The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories

Stigma following acquired brain injury and spinal cord injury: relationship to psychological distress and community integration in the first-year post-discharge

PURPOSE

This study aimed to compare stigma levels after acquired brain injury (ABI) and spinal cord injury (SCI) during the first 12-months post-discharge and investigate relationships between stigma, psychological distress and community integration.

METHODS

110 adults with ABI (55%) or SCI (45%) were recruited from brain and spinal cord injury inpatient rehabilitation units of a tertiary healthcare facility. They were administered Neuro-QOL Stigma subscale and Depression Anxiety and Stress Scales (DASS-21) at discharge, 3-months and 12-months post-discharge, and Community Integration Measure at 12-months post-discharge.

RESULTS

Stigma levels did not significantly differ between individuals with ABI and SCI. However, stigma significantly decreased between discharge and 12-months post-discharge for the total sample. Stigma was positively associated with psychological distress at discharge and 3-months post-discharge, but not at 12-months post-discharge. Lower functional status and power wheelchair use were associated with higher stigma at 12-months post-discharge. Stigma at 3-months post-discharge predicted community integration at 12-months post-discharge, controlling for psychological distress and functional status.

CONCLUSION

Experience of stigma in the first few months post-discharge may negatively impact individuals' community reintegration. The early post-discharge period may be a pivotal time for supporting individuals to explore disability and injury-related appraisals and enhance connection to their community.

The Brazilian version of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) is reliable and valid for chronic stroke survivors

BACKGROUND

Stroke is the leading cause of disability worldwide. Assessing stroke's impact on patients' daily activities and social participation can provide important complementary information to their rehabilitation process. However, no previous study had been conducted on the psychometric properties of the Brazilian version of the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) in the stroke population.

OBJECTIVES

This study aimed to examine the internal consistency, test-retest and inter-rater reliability, convergent validity and floor/ceiling effect of the Brazilian version of the WHODAS 2.0 in individuals after chronic stroke.

METHODS

Two examiners interviewed 53 chronic stroke individuals who responded to the Brazilian 36-item version of the WHODAS 2.0 three times to analyze test-retest and inter-rater reliabilities. Floor/ceiling effects were calculated as relative frequencies of the lowest or the highest possible WHODAS 2.0 scores. Participants also responded to the Stroke Impact Scale 3.0 (SIS 3.0) and the Functional Independence Measure (FIM) to analyze convergent validity.

RESULTS

The internal consistency analyses for domains of WHODAS showed a strong correlation among the items of each domain (0.76-0.91) except for the "getting along" domain, which presented a moderate correlation (ρ = 0,62). Total scores of WHODAS 2.0 showed satisfactory internal consistency (α = 0.93), good inter-rater reliability (ICC = 0.85), excellent test-retest reliability (ICC = 0.92) and no significant floor/ceiling effect. Convergent validity indicated moderate to strong correlations (ρ=-0.51 to ρ=-0.88; p < 0.001), with the highest values associated with the correlation with the SIS scale.

CONCLUSIONS

The Brazilian version of the WHODAS 2.0 instrument presented evidence of reliability and validity for chronic post-stroke individuals.

Presence and Characteristics of Behavioral and Psychological Symptoms in Subacute Stroke Patients with Cognitive Impairment

This retrospective cross-sectional study is aimed at investigating the prevalence and characteristics of behavioral and psychological symptoms (BPS) in subacute stroke patients with cognitive impairment. The Neuropsychiatric Inventory-Questionnaire (NPI-Q) was used to assess BPS. A total of 358 consecutive patients with first-ever stroke admitted to rehabilitation wards and with Mini-Mental State Examination (MMSE) scores < 24 on admission were included. BPS was defined as a total NPI-Q Severity or Distress score ≥ 1. Differences between the severity and presence of BPS among patients with severe cognitive impairment (MMSE scores 0-17) and those with mild cognitive impairment (MMSE scores 18-23) were analyzed using the Mann-Whitney U test and chi-squared test, respectively. Eighty-one patients (mean (standard deviation) age, 73.5 (13.1) years) were enrolled for analysis. BPS were observed in 69.1% and 74.1% of patients when assessed with NPI-Q Severity and NPI-Q Distress, respectively. The most frequently observed BPS was apathy, followed by depression (approximately 44% and 40%, respectively). The severity and frequency of delusions, euphoria, apathy, and disinhibition were significantly higher in the severe cognitive impairment group than in the mild cognitive impairment group. However, the severity, distress, and frequency of depression were not dependent on the severity of cognitive impairment. The presence of BPS, especially apathy and depression, in subacute stroke patients with cognitive impairment is high. The severity and frequency of some BPS are higher in patients with severe cognitive impairment than in those with mild cognitive impairment. However, depression is highly prevalent among the patients regardless of the severity of cognitive impairment.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Changes in Functional Outcomes After an Inpatient Rehabilitation Program for Solid-Organ Transplant Recipients

Introduction: Outpatient exercise training has been shown to be beneficial for solid organ transplant recipients. Little is known about the effects of inpatient rehabilitation programs for recipients with a more complicated postoperative course. Research Question: This study was designed to (1) describe the changes in functional outcomes after an inpatient rehabilitation program, and (2) determine whether the changes in lower body strength and quadriceps strength are associated with changes in functional exercise capacity. Design: This was a single-arm prospective longitudinal study. The recipients participated in an inpatient rehabilitation program twice a day, 7 days a week for 3 to 4 weeks. Outcome Measures Included: 2-Minute Walking Test, Timed Up and Go, Berg Balance Scale, 30-Second Sit to Stand, biceps and quadriceps strength, Functional Independence Measure, SF-36, and Canadian Occupational Performance Measure. Results: Twenty-eight patients (54% female, mean age = 55 [11]) completed the study. Participants were mostly liver (42%) and lung recipients (35%). There were statistically significant improvements in all outcomes after the intervention. There was no relationship between changes in functional exercise capacity and quadriceps strength or lower body strength. Conclusion: An inpatient rehabilitation program may improve several functional outcomes and health-related quality of life in transplant recipients with a complicated postoperative course.

Group-Based Patterns of Life Satisfaction and Functional Independence over the 10 Years after Traumatic Brain Injury in Older Adults: A Model Systems Study

BACKGROUND

Older adults who sustain a traumatic brain injury (TBI) have been shown to have reduced functional independence and life satisfaction relative to younger individuals with TBI. The purpose of this study was to examine the covarying patterns of functional independence and life satisfaction over the 10 years after TBI in adults who were 60 years of age or older upon injury.

METHOD

Participants were 1841 individuals aged 60 or older at the time of TBI, were enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure and Satisfaction with Life Scale scores during at least one time point at 1, 2, 5, and 10 years after TBI.

RESULTS

A k-means cluster analysis identified four distinct group-based longitudinal patterns of these two variables. Three cluster groups suggested that functional independence and life satisfaction generally traveled together over time, with one group showing relatively high functional independence and life satisfaction over time (Cluster 2), one group showing relatively moderate functional independence and life satisfaction (Cluster 4), and one group showing relatively low functional independence and life satisfaction (Cluster 1). Cluster 3 had relatively high functional independence over time but, nonetheless, relatively low life satisfaction; they were also the youngest group upon injury. Participants in Cluster 2 generally had the highest number of weeks of paid competitive employment but lower percentages of underrepresented racial/ethnic minority participants, particularly Black and Hispanic individuals. Women were more likely to be in the cluster with the lowest life satisfaction and functional independence (Cluster 1).

CONCLUSION

Functional independence and life satisfaction generally accompany one another over time in older adults, although this does not always occur, as life satisfaction can still be low in a subgroup of older individuals after TBI with higher functioning. These findings contribute to a better understanding of post-TBI recovery patterns in older adults over time that may inform treatment considerations to improve age-related discrepancies in rehabilitation outcomes.

