has been on severe TBI and long-term rehabilitation. Gaps identified were rehabilitation of mild/moderate TBI populations, older populations, acute/sub-phase rehabilitation, return to work issues and studies including the family.Implications for rehabilitationA substantial number of interventional studies exist to guide long-term rehabilitation after traumatic brain injury with focus on daily life, physical, emotional and cognitive functioning.We recommend a stronger focus in the clinic on the following groups; people with mild/moderate traumatic brain injury, people in the acute and sub-acute phase, and older people with traumatic brain injury.Issues that target challenges returning to work should be addressed, while they are of importance to patients and families.Emphasis should be put on continuity of care and peer-support.

Many inpatients may not be physically prepared for community ambulation on discharge from a publicly funded rehabilitation centre: a cross-sectional cohort study

PURPOSE

We assessed the ability of patients discharging home from inpatient rehabilitation to meet criteria for community ambulation.

METHODS

Cross-sectional observational study design. Participants were assessed, within 48-hours of discharge on their ability to: ascend/descend three steps, walk at a speed of 0.44 m/s, ascend/descend a slope, ascend/descend a kerb, and walk 315 m continuously. Demographic data were collected from medical records. Multiple logistic regression determined factors predictive of meeting criteria.

RESULTS

Of 200 participants (mean 73 years, 66% women, mixed diagnosis), 64 (32%) met all criteria. The least commonly met criteria were walking 315 m continuously (37%) and ascending/descending steps (70%). Participants who were female (OR: 0.27, 95%CI: 0.12-0.61), with a high comorbidity index (OR: 0.71, 95%CI: 0.56-0.91) or a traumatic orthopaedic diagnosis (OR: 0.22, 95%CI: 0.05-0.96) were less likely to meet all criteria. Participants with a higher admission functional independence walk item score (OR: 1.37, 95%CI: 1.05-1.78) or higher ambulatory self-confidence (OR: 1.02, 95%CI: 1.01-1.04) were more likely to meet all criteria.

CONCLUSIONS

Approximately, one-third of inpatients discharged home from a publicly funded rehabilitation centre met the community ambulation criteria, suggesting many may not be physically prepared to participate in their community.Implications for RehabilitationOnly about one in three inpatients discharging home from a publicly funded rehabilitation centre met physical criteria for community ambulation.Patients discharging home from inpatient rehabilitation have most difficulty walking long distances (≥315 m) compared to other criteria required for community ambulation (i.e., walking at a speed of 0.44 m/s, stepping up/down a kerb, ascending/descending a slope and ascending/descending three steps) and rehabilitation during this phase may require an increased focus on improving walking endurance/physical activity.Women with a high co-morbidity index, traumatic orthopaedic diagnosis, low self-confidence with ambulation on discharge and who require more assistance with walking on admission are least likely to meet the physical criteria for community ambulation at discharge, and therefore may require additional rehabilitation or supports.

Preliminary steps of the development of a Minimum Uniform Dataset applicable to the international wheelchair sector

Assistive products outcomes are needed globally to inform policy, practice, and drive investment. The International Society of Wheelchair Professionals developed a Minimum Uniform Dataset (MUD) for wheelchair services worldwide with the intent to gather data that is comparable globally. The MUD was developed with the participation of members from around the globe and its feasibility piloted at 3 sites. Three versions of the MUD are now available—a short form with 29 data points (available in English, Spanish, and French) and a standard version with 38 data points in English. Future work is to validate and complete the translation cycles followed by promoting the use of the MUD globally so that the data can be leveraged to inform policy, practice and direct investments.

Effects of a rehabilitation program for individuals with chronic spinal cord injury in Shanghai, China

Background

Specialized Institution-Based Rehabilitation (SIBR) is the cornerstone of care and treatment for individuals with spinal cord injury, but most people with chronic spinal cord injury (CSCI) living in China have no SIBR experience after acute care hospital discharge. In 2009, an SIBR facility was set up in Shanghai (China) to fill this important gap in care. The purpose of the study was to evaluate the effectiveness of an integrated rehabilitation training program among individuals with CSCI living in Shanghai.

Methods

A within-subject pre-posttest design was used to evaluate the SIBR. The sample included 455 individuals ≥1 year post-SCI, who were older than 18 years of age and were enrolled in a rehabilitation center in Shanghai, China, between 2013 and 2019. The data included individuals’ sociodemographic and injury characteristics, and twenty-three indicators were used as outcome measurements to evaluate basic life skills and their applications in family and social life. Multivariate linear regression was conducted to determine which factors might have influenced the effectiveness of the SIBR.

Results

All basic life skills and their applications in family and social life were improved, but with variations across socio-demographics. Female individuals with CSCI had better outcomes in basic life skills than did males. In terms of basic life skills and their applications in family and social life, individuals with a low level (thoracic or lumbosacral) of injury achieved more significant functional gains than those with a higher level (cervical). The baseline score was also a relevant factor in functional outcome.

