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Metzger S, Polanco B, Eriks-Hoogland I, Scheel-Sailer A, Pacheco Barzallo D. Utilization and features of rehabilitation and health services for persons with spinal cord injury. Eur J Phys Rehabil Med 2024; 60:634-642. [PMID: 38922316 PMCID: PMC11403627 DOI: 10.23736/s1973-9087.24.08391-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
BACKGROUND The increasing prevalence of individuals experiencing disabilities underscores the importance of rehabilitation. Nevertheless, healthcare systems are already facing financial constraints, which makes it imperative to strive for a more efficient delivery of services. The first step, however, is to understand how the provision of services behaves for patients with different characteristics. AIM To determine the most frequently used healthcare services in the (sub)acute phase of rehabilitation of patients with spinal cord injury/disease (SCI/D) and the link with patient characteristics. DESIGN Observational cohort study. POPULATION This study analyzes the clinical data of patients discharged from a specialized SCI hospital and rehabilitation center in Switzerland. METHODS We implemented a compound risk model to estimate the total amount of healthcare services used, defined by length of stay (LOS) and the units per day of health services (sub)acute phase of rehabilitation. RESULTS The study included 403 individuals with SCI/D. The analysis of the intensity and severity of healthcare services across different patient and injury characteristics revealed differences in the intensity of healthcare use and variations in the length of stay (LOS). Male patients with a low SCIM upon admission tended to use healthcare services more extensively than female patients. In terms of etiology, therapies were employed more intensively for patients with traumatic SCI (TSCI). In addition, the analysis revealed that variations in the intensity of healthcare services used were more significant than those adjusted for LOS. Ultimately, similar patient groups received comparable quantities of healthcare services at the end of treatment. CONCLUSIONS This population-based study provides information for a better understanding of the determinants of health service use during the (sub)acute rehabilitation phase of individuals with SCI/D. When analyzing LOS, intensity, and severity of services, it shows that the use of healthcare services significantly differs for the level of SCIM at admission, age groups, sex, and etiology. However, the variation among individual patients also suggests the presence of other influential modifiers that were not considered in this analysis. CLINICAL REHABILITATION IMPACT The approach outlined enables a systematic follow-up of this data analysis by enriching the computed data with additional details about the patient, the patient's treatment, and outcomes.
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Affiliation(s)
- Stefan Metzger
- Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
- Swiss Paraplegic Center, Nottwil, Switzerland
| | - Boris Polanco
- Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
| | - Inge Eriks-Hoogland
- Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
- Swiss Paraplegic Center, Nottwil, Switzerland
| | - Anke Scheel-Sailer
- Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Center, Nottwil, Switzerland
| | - Diana Pacheco Barzallo
- Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland -
- Swiss Paraplegic Research, Nottwil, Switzerland
- Center for Rehabilitation in Global Health Systems, WHO Collaborating Center, Lucerne, Switzerland
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Green REA, Dabek MK, Changoor A, Rybkina J, Monette GA, Colella B. Moderate-Severe TBI as a Progressive Disorder: Patterns and Predictors of Cognitive Declines in the Chronic Stages of Injury. Neurorehabil Neural Repair 2023; 37:799-809. [PMID: 37990972 DOI: 10.1177/15459683231212861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
BACKGROUND Moderate-severe traumatic brain injury (TBI) has been associated with progressive cognitive decline in the chronic injury stages in a small number of studies. OBJECTIVE This study aimed to (i) replicate our previous findings of decline from 1 to 3+ years post-injury in a larger, non-overlapping sample and (ii) extend these findings by examining the proportion of decliners in 2 earlier time windows, and by investigating novel predictors of decline. METHODS N = 48 patients with moderate-severe TBI underwent neuropsychological assessment at 2, 5, 12 months, and 30+ months post-injury. We employed the Reliable Change Index (RCI) to evaluate decline, stability and improvement across time and logistic regression to identify predictors of decline (demographic/cognitive reserve; injury-related). RESULTS The proportions of patients showing decline were: 12.5% (2-5 months post-injury), 17% (5-12 months post-injury), and 27% (12-30+ months post-injury). Measures of verbal retrieval were most sensitive to decline. Of the predictors, only left progressive hippocampal volume loss from 5 to 12 months post-injury significantly predicted cognitive decline from 12 to 30+ months post-injury. CONCLUSIONS Identical to our previous study, 27% of patients declined from 12 to 30+ months post-injury. Additionally, we found that the further from injury, the greater the proportion of patients declining. Importantly, earlier progressive hippocampal volume loss predicted later cognitive decline. Taken together, the findings highlight the need for ongoing research and treatment that target these deleterious mechanisms affecting patients in the chronic stages of moderate-severe TBI.
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Affiliation(s)
- Robin E A Green
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Marika K Dabek
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Alana Changoor
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Julia Rybkina
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | | | - Brenda Colella
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
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Lasprilla JCA, Watson JD, Merced K, Mascialino G, Lequerica AH, Perrin PB. Trajectories of Cognitive and Motor Functional Independence in Hispanic Individuals During the 10 yrs After Traumatic Brain Injury. Am J Phys Med Rehabil 2023; 102:308-315. [PMID: 36098351 DOI: 10.1097/phm.0000000000002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Juan Carlos Arango Lasprilla
- From the Department of Psychology, Virginia Commonwealth University, Richmond, Virginia (JCAL, JDW); Central Virginia Veterans Affairs Health Care System, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia (KM); Escuela de Psicología, Universidad de Las Américas, Quito, Ecuador (GM); Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, New Jersey (AHL); Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, New Jersey (AHL); and Departments of Psychology and Physical Medicine and Rehabilitation, Virginia Commonwealth University, Central Virginia Veterans Affairs Health Care System, Richmond, Virginia (PBP)
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Görgülü B, Dong J, Hunter K, Bettio KM, Vukusic B, Ranisau J, Spencer G, Tang T, Sarhangian V. Association Between Delayed Discharge From Acute Care and Rehabilitation Outcomes and Length of Stay: A Retrospective Cohort Study. Arch Phys Med Rehabil 2023; 104:43-51. [PMID: 35760110 DOI: 10.1016/j.apmr.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the association between discharge delays from acute to rehabilitation care because of capacity strain in the rehabilitation units, patient length of stay (LOS), and functional outcomes in rehabilitation. DESIGN Retrospective cohort study using an instrumental variable to remove potential biases because of unobserved patient characteristics. SETTING Two campuses of a hospital network providing inpatient acute and rehabilitation care. PARTICIPANTS Patients admitted to and discharged from acute care categories of Medicine and Neurology/Musculoskeletal (Neuro/MSK) and subsequently admitted to and discharged from inpatient rehabilitation between 2013 and 2019 (N=10486). INTERVENTIONS None. MAIN OUTCOME MEASURES Rehabilitation LOS, FIM scores at admission and discharge, and rehabilitation efficiency defined as FIM score improvement per day of rehabilitation. RESULTS The final cohort contained 3690 records for Medicine and 1733 for Neuro/MSK categories. For Medicine, 1 additional day of delayed discharge was associated with an average 5.1% (95% confidence interval [CI], 3%-7.3%) increase in rehabilitation LOS and 0.08 (95% CI, 0.03-0.13) reduction in rehabilitation efficiency. For Neuro/MSK, 1 additional day of delayed discharge was associated with an average 11.6% (95% CI, 2.8%-20.4%) increase in rehabilitation LOS and 0.08 (95% CI, -0.07 to 0.23) reduction in rehabilitation efficiency. CONCLUSIONS Delayed discharge from acute care to rehabilitation because of capacity strain in rehabilitation had a strong association with prolonged LOS in rehabilitation. An important policy implication of this "cascading" effect of delays is that reducing capacity strain in rehabilitation could be highly effective in reducing discharge delays from acute care and improving rehabilitation efficiency.
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Affiliation(s)
- Berk Görgülü
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
| | - Jing Dong
- Decision, Risk, and Operations Division, Columbia Business School, Columbia University, New York, NY
| | | | | | | | - Jonathan Ranisau
- Trillium Health Partners, Mississauga, Canada; Institute for Better Health, Mississauga, Canada
| | | | - Terence Tang
- Trillium Health Partners, Mississauga, Canada; Institute for Better Health, Mississauga, Canada
| | - Vahid Sarhangian
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada.