Unmet Need for Sexual Rehabilitation after Acquired Brain Injury (ABI): A Cross-Sectional Study Concerning Sexual Activity, Sexual Relationships, and Sexual Rehabilitation after ABI

In relation to brain injury rehabilitation, research has stressed the importance of including sexuality issues due to increased risk for sexual dysfunctions after Acquired Brain Injury (ABI). This study aims to explore experiences after non-stroke ABI concerning individual and relational aspects of sexuality, received information about sexuality at rehabilitation, and gender differences. A postal nationwide survey was conducted in Sweden, 2018–2019. The sample included individuals who had participated in brain injury rehabilitation 2014–2016, response rate 40% (250/624). Among all participants 78% had resumed sexual activity, and there was a significant difference between males (84%, 118/140) and females (69%, 76/110, p = 0.004). Among all participants, 95% reported physical intimacy as important, 80% considered sex as important on an individual level, and 91% stated sexuality as important for the relationship (no gender differences). Significantly more females (52%) than males (22%) reported that they had tried sexual aids (p = 0.000), and more males (29%) than females (16%) reported that professionals addressed sexuality issues during brain injury rehabilitation (p = 0.024). However, only a few participants were offered specific sexual counseling during brain injury rehabilitation, such as individual counseling (3%), couples counseling (2%), and group counseling (3%). To conclude, the vast majority valued both individual and relational aspects of sex and sexuality highly, and more males than females had resumed sexual activity. Few had received information about sexuality after ABI, and even fewer females compared to males reported that the issue was raised during rehabilitation. Clinical implications are discussed in relation to sexual rehabilitation.

Trajectories of Cognitive and Motor Functional Independence in Hispanic Individuals During the 10 yrs After Traumatic Brain Injury

OBJECTIVE

This study examined demographic and injury-related predictors of cognitive and motor functional independence in Hispanics with traumatic brain injury at years 1, 2, 5, and 10 after hospital discharge.

DESIGN

Hispanic participants ( n = 1360) from the TBI Model Systems Study were included if they had at least one Functional Independence Measure (FIM) Cognitive and Motor score at any time point (years 1, 2, 5, or 10). Hierarchical linear modeling was used to examine baseline predictors of FIM Cognitive and Motor trajectories across this period.

RESULTS

FIM Cognitive trajectories showed a quadratic movement (initial increase followed by a plateau or slight decrease), whereas FIM Motor trajectories showed a cubic movement (initial increase, followed by a plateau, then another increase). Higher FIM Cognitive trajectories were predicted by younger age, shorter length of posttraumatic amnesia, higher education, and having experienced a nonviolent mechanism of injury. Higher FIM Motor trajectories were predicted by younger age, shorter posttraumatic amnesia, and a nonviolent mechanism of injury.

CONCLUSIONS

The baseline predictors of functional trajectories identified may help create tailored, evidence-based rehabilitation interventions along the continuum of recovery during the first 10 yrs for Hispanics with traumatic brain injury at risk for reduced functional outcomes.

Regression-based prognostic models for functional independence after postacute brain injury rehabilitation are not transportable: a systematic review

BACKGROUND AND OBJECTIVES

To identify and summarize validated multivariable prognostic models for the Functional Independence Measure® (FIM®) at discharge from post-acute inpatient rehabilitation in adults with acquired brain injury (ABI).

METHODS

This review was conducted based on the recommendations of the Cochrane Prognosis Methods Group and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases were systematically searched in May 2021 and updated in April 2022. Main inclusion criteria were: a) adult patients with ABI, b) validated multivariable prognostic model, c) time of prognostication within 1-week of admission to post-acute rehabilitation, and d) outcome was the FIM® at discharge from post-acute rehabilitation.

RESULTS

The search yielded 3,169 unique articles. Three articles fulfilled the inclusion criteria, accounting for n = 6 internally and n = 2 externally validated prognostic models. Discrimination was estimated as an area under the curve between 0.76 and 0.89. Calibration was deemed to be assessed insufficiently. The included models were judged to be of high risk of bias.

CONCLUSION

Current prognostic models for the FIM® in post-acute rehabilitation for patients with ABI lack the methodological rigor to support clinical use outside the development setting. Future studies addressing functional independence should ensure appropriate model validation and conform to uniform reporting standards for prognosis research.

Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS).

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up.

CONCLUSIONS

There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.

Recommendations from the ISPO lower-limb COMPASS: Patient-reported and performance-based outcome measures

BACKGROUND

Outcome measures (patient-reported and performance-based) are used widely but not uniformly within the clinical setting for individuals with lower-limb absence (LLA). The need for more detailed information by funding bodies, service planners and providers, and researchers requires the systematic and routine use of outcome measures. Currently, there is no consensus on which outcome measure(s) should be used for individuals with LLA. The aim of the International Society of Prosthetics and Orthotics (ISPO) lower-limb Consensus Outcome Measures for Prosthetic and Amputation Services (COMPASS) was to produce a recommended list of outcome measures to be actively promoted for routine use within clinical practice before and after an episode of care.

METHODS

Between May and June 2021, 46 users, clinicians, researchers, managers, and policymakers working in the field of LLA and prosthetic users met virtually. Consensus participants were first asked to complete an online survey with questions based on the results from a systematic review and the outcomes from an expert panel. A modified Delphi technique was used to determine outcome measures for use in routine clinical practice. This paper discusses the ISPO lower-limb COMPASS process from which recommendations were made.

RESULTS

The ISPO lower-limb COMPASS resulted in the following 6 recommendations: (1) Amputee Mobility Predictor, Timed Up and Go, Two-Minute Walk Test, Prosthetic Evaluation Questionnaire-Residual Limb Health, Prosthetic Evaluation Questionnaire-Utility, and Trinity Amputation and Prosthesis Experience Scales-Revised, which make up the ISPO lower-limb COMPASS ; (2) Comprehensive High-Level Activity Mobility Predictor and Six-Minute Walk Test are 2 additional outcome measures recommended for higher-activity-level individuals with LLA, which make up the COMPASS+ ; (3) Patient-Specific Function Scale makes up the COMPASS Adjunct ; (4) a generic health-related quality of life outcome measure such as the European Quality of Life-5D-5L or Patient-Reported Outcomes Measurement Information System-29 item can be used to supplement the COMPASS; (5) outcome measures suited to low- and middle-income countries need to be developed with a focus on activities such as sitting cross-legged, kneeling, squatting, and other culturally important mobility-related activities; and (6) translation, validation, and open sharing of translated outcome measures included in the COMPASS, COMPASS+, and COMPASS Adjunct occurs.

CONCLUSION

The above recommendations represent the current status of knowledge on outcome measures for LLA based on research and international consensus and hence, will change over time. This work has been developed for clinicians and researchers to improve knowledge on outcome measures to guide clinical decision-making and future research initiatives.

A multicenter prospective study validated a nomogram to predict individual risk of dependence in ambulation after rehabilitation

OBJECTIVES

To develop the Functional Risk Index for Dependence in Ambulation (FRIDA) score, a nomogram to predict individual risk of dependence in ambulation at discharge from postacute rehabilitation and validate its performance temporally and spatially.

STUDY DESIGN AND SETTING

We analyzed the database of a multicenter prospective observational quality cohort study conducted from January 2012 to March 2016, including data from 8,796 consecutive inpatients who underwent rehabilitation after stroke, hip fracture, lower limb joint replacement, debility, and other neurologic, orthopedic, or miscellaneous conditions.

RESULTS

A total of 3,026 patients (34.4%) were discharged dependent in ambulation. In the training set of 5,162 patients (58.7%), Lasso-regression selected advanced age, premorbid disability, and eight indicators of medical and functional adverse syndromes at baseline to establish the FRIDA score. At the temporal validation obtained on an external set of 3,234 patients (41.3%), meta-analyses showed that the FRIDA score had good and homogeneous discrimination (summary area under the curve 0.841, 95% confidence interval = 0.826-0.855, I² = 0.00%) combined with accurate calibration (summary Log O/E ratio 0.017, 95% confidence interval -0.155 to 0.190). These performances remained stable at spatial validation obtained on 3,626 patients, with substantial heterogeneity of estimates across nine facilities. Decision curve analyses showed that a FRIDA score-supported strategy far outperformed the usual "treat all" approach in each impairment categories.

