Satisfaction with medical rehabilitation after spinal cord injury

Spinal cord injury rehabilitation patient and physical therapist perspective: a pilot study

The objectives of this retrospective observational study were to explore physical therapists' perceived involvement of patients with SCI in physical therapy (PT) rehabilitation, second to explore individuals with SCI perceived involvement in PT rehabilitation, third to compare how patients and physical therapists perceive involvement in PT rehabilitation and last to explore patients' perceived involvement with satisfaction with life (SWL). This study was conducted in the United States. Two 11-item questionnaires were designed one for physical therapists and one for patients. The items were rated on a Likert-type agreement scale. Thirty physical therapists completed the patient involvement questionnaire for physical therapists and nine individuals with SCI completed the patient involvement questionnaire and SWL scale. We certify that all applicable governmental and institutional guidelines were followed during the course of this research. The results indicated that both physical therapists and patients were overall in agreement that patients were involved in their PT rehabilitation on most items. The two items that received the lowest Likert scores by the therapists and patients were friends and family involvement in therapy and gender-related issues. The item, individualized patient goals, received the largest discrepancy between therapists and patients. The sample size was too small to observe a trend with SWL and perceived involvement. Patients and PTs from this pilot overall agree patients are included in treatment; however, the discrepancy in scores related to individualized goals requires further research.

Factors predicting client satisfaction in occupational therapy and rehabilitation

Client satisfaction, a widely used outcome indicator of quality in health care, is inherently client centered and important in occupational therapy. We developed an instrument called the Satisfaction With Continuum of Care Revised (SCC-R) and tested a logistic regression model of satisfaction for six predictive research questions. Data collected from 769 clients from a large rehabilitation hospital using the SCC-R were paired with data that included demographics, functional status, and measures of the rehabilitation including occupational therapy. Satisfaction was stratified into two groups, satisfied and dissatisfied. The most robust and consistent predictors of satisfaction were functional status and improvements in functional status, presence of a neurological disorder, total rehabilitation hours, and admission to rehabilitation within 15 days of condition onset. The finding that improvements in functional status, especially self-care, were predictive of satisfaction is particularly relevant for occupational therapy. Implications for practice and future research are discussed.

Does sagittal position of the CTDR-related centre of rotation influence functional outcome? Prospective 2-year follow-up analysis

PURPOSE

Recent studies describe significant rates of heterotopic ossification (HO) after cervical total disc replacement (CTDR). Little is known about the reasons, and one aspect that requires further in vivo investigation is the biomechanical alteration after CTDR and the role of the implant-related centre of rotation (CORi) in particular. The role of the sagittal position of the CORi on functional outcome in two versions of a semi-constrained disc prosthesis with sagittally different CORi is the topic of this study.

METHODS

Patients were candidates for single-level CTDR between C3 and C7 who suffered from CDDD and received a standard or flat version of activ C™ (Aesculap AG, Tuttlingen). Clinical and radiographic assessments were determined preoperatively, intraoperatively, at discharge and again at 6 weeks, 6 months, 1 and 2 years. Radiographic examinations were performed independently using specialized quantitative motion analysis software.

RESULTS

Clinical outcome improved significantly regarding NDI as well as VAS on neck and arm pain with no differences in mean improvement by study group. Segmental angle measures show a significantly better lordotic alignment for both groups after surgery, but the degree of correction achieved is higher in the flat group. Correlation analysis proves that the more anterior the CORi is positioned, the higher the lordotic correction is achieved (Pearson rho -0.385). Segmental ROM decreased in the standard group but was maintained for flat implants. At present, our data do not demonstrate a correlation between CORi and ROM at 2 years. Two years after surgery, severe HO grade III-IV was present in 31.6 % standard and 13.1 % flat cases with significant differences. Grouping according to HO severity showed comparable sagittal positions of CORi for flat implants but a more posterior position in the severe HO group for standard implants.

CONCLUSIONS

Our results confirm the influence of CORi location on segmental alignment, kinematics and HO for a semi-constrained CTDR, but it also indicates a multifactorial process.

Prospective analysis of imaging prediction of pseudarthrosis after anterior cervical discectomy and fusion: computed tomography versus flexion-extension motion analysis with intraoperative correlation

STUDY DESIGN

A prospective comparison of quantitative motion analyzed (QMA) flexion/extension radiographs versus computed tomography (CT) as an analytical predictor of cervical pseudarthrosis. Intraoperative confirmation of the fusion was performed.