Conclusions

Even for individuals with a long SCI history, SIBR training can improve basic life skills and the applications of those skills in family and social life settings.

The effects of two periods of rehabilitation for people with spinal cord injury from Shanghai, China

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate the effects of two periods of rehabilitation among people with spinal cord injury (SCI).

SETTING

Shanghai Sunshine Rehabilitation Center (SSRC), China.

METHODS

A total of 130 people with SCI who received two periods of rehabilitation participated in the study. Outcome measures included basic life skills (15 items) and their applications in family and social life (8 items). Six factors were identified from the 23 items by factor analysis: self-care and transfer skills; basic life skills application in social life; cognition and emotion; basic life skills application in family life; walking and climbing stairs; and wheelchair skills. Standardized scores ranging from 0 to 100 were used to show the rehabilitation outcome in a histogram.

RESULTS

Median scores for self-care and transfer skills, wheelchair skills, cognition and emotion, and their applications in family and social life improved significantly (7-80%, p < 0.01) over the first rehabilitation period, while no improvement was observed in walking and climbing stairs. Five factors showed a significant sustained effect (p < 0.01) upon admission to the second rehabilitation period, except walking and climbing stairs. By enrolling in the second period of rehabilitation, participants acquired significant additional improvement (5-43%, p < 0.01) in rehabilitation outcomes, except in cognition and emotion, walking and climbing stairs.

CONCLUSIONS

Two periods of rehabilitation were efficacious at increasing the abilities of basic life skills and their applications in family and social life. The potential benefits of continuous rehabilitation merit further research.

The Process of Patient Engagement in Outpatient Cardiac Rehabilitation Programs

The primary aim of this study was to test the causal structure of the model of therapeutic engagement (MTE) for the first time, to examine whether the model assists in understanding the process of patient engagement in cardiac rehabilitation (CR) programs. This study used a prospective design, following up patients from the Gold Coast University Hospital Cardiology ward who attended Robina Cardiac Rehabilitation Clinic. A structural equation model of the interactions among the proposed variables within the three stages of the MTE (intention to engage in CR programs, CR initiation, and sustained engagement) revealed significant relationships among these variables in a dataset of 101 patients who attended a CR program. However, no relationship was discerned between outcome expectancies and patient intention to engage in CR. Patients’ willingness to consider the treatment also mediated the relationship between perceived self-efficacy and patient intention to engage in CR. These findings help clarify the process proposed by Lequerica and Kortte (2010) in the context of patient engagement in CR programs. The findings also reveal information on how patients engage in CR programs. Importantly, this provides new information for healthcare providers, enabling them to more effectively engage patients according to their stage of engagement.

The association of patient-reported improvement and rehabilitation characteristics with mortality

This study aims to investigate the association of patient-reported improvement and rehabilitation characteristics with mortality among older adults who received rehabilitation. To do so, a national sample of Medicare beneficiaries from the National Health and Aging Trends Study was examined. Among those who reported receiving rehabilitation services in the 2015 interview (N = 1,188), 4.2% were deceased at the 2016 follow-up interview. Mortality was more common among those who had received rehabilitation in nursing home or inpatient and in-home settings compared to outpatient rehabilitation settings. In multivariable analyses accounting for demographics and health status, patient-reported worsening of functioning during rehabilitation (OR=15.69; 95% CI: 1.84-133.45) and cardiovascular disease (OR=4.15; 95% CI: 1.41-12.17) were associated with mortality. Among older adults who received rehabilitation, 1 in 25 were deceased at follow-up. That patient-reported functioning is associated with mortality suggests that more systematically including patient-reported outcomes in rehabilitation care may be clinically pertinent.

Applying bifactor modelling to improve the clinical interpretive values of Functional Independence Measure in adults with acquired brain injury

Purpose: To apply a modern robust approach, bifactor modeling, to critically examine psychometric properties of Functional Independence Measure (FIM) in adults with acquired brain injury and to propose a solution to improve the clinical interpretive values of the FIM to inform policy and clinical practice.Methods: The data came from a state-wide specialist in-patient brain injury rehabilitation service in Queensland, Australia for adults with acquired brain injury and discharged between 2012 and 2017. The sample included 457 people. Three measurement models (unidimensional, correlated first-order and bifactor) for FIM were tested using confirmatory factor analysis with structural equation modeling. Then, model-based reliability and incremental validity were assessed.Results: The bifactor model best fit the data. When operationalized as latent factors under structural equation modeling framework, general care burden had a large predictive effect, while Motor and Cognitive showed medium and small predictive effects respectively on rehabilitation length of stay.Conclusions: The total score of FIM was a reliable measure of general care burden, while the subscale scores were not. A solution is to apply a bifactor modeling approach based on structural equation modeling to disentangle the unique variance attributable to Motor and Cognitive factors. In the structural equation modeling framework, the FIM demonstrated good incremental validity to inform policy and clinical practice.Implications for rehabilitationClinicians and researchers can confidently use FIM total score in adults with acquired brain injury.The current study proposed an alternative solution to the poor reliability of Motor and Cognitive scores, that is, by applying a bifactor modeling approach, the unique contributions of the Motor and Cognitive factors can be examined.The current study has demonstrated the strengths of bifactor modeling in the robust validation and interpretation of FIM to better inform clinical practice and policy decision-making.The current study has the potential to make an important contribution to enhance more equitable decision-making in the areas of national benchmarking of rehabilitation outcomes and other program eligibility criteria and funding allocation.