CONCLUSION

The FRIDA score is a new clinically useful tool to predict an individual risk for dependence in ambulation at rehabilitation discharge in many different disabilities, and may also reflect well the case-mix composition of the rehabilitation facilities.

Prolonged disorders of consciousness: identification using the UK FIM + FAM and cohort analysis of outcomes from a UK national clinical database

PURPOSE

1: To determine whether Total UK FIM + FAM scores can identify patients in VS/MCS. 2: Using the identified cut-off points, to examine outcomes from specialist rehabilitation.

METHODS

Part 1: Retrospective analysis of a consecutive clinical cohort (n = 388) presenting to a single specialist PDOC evaluation programme 2007-2021. FIM + FAM scores were analysed by PDOC diagnosis to define cut-off points for vegetative (VS) and minimally conscious states (MCS). Part 2: Multicentre cohort analysis of prospectively-collected clinical outcomes data from the UK Rehabilitation Outcomes Collaborative database of adults in PDOC registered 2011-2020 (n = 2384 in 68 centres).

RESULTS

Cut-off points of ≤31 and 32-35 in FIM + FAM total scores respectively identified patients in VS/MCS-Minus and MCS-Plus. Approximately 365 PDOC patients are admitted to specialist rehabilitation units in England each year. By discharge, 43% have emerged into consciousness and demonstrate a wide range of disability. A few reached full independence, but the majority remained severely dependent. Nevertheless, those who emerged generated mean net life-time savings of over £436,000 (£400 million for this cohort).

CONCLUSION

In absence of a dedicated PDOC registry, FIM + FAM scores can identify patients in VS/MCS at population level. Identifying those who emerge and providing timely rehabilitation generates cost-savings well-exceeding the cost of the evaluation/rehabilitation programme.Implications for rehabilitationThe UK National Health Service currently collects no systematic data to identify patients in PDOC, so we have no accurate information on how many patients there are, where they are managed or what their outcomes are.In the absence of more direct data, total FIM + FAM scores of < =31 and 32-35 respectively can be used to identify patients in vegetative and minimally conscious states.Of the 365 or so patients admitted to specialist rehabilitation units per year, 43% emerge into consciousness leaving about 150 patients per year in PDOC states that are likely to be permanent.Identifying those who emerge and providing timely rehabilitation generates cost-savings that pay for the entire PDOC evaluation/rehabilitation programme many times over.

Sexuality >1 year after brain injury rehabilitation: A cross-sectional study in Sweden

PURPOSE

This study investigates whether Acquired Brain Injury (ABI) is associated with changes in sexual function and satisfaction and how such changes are experienced, focusing on invisible impairments after ABI.

MATERIALS AND METHODS

A study-specific questionnaire was distributed in 2018-2019. The sample included individuals aged 20-90 years diagnosed with ABI due to subarachnoid hemorrhage (SAH), trauma, infection, or anoxia (ischemic stroke and intracerebral hemorrhage excluded), who participated in brain injury rehabilitation in Sweden, 2014-2016. Chi-square and Logistic regression analyses were used.

RESULTS

The study consists of 250 participants (response rate was 40%). Among participants 78% (194/250) had resumed sexual life. Participants reporting sexual changes also experienced more consequences related to ABI. Those with decreased sexual desire (63%, 148/234) reported more ABI consequences, including decreased memory (86% vs 65%, p = 0.000), decreased concentration ability (82% vs 65%, p = 0.003), and increased tiredness (91% vs 70%, p = 0.000) compared to those with intact desire. Such consequences can be invisible to others.

CONCLUSION

Visible impairments are known to impact sexual functions and satisfaction after ABI. Our results show how invisible impairments also have a great impact. From a biopsychosocial perspective, these results imply that individuals should receive sexual rehabilitation, irrespective of ABI impairment.

Monitoring independence in daily life activities after trauma in humanitarian settings: Item reduction and assessment of content validity of the Activity Independence Measure-Trauma (AIM-T)

A standardized set of measures to assess functioning after trauma in humanitarian settings has been called for. The Activity Independence Measure for Trauma (AIM-T) is a clinician-rated measure of independence in 20 daily activities among patients after trauma. Designed in Afghanistan, it has since been used in other contexts. Before recommending the AIM-T for wider use, its measurement properties required confirmation. This study aims at item reduction followed by content validity assessment of the AIM-T. Using a two-step revision process, first, routinely collected data from 635 patients at five facilities managing patients after trauma in Haiti, Burundi, Yemen, and Iraq were used for item reduction. This was performed by analyzing inter-item redundancy and distribution of the first version of the AIM-T (AIM-T1) item scores, resulting in a shortened version (AIM-T2). Second, content validity of the AIM-T2 was assessed by item content validity indices (I-CVI, 0-1) based on structured interviews with 23 health care professionals and 60 patients in Haiti, Burundi, and Iraq. Through the analyses, nine pairs of redundant items (r≥0.90) were identified in the AIM-T1, leading to the removal of nine items, and resulting in AIM-T2. All remaining items were judged highly relevant, appropriate, clear, feasible and representative by most of participants (I-CVI>0.5). Ten items with I-CVI 0.5-0.85 were revised to improve their cultural relevance or appropriateness and one item was added, resulting in the AIM-T3. In conclusion, the proposed 12-item AIM-T3 is overall relevant, clear, and representative of independence in daily activity after trauma and it includes items appropriate and feasible to be observed by clinicians across different humanitarian settings. While some additional measurement properties remain to be evaluated, the present version already has the potential to serve as a routine measure to assess patients after trauma in humanitarian settings.

Association of Cognitive Impairment With Rate of Functional Gain Among Older Adults With Stroke

OBJECTIVES

This study explored the association between cognitive impairment at admission with self-care and mobility gain rate (amount of change per week) during a post-acute care stay (admission to discharge) for older adults with stroke.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Four inpatient rehabilitation and 6 skilled nursing facilities. A total of 100 adults with primary diagnosis of stroke; mean age 79 years (SD 7.7); 67% women.

METHODS

Retrospective cohort study. We evaluated the extent to which cognitive impairment at admission explained variation in weekly gain rate separately for self-care and mobility. Additional covariates were occupational and physical therapy minutes per day, self-care and mobility function at admission, age, and number of comorbidities.

RESULTS

Participants were classified as having severe (n = 16), moderate (n = 39), or mild (n = 45) cognitive impairment at admission. Occupational therapy minutes per day (β = 0.04; P < .01) and Functional Independence Measure (FIM) self-care function at admission (β = 0.48; P < .01) were both significantly associated with self-care gain rate (Adjusted R² = 0.18); cognitive impairment group, age, and number of comorbidities were not significant. Only FIM mobility function at admission (β = 0.29; P < .001) was significantly associated with mobility gain rate (Adjusted R² = 0.18); cognitive impairment group, physical therapy minutes, age, and number of comorbidities were not significant.

CONCLUSIONS AND IMPLICATIONS

These results provide preliminary evidence that patients with stroke who have severe cognitive impairment may benefit from intensive therapy services as well as less severely impaired patients, particularly occupational therapy for improvement in self-care function.

Development of a 30-Day Readmission Risk Calculator for the Inpatient Rehabilitation Setting

OBJECTIVES

Readmission to acute care from the inpatient rehabilitation facility (IRF) setting is potentially preventable and an important target of quality improvement and cost savings. The objective of this study was to develop a risk calculator to predict 30-day all-cause readmissions from the IRF setting.

DESIGN

Retrospective database analysis using the Uniform Data System for Medical Rehabilitation (UDSMR) from 2015 through 2019.

SETTING AND PARTICIPANTS

In total, 956 US inpatient rehabilitation facilities and 1,849,768 IRF discharges comprising patients from 14 impairment groups.