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Gustavson AM, Malone DJ, Boxer RS, Forster JE, Stevens-Lapsley JE. Application of High-Intensity Functional Resistance Training in a Skilled Nursing Facility: An Implementation Study. Phys Ther 2020; 100:1746-1758. [PMID: 32750132 PMCID: PMC7530575 DOI: 10.1093/ptj/pzaa126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/20/2019] [Accepted: 04/24/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Rehabilitation in skilled nursing facilities (SNFs) is under scrutiny to deliver high-quality care and superior outcomes in less time. High-intensity resistance training demonstrates functional improvements in community-dwelling and long-term care populations but has not been generalized to the SNF population. The purpose of this study was to evaluate implementation issues including safety and feasibility and to provide preliminary information on effectiveness of rehabilitation focused on high-intensity functional resistance training in an SNF. METHODS The implementation study design consisted of 2 nonrandomized independent groups (usual care and high intensity) that were staged within a single SNF. The i-STRONGER program (IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE Residents) integrates principles of physiologic tissue overload into rehabilitation. Physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate the implementation process. An observational checklist and documentation audits were used to assess treatment fidelity. Regression analyses evaluated the response of functional change by group. RESULTS No treatment-specific adverse events were reported. Treatment fidelity was high at >99%, whereas documentation varied from 21% to 50%. Patient satisfaction was greater in i-STRONGER, and patient refusals to participate in therapy sessions trended downward in i-STRONGER. Patients in i-STRONGER exhibited a 0.13 m/s greater change in gait speed than in the usual care group. Although not significant, i-STRONGER resulted in a 0.64-point greater change in the Short Physical Performance Battery than usual care, and average SNF length of stay was 3.5 days shorter for i-STRONGER patients. CONCLUSION The findings from this study indicate that implementation of a high-intensity resistance training framework in SNFs is safe and feasible. Furthermore, results support a signal effectiveness of improving function and satisfaction, although the heterogeneity of the population necessitates a larger implementation study to confirm. IMPACT STATEMENT This pragmatic study demonstrates that high-intensity resistance training in medically complex older adults is safe and favorable in SNFs. This work supports the need to fundamentally change the intensity of rehabilitation provided to this population to promote greater value within post-acute care. Furthermore, this study supports the application of implementation science to rehabilitation for rapid and effective translation of evidence into practice.
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Affiliation(s)
- Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado
| | - Daniel J Malone
- CCS, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, and Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado
| | - Jeri E Forster
- Rocky Mountain Regional Veterans Affairs Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora; Department of Physical Medicine and Rehabilitation, University of Colorado; and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
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Hwang F, Pentakota SR, McGreevy CM, Glass NE, Livingston DH, Mosenthal AC. Preinjury Palliative Performance Scale predicts functional outcomes at 6 months in older trauma patients. J Trauma Acute Care Surg 2020; 87:541-551. [PMID: 31135771 DOI: 10.1097/ta.0000000000002382] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Older trauma patients have increased risk of adverse in-hospital outcomes. We previously demonstrated that low preinjury Palliative Performance Scale (PPS) independently predicted poor discharge outcomes. We hypothesized that low PPS would predict long-term outcomes in older trauma patients. METHODS Prospective observational study of trauma patients aged ≥55 years admitted between July 2016 and April 2018. Preinjury PPS was assessed at admission; low PPS was defined as 70 or less. Primary outcomes were mortality and functional outcomes, measured by Extended Glasgow Outcome Scale (GOSE), at discharge and 6 months. Poor functional outcomes were defined as GOSE score of 4 or less. Secondary outcomes were patient-reported outcomes at 6 months: EuroQol-5D and 36-Item Short Form Survey. Adjusted relative risks (aRRs) were obtained for each primary outcome using multivariable modified Poisson regression, adjusting for PPS, age, race/ethnicity, sex, and injury severity. RESULTS In-hospital data were available for 516 patients; mean age was 70 years and median Injury Severity Score was 13. Thirty percent had low PPS. Six percent (n = 32) died in the hospital, and half of the survivors (n = 248) had severe disability at discharge. Low PPS predicted hospital mortality (aRR, 2.6; 95% confidence interval [CI], 1.2-5.3) and poor outcomes at discharge (aRR, 2.0; 95% CI, 1.7-2.3). Six-month data were available for 176 (87%) of 203 patients who were due for follow-up. Functional outcomes improved in 64% at 6 months. However, 63% had moderate to severe pain, and 42% moderate to severe anxiety/depression. Mean GOSE improved less over time in low PPS patients (7% vs. 24%; p < 0.01). Low PPS predicted poor functional outcomes at 6 months (aRR, 3.1; 95% CI, 1.8-5.3) while age and Injury Severity Score did not. CONCLUSION Preinjury PPS predicts mortality and poor outcomes at discharge and 6 months. Despite improvement in function, persistent pain and anxiety/depression were common. Low PPS patients fail to improve over time compared to high PPS patients. Preinjury PPS can be used on admission for prognostication of short- and long-term outcomes and is a potential trigger for palliative care in older trauma patients. LEVEL OF EVIDENCE Prognostic study, Therapeutic level IV.
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Affiliation(s)
- Franchesca Hwang
- From the Department of Surgery, Rutgers New Jersey Medical School (F.H., S.R.P., N.E.G., D.H.L., A.C.M), Newark, New Jersey; and Hospital of the University of Pennsylvania (C.M.M), Philadelphia, Pennsylvania
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Zarshenas S, Colantonio A, Horn SD, Jaglal S, Jacob B, Cullen N. Occupational and Physical Therapy Activities and Level of Effort in Patients With Traumatic Brain Injury: Association With Functional Outcomes. PM R 2019; 12:339-348. [PMID: 31600430 DOI: 10.1002/pmrj.12260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 09/17/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although some attention has been given to the association of functional outcomes with rehabilitation intensity, the evidence is still sparse in this field. OBJECTIVE To investigate the effect of inpatient rehabilitation (IR) on discharge cognitive and motor function and the association of time spent in occupational and physical therapy and level of effort with cognitive and motor function in patients with traumatic brain injury (TBI). DESIGN Secondary analysis of TBI-Practice Based Evidence dataset. SETTINGS Inpatient rehabilitation. PARTICIPANTS One hundred forty-nine patients with TBI who were consecutively admitted for IR between 2008 and 2011 in Ontario, Canada. INTERVENTIONS Not applicable. MAIN OUTCOME MEASUREMENTS Admission and discharge Functional Independence Measure-Rasch Cognitive and Motor Scores. RESULTS Patients showed significant improvement in cognitive and motor function from admission to discharge (P < .0001). After controlling for confounding factors, discharge FIM-Rasch cognitive and motor scores were not associated with either level of effort or time spent in physical therapy activities. Discharge motor, but not cognitive function, was associated with more time spent in the complex (β = 0.20, confidence interval [CI] 0.005, 0.05) and less time spent in simple OT activities (β = -0.13, CI -0.13, -0.01). CONCLUSION This study provides valuable information for clinicians about the effectiveness of IR on the improvement of motor and cognitive outcomes and the importance of considering the amount of time spent in activities based on their level of complexity rather than the total time of therapy to improve motor outcomes in this population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sareh Zarshenas
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada.,Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Susan D Horn
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake, UT
| | - Susan Jaglal
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
| | - Binu Jacob
- University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
| | - Nora Cullen
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
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Timpson M, Hade EM, Beaulieu C, Horn SD, Hammond FM, Peng J, Montgomery E, Giuffrida C, Gilchrist K, Lash A, Dijkers M, Corrigan JD, Bogner J. Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge. Arch Phys Med Rehabil 2019; 100:1818-1826. [DOI: 10.1016/j.apmr.2018.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/03/2018] [Accepted: 11/06/2018] [Indexed: 01/07/2023]
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Abstract
The aim of this study was to determine whether patients whose treatment is consistent with the 3-hour rule have better outcomes than patients whose treatment is not consistent with the 3-hour rule.This is a retrospective review of the records of 581 patients. The authors compared the outcomes of 397 patients whose therapy was consistent with the 3-hour rule to the outcomes of 184 patients whose therapy was not consistent with the rule for at least one 7-day period during the stay on an inpatient rehabilitation facility.Patients whose care was consistent with the rule did not have more improvement in function or shorter length of stay than patients whose care was not consistent with the 3-hour rule.There is not good evidence to support the 3-hour rule as a determinant of the care that a patient at an IRF needs to achieve a good outcome.