The Influence of Speech-Language-Hearing Therapy Duration on the Degree of Improvement in Poststroke Language Impairment

Background. The relevance of speech-language-hearing therapy (ST) duration to language impairment remains unclear. Objective. To determine the effect of ST duration on improvement in language impairment as a stroke sequela and to compare the findings with those for occupational therapy (OT) and physical therapy (PT). Methods. Data regarding patients with stroke sequelae who were registered in the Japanese Association of Rehabilitation Medicine database were analyzed. Propensity scores for ST, OT, and PT duration were calculated using logistic regression, followed by inverse probability weighting in generalized estimating equations to examine the odds ratio for improvement in the Functional Independence Measures scores for comprehension, expression, and memory. Analyses stratified by age and dementia severity were also conducted. Results. Compared with short-duration ST, long-duration ST was significantly associated with improved scores for comprehension and expression in the overall study population and in some groups, with higher benefit especially for younger participants (<64 years) and those with more severe dementia. A significant but less pronounced effect was also observed for OT and PT. Conclusion. Long-duration ST is more effective than long-duration OT or PT for improving language impairment occurring as stroke sequela. However, these effects are limited by age and severity of dementia.

A Comprehensive Rehabilitation Program and Follow-up Assessment for Acute Intermittent Porphyria

Acute intermittent porphyria (AIP) is an infrequent metabolic disease that can cause severe disability or death without timely treatment. A porphyric attack occurs when genetic factors combine with trigger factors, and diagnosis may be delayed owing to nonspecific symptoms. Recovery from AIP can be nearly or fully complete with proper treatment, which includes intravenous hematin administration, the control of trigger factors, and a comprehensive rehabilitation program. The aim of this case report was to describe the clinical evolution of a 43-year-old woman with AIP and a polyneuropathy. The patient was treated through a comprehensive rehabilitation program, with outcomes evaluated by the Functional Independence Measure and the Berg scales during rehabilitation and postdischarge follow-up. After completing the comprehensive rehabilitation program, the patient achieved a satisfactory level of functional independence, allowing for social and work reintegration. We conclude that an early and multidisciplinary approach is essential for regaining optimal functionality after AIP.

Cost-efficiency of specialist inpatient rehabilitation for working-aged adults with complex neurological disabilities: a multicentre cohort analysis of a national clinical data set

OBJECTIVES

To evaluate functional outcomes, care needs and cost-efficiency of specialist rehabilitation for a multicentre cohort of inpatients with complex neurological disability, comparing different diagnostic groups across 3 levels of dependency.

DESIGN

A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2010-2015.

SETTING

All 62 specialist (levels 1 and 2) rehabilitation services in England.

PARTICIPANTS

Working-aged adults (16-65 years) with complex neurological disability.

INCLUSION CRITERIA

all episodes with length of stay (LOS) 8-400 days and complete outcome measures recorded on admission and discharge. Total N=5739: acquired brain injury n=4182 (73%); spinal cord injury n=506 (9%); peripheral neurological conditions n=282 (5%); progressive conditions n=769 (13%).

INTERVENTION

Specialist inpatient multidisciplinary rehabilitation.

OUTCOME MEASURES

Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK Functional Independence Measure (FIM)+FAM). Cost-efficiency: (1) time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of ongoing care, (2) FIM efficiency (FIM gain/LOS days), (3) FIM+FAM efficiency (FIM+FAM gain/LOS days). Patients were analysed in 3 groups of dependency.

RESULTS

Mean LOS 90.1 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in 'weekly care costs' was greatest in the high-dependency group at £760/week (95% CI 726 to 794)), compared with the medium-dependency (£408/week (95% CI 370 to 445)), and low-dependency (£130/week (95% CI 82 to 178)), groups. Despite longer LOS, time taken to offset the cost of rehabilitation was 14.2 (95% CI 9.9 to 18.8) months in the high-dependency group, compared with 22.3 (95% CI 16.9 to 29.2) months (medium dependency), and 27.7 (95% CI 15.9 to 39.7) months (low dependency). FIM efficiency appeared greatest in medium-dependency patients (0.54), compared with the low-dependency (0.37) and high-dependency (0.38) groups. Broadly similar patterns were seen across all 4 diagnostic groups.

CONCLUSIONS

Specialist rehabilitation can be highly cost-efficient for all neurological conditions, producing substantial savings in ongoing care costs, especially in high-dependency patients.