METHODS

Logistic regression models were developed to calculate risk-standardized 30-day all-cause hospital readmission rates for patients admitted to an IRF. Models for each impairment group were assessed using 12 common clinical and demographic variables and all but 4 models included various special variables. Models were assessed for discrimination (c-statistics), calibration (calibration plots), and internal validation (bootstrapping). A readmission risk scoring system was created for each impairment group population and was graphically validated.

RESULTS

The mean age of the cohort was 68.7 (15.2) years, 50.7% were women, and 78.3% were Caucasian. Medicare was the primary payer for 73.1% of the study population. The final models for each impairment group included between 4 and 13 total predictor variables. Model c-statistics ranged from 0.65 to 0.70. There was good calibration represented for most models up to a readmission risk of 30%. Internal validation of the models using bootstrap samples revealed little bias. Point systems for determining risk of 30-day readmission were developed for each impairment group.

CONCLUSIONS AND IMPLICATIONS

Multivariable risk factor algorithms based upon administrative data were developed to assess 30-day readmission risk for patients admitted from IRF. This report represents the development of a readmission risk calculator for the IRF setting, which could be instrumental in identifying high risk populations for readmission and targeting resources towards a diverse group of IRF impairment groups.

Predictors of 10-year functional independence trajectories in older adults with traumatic brain injury: A Model Systems study

BACKGROUND

Older adults have the highest traumatic brain injury (TBI)-related morbidity and mortality, and rates in older adults are increasing, chiefly due to falls.

OBJECTIVE

This study used hierarchical linear modeling (HLM) to examine baseline predictors of functional independence trajectories across 1, 2, 5, and 10 years after TBI in older adults.

METHODS

Participants comprised 2,459 individuals aged 60 or older at the time of TBI, enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure Motor and Cognitive subscale scores and Glasgow Outcome Scale-Extended scores during at least 1 time point.

RESULTS

Functional independence trajectories generally declined over the 10 years after TBI. Individuals who were older, male, underrepresented minorities, had lower education, were unemployed at time of injury, had no history of substance use disorder, or had difficulties with learning, dressing, and going out of the home prior to the TBI, or longer time in posttraumatic amnesia had lower functional independence trajectories across at least one of the functional independence outcomes.

CONCLUSION

These predictors of functional independence in older adults with TBI may heighten awareness of these factors in treatment planning and long-term health monitoring and ultimately as a way to decrease morbidity and mortality.

An Internet-Based Self-Management Intervention to Reduce Fatigue Among People With Traumatic Brain Injury: A Pilot Randomized Controlled Trial

IMPORTANCE

Fatigue is a chronic and distressing sequela of traumatic brain injury (TBI). Little evidence exists for the efficacy of interventions that address post-TBI fatigue.

OBJECTIVE

To evaluate the preliminary efficacy of a self-management intervention (Maximizing Energy; MAX) for reducing the impact (primary outcome) and severity of fatigue on daily life, improving fatigue experience, and increasing participation compared with a health education (HE) intervention.

DESIGN

Pilot randomized controlled trial (RCT).

SETTING

Community.

PARTICIPANTS

Forty-one participants randomly assigned to the MAX (n = 20) or HE (n = 21) intervention.

INTERVENTIONS

The MAX intervention included problem-solving therapy with energy conservation education to teach participants fatigue management. The HE intervention included diet, exercise, and energy conservation education. Both interventions (30 min/day, 2 days/wk for 8 wk) were delivered online by occupational therapists.

OUTCOME AND MEASURES

The primary outcome was the modified Fatigue Impact Scale (mFIS). Outcome measures were collected at baseline, postintervention, and 4- and 8-wk postintervention.

RESULTS

At 8 wk postintervention, participants in the MAX group reported significantly lower levels of fatigue impact (mFIS) than those in the HE group, F(1, 107) = 29.54, p = .01; Cohen's d = 0.87; 95% confidence interval [0.18, 1.55].

CONCLUSIONS AND RELEVANCE

These findings provide preliminary evidence that the MAX intervention may decrease the impact of fatigue on daily life among people with post-TBI fatigue. What This Article Adds: An internet-based, self-management intervention combining occupational therapy- delivered energy conservation education with cognitive-behavioral therapy seems to reduce fatigue impact and severity among people with post-TBI fatigue. Future appropriately powered RCTs could positively contribute to the evidence available to occupational therapy practitioners for this chronic, debilitating, and often overlooked symptom.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation After Stroke

OBJECTIVE

The aim of the study was to identify causes for readmission to acute care of patients admitted to inpatient rehabilitation facility after stroke.

DESIGN

The institutional Uniform Data System for Medical Rehabilitation database was used to identify stroke patients who experienced readmission to acute care and an equal number of age-/sex-matched group of patients who successfully completed their inpatient rehabilitation facility stay during 2005-2018. Retrospective chart review was used to extract clinical data. The two study groups were compared using univariate and multivariate analyses.

RESULTS

The rate of readmission to acute care was 4.7% (n = 89; age = 65 ± 14 yrs; 37% female; 65% White; 73% ischemic stroke). The most common indications for transfer were neurological (31%) and cardiovascular (28%). Compared with control group, the readmission to acute care group had statistically higher rates of comorbid conditions, lower median (interquartile range) Functional Independence Measure score on inpatient rehabilitation facility admission (55 [37-65] vs. 64 [51-78], P < 0.001), and a higher rate of sedative/hypnotic prescription (82% vs. 23%, P < 0.001).

CONCLUSIONS

Readmission to acute care is not common in our cohort. Patients who experienced readmission to acute care had higher medical complexity and were prescribed more sedative/hypnotic medications than the control group. Practitioners should be vigilant in patients who meet these criteria.

The influence of personal factors, unmet need and service obstacles on the relationship between health service use and outcome after brain injury

Background

This exploratory study aimed to: (i) examine the relationship between health service use and quality of life, psychological wellbeing, global function and participation after discharge from brain injury inpatient rehabilitation, and (ii) determine the influence of personal factors, unmet need for services and service obstacles on the relationship between service use and these outcomes.

Methods

Using a prospective cohort design, 41 adults with acquired brain injury (median age = 46 years; 71% male; 61% severe traumatic injury) were followed for 6-months after discharge from specialist brain injury inpatient rehabilitation. Service use was continuously recorded and obtained through data linkage methods, focusing on the use of: outpatient medical services, outpatient nursing, outpatient allied health; medical acute services; incidents of re-hospitalization; and transitional rehabilitation service use. Outcome questionnaire measures were completed via telephone, at 6-months after discharge, and included: the EuroQol-5D; Depression Anxiety and Stress Scale, Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale. Data were analyzed in a heterogeneous treatment effects framework, using Bayesian Additive Regression Trees.

Results

There was weak evidence that transitional rehabilitation service use was associated with better psychological wellbeing scores. The posterior probability of lower depression, anxiety and stress scores was .87, .81 and .86, respectively (average treatment effect). There was also weak evidence that re-hospitalization was associated with worse independent living skills scores. The posterior probability of worse scores was .87. However, most re-hospitalizations were due to unavoidable medical complications. We did not find that place of residence at discharge, marital status, unmet need, or service obstacles affected the relationship between service use and the studied outcomes.

Conclusions

This study may highlight the importance of participation in transitional rehabilitation, in the 6-months after discharge from brain injury rehabilitation. Replication in a larger sample size is required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07811-y.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Lesion location may attenuate response to strategy training in acute stroke

BACKGROUND

Strategy training, a rehabilitation intervention, reduces disability and improves functional skills associated with goal-directed behavior. Stroke lesions impacting selected ventromedial regions of interest associated with initiation of goal-directed behavior may attenuate intervention response. If so, strategy training may not be optimal for people with stroke lesions in these regions.

OBJECTIVE

To examine whether ventromedial regions of interest attenuate changes in disability status attributed to strategy training.

DESIGN

Secondary analysis of data from two randomized controlled clinical trials.

SETTING

Inpatient stroke rehabilitation.

PARTICIPANTS

People with acute stroke diagnosis and available diagnostic studies enrolled in inpatient rehabilitation randomized controlled studies between 2009 and 2017.