OBJECTIVE

To prospectively compare motion analyzed flexion/extension radiographs to CT to predict pseudarthroses. Define motion thresholds on flexion/extension radiographs to define pseudarthroses.

SUMMARY OF BACKGROUND DATA

Assessment of postoperative fusion success is an important factor in assessing success after anterior cervical spine fusion. Gross intervertebral motion can be used as a measure; however, the current "gold standard" for determining fusion status is a CT to assess bridging bone. Defining the amount of intervertebral motion at the fusion site has been previously addressed and definitions have varied widely.

METHODS

Data were analyzed at 47 fusion segments. Intervertebral motion at the fusion site was measured from flexion/extension radiographs taken at least 1 year after the cervical spine fusion. Motion was quantified from digitized radiographs by an independent researcher using proprietary quantitative motion analysis (QMA) software. CT scans on all patients were analyzed for fusion status by a neuroradiologist. Those patients determined to have a symptomatic pseudarthrosis were revised and intraoperative motion at the facet joints was documented. Correlation between intraoperative findings, CT and QMA was performed.

RESULTS

Using greater than 4° of measured motion on flexion/extension radiographs resulted in a Spearman correlation P-value of 0.096 (95% confidence interval: -0.06 to 0.66). Using greater than 1° of motion, the Spearman correlation P < 0.0001 (95% CI: 0.54-0.90). The positive predictive value (PPV) using 4° of motion as the criterion was 100%, indicating a high specificity. The negative predictive value (NPV) was 52%, indicating a low sensitivity. Using greater than 1° of motion, the PPV was 100% and the NPV was 73%. Findings from CT showed an identical PPV and NPV to assessments made using greater than 1° of rotation. Specificity and positive predictive value were 100% for all criteria. Using a lack of bridging on CT or more than 1° of intervertebral motion during flexion/extension increased the sensitivity to 85% and the negative predictive value to 85%.

CONCLUSION

A threshold level of 4° of motion is commonly used to identify a pseudarthrosis. Our prospective study suggests that this value has a high PPV, but a low specificity and would miss many of the pseudarthroses that have angular motion less than 4° (sensitivity 23%). By lowering the threshold for angular motion to 1°, the sensitivity improves to 77%. CT scan has been touted as the gold standard, and it has a high positive predictive value of 100%. However, its NPV was slightly lower than using 1° of motion on QMA analyzed flexion-extension films (73% vs. 79%). In conclusion, although CT scan has long been regarded as the gold standard for determining a pseudarthrosis in the cervical spine, the interpretation is subjective and vulnerable to both type I and type II errors. Analysis of motion using Quantitative Motion Analysis is seemingly less subjective than CT and in our prospective study was more predictive of an operatively confirmed pseudarthrosis.

Towards personalized care for persons with spinal cord injury: a study on patients' perceptions

OBJECTIVE/BACKGROUND

A newly designed Spinal Cord Unit (SCU) was set up at the Orthopedic Traumatology Center (OTC), Turin, Italy, in July 2007. With the relocation of the SCU came the need to reorganize and improve the delivery of its services. The study reported here is a preliminary part of a project entitled 'Experimentation and evaluation of personalized healthcare for patients with spinal cord injury', which is a component of an overarching program of targeted research into healthcare funded by the Piedmont Region in 2006. The aim of this study was to assess the perception of care by patients with spinal cord injury (SCI) by collecting important data in order to determine whether an integrated and personalized care pathway could be effective both in hospital and in a rehabilitation setting.

DESIGN

Qualitative research study. The interview format was based on a narrative approach.

METHODS

Qualitative in-depth semi-structured interviews were conducted with 21 patients with SCI. Qualitative content analysis was used to identify categories and themes arising from the data.

RESULTS

Six main categories emerged from the perspectives of patients: expectations of rehabilitation care, impact and welcome, relationship with nurses and their involvement in treatment, relationship with physical therapists and participation in rehabilitation programs, relationship with physicians and their availability and attendance, and imparting of information on injury and rehabilitation outcomes. Care was the aspect new patients admitted to the SCU found most important. When closer relationships with staff formed, the healthcare professionals became an essential support. Patients with SCI commonly stated that receiving explicit information was necessary for accepting their condition.