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Affiliation(s)
- George Forrest
- Department of Physical Medicine and Rehabilitation, Albany Medical College, Albany, NY
- Department of internal medicine, St. Peter's Health Partners, Albany, NY
| | | | - Mina Kodsi
- Department of Physical Medicine and Rehabilitation, University Rochester Medical College, Rochester, NY
| | - Joshua Smith
- Department of Physical Medicine and Rehabilitation, University Rochester Medical College, Rochester, NY
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Park EY, Kim EJ. Effect of the frequency of therapy on the performance of activities of daily living in children with cerebral palsy. J Phys Ther Sci 2018; 30:707-710. [PMID: 29765186 PMCID: PMC5940478 DOI: 10.1589/jpts.30.707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study investigated the frequency effect of physical and occupational
therapy on activities of daily living performance in children with cerebral palsy.
[Subjects and Methods] A total of 162 children with cerebral palsy who attended a
convalescent or rehabilitation center for disabled individuals or a special school for
physical disabilities in South Korea participated in this study. The Pediatric Evaluation
Disability Inventory was used to collect data on activities of daily living performance
according to physical therapy frequency based on neurodevelopmental therapy for 1 year.
[Results] The relationships between physical therapy frequency and activities of daily
living performance (mobility, social function, and total functional skill) and between
occupational therapy frequency and activities of daily living performance (social function
and total functional skill) were significant. There was no significant difference in
activities of daily living performance according to physical therapy frequency. The
difference in the activities of daily living performance according to occupational therapy
frequency was significant for social function. [Conclusion] Intensive occupational therapy
was more effective in improving activities of daily living performance in children with
cerebral palsy. In particular, their social function further improved with intensive
physical therapy.
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Affiliation(s)
- Eun-Young Park
- Department of Secondary Special Education, College of Education, Jeonju University, Republic of Korea
| | - Eun-Joo Kim
- Department of Occupational Therapy, College of Medical Sciences, Jeonju University: 1200 3-ga, Hyoja-dong, Wansan-gu, Jeonju 560-759, Republic of Korea
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Budnick HC, Tyroch AH, Milan SA. Ethnic disparities in traumatic brain injury care referral in a Hispanic-majority population. J Surg Res 2017; 215:231-238. [DOI: 10.1016/j.jss.2017.03.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/10/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
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Truchon C, Fallah N, Santos A, Vachon J, Noonan VK, Cheng CL. Impact of Therapy on Recovery during Rehabilitation in Patients with Traumatic Spinal Cord Injury. J Neurotrauma 2017; 34:2901-2909. [PMID: 28493787 PMCID: PMC5652980 DOI: 10.1089/neu.2016.4932] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Evidence-based planning of rehabilitation interventions is important to improving cost efficiency while maintaining patient and system outcomes. This article aims to explore the relationship between rehabilitation therapy, functional outcome, bed utilization, and care costs after traumatic spinal cord injury (tSCI). A retrospective review of 262 persons with tSCI admitted to an inpatient rehabilitation facility from 2005–2012 was conducted. Treatment variables and outcome measures included rehabilitation length of stay (LOS), days to rehabilitation (onset), hours and intensity of therapy, and Functional Independence Measure (FIM). Polynomial regression models and generalized additive models were applied to explore the relationship between therapy hours and motor FIM change. Simulation modeling was used to assess the impact of hypothetically increasing therapy intensity. Patients were grouped by injury as: C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A,B,C; C5–8 AIS A,B,C; T1–S5 AIS A,B,C; and AIS D. The sample was 85% male, mean age 45.9, median LOS 102 days, and mean therapy intensity 5.7 h/week. Motor FIM change was positively associated with total hours of therapy (β = 0.40, p < 0.0001) up to a certain time point, adjusted for age, gender, injury, complications, and rehabilitation onset. Hypothetically increasing therapy intensity by 50% and 100% resulted in average motor FIM efficiency gain ranging between 0.04–0.07 and 0.1–0.17, respectively, across injury groups. The hypothetical changes resulted in reductions in the average LOS and bed utilization rate, translating to cost savings of $20,000 and $50,000 (2011 CAD) for the +50% and +100% scenarios, respectively. The results highlight the importance of monitoring functional change throughout rehabilitation after tSCI and the need for customized therapeutic strategies.
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Affiliation(s)
- Catherine Truchon
- Institut national d'excellence en santé et en services sociaux, Québec City, Québec, Canada
| | - Nader Fallah
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Argelio Santos
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Joëlle Vachon
- Institut de réadaptation en déficience physique de Québec, Québec City, Québec, Canada
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Scivoletto G, Miscusi M, Forcato S, Ricciardi L, Serrao M, Bellitti R, Raco A. The Rehabilitation of Spinal Cord Injury Patients in Europe. ACTA NEUROCHIRURGICA SUPPLEMENT 2017; 124:203-210. [DOI: 10.1007/978-3-319-39546-3_31] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Movement repetitions in physical and occupational therapy during spinal cord injury rehabilitation. Spinal Cord 2016; 55:172-179. [PMID: 27752057 PMCID: PMC5292050 DOI: 10.1038/sc.2016.129] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 07/13/2016] [Accepted: 07/19/2016] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Longitudinal observational study. OBJECTIVE To quantify the amount of upper- and lower-extremity movement repetitions (that is, voluntary movements as part of a functional task or specific motion) occurring during inpatient spinal cord injury (SCI), physical (PT) and occupational therapy (OT), and examine changes over the inpatient rehabilitation stay. SETTING Two stand-alone inpatient SCI rehabilitation centers. METHODS Participants: A total of 103 patients were recruited through consecutive admissions to SCI rehabilitation. INTERVENTIONS Trained assistants observed therapy sessions and obtained clinical outcome measures in the second week following admission and in the second to last week before discharge. MAIN OUTCOME MEASURES PT and OT time, upper- and lower-extremity repetitions and changes in these outcomes over the course of rehabilitation stay. RESULTS We observed 561 PT and 347 OT sessions. Therapeutic time comprised two-thirds of total therapy time. Summed over PT and OT, the median upper-extremity repetitions in patients with paraplegia were 7 repetitions and in patients with tetraplegia, 42 repetitions. Lower-extremity repetitions and steps primarily occurred in ambulatory patients and amounted to 218 and 115, respectively (summed over PT and OT sessions at discharge). Wilcoxon-signed rank tests revealed that most repetition variables did not change significantly over the inpatient rehabilitation stay. In contrast, clinical outcomes for the arm and leg improved over this time period. CONCLUSIONS Repetitions of upper- and lower-extremity movements are markedly low during PT and OT sessions. Despite improvements in clinical outcomes, there was no significant increase in movement repetitions over the course of inpatient rehabilitation stay.
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Traumatic Brain Injury Rehabilitation Comparative Effectiveness Research: Introduction to the Traumatic Brain Injury-Practice Based Evidence Archives Supplement. Arch Phys Med Rehabil 2015. [PMID: 26212395 DOI: 10.1016/j.apmr.2015.03.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This supplement of the Archives of Physical Medicine and Rehabilitation is devoted to the Traumatic Brain Injury-Practice Based Evidence study, the first practice-based evidence study, to our knowledge, of traumatic brain injury rehabilitation. The purpose of this preface is to place this study in the broader context of comparative effectiveness research and introduce the articles in the supplement.
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Horn SD, Corrigan JD, Beaulieu CL, Bogner J, Barrett RS, Giuffrida CG, Ryser DK, Cooper K, Carroll DM, Deutscher D. Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge. Arch Phys Med Rehabil 2015; 96:S304-29. [PMID: 26212406 PMCID: PMC4517296 DOI: 10.1016/j.apmr.2014.11.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 10/28/2014] [Accepted: 11/20/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN Prospective, longitudinal observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. CONCLUSIONS At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT.
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | | | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT
| | | | - David K Ryser
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
| | - Kelli Cooper
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
| | - Deborah M Carroll
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
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Beaulieu CL, Dijkers MP, Barrett RS, Horn SD, Giuffrida CG, Timpson ML, Carroll DM, Smout RJ, Hammond FM. Occupational, Physical, and Speech Therapy Treatment Activities During Inpatient Rehabilitation for Traumatic Brain Injury. Arch Phys Med Rehabil 2015; 96:S222-34.e17. [PMID: 26212399 PMCID: PMC4538942 DOI: 10.1016/j.apmr.2014.10.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/13/2014] [Accepted: 10/16/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury. DESIGN Multisite prospective observational cohort study. SETTING Inpatient rehabilitation settings. PARTICIPANTS Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined. RESULTS Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay. CONCLUSIONS The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups.