INTERVENTION

Participants were randomized to strategy training or a control condition in addition to the usual care during inpatient rehabilitation.

MAIN OUTCOME MEASURES

Diagnostic magnetic resonance imaging studies were retrieved from electronic medical records, and stroke lesion location was characterized by a neuroradiologist. Intervention response was defined by Functional Independence Measure change scores of 22 points or greater.

RESULTS

Only 186 of 275 participants had diagnostic studies available; 13 patients showed no apparent lesion on their diagnostic study. Among 173 cases, 156 had complete data at discharge (strategy training n = 71, control n = 85). Twenty-five cases had a lesion within a region of interest (strategy training n = 14, control n = 11). Intervention response was attenuated in the strategy training group for those with lesions in regions of interest [χ² (1, n = 71) = 4.60, P = .03], but not for those in the control group [Fisher exact test, n = 85, P = .19).

CONCLUSIONS

Lesions in the ventromedial regions of interest may attenuate response to strategy training.

Functional status of community-dwelling older adults after inpatient rehabilitation

Background/aims:

Factors that influence functional ability in older adults after rehabilitation are not well understood. The aim of this study was to investigate how older people function in their community after being discharged from inpatient rehabilitation.

Methods

A cross-sectional study was undertaken of community-dwelling older adults (n=86, 75 ± 6 years) discharged from rehabilitation in the previous 12 months. Basic functional independence was assessed using the Functional Independence Measure and complex functional independence was assessed using the Frenchay Activities Index. Multiple regression analyses were conducted to assess any association between predetermined factors and function.

Results

Functional Independence Measure scores and physical activity levels after being discharged accounted for 50% of the variance in basic function (R2=0.50, F=40.75, P<0.001). Frenchay Activities Index scores, physical activity, age, sex and migrant status accounted for 68% of variance in complex function (R2=0.68, F=29.75, P<0.001).

Conclusions

Clinicians are encouraged to implement strategies to improve function at discharge from rehabilitation and to promote physical activity among older people at risk of poor function following rehabilitation.

Effectiveness of Rehabilitation for Cancer Patients with Bone Metastasis

Objectives:

Advances in cancer treatment have led to extended survival, and, as a result, the number of patients with bone metastases is increasing. Activities of daily living (ADL) decrease with bone metastasis and the need for rehabilitation is increasing. This study examined the effects of rehabilitation in patients with bone metastases.

Methods:

We retrospectively reviewed data of cancer patients with bone metastasis who received rehabilitation between 2016 and 2018. Efficacy of rehabilitation was evaluated in 92 patients as the change in the Functional Independence Measure (FIM) score divided by rehabilitation days (FIM change/day) and assessed by different metastatic sites.

Results:

Overall FIM scores significantly improved after rehabilitation. Moreover, FIM change/day improved in patients with pelvic metastases (n=44) more than in patients with other metastatic sites (n=48) (P=0.015). In FIM motor components, improvements in toilet, tub/shower, walk/wheelchair, and stairs were significantly greater in patients with pelvic metastasis than in those with other metastasis sites.

Conclusions:

Rehabilitation improved ADL status to a greater extent in patients with pelvic metastases than in those with other metastasis sites. Patients with pelvic metastases may fear fractures, limiting their ADL, but rehabilitation could eliminate this fear and improve FIM.

Trauma Indicators in Spinal Cord Injury Rehabilitation Outcomes: A Retrospective Cohort Analysis of the National Trauma Data Bank and National Spinal Cord Injury Database

OBJECTIVE

To investigate whether initial emergency room physiologic measures and metrics of trauma severity predict functional outcomes and neurologic recovery in traumatic spinal cord injury.

DESIGN

Retrospective analysis of a clinical database.

SETTING

Merged multi-center data from the Spinal Cord Injury Model Systems (SCIMS) database and National Trauma Data Bank (NTDB) from six academic medical centers across the United States.

PARTICIPANTS

319 patients admitted to SCIMS rehabilitation centers within one-year of injury. The majority of patients were male (76.2%), with a mean age of 44 (SD 19). At rehabilitation admission, the most common neurologic level of injury was low cervical (C5-C8, 39.5%) and ASIA impairment scale (AIS) was A (34.4%).

MAIN OUTCOME MEASURES(S)

Primary outcomes were (1) Functional Independence Measure (FIM) motor score at discharge from inpatient rehabilitation and (2) change in FIM motor score between inpatient rehabilitation admission and discharge. We hypothesized that derangements in emergency room physiologic measures, such as decreased blood pressure and oxygen saturation, as well as increased severity of trauma burden, would predict poorer functional outcomes.

RESULTS

Linear regression analysis showed that neurologic level of injury and AIS predicted discharge FIM motor score. Systolic blood pressure, heart rate, oxygen saturation, need for assisted respiration, and presence of penetrating injury did not predict discharge motor FIM or FIM motor score improvement.

CONCLUSIONS

Initial emergency room physiologic parameters did not prognosticate functional outcomes in this cohort.

Comparison of content and psychometric properties for assessment tools used for brain tumor patients: a scoping review

AIMS

To determine the most frequently utilized functional status assessment instruments for patients with brain tumors, compare their contents, using the International Classification of Functioning, Disability and Health (ICF), and their psychometric properties.

METHODS

A scoping review was conducted to explore possible assessment instruments and summarize the evidence. A systematic literature search was performed for identification of the frequently used functional assessment tool in clinical trials in PubMed, ScienceDirect, and ProQuest databases. The content of most used instruments was linked to the ICF categories. The psychometric qualities of these assessment tools were systematically searched and analyzed.

RESULTS

Nine most used assessment tools in clinical trials were identified. The most frequently used assessment instrument is the Karnofsky Performance Scale, which is developed for a general assessment of oncological patients. Out of four self-assessment tools, two were disease-specific (EORTC QLQ-BN20 and FACT-Br), EORTC QLQ-C30 has been shown good psychometric properties in patients with brain tumors as well as in patients with various oncological diseases, similar to the SF-36, it is used in patients with brain tumors as well as in patients with various diseases. The Functional Independence Measure and the Barthel Index were two objective assessment tools that described functioning, but two were neuropsychological tests (MMSE and Trial Making Test). Two hundred eighty-three meaningful concepts were identified and linked to 102 most relevant second-level categories covering all components of the ICF. Forty-nine studies reporting psychometric properties of those nine assessment tools were identified, indicating good reliability and validity for all the instruments.

CONCLUSION

Nine most frequently utilized functional status assessment instruments for patients with brain tumors represent all components of the ICF and have good psychometric properties. However, the choice of the tool depends on the clinical question posed and the aim of its use.

Development and Validation of Crosswalks Between FIM® and SCIM III for Voluntary Musculoskeletal Movement Functions

Background. In spinal cord injury, there are multiple databases containing information on functional recovery, but data cannot be pooled or compared due to differences in how function is measured. A crosswalk is needed to link or convert scores between instruments. Objectives. To create a crosswalk between the voluntary musculoskeletal movement items in the Functional Independence Measure (FIM®) and the Spinal Cord Independence Measure III (SCIM III) for spinal cord injury. Methods. Retrospective datasets with FIM® and SCIM III on the same people were used to develop (Swiss dataset, n = 662) and validate (US, n = 119, and Canadian datasets, n = 133) the crosswalks. Three different crosswalk methods (expert panel, equipercentile, and Rasch analysis) were employed. We used the correlation between observed scores on FIM® and SCIM III to crosswalked scores as the primary criterion to assess the strength of the crosswalk. Secondary criteria such as score distributions, Cohen's effect size, point differences, and subgroup invariance were also evaluated. Results. All three methods resulted in strong correlation coefficients, exceeding the primary criterion value of r = .866 (.897-.972). Assessment of secondary criteria suggests the equipercentile and Rasch methods produced the strongest crosswalks. Conclusions. The Rasch FIM®/SCIM III crosswalk is recommended because it is based on co-calibration of linearized measures, allowing for more sophisticated parametric analyses. The crosswalk will allow comparisons of voluntary musculoskeletal functional recovery across international databases using different functional measures, as well as different systems of care and rehabilitation approaches.