CONCLUSIONS

Analysis of the patients' perceptions revealed a wealth of details on their experience in the SCU and the need for flexible planning of care time in particular. Incorporating the patients' perceptions into a new care model could increase professionals' awareness of patients' needs and provide a useful basis for constructing a personalized care plan.

The Effect of Medicare's Prospective Payment System on Patient Satisfaction

OBJECTIVE

To examine the impact of Medicare's Prospective Payment System (PPS) on patient satisfaction at four inpatient rehabilitation hospitals.

DESIGN

Prospective study using a satisfaction survey to examine the effects of Medicare's PPS for rehabilitation hospitals. Surveys were conducted at four affiliated rehabilitation hospitals in the Midwest.

RESULTS

Patient characteristics varied only slightly pre- to post-PPS, and several characteristics were related to overall satisfaction, including motor functional gain, discharge to home, and respondent (patient or proxy). A 12-point increase on a 12-item motor function scale resulted in 1.13 greater odds (95% CI: 1.04, 1.24) of reporting excellent satisfaction. Patient respondents were 1.27 times more likely (95% CI: 1.07, 1.50) than proxies to report excellent satisfaction, and patients discharged home were 1.65 times more likely (95% CI: 1.31, 2.07) to report excellent satisfaction than patients discharged elsewhere. We found an increase in observed satisfaction from 60.3 to 63.4% (P < 0.05) after PPS implementation, despite a decrease in motor FIM gain.

CONCLUSIONS

Patient characteristics such as motor FIM gain, discharge status, and respondent type were significantly associated, although only slightly, with patient satisfaction in inpatient rehabilitation. Percentage of excellent satisfaction improved at these four facilities after PPS implementation, despite declines in motor FIM gain. The improvement may be the result of numerous ongoing quality-improvement initiatives directed at improving patient satisfaction at these facilities.

Radiographic assessment and quantitative motion analysis of the cervical spine after serial sectioning of the anterior ligamentous structures

STUDY DESIGN

Cadaveric study of a diagnostic test for cervical spine instability.

OBJECTIVE

Determine if flexion-extension (FE) radiographs can be used to detect incremental damage to anterior cervical structures.

SUMMARY OF BACKGROUND DATA

Prior studies have shown that damage to cervical structures can alter motion between vertebrae, and FE radiographs are sometimes used to detect this damage. However, no study has determined if FE radiographs are sensitive and specific for acute injury.

METHODS

FE radiographs were taken of the intact neck and after each incremental increase in damage to the anterior structures. Intervertebral motion was quantified using previously validated methods. The sensitivity and specificity of intervertebral motion measurements were assessed.

RESULTS

Motion within the intact spines was within normal ranges. Although intervertebral rotation changed significantly after certain anterior structures were damaged, rotation frequently remained within normal ranges, even after extensive damage. A center of rotation that was posterior to the 95% confidence interval for normal motion was 100% sensitive and specific for damage to the anterior structures of the spine.

CONCLUSIONS

The results suggest that extensive damage to the anterior cervical spine could be missed if instability assessment was based on intervertebral rotation or displacements measured from FE radiographs. In contrast, a center of rotation that was located posterior to normal was both sensitive and specific for damage to anterior structures.

Orthopedic impairment after medical rehabilitation: functional performance and satisfaction with community participation

OBJECTIVE

To determine the prevalence of satisfaction with community participation and to examine associations between change in functional status and satisfaction with community participation for persons with orthopedic impairments.

DESIGN

Retrospective study of 3832 patients discharged from medical rehabilitation facilities in 2001 using information from the IT Health Track database.

RESULTS

Primary measures were the FIM instrument and satisfaction with community participation. The majority of patients (86.9%) were satisfied (very or somewhat) with their level of community participation. Positive-change scores in FIM total from admission to the 80- to 180-day follow-up were associated with an 8% increased odds of being in a higher satisfaction with community participation level (odds ratio, 1.08; 95% confidence interval: 1.07, 1.09) after controlling for age, gender, marital status, race/ethnicity, insurance source, length of stay and functional status. Similarly, positive-change score in motor (odds ratio, 1.09; 95% confidence interval: 1.08, 1.10) and cognition (odds ratio, 1.26; 95% confidence interval: 1.19, 1.32) FIM measures from admission to follow-up were associated with greater satisfaction with community participation.