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Affiliation(s)
| | | | - Ryan S Barrett
- Institute for Clinical Outcomes Research, Salt Lake City, UT
| | - Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT
| | | | - Misti L Timpson
- Intermountain Medical Center, Salt Lake City, UT; Rocky Mountain University of Health Professions, Provo, UT
| | | | - Randy J Smout
- Institute for Clinical Outcomes Research, Salt Lake City, UT
| | - Flora M Hammond
- Carolinas Rehabilitation, Charlotte, NC; Indiana University School of Medicine, Indianapolis, IN
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Horn SD, Corrigan JD, Bogner J, Hammond FM, Seel RT, Smout RJ, Barrett RS, Dijkers MP, Whiteneck GG. Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes. Arch Phys Med Rehabil 2015; 96:S178-96.e15. [PMID: 26212396 PMCID: PMC4516907 DOI: 10.1016/j.apmr.2014.09.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 08/26/2014] [Accepted: 09/09/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population. DESIGN Prospective, longitudinal, observational study. SETTING Ten inpatient rehabilitation centers. PARTICIPANTS Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being. RESULTS The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations. CONCLUSIONS This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT.
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Flora M Hammond
- Carolinas Rehabilitation, Charlotte, NC; Indiana University School of Medicine, Indianapolis, IN
| | - Ronald T Seel
- Crawford Research Institute, Shepherd Center, Atlanta, GA
| | - Randall J Smout
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT
| | - Marcel P Dijkers
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Van Stan JH, Roy N, Awan S, Stemple J, Hillman RE. A taxonomy of voice therapy. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2015; 24:101-25. [PMID: 25763678 PMCID: PMC6195037 DOI: 10.1044/2015_ajslp-14-0030] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 06/30/2014] [Accepted: 02/10/2015] [Indexed: 05/23/2023]
Abstract
PURPOSE Voice therapy practice and research, as in most types of rehabilitation, is currently limited by the lack of a taxonomy describing what occurs during a therapy session (with enough precision) to determine which techniques/components contribute most to treatment outcomes. To address this limitation, a classification system of voice therapy is proposed that integrates descriptions of therapeutic approaches from the clinical literature into a framework that includes relevant theoretical constructs. METHOD Literature searches identified existing rehabilitation taxonomies/therapy classification schemes to frame an initial taxonomic structure. An additional literature search and review of clinical documentation provided a comprehensive list of therapy tasks. The taxonomy's structure underwent several iterations to maximize accuracy, intuitive function, and theoretical underpinnings while minimizing redundancy. The taxonomy was then used to classify established voice therapy programs. RESULTS The taxonomy divided voice therapy into direct and indirect interventions delivered using extrinsic and/or intrinsic methods, and Venn diagrams depicted their overlapping nature. A dictionary was developed of the taxonomy's terms, and 7 established voice therapy programs were successfully classified. CONCLUSION The proposed taxonomy represents an important initial step toward a standardized voice therapy classification system expected to facilitate outcomes research and communication among clinical stakeholders.
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Affiliation(s)
- Jarrad H. Van Stan
- MGH Institute of Health Professions, Boston, MA
- Massachusetts General Hospital, Boston
| | | | | | | | - Robert E. Hillman
- MGH Institute of Health Professions, Boston, MA
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
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20
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Roth EJ, Lovell L. Seven-Year Trends in Stroke Rehabilitation: Patient Characteristics, Medical Complications, and Functional Outcomes. Top Stroke Rehabil 2015; 9:1-9. [PMID: 14523695 DOI: 10.1310/plfl-ubhj-jnr5-e0fc] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.
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Affiliation(s)
- Elliot J Roth
- Rehabilitation Institute of Chicago and Rehabilitation Research, Training Center on Enhancing the Quality of Life of Stroke Survivors, and Physical Medicine and Rehabilitation, Northwestern University's Feinberg School of Medicine, Chicago, Illinois, USA
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21
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Strasser DC, Falconer JA. Linking Treatment to Outcomes through Teams: Building a Conceptual Model of Rehabilitation Effectiveness. Top Stroke Rehabil 2015; 4:15-27. [DOI: 10.1310/kl5r-u470-vf9m-3hln] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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22
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Bode RK, Rychlik K, Heinemann AW, Lovell L, Modla L. Reconceptualizing Poststroke Activity Level Using the Frenchay Activities Index. Top Stroke Rehabil 2015; 9:82-91. [PMID: 14523702 DOI: 10.1310/rcwl-75jj-jrew-fvqt] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Modifications of the Frenchay Activities Index were implemented in a study of postacute stroke rehabilitation outcomes. These modifications incorporated the prestroke activity levels and postrehabilitation goals and assessments of activity importance of 136 persons with stroke who received services in either a single modality or comprehensive outpatient rehabilitation setting. Prestroke activity levels were assessed retrospectively at admission to postacute rehabilitation, and current activity levels were assessed at discharge and 3 months post discharge. Prestroke activity levels were used to determine postrehabilitation goal attainment. Results showed that activities for which goals were less likely to be attained were more strenuous in nature, and activities for which goals were more likely to be attained were more sedentary in nature. The importance persons placed on specific activities was used to tailor the estimates of overall activity levels to reflect their importance to each person. Results showed that adjusting for importance decreased the estimate of prestroke activity level but had little effect on poststroke activity level. Incorporation of these modifications represents a reconceptualization of poststroke activity levels that clinicians can use to guide their selection of postacute rehabilitation therapy goals.
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Affiliation(s)
- Rita K Bode
- Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, and Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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23
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Alexandrescu R, Siegert RJ, Turner-Stokes L. The Northwick Park Therapy Dependency Assessment scale: a psychometric analysis from a large multicentre neurorehabilitation dataset. Disabil Rehabil 2015; 37:1976-83. [PMID: 25598001 PMCID: PMC4720035 DOI: 10.3109/09638288.2014.998779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Purpose: To assess the internal reliability, construct and concurrent validity and responsiveness of the Northwick Park Therapy Dependency Assessment (NPTDA) scale. Method: A cohort of 2505 neurorehabilitation patients submitted to the UK Rehabilitation Outcomes Collaborative database. Cronbach’s coefficient-α was used to assess internal reliability and factor analysis (FA) to assess construct validity. We compared NPTDA scores at admission and discharge to determine responsiveness. Results: Coefficient-α for the whole scale was 0.74. The exploratory FA resulted in a four-factor model (Physical, Psychosocial, Discharge planning and Activities) that accounted for 43% of variance. This model was further supported by the confirmatory FA. The final model had a good fit: root-mean-square error of approximation of 0.069, comparative fit index/Tucker–Lewis index of 0.739/0.701 and the goodness of fit index of 0.909. The NPTDA scores at admission and discharge were significantly different for each of the factors. Expected correlations were seen between the admission scores for the NPTDA, the Rehabilitation Complexity Scale (r = 0.30, p < 0.01) and the Functional Independence Measure (r = −0.25, p < 0.01). Conclusions: The scale demonstrated acceptable internal reliability and good construct and concurrent validity. NPTDA may be used to describe and quantify changes in therapy inputs in the course of a rehabilitation programme.Implications for Rehabilitation The Northwick Park Therapy Dependency Assessment (NPTDA) is designed as a measure therapy intervention, which reflects both quantitative and qualitative aspects of the inputs provided (including staff time and the different types of intervention) during inpatient rehabilitation. The scale demonstrated acceptable internal reliability and good construct and concurrent validity. NPTDA is responsive to change in the therapy inputs provided during neurorehabilitation between admission and discharge.
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Affiliation(s)
- Roxana Alexandrescu
- a Department of Palliative Care, Policy and Rehabilitation , School of Medicine, King's College London , London , UK
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24
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Niemeier JP, Perrin PB, Holcomb MG, Rolston CD, Artman LK, Lu J, Nersessova KS. Gender differences in awareness and outcomes during acute traumatic brain injury recovery. J Womens Health (Larchmt) 2014; 23:573-80. [PMID: 24932911 DOI: 10.1089/jwh.2013.4535] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent literature on traumatic brain injury (TBI), though mixed when reporting outcomes, seems collectively to suggest possible gender advantage for women in postinjury recovery, especially in executive functions. Hormonal neuroprotection, through female reproductive hormones, is often proposed as an underlying factor in these results. We explored potential gender differences in an aspect of executive functions, self-awareness (SA), which is often impaired after TBI, limits patient effort in critical rehabilitation, and increases caregiver burden. METHODS Within a prospective survey, repeated-measures design, 121 patients with moderate or severe TBI undergoing acute rehabilitation in a Level 1 trauma center, a family member or caregiver informant, and a treating clinician were asked to complete the Patient Competency Rating Scale (PCRS) and the Frontal Systems Behavior Scale (FrSBe) at admission and discharge. RESULTS Although overall, women and men with TBI showed generally similar levels of SA, women had significantly better awareness of their injury-related deficits at acute rehabilitation discharge, even when controlling for age, education, and injury severity. CONCLUSIONS Mixed findings in this study mirror the pattern of results that dominate the published literature on gender and TBI. Gender differences in executive dysfunction may not be as large or robust as some researchers argue. In addition, complex interplays of socialization, gender-role expectations, naturally occurring male and female ability differences, and differences in access to postinjury rehabilitation are understudied potential moderators.
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Affiliation(s)
- Janet P Niemeier
- 1 Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation , Charlotte, North Carolina
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25
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Brusco NK, Watts JJ, Shields N, Taylor NF. Are weekend inpatient rehabilitation services value for money? An economic evaluation alongside a randomized controlled trial with a 30 day follow up. BMC Med 2014; 12:89. [PMID: 24885811 PMCID: PMC4053313 DOI: 10.1186/1741-7015-12-89] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 04/24/2014] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Providing additional Saturday rehabilitation can improve functional independence and health related quality of life at discharge and it may reduce patient length of stay, yet the economic implications are not known. The aim of this study was to determine from a health service perspective if the provision of rehabilitation to inpatients on a Saturday in addition to Monday to Friday was cost effective compared to Monday to Friday rehabilitation alone. METHODS Cost utility and cost effectiveness analyses were undertaken alongside a multi-center, single-blind randomized controlled trial with a 30-day follow up after discharge. Participants were adults admitted for inpatient rehabilitation in two publicly funded metropolitan rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus an additional rehabilitation service on Saturday. Incremental cost utility ratio was reported as cost per quality adjusted life year (QALY) gained and an incremental cost effectiveness ratio (ICER) was reported as cost for a minimal clinically important difference (MCID) in functional independence. RESULTS 996 patients (mean age 74 (standard deviation 13) years) were randomly assigned to the intervention (n = 496) or the control group (n = 500). Mean difference in cost of AUD$1,673 (95% confidence interval (CI) -271 to 3,618) was a saving in favor of the intervention group. The incremental cost utility ratio found a saving of AUD$41,825 (95% CI -2,817 to 74,620) per QALY gained for the intervention group. The ICER found a saving of AUD$16,003 (95% CI -3,074 to 87,361) in achieving a MCID in functional independence for the intervention group. If the willingness to pay per QALY gained or for a MCID in functional independence was zero dollars the probability of the intervention being cost effective was 96% and 95%, respectively. A sensitivity analysis removing Saturday penalty rates did not significantly alter the outcome. CONCLUSIONS From a health service perspective, the provision of rehabilitation to inpatients on a Saturday in addition to Monday to Friday, compared to Monday to Friday rehabilitation alone, is likely to be cost saving per QALY gained and for a MCID in functional independence. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213.
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Affiliation(s)
- Natasha Kareem Brusco
- Physiotherapy Department, Faculty of Health Science, La Trobe University, Bundoora Campus, Bundoora, Victoria 3086, Australia.
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26
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Dijkers MP, Hart T, Tsaousides T, Whyte J, Zanca JM. Treatment taxonomy for rehabilitation: past, present, and prospects. Arch Phys Med Rehabil 2014; 95:S6-16. [PMID: 24370326 DOI: 10.1016/j.apmr.2013.03.032] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 03/04/2013] [Accepted: 03/07/2013] [Indexed: 10/25/2022]
Abstract
The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration.
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Affiliation(s)
- Marcel P Dijkers
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Tessa Hart
- Moss Rehabilitation Research Institute, Elkins Park, PA
| | - Theodore Tsaousides
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA
| | - Jeanne M Zanca
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Watson MJ. Do Patients with Severe Traumatic Brain Injury Benefit from Physiotherapy? A Review of the Evidence. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/ptr.2001.6.4.233] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Jeyaraj JA, Clendenning A, Bellemare-Lapierre V, Iqbal S, Lemoine MC, Edwards D, Korner-Bitensky N. Clinicians' perceptions of factors contributing to complexity and intensity of care of outpatients with traumatic brain injury. Brain Inj 2013; 27:1338-47. [PMID: 23923818 DOI: 10.3109/02699052.2013.823650] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE This study investigated clinicians' perceptions on factors linked to patient complexity in traumatic brain injury (TBI) outpatient rehabilitation. METHOD Twelve clinicians from various disciplines, working in TBI outpatient programmes from three rehabilitation institutions in Montreal, Quebec, were recruited using convenience and snowball sampling. Data was collected through focus groups and individual interviews and thematic analysis was used to identify themes. MAIN OUTCOMES AND RESULTS Participants identified complexity factors falling under the following themes: sequelae of TBI (cognitive/behavioural/psychological impacts), personal factors (personality traits, pre-medical state, lifestyle and age), patients' environment (architectural, social, language, cultural and financial) and therapeutic relationship (mismatch, misunderstanding and personality clashes). Clinicians also reported facilitators to optimal treatment delivery such as quality of services and working in an interdisciplinary team. Limited time, training and resources were identified as barriers to treatment. CONCLUSION A substantial proportion of patients in outpatient TBI programmes seem to follow an atypical evolution and exhibit added complexity. In order to optimize quality of care, clinicians recommended increased community awareness about TBI, increased resources for rehabilitation clinicians and specialized services post-discharge. These findings are insightful for stakeholders; providing a basis for discussions on policy changes that can better meet this population's needs.
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Affiliation(s)
- Jerine Anton Jeyaraj
- School of Physical and Occupational Therapy, McGill University , Montreal , Canada
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Kim H, Colantonio A, Dawson DR, Bayley MT. Community integration outcomes after traumatic brain injury due to physical assault. Can J Occup Ther 2013; 80:49-58. [PMID: 23550497 DOI: 10.1177/0008417412473262] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Community integration is considered an ultimate goal for rehabilitation after traumatic brain injury (TBI). PURPOSE To determine (a) whether differences exist in rehabilitation outcomes between intentional and unintentional TBI populations and (b) whether TBI from assault is a predictor of community integration following inpatient rehabilitation. METHOD Retrospective cohort study using population-based data from Canadian hospital administration records, 2001 to 2006. Outcome measure was the Reintegration to Normal Living Index (RNLI). FINDINGS From a sample of 243 persons, 24 (9.9%) had sustained TBI from physical assault. Persons with TBI from physical assault reported significantly lower scores on two items on the RNLI's Daily Functioning subscale: "recreation" and "family role." IMPLICATIONS These findings suggest that targeted intervention in these specific areas could be beneficial, which are often primarily addressed by occupational therapists in both inpatient rehabilitation and community settings.
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Affiliation(s)
- Hwan Kim
- Department of Occupational Therapy, College of Rehabilitation Sciences, Daegu University, Jullyang, Gyeongsan, Gyeongbuk, Republic of Korea
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30
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Factors that Influence Functional Mobility Outcomes of Patients after Traumatic Brain Injury. Hong Kong J Occup Ther 2013. [DOI: 10.1016/j.hkjot.2013.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective/Background The consequences of traumatic brain injury (TBI) include physical, cognitive, psychological, behavioural, and emotional deficits. Prognostic factors such as age, mechanism of injury, and severity of injury assist in determining the outcome of the patient. It is believed that predictors of recovery assist both the patient as well as family members in determining the potential outcomes for the patient. The objective of this study was to identify factors that influence functional mobility outcome of patients after TBI. Methods This was a cross-sectional study. Participants were assessed predischarge. The Glasgow Coma Scale on admission was noted to establish the severity of the TBI. The Rivermead Mobility Index was used to establish the functional mobility outcome. Results The sample consisted of 60 participants of which 56 (93%) were males. The average age of the participants in the study was 28 ± 8.5 years. More than 50% of the participants were unable to walk outside and 37% were able to climb a flight of stairs without help at the time of discharge from the hospital. Younger age (p < .001), male gender (p = .001), Grade 12 education (p = .001), being self employed (p < .001), having bowel and bladder continence (p < .001), not smoking and drinking (p < .001), and having occupational therapy sessions (p = .002) had a positive impact on function after TBI. Conclusion Previous studies have identified a multitude of factors and this study has served to confirm factors that have a positive impact on physical function after TBI within this study group.
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Frasca D, Tomaszczyk J, McFadyen BJ, Green RE. Traumatic brain injury and post-acute decline: what role does environmental enrichment play? A scoping review. Front Hum Neurosci 2013; 7:31. [PMID: 23616755 PMCID: PMC3628363 DOI: 10.3389/fnhum.2013.00031] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 01/25/2013] [Indexed: 12/26/2022] Open
Abstract
Objectives: While a growing number of studies provide evidence of neural and cognitive decline in traumatic brain injury (TBI) survivors during the post-acute stages of injury, there is limited research as of yet on environmental factors that may influence this decline. The purposes of this paper, therefore, are to (1) examine evidence that environmental enrichment (EE) can influence long-term outcome following TBI, and (2) examine the nature of post-acute environments, whether they vary in degree of EE, and what impact these variations have on outcomes. Methods: We conducted a scoping review to identify studies on EE in animals and humans, and post-discharge experiences that relate to barriers to recovery. Results: One hundred and twenty-three articles that met inclusion criteria demonstrated the benefits of EE on brain and behavior in healthy and brain-injured animals and humans. Nineteen papers on post-discharge experiences revealed that variables such as insurance coverage, financial, and social support, home therapy, and transition from hospital to home, can have an impact on clinical outcomes. Conclusion: There is evidence to suggest that lack of EE, whether from lack of resources or limited ability to engage in such environments, may play a role in post-acute cognitive and neural decline. Maximizing EE in the post-acute stages of TBI may improve long-term outcomes for the individual, their family and society.
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Affiliation(s)
- Diana Frasca
- Graduate Department of Rehabilitation Science, University of Toronto Toronto, ON, Canada ; Cognitive Neurorehabilitation Sciences Laboratory, Toronto Rehabilitation Institute Toronto, ON, Canada
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32
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Kim H, Bayley M, Dawson D, Mollayeva T, Colantonio A. Characteristics and functional outcomes of brain injury caused by physical assault in Canada: a population-based study from an inpatient rehabilitation setting. Disabil Rehabil 2013; 35:2213-20. [PMID: 23480674 DOI: 10.3109/09638288.2013.774063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To investigate the characteristics and inpatient rehabilitation outcomes of persons who sustained a traumatic brain injury (TBI) resulting from physical assault - a form of intentional TBI - and compare these outcomes to those of persons with TBI resulting from other aetiologies. METHOD A prospective population-based cohort study using inpatient rehabilitation data from Canadian population-based administrative databases for the fiscal years 2001-2006. Outcome measures were measures of functional independence (motor and cognitive), as measured by the FIM™ Instrument, and discharge destinations. RESULTS Characteristics associated with intentional TBI were being male, younger in age and unemployed; living alone and having a greater likelihood of alcohol/drug abuse prior to admission. The intentional TBI group showed poorer total functional gains at discharge from inpatient rehabilitation. Multivariate regression analyses showed that persons with intentional injury were less likely to be discharged home. CONCLUSIONS Persons with TBI from physical assault are a distinct clinical group in Canadian inpatient rehabilitation settings. These findings can support clinicians in determining proper assessment, management, discharge planning and post-rehabilitation care that target specific needs of persons with TBI resulting from physical assault. IMPLICATIONS FOR REHABILITATION Clinicians should have appropriate training to properly assess the mental health status of this patient group. Inpatient rehabilitation facilities should be prepared to provide services targeting psychosocial, substance abuse and interpersonal relationship issues to persons with a TBI from physical assault while patients are still within a hospital setting. Follow-up clinical care and community support services are warranted for those with intentional TBIs, including provision of occupational rehabilitation services, such as vocational rehabilitation. The discharge team should be responsible for ensuring appropriate discharge to community in the absence of family or other advocates on behalf of the patient.
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Affiliation(s)
- Hwan Kim
- Department of Occupational Therapy, College of Rehabilitation Sciences, Daegu University , Gyeongbuk , Republic of Korea
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Larson CA, Dension PM. Effectiveness of intense, activity-based physical therapy for individuals with spinal cord injury in promoting motor and sensory recovery: is olfactory mucosa autograft a factor? J Spinal Cord Med 2013; 36:44-57. [PMID: 23433335 PMCID: PMC3555107 DOI: 10.1179/2045772312y.0000000026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/OBJECTIVES Rehabilitation for individuals with spinal cord injury (SCI) is expanding to include intense, activity-based, out-patient physical therapy (PT). The study's primary purposes were to (i) examine the effectiveness of intense PT in promoting motor and sensory recovery in individuals with SCI and (ii) compare recovery for individuals who had an olfactory mucosa autograft (OMA) with individuals who did not have the OMA while both groups participated in the intense PT program. METHODS Prospective, non-randomized, non-blinded, intervention study. Using the American Spinal Injury Association examination, motor and sensory scores for 23 (7 OMA, 6 matched control and 10 other) participants were recorded. RESULTS Mean therapy dosage was 137.3 total hours. The participants' total, upper and lower extremity motor scores improved significantly while sensory scores did not improve during the first 60 days and from initial to discharge examination. Incomplete SCI or paraplegia was associated with greater motor recovery. Five of 14 participants converted from motor-complete to motor-incomplete SCI. Individuals who had the OMA and participated in intense PT did not have greater sensory or greater magnitude or rate of motor recovery as compared with participants who had intense PT alone. CONCLUSION This study provides encouraging evidence as to the effectiveness of intense PT for individuals with SCI. Future research is needed to identify the optimal therapy dosage and specific therapeutic activities required to generate clinically meaningful recovery for individuals with SCI including those who elect to undergo a neural recovery/regenerative surgical procedure and those that elect intense therapy alone.
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Affiliation(s)
- Cathy A. Larson
- Rehabilitation Institute of Michigan, Center for Spinal Cord Injury Recovery, Detroit, MI, USA; and Oakland University Physical Therapy program, Rochester, MI, USA,Correspondence to: Cathy A. Larson PT, PhD, University of Michigan-Flint, Physical Therapy Program, 303 E. Kearsley Street, 2157 WSW, Flint, MI 48502, USA.
| | - Paula M. Dension
- Rehabilitation Institute of Michigan, Center for Spinal Cord Injury Recovery, Detroit, MI, USA
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Whiteneck G, Gassaway J, Dijkers MP, Heinemann AW, Kreider SED. Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: the SCIRehab project. J Spinal Cord Med 2012; 35:484-502. [PMID: 23318033 PMCID: PMC3522893 DOI: 10.1179/2045772312y.0000000057] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE To examine associations of patient characteristics along with treatment quantity delivered by seven clinical disciplines during inpatient spinal cord injury (SCI) rehabilitation with outcomes at rehabilitation discharge and 1-year post-injury. METHODS Six inpatient SCI rehabilitation centers enrolled 1376 patients during the 5-year SCIRehab study. Clinicians delivering standard care documented details of treatment. Outcome data were derived from SCI Model Systems Form I and II and a project-specific interview conducted at approximately 1-year post-injury. Regression modeling was used to predict outcomes; models were cross-validated by examining relative shrinkage of the original model R(2) using 75% of the dataset to the R(2) for the same outcome using a validation subsample. RESULTS Patient characteristics are strong predictors of outcome; treatment duration adds slightly more predictive power. More time in physical therapy was associated positively with motor Functional Independence Measure at discharge and the 1-year anniversary, CHART Physical Independence, Social Integration, and Mobility dimensions, and smaller likelihood of rehospitalization after discharge and reporting of pressure ulcer at the interview. More time in therapeutic recreation also had multiple similar positive associations. Time spent in other disciplines had fewer and mixed relationships. Seven models validated well, two validated moderately well, and four validated poorly. CONCLUSION Patient characteristics explain a large proportion of variation in multiple outcomes after inpatient rehabilitation. The total amount of treatment received during rehabilitation from each of seven disciplines explains little additional variance. Reasons for this and the phenomenon that sometimes more hours of service predict poorer outcome, need additional study. Note: This is the first of nine articles in the SCIRehab series.
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Affiliation(s)
- Gale Whiteneck
- Department of Research, Craig Hospital, Englewood, CO, USA.
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Teeter L, Gassaway J, Taylor S, LaBarbera J, McDowell S, Backus D, Zanca JM, Natale A, Cabrera J, Smout RJ, Kreider SED, Whiteneck G. Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project. J Spinal Cord Med 2012; 35:503-26. [PMID: 23318034 PMCID: PMC3522894 DOI: 10.1179/2045772312y.0000000058] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury. METHODS Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia. RESULTS PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries. CONCLUSION Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.
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Affiliation(s)
| | - Julie Gassaway
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | - Sally Taylor
- Rehabilitation Institute of Chicago, Chicago, IL, USA
| | | | | | | | | | | | | | - Randall J. Smout
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | | | - Gale Whiteneck
- Craig Hospital, Englewood, CO, USA,Correspondence to: Gale Whiteneck, Craig Hospital, 3425 S. Clarkson St, Englewood, CO 80113.
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Practice-Based Evidence Research in Rehabilitation: An Alternative to Randomized Controlled Trials and Traditional Observational Studies. Arch Phys Med Rehabil 2012; 93:S127-37. [DOI: 10.1016/j.apmr.2011.10.031] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 10/19/2011] [Accepted: 10/19/2011] [Indexed: 11/19/2022]
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Abstract
BACKGROUND Research in both humans and animals indicates that physical activity can enhance cognitive activity, but whether this is true in patients with stroke is largely unknown.We aimed to evaluate the relationship between increased physical activity after stroke and cognitive performance. METHODS A systematic review was conducted of MEDLINE, EMBASE, PsycINFO and other electronic databases. All randomized controlled trials and controlled clinical studies that evaluated the effect of physical activity or exercise on cognitive function in stroke were included. Study quality was assessed using four criteria concerning sources of bias (use of randomization, allocation concealment, blinding of outcome assessment, whether all patients were accounted for in outcome data). RESULTS The literature search (first run in 2008, updated in 2011) yielded 12 studies that satisfied inclusion criteria. Exercise interventions were heterogeneous; some studies compared different intensities of movement rehabilitation, others included a specific exercise program. Cognitive function was rarely the primary outcome measure, and cognitive assessment tools used were generally suboptimal. Nine studies had sufficient data to be included in a meta-analysis, which indicated a significant benefit of intervention over control (SMD = 0.20, 95% CI: 0.04–0.36; z = 2.43, p = 0.015). Studies that met all four quality criteria reported smaller treatment benefit than studies that did not. CONCLUSIONS There is some evidence that increased physical activity after stroke enhances cognitive performance. The pool of studies identified, however, was small and methodological shortcomings were widespread.
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Turner-Stokes L, Sutch S, Dredge R, Eagar K. International casemix and funding models: lessons for rehabilitation. Clin Rehabil 2011; 26:195-208. [DOI: 10.1177/0269215511417468] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘An understanding of the different international models for funding of health care services and casemix systems, as exemplified by those in the US, Australia and the UK.’ Background: Payment for treatment in healthcare systems around the world is increasingly based on fixed tariff models to drive up efficiency and contain costs. Casemix classifications, however, must account adequately for the resource implications of varying case complexity. Rehabilitation poses some particular challenges for casemix development. Objective: The objectives of this educational narrative review are (a) to provide an overview of the development of casemix in rehabilitation, (b) to describe key characteristics of some well-established casemix and payment models in operation around the world and (c) to explore opportunities for future development arising from the lessons learned. Results: Diagnosis alone does not adequately describe cost variation in rehabilitation. Functional dependency is considered a better cost indicator, and casemix classifications for inpatient rehabilitation in the United States and Australia rely on the Functional Independence Measure (FIM). Fixed episode-based prospective payment systems are shown to contain costs, but at the expense of poorer functional outcomes. More sophisticated models incorporating a mixture of episode and weighted per diem rates may offer greater flexibility to optimize outcome, while still providing incentive for throughput. Conclusion: The development of casemix in rehabilitation poses similar challenges for healthcare systems all around the world. Well-established casemix systems in the United States and Australia have afforded valuable lessons for other countries to learn from, but have not provided all the answers. A range of casemix and payment models is required to cater for different healthcare cultures, and casemix tools must capture all the key cost-determinants of treatment for patients with complex needs.
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Affiliation(s)
- Lynne Turner-Stokes
- King’s College London School of Medicine, Department of Palliative Care, Policy and Rehabilitation, London, UK
- Regional Rehabilitation Unit, Northwick Park Hospital, Harrow, UK
| | - Stephen Sutch
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kathy Eagar
- University of Wollongong, Centre for Health Service Development, Wollongong, NSW, Australia
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Turner-Stokes L, Sutch S, Dredge R. Healthcare tariffs for specialist inpatient neurorehabilitation services: rationale and development of a UK casemix and costing methodology. Clin Rehabil 2011; 26:264-79. [DOI: 10.1177/0269215511417467] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To describe the rationale and development of a casemix model and costing methodology for tariff development for specialist neurorehabilitation services in the UK. Rationale for development of a new methodology: Patients with complex needs incur higher treatment costs. Fair payment should be weighted in proportion to costs of providing treatment, and should allow for variation over time Casemix model and band-weighting: Case complexity is measured by the Rehabilitation Complexity Scale (RCS). Cases are divided into five bands of complexity, based on the total RCS score. The principal determinant of costs in rehabilitation is staff time. Total staff hours/week (estimated from the Northwick Park Nursing and Therapy Dependency Scales) are analysed within each complexity band, through cross-sectional analysis of parallel ratings. A ‘band-weighting’ factor is derived from the relative proportions of staff time within each of the five bands. Costing methodology: Total unit treatment costs are obtained from retrospective analysis of provider hospitals’ budget and accounting statements. Mean bed-day costs (total unit cost/occupied bed days) are divided broadly into ‘variable’ and ‘non-variable’ components. In the weighted costing model, the band-weighting factor is applied to the variable portion of the bed-day cost to derive a banded cost, and thence a set of cost-multipliers. Preliminary data from one unit are presented to illustrate how this weighted costing model will be applied to derive a multilevel banded payment model, based on serial complexity ratings, to allow for change over time.
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Affiliation(s)
- Lynne Turner-Stokes
- King’s College London School of Medicine, Department of Palliative Care, Policy and Rehabilitation, London, UK
- Regional Rehabilitation Unit, Northwick Park Hospital, Harrow, UK
| | - Stephen Sutch
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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Niemeier JP, Kreutzer JS, Marwitz JH, Gary KW, Ketchum JM. Efficacy of a brief acute neurobehavioural intervention following traumatic brain injury: A preliminary investigation. Brain Inj 2011; 25:680-90. [DOI: 10.3109/02699052.2011.573520] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Whiteneck G, Gassaway J, Dijkers M, Backus D, Charlifue S, Chen D, Hammond F, Hsieh CH, Smout RJ. The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med 2011; 34:133-48. [PMID: 21675353 PMCID: PMC3066504 DOI: 10.1179/107902611x12971826988011] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/30/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs. METHODS Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline. RESULTS Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics. CONCLUSIONS Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.
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Affiliation(s)
- Gale Whiteneck
- Rocky Mountain Regional Spinal Injury System, Craig Hospital, Englewood, CO, USA
| | - Julie Gassaway
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | - Marcel Dijkers
- Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Deborah Backus
- Shepherd Center, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Susan Charlifue
- Rocky Mountain Regional Spinal Injury System, Craig Hospital, Englewood, CO, USA
| | - David Chen
- Rehabilitation Institute of Chicago, Chicago, IL, USA
| | - Flora Hammond
- Carolinas Rehabilitation, Charlotte, NC, USA
- Indiana University, Indianapolis, IN, USA
| | - Ching-Hui Hsieh
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington, DC, USA
| | - Randall J. Smout
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
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Abstract
BACKGROUND Investigating determinants of physical therapy workload in the acute care setting is essential for planning interventions, for justifying resource allocation, and for reimbursement. OBJECTIVE The objective of this study was to examine whether International Classification of Functioning, Disability and Health (ICF) intervention goals (ICF categories representing goals of physical therapy interventions typical for an acute care hospital) could predict physical therapy workload in the acute care hospital setting. DESIGN This investigation was a multicenter, observational cohort study. METHODS Patients were recruited from a representative sample of 32 acute care hospitals across Switzerland if they received physical therapy during their inpatient stay for the treatment of any injury or disease in 1 of 3 main diagnostic categories: musculoskeletal, neurological, and cardiopulmonary conditions. Physical therapists completed questionnaires at the time of the patients' discharge to report on ICF intervention goals. Information on workload was collected retrospectively from hospital documentation systems. Multivariable regression models were used to identify the intervention goals independently associated with workload. RESULTS The mean workload for 642 patients (mean age=61 years [SD=18 years], 45% women) was 370 minutes. The daily workload for interventions ranged from 33 minutes (cardiopulmonary conditions) to 49 minutes (neurological conditions). There were significant variations in workload across hospital sites and medical disciplines. The goal "maintaining a body position" emerged as a significant indicator of a higher workload for all condition groups; the goals "attention functions" and "transferring oneself" were indicators for neurological and musculoskeletal conditions, respectively. LIMITATIONS Not all potential predictors of workload could be examined. Other, person- or setting-specific variables might have been relevant to workload. Case mix and clinical practice were representative only for Swiss hospitals. CONCLUSIONS A small set of intervention goals were the major factors influencing physical therapy workload, independent of diagnosis or clinical specialty. Describing variability in physical therapists' practices in the acute care setting and relating these data to relevant patient-centered outcomes are the initial steps for improving resource allocation and reimbursement for interventions that maintain or improve functioning.
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Practice based evidence: incorporating clinical heterogeneity and patient-reported outcomes for comparative effectiveness research. Med Care 2010; 48:S17-22. [PMID: 20421825 DOI: 10.1097/mlr.0b013e3181d57473] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Comparative effectiveness research analyzes groups of patients and looks for associations between medical treatments and patient outcomes. To make meaningful comparisons of medical interventions, one must consider clinical heterogeneity of patient populations, intervention combinations, and outcomes. OBJECTIVES To explain how practice-based evidence (PBE) study methodology measures and controls for heterogeneity of patients, treatments, and outcomes seen in real-world clinical settings. RESEARCH DESIGN Overview of PBE methodology. CONCLUSIONS PBE study designs address comparative effectiveness by creating a comprehensive set of patient, treatment, and outcome variables, and analyzing them to identify treatments associated with better outcomes for specific types of patients. PBE studies are an alternative to randomized controlled trials, well suited to determine what works best for specific patient types, and provide clinicians with a rational basis for treatment recommendations for individual patients. They provide a holistic picture of patients, treatments, and outcomes, with no preset limits to the number of variables that can be included. Such an approach is needed for high quality comparative effectiveness research.
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Whiteneck G, Gassaway J. SCIRehab: a model for rehabilitation research using comprehensive person, process and outcome data. Disabil Rehabil 2010; 32:1035-42. [DOI: 10.3109/09638281003775584] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences exist in post-injury outcomes after TBI? A comprehensive review of the literature. Brain Inj 2009; 23:775-89. [DOI: 10.1080/02699050903200563] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cartwright DL, Madill HM, Dennis S. Cognitive Impairment and Functional Performance of Patients Admitted to a Geriatric Assessment and Rehabilitation Centre. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2009. [DOI: 10.1080/j148v14n03_01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pyöriä O, Talvitie U, Nyrkkö H, Kautiainen H, Pohjolainen T, Kasper V. The effect of two physiotherapy approaches on physical and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary follow-up study. Disabil Rehabil 2009; 29:503-11. [PMID: 17364805 DOI: 10.1080/09638280600902497] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Activating physiotherapy was used to support the principle of post stroke functional recovery as a learning process which requires both cognitive and physical actions. The purpose of the present preliminary study was to examine the influence of activating physiotherapy on stroke patients' cognitive and physical functions and independent living at home compared with traditional treatment over a 12-month follow-up. METHODS The 40 patients who received activating physiotherapy were compared with 40 patients receiving traditional therapy. Patients' physical functional capacity was measured one week and 12 months post stroke with the Barthel Index (BI), 10-m gait speed, the Postural Control and Balance for Stroke (PCBS) test, walking distances and patients' abilities to cope without outside help. Cognitive capacity was measured with specific neuropsychological tests: language, visuospatial functions, visual inattention and memory. RESULTS Physical functional capacity improved significantly (p = 0.001) in both groups at the 12-month follow-up, but no significant differences were found between groups. However, the patients in the activating therapy group coped better without outside help (p = 0.042) and covered longer distances outdoors (p = 0.012). At follow-up all the measured cognitive functions had improved significantly in the activating therapy group and the change in memory in the same group differed significantly from that in the traditional therapy group (p < 0.001), where no significant improvement was observed. CONCLUSIONS Activating therapy advanced stroke patients' cognitive and physical functional recovery and supported their return to independent life at home more than did traditional physiotherapy. In this respect activating therapy seems to have a beneficial influence on long-term stroke rehabilitation.
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Affiliation(s)
- Outi Pyöriä
- Central Hospital of Savonlinna, Physical Therapy Services, Savonlinna, Finland.
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Riis V, Verrier MC. Outpatient spinal cord injury rehabilitation: Managing costs and funding in a changing health care environment. Disabil Rehabil 2009; 29:1525-34. [PMID: 17852226 DOI: 10.1080/09638280601055741] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans. METHOD Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation. RESULTS There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation. CONCLUSIONS A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.
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Affiliation(s)
- V Riis
- Graduate Department of Rehabilitation Science, Faculty of Medicine, University of Toronto, Toronto, Canada
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Zhu XL, Poon WS, Chan CCH, Chan SSH. Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Inj 2009; 21:681-90. [PMID: 17653942 DOI: 10.1080/02699050701468941] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI). DESIGN AND METHODS Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed. OUTCOME AND RESULTS No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044). CONCLUSIONS Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.
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Affiliation(s)
- X L Zhu
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, PR China
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Wilson C, Huston T, Koval J, Gordon SA, Schwebel A, Gassaway J. SCIRehab Project series: the psychology taxonomy. J Spinal Cord Med 2009; 32:319-28. [PMID: 19810633 PMCID: PMC2718824 DOI: 10.1080/10790268.2009.11760785] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
CONTEXT The integration of psychologists as members of the rehabilitation team has occurred in conjunction with the evolution and adoption of interdisciplinary teams as the standard of care in spinal cord injury (SCI) rehabilitation. Although the value of psychological services during rehabilitation is endorsed widely, specific interventions and their association with patient outcomes have not been examined adequately. OBJECTIVE To address this shortcoming, psychologists from 6 SCI centers collaborated to develop a psychology intervention taxonomy and documentation framework. METHODS Utilizing an interactive process, the lead psychologists from 6 centers compiled an inclusive list of patient characteristics assessed and interventions delivered in routine psychological practice at the participating rehabilitation facilities. These were systematically grouped, defined, and compared. RESULTS The resulting taxonomy became the basis of a documentation framework utilized by psychologists for the study. The psychology taxonomy includes 4 major clinical categories (assessment, psychotherapeutic interventions, psychoeducational interventions, and consultation) with 5 to 10 specific activities in each category. CONCLUSIONS Examination of psychological interventions and their potential association with positive outcomes for persons who sustain SCI requires the development of a taxonomy. Results of these efforts illustrate similarities and differences in psychological practice among SCI centers and offer the opportunity to blend research and clinical practice in an innovative approach to evidence-based practice improvement. The established taxonomy provides a basic framework for future studies on the effect of psychological interventions.
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Affiliation(s)
- Catherine Wilson
- 1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4National Rehabilitation Hospital, Washington, DC; 5Carolinas Rehabilitation, Charlotte, North Carolina; 6Institute for Clinical/Outcomes Research, Salt Lake City, Utah
| | - Toby Huston
- 1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4National Rehabilitation Hospital, Washington, DC; 5Carolinas Rehabilitation, Charlotte, North Carolina; 6Institute for Clinical/Outcomes Research, Salt Lake City, Utah
| | - Jill Koval
- 1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4National Rehabilitation Hospital, Washington, DC; 5Carolinas Rehabilitation, Charlotte, North Carolina; 6Institute for Clinical/Outcomes Research, Salt Lake City, Utah
| | - Samuel A Gordon
- 1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4National Rehabilitation Hospital, Washington, DC; 5Carolinas Rehabilitation, Charlotte, North Carolina; 6Institute for Clinical/Outcomes Research, Salt Lake City, Utah
| | - Andrea Schwebel
- 1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4National Rehabilitation Hospital, Washington, DC; 5Carolinas Rehabilitation, Charlotte, North Carolina; 6Institute for Clinical/Outcomes Research, Salt Lake City, Utah
| | - Julie Gassaway
- 1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4National Rehabilitation Hospital, Washington, DC; 5Carolinas Rehabilitation, Charlotte, North Carolina; 6Institute for Clinical/Outcomes Research, Salt Lake City, Utah
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