A Tribute to Margaret Grace Stineman, MD

ABSTRACT

The field of physical medicine and rehabilitation mourns the death of Margaret Grace Stineman, MD. She was an incredibly productive researcher who helped to shape the delivery of rehabilitation care. She was a trusted colleague, mentor, and friend to many. Her outstanding accomplishments were acknowledged by her numerous awards and her election into honorary societies. Dr Stineman spent her career at the University of Pennsylvania and retired as Professor Emeritus in 2014. She is survived by her mother and innumerable colleagues and friends who were touched by her passion, intelligence, and dedication.

Thirty-day hospital readmission rate, reasons, and risk factors after acute inpatient cancer rehabilitation

Objectives

To evaluate the 30‐day hospital readmission rate, reasons, and risk factors for patients with cancer who were discharged to home setting after acute inpatient rehabilitation.

Design, Setting, and Participants

This was a secondary retrospective analysis of participants in a completed prospective survey study that assessed the continuity of care and functional safety concerns upon discharge and 30 days after discharge in adults. Patients were enrolled from September 5, 2018, to February 7, 2020, at a large academic quaternary cancer center with National Cancer Institute Comprehensive Cancer Center designation.

Main Outcomes and Measures

Thirty‐day hospital readmission rate, descriptive summary of reasons for readmissions, and statistical analyses of risk factors related to readmission.

Results

Fifty‐five (21%) of the 257 patients were readmitted to hospital within 30 days of discharge from acute inpatient rehabilitation. The reasons for readmissions were infection (20, 7.8%), neoplasm (9, 3.5%), neurological (7, 2.7%), gastrointestinal disorder (6, 2.3%), renal failure (3, 1.1%), acute coronary syndrome (3, 1.1%), heart failure (1, 0.4%), fracture (1, 0.4%), hematuria (1, 0.4%), wound (1, 0.4%), nephrolithiasis (1, 0.4%), hypervolemia (1, 0.4%), and pain (1, 0.4%). Multivariate logistic regression modeling indicated that having a lower locomotion score (OR = 1.29; 95% CI, 1.07–1.56; p = 0.007) at discharge, having an increased number of medications (OR = 1.12; 95% CI, 1.01–1.25; p = 0.028) at discharge, and having a lower hemoglobin at discharge (OR = 1.31; 95% CI, 1.03–1.66; p = 0.031) were independently associated with 30‐day readmission.

Conclusion and Relevance

Among adult patients with cancer discharged to home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation.

Research is needed to determine the rates of and risk factors for 30‐day hospital readmission after acute inpatient cancer rehabilitation to understand the nature of this problem and to decrease costs associated with readmissions. Among adult patients with cancer discharged to a home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation. Cancer rehabilitation patients may have unique risk factors for readmission.

Functional outcomes following inpatient rehabilitation of Guillain-Barré syndrome patients: Intravenous immunoglobulins versus plasma exchange

BACKGROUND

Treatment with either Intravenous immunoglobulin (IVIg) or plasma exchange (PE) in patients with Guillain-Barré Syndrome (GBS) showed equivalent efficacy as attested by a commonly used disability scale. However, it has been suggested that this scale may not be sensitive enough to detect subtle functional changes between the two treatments since it mainly focuses on walking capability and respiratory function.

OBJECTIVE

To evaluate functional outcomes following treatment with IVIg or PE using comprehensive scales that incorporate parameters of basic activities of daily living.

METHODS

A retrospective cohort study was conducted between 2007 and 2013 in an inpatient neurologic rehabilitation department. The study group included 70 individuals with GBS: 39 were treated with PE and 31 with IVIg. A comparison of functional outcomes was performed using Functional Independence Measure (FIM), rehabilitation efficiency (REy), rehabilitation effectiveness (REs), and the GBS disability scale (GDS).

RESULTS

Both treatments had a comparable effect on the various functional outcomes. Patients showed a significant increase in total FIM scores (30 points on average) during rehabilitation mainly as a result of an increase in motor sub-scores. A mean improvement of 1.23 (SD 0.9) in GDS was also observed. On average, individuals with GBS spent 20 days combined in the acute departments and 61 days in the rehabilitation department, with length of stay being similar for both treatments.

CONCLUSIONS

IVIg and PE treatments have similar basic activities of daily living (ADL) functional outcomes. Nevertheless, due to the different mechanism of actions of these treatments and the multitude of GBS variants, it is possible that further comprehensive assessment tools may demonstrate differences in activity and participation of individuals with GBS.

The Impact of Adherence to Disease-Modifying Therapies on Functional Outcomes in Veterans with Multiple Sclerosis

Background:

Patients who adhere to their DMTs have lower rate of MS-related relapses and disability.

Objective:

We sought to determine the adherence rate to disease-modifying therapies (DMTs) and its impact on functional outcome(s) in veterans with multiple sclerosis (MS).

Method:

We reviewed the electronic records of 279 veterans with MS who were periodically followed in our MS clinic. We compared 3 groups of patients, defined according to their adherence to DMTs (non-adherent; poorly adherent; adherent) on their effect on disability progression and time to sustained EDSS score of 6.

Results:

There were 148 (53%) veterans with MS who were non-adherent to any DMT medication(s) while of the 131 (47%) veterans who were taking medications, 118 (42%) had a good- and 13 (5%) had poor-adherence. The mean age at MS onset was 36.6 (± 11.2) and mean duration of MS for the sample was 24 ± 13.5 years. The mean initial EDSS and TFIM scores were 4.09 ± 2.9 SD and 104 ± 25.7 for the study sample. The change in MMSE, TFIM scores, and time to sustained EDSS score of 6 significantly favored the good- compared to the non-adherence group (P < .01).

Conclusion:

This study suggests that veterans with MS who adhered to their DMTs had less decline in their MS-related cognition, disease severity and disability compared to non- and poorly-adherent groups even after adjusting for age, gender, MS duration, and type. Time to EDSS score of 6 was significantly prolonged in the good-adherence group.

Differences in functional improvement based on history of substance abuse and pain severity following spinal cord injury

Background: This study explored the relationship between history of substance abuse and pain severity during inpatient rehabilitation following traumatic spinal cord injury (SCI). Methods: Secondary analysis of a prospective longitudinal study. An adjusted general linear model was used to examine differences in functional improvement based on history of substance abuse and pain severity. Results: Over 50% of the sample had a history of substance abuse, and 94% reported moderate or severe pain. There was a significant interaction between the history of substance abuse and pain severity (p = 0.01, partial η² = 0.012). A difference in functional improvement was found among individuals who reported low pain; those with a history of substance abuse achieved less functional improvement than those without a history of substance abuse, M = 5.32, SE = 1.95, 95% CI 0.64-10.01. Conclusions: A history of substance abuse and post-injury pain are prevalent among individuals with SCI in rehabilitation, and there may be a meaningful relationship between these two patient characteristics and functional improvement. The results provide potential new insights into the characteristics of vulnerable subpopulations during SCI rehabilitation. Furthering our understanding of these results warrants future investigation to prevent and minimize poor outcomes among vulnerable SCI patients.