CONCLUSION

Gains in functional status were significantly associated with greater satisfaction with community participation. Satisfaction with community participation provides information useful to evaluate patient recovery after discharge from inpatient medical rehabilitation.

Intervertebral motion after incremental damage to the posterior structures of the cervical spine

STUDY DESIGN

Compare intervertebral motion after incremental damage to posterior cervical structures in whole cadavers to motion in asymptomatic subjects.

OBJECTIVE

Determine if damage to the posterior structures of the cervical spine can be detected by quantitative analysis of flexion-extension radiographs.

SUMMARY OF BACKGROUND DATA

Simulated damage to the posterior structures of the cervical spine can change intervertebral motion, if intervertebral motion before damage is known. It is not known if intervertebral motion measured from flexion-extension radiographs can be used to detect damage to the posterior structures if motion before damage is not known.

METHODS

Incremental injury to posterior ligaments and facet joints was simulated in 12 whole cadavers. Intervertebral motion was measured from flexion-extension images using validated and clinically applicable software. Measurements were compared to previously published measurements for asymptomatic subjects.

RESULTS

Extensive damage could be simulated in all the cervical spines without intervertebral motion exceeding the 95% confidence limits for asymptomatic subjects. After sectioning all posterior ligaments, destroying both facet joints, and then sectioning the posterior longitudinal ligaments, intervertebral motion exceeded the 95% confidence intervals in 69% of the cadavers. Intervertebral shear decreased with incremental damage to posterior structures.

CONCLUSIONS

Radiographic assessment of the cervical spine may not be sufficient to exclude even extensive damage to the posterior structures of the cervical spine.

Patients' perspective on the comprehensive preventive health evaluation in veterans with spinal cord injury

STUDY DESIGN

Survey research methods.

OBJECTIVES

To assess patient satisfaction with the annual comprehensive preventative health evaluation (CPHE) and to determine if the patient's needs were being met.

SETTING

Department of Veterans Affairs National Survey, United States.

METHODS

A total of 853 subjects with spinal cord injuries participated in a mailed survey regarding the annual CPHE. Subjects were asked about satisfaction with the examination, preferences on how the examination is conducted and whether their needs were being met with the examination.

RESULTS

In all, 76% of the subjects that responded to the survey had completed a CPHE within the previous year. Subjects cited getting their medication and supplies refilled and talking to the doctor as the top two reasons for completing the evaluation. Subjects indicated that they would most like to discuss their muscle strength and weakness, bladder care, chronic pain, digestion and bowel care issues, and equipment problems during their evaluation. The majority of subjects (81%) indicated that they were satisfied with the CPHE. Subjects that were satisfied with the CPHE were also more satisfied with other aspects of care as well.

CONCLUSION

The majority of respondents had completed a CPHE within the previous year. Most respondents cite health issues related to the spinal cord injury as areas they would most like to discuss during the evaluation. The majority of subjects were satisfied with the conduct of the CPHE.

Relationship of depression to patient satisfaction: findings from the barriers to breast cancer study

OBJECTIVE

Examine the association between depressive symptoms and patient satisfaction for older women with a diagnosis of breast cancer.

METHODS

Prospective study of 210 women aged 65 or older from southeast Texas newly diagnosed with breast cancer. Baseline (<2 months after diagnosis) and 12 month follow-up interviews were conducted face-to-face to collect information on sociodemographic characteristics, physical and emotional health, use of health services and satisfaction with medical care. Data analyses included descriptive statistics, chi2 analysis, and multivariate logistic regression analysis.

RESULTS

Average age at baseline interview was 71.8 years (SD 6.6). The sample was 70.5% non-Hispanic white, 61.0% were unmarried, and 85.2% reported no ADL limitations. Logistic regression analysis showed a significant association between increasing depressive symptoms at baseline and lower patient satisfaction at follow-up. Each unit increase in depressive symptoms at baseline was associated with a 6% decrease in the predicted odds of being "very satisfied" with medical care at follow up (OR = 0.94, 95% CI = 0.89, 0.99), after adjusting for age, marital status, race/ethnicity, stage of diagnosis and other relevant factors. Similarly, patients who had an increase in CES-D score between baseline and follow-up interview were less likely to be satisfied with their medical care at follow up.

CONCLUSION

Increasing depressive symptoms are associated with lower patient satisfaction. Early recognition and treatment of