Physical Therapy Interventions in a Patient with Nontraumatic Incomplete Spinal Cord Injury Secondary to Metastatic Lung Cancer: A Case Report

Background and Introduction: Individuals with dual cancer and spinal cord injury diagnoses present unique challenges to rehabilitation teams. This case report describes the modification of a physical therapy plan of care for an individual with incomplete spinal cord injury (iSCI) resulting from metastatic lung cancer who underwent adjunctive cancer treatment.Case Description: A 61-year-woman with small cell lung cancer and T5 iSCI presenting to inpatient rehabilitation (IPR) to address function limitations from iSCI following metastatic epidural tumor resection.Intervention: Interventions focused on task-specific training of mobility skills with modifications made to address cancer-related fatigue, promote energy conservation, and prioritize functional skills for home discharge given anticipated disease progression.Outcomes: IPR length of stay was 31 days. Functional Independence Measure (FIM) total score increased from 52/133 at admissions to 106/133 at discharge. Spinal Cord Independence Measure - III (SCIM-III) total score increased from 31/100 to 55/100. Functional Assessment of Chronic Illness Therapy-Fatigue Subscale score increased from 21/52 to 41/52 reflecting reduced fatigue level compared to admission. These gains facilitated discharge home with family support.Conclusion: Physical therapy plan of care required consideration of dual diagnosis, cancer-related fatigue, and patient-centered goals. Participation in IPR positively affected quality of life and ability to return home with family.

Variation in 30-Day Readmission Rates from Inpatient Rehabilitation Facilities to Acute Care Hospitals

OBJECTIVES

To quantify the rate of readmission from inpatient rehabilitation facilities (IRFs) to acute care hospitals (ACHs) during the first 30 days of rehabilitation stay. To measure variation in 30-day readmission rate across IRFs, and the extent that patient and facility characteristics contribute to this variation.

DESIGN

Retrospective analysis of an administrative database.

SETTING AND PARTICIPANTS

Adult IRF discharges from 944 US IRFs captured in the Uniform Data System for Medical Rehabilitation database between October 1, 2015 and December 31, 2017.

METHODS

Multilevel logistic regression was used to calculate adjusted rates of readmission within 30 days of IRF admission and examine variation in IRF readmission rates, using patient and facility-level variables as predictors.

RESULTS

There were a total of 104,303 ACH readmissions out of a total of 1,102,785 IRFs discharges. The range of 30-day readmission rates to ACHs was 0.0%‒28.9% (mean = 8.7%, standard deviation = 4.4%). The adjusted readmission rate variation narrowed to 2.8%‒17.5% (mean = 8.7%, standard deviation = 1.8%). Twelve patient-level and 3 facility-level factors were significantly associated with 30-day readmission from IRF to ACH. A total of 82.4% of the variance in 30-day readmission rate was attributable to the model predictors.

CONCLUSIONS AND IMPLICATIONS

Fifteen patient and facility factors were significantly associated with 30-day readmission from IRF to ACH and explained the majority of readmission variance. Most of these factors are nonmodifiable from the IRF perspective. These findings highlight that adjusting for these factors is important when comparing readmission rates between IRFs.

Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains

PURPOSE

The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF).

MATERIALS AND METHODS

The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data.

RESULTS

There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model.

CONCLUSIONS

The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.

Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma

BACKGROUND

Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma.

MATERIALS AND METHODS

We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models.

RESULTS

Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk.

CONCLUSIONS

Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.

Virtual reality stimulation to reduce the incidence of delirium in critically ill patients: study protocol for a randomized clinical trial

BACKGROUND

Delirium has been long considered as a major contributor to cognitive impairments and increased mortality following a critical illness. Pharmacologic and non-pharmacologic strategies are used against delirium in the intensive care unit (ICU), despite these strategies remaining controversial. Previous studies have shown the feasibility of using virtual reality within the ICU setting, and we propose to use this technology to investigate the effect of immersive virtual reality stimulation on the incidence of delirium in the ICU. Moreover, we propose to use motion sensors to determine if patient movement patterns can lead to early prediction of delirium onset.

METHODS

This study is conducted as a randomized clinical trial. A total of 920 critically ill patients in the ICU will participate. The control group will receive standard ICU care, whereas the intervention group will, in addition to the standard ICU care, receive relaxing 360-degree immersive virtual reality content played inside a head-mounted display with noise-cancelling headphones, three times a day. The first 100 patients, regardless of their group, will additionally have their movement patterns recorded using wearable and ambient sensors. Follow-up measurements will take place 6 months after discharge from the ICU.

DISCUSSION

Delirium is widely present within the ICU setting but lacks validated prevention and treatment strategies. By providing patients with virtual reality stimulation presented inside a head-mounted display and noise-cancelling headphones, participants may be isolated from disturbances on an ICU. It is believed that by doing so, the incidence of delirium will be decrease among these patients. Moreover, identifying movement patterns associated with delirium would allow for early detection and intervention, which may further improve long-term negative outcomes associated with delirium during critical care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04498585 . Registered on August 3, 2020.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

Introduction

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

Methods

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

Results

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

Conclusions

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

Systematic review registration

PROSPERO CRD42014013190.

Machine Learning Algorithms to Predict Mortality and Allocate Palliative Care for Older Patients With Hip Fracture

OBJECTIVES

To evaluate a machine learning model designed to predict mortality for Medicare beneficiaries aged >65 years treated for hip fracture in Inpatient Rehabilitation Facilities (IRFs).

DESIGN

Retrospective design/cohort analysis of Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility-Patient Assessment Instrument data.

SETTING AND PARTICIPANTS

A total of 17,140 persons admitted to Medicare-certified IRFs in 2015 following hospitalization for hip fracture.

MEASURES

Patient characteristics include sociodemographic (age, gender, race, and social support) and clinical factors (functional status at admission, chronic conditions) and IRF length of stay. Outcomes were 30-day and 1-year all-cause mortality. We trained and evaluated 2 classification models, logistic regression and a multilayer perceptron (MLP), to predict the probability of 30-day and 1-year mortality and evaluated the calibration, discrimination, and precision of the models.

RESULTS

For 30-day mortality, MLP performed well [acc = 0.74, area under the receiver operating characteristic curve (AUROC) = 0.76, avg prec = 0.10, slope = 1.14] as did logistic regression (acc = 0.78, AUROC = 0.76, avg prec = 0.09, slope = 1.20). For 1-year mortality, the performances were similar for both MLP (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.96) and logistic regression (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.95).

CONCLUSION AND IMPLICATIONS

A scoring system based on logistic regression may be more feasible to run in current electronic medical records. But MLP models may reduce cognitive burden and increase ability to calibrate to local data, yielding clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively.

Recovery process of respiratory muscle strength in patients following stroke: A Pilot Study

OBJECTIVE

To determine the recovery process of respiratory muscle strength during 3 months following stroke, and to investigate the association of change in respiratory muscle strength and physical functions. Additionally, we compared respiratory muscle strength with those of healthy subjects.

METHOD

In this prospective, observational study, 19 stroke patients and 19 healthy subjects were enrolled. Maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), motricity index, trunk control test, 6-minute walk test (6MWT) and functional independence measure were assessed at 1, 2, and 3 months from stroke onset in stroke patients. MIP and MEP were assessed at arbitrary times in healthy subjects. Repeated one-way analysis of variance with Bonferroni post-hoc test was used to compare the change in respiratory muscle strength in each period in stroke patients. Pearson's correlation coefficient was computed for changes in respiratory muscle strength and physical functions. Student's t-test was used to compare respiratory muscle strength between stroke patients at 3 months from onset and healthy subjects.

RESULTS

MIP was significantly increased at 3 months compared to 1 month. MEP was significantly increased in 2 months and 3 months, compared to 1 month. MIP changes associated with 6MWT changes. Compared to healthy subjects, MIP and MEP at 3 months were significantly lower in stroke patients.

CONCLUSION

Respiratory muscle strength significantly increased during 3 months following stroke. However, the trend of recovery may be different. MIP changes may associated with walking endurance changes. During 3 months following stroke, respiratory muscle strength did not recover to healthy subjects.

Validation of the Spinal Cord Injury Functional Index for Use in Community-Dwelling Individuals With SCI

OBJECTIVE

To evaluate the psychometric properties of the Spinal Cord Injury Functional Index (SCI-FI) instruments in a community-dwelling sample.

DESIGN

Cross-sectional study.

SETTING

Community setting.

PARTICIPANTS

Individuals (N=269) recruited from 6 SCI Model Systems sites.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed computer adaptive test and short form versions of 4 SCI-FI/Capacity (C) banks (ie, Ambulation, Basic Mobility, Fine Motor, Self-Care) and 1 SCI-FI/Assistive Technology (AT) bank (Wheelchair Mobility) at baseline and after 2 weeks. The Self-Report Functional Measure (SRFM) and the clinician-rated motor FIM were used to evaluate evidence of convergent validity.

RESULTS

Pearson correlations, intraclass correlation coefficients, minimal detectable change, and Bland-Altman plots supported the test-retest reliability of the SCI-FI instruments. Correlations were large with the SRFM (.69-.89) and moderate-to-large for the FIM instrument (.44-.64), supporting convergent validity. Known-groups validity was demonstrated by a significant main effect of injury level on all instruments and a main effect of injury completeness on the SCI-FI/C instruments. A ceiling effect was detected for individuals with incomplete paraplegia on the Fine Motor/C and Self-Care/C Short Forms.

CONCLUSION

Findings support the test-retest reliability, convergent validity, and known-groups validity of the SCI-FI/C instruments and the SCI-FI/AT Wheelchair Mobility instruments for use by community-dwelling individuals.

Development of Reaching, Grasping & Manipulation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

OBJECTIVE

To describe the development of structure, process, and outcome indicators aimed to advance the quality of Reaching, Grasping & Manipulation (RG&M) rehabilitation for Canadians living with spinal cord injury or disease (SCI/D).

METHOD

Upper extremity rehabilitation experts developed a framework of indicators for evaluation of RG&M rehabilitation quality. A systematic search of the literature identified potential upper extremity indicators that influence RG&M outcomes. A Driver diagram summarized factors influencing upper extremity outcomes to inform the selection of structure and process indicators. Psychometric properties, clinical utility, and feasibility of potential upper extremity measures were considered when selecting outcome indicators.

RESULTS

The selected structure indicator is the number of occupational and physical therapists with specialized certification, education, training and/or work experience in upper extremity therapy related to RG&M at a given SCI/D rehabilitation center. The process indicator is the total hours of upper extremity therapies related to RG&M and the proportion of this time allocated to neurorestorative therapy for each individual with tetraplegia receiving therapy. The outcome indicators are the Graded Redefined Assessment of Strength, Sensation and Prehension (GRASSP) strength and Spinal Cord Independence Measure III (SCIM III) Self-Care subscores implemented at rehabilitation admission and discharge, and SCIM III Self-Care subscore only at 18 months post-admission.

CONCLUSION

The selected indicators align with current practice, will direct the timing of routine assessments, and enhance the volume and quality of RG&M therapy delivered, with the aim to ultimately increase the proportion of individuals with tetraplegia achieving improved upper extremity function by 18 months post-rehabilitation.

Vitality index is a predictor of the improvement in the functional independence measure score in subacute stroke patients with cognitive impairment

OBJECTIVES

To investigate the effect of motivation on improvements in the Functional Independence Measure (FIM) scores in subacute stroke patients with cognitive impairment.

METHODS

This retrospective cohort study included 358 consecutive subacute stroke patients with first-ever stroke and Mini-Mental State Examination score ≤23 at admission. We determined motivation and rehabilitation outcome using the vitality index and FIM-motor gain, respectively. Stepwise multiple regression analysis was performed to identify the factors at admission related to FIM-motor gain.

RESULTS

Of 80 participants enrolled in this study (mean age: 74.2 ± 11.3 years). The median (interquartile range) vitality index at admission and FIM-motor gain were 7 (4) and 23 (22) points, respectively. Stepwise multiple regression analysis revealed that age (B, -0.43; 95% confidence interval [CI], -0.65-(-0.21); β, -0.31; P <.001), duration from stroke onset to admission (B, -0.18; 95% CI, -0.33-(-0.04); β, -0.20; P =.014) and Stroke Impairment Assessment Set-motor function (B, 1.27; 95% CI, 0.92-1.61; β, 0.78; P <.001), FIM-motor (B, -0.80; 95% CI, -1.01-(-0.60); β, -0.95; P <.001), and vitality index (B, 3.79; 95% CI, 2.37-5.21; β, 0.50; P <.001) scores at admission were significantly associated with the FIM-motor gain.

DISCUSSION

The vitality index was significantly associated with FIM improvement in subacute stroke patients with cognitive impairment.

Rapid nutritional assessment and intervention in orthopedic rehabilitation patients

OBJECTIVES

The aim of this study was to identify the effect of early nutritional assessment and nutritional intervention on outcomes of older adult patients after discharge from an acute care hospital following fall related fracture.

METHODS

This was a feasibility pilot study with post intervention data. One group pretest-posttest study design was implemented. All participants were admitted to a rehabilitation facility in the Southwestern US after a fall related fracture.

MEASURES

Discharge destination, Functional Independence Measure (FIM), and length of stay (LOS).

RESULTS

A total of 69% of the participants were discharged home. Total FIM scores improved (p<0.01). No significant association was identified between prealbumin change and total FIM change. Patients who had improved prealbumin experienced improved FIM and shorter LOS; however, no significant correlations were determined between LOS and prealbumin change.

CONCLUSION

Nutritional interventions are important for recovery during rehabilitation of a fall-related fracture.

SUMMARY

This project supports early nutritional evaluation and intervention for older adult patients after major orthopedic procedure. Participants who received early intervention had improved outcomes. (194 characters).

Combining Items From 3 Federally Mandated Assessments Using Rasch Measurement to Reliably Measure Cognition Across Postacute Care Settings

OBJECTIVE

To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery.

DESIGN

Rasch analysis of data from a prospective, observational cohort study.

SETTING

Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.

PARTICIPANTS

Patients (N=147) receiving rehabilitation services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional Independence Measure, MDS 2.0, and the OASIS-B.

RESULTS

Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge.

CONCLUSIONS

This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Acute Respiratory Distress Syndrome Following Pediatric Trauma: Application of Pediatric Acute Lung Injury Consensus Conference Criteria

OBJECTIVES

To assess the incidence, severity, and outcomes of pediatric acute respiratory distress syndrome following trauma using Pediatric Acute Lung Injury Consensus Conference criteria.

DESIGN

Retrospective cohort study.

SETTING

Level 1 pediatric trauma center.

PATIENTS

Trauma patients less than or equal to 17 years admitted to the ICU from 2009 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We queried electronic health records to identify patients meeting pediatric acute respiratory distress syndrome oxygenation criteria for greater than or equal to 6 hours and determined whether patients met complete pediatric acute respiratory distress syndrome criteria via chart review. We estimated associations between pediatric acute respiratory distress syndrome and outcome using generalized linear Poisson regression adjusted for age, injury mechanism, Injury Severity Score, and serious brain and chest injuries. Of 2,470 critically injured children, 103 (4.2%) met pediatric acute respiratory distress syndrome criteria. Mortality was 34.0% among pediatric acute respiratory distress syndrome patients versus 1.7% among patients without pediatric acute respiratory distress syndrome (adjusted relative risk, 3.7; 95% CI, 2.0-6.9). Mortality was 50.0% for severe pediatric acute respiratory distress syndrome at onset, 33.3% for moderate, and 30.5% for mild. Cause of death was neurologic in 60.0% and multiple organ failure in 34.3% of pediatric acute respiratory distress syndrome nonsurvivors versus neurologic in 85.4% of nonsurvivors without pediatric acute respiratory distress syndrome (p = 0.001). Among survivors, 77.1% of pediatric acute respiratory distress syndrome patients had functional disability at discharge versus 30.7% of patients without pediatric acute respiratory distress syndrome patients (p < 0.001), and only 17.5% of pediatric acute respiratory distress syndrome patients discharged home without ongoing care versus 86.4% of patients without pediatric acute respiratory distress syndrome (adjusted relative risk, 1.5; 1.1-2.1).

CONCLUSIONS

Incidence and mortality associated with pediatric acute respiratory distress syndrome following traumatic injury are substantially higher than previously recognized, and pediatric acute respiratory distress syndrome development is associated with high risk of poor outcome even after adjustment for underlying injury type and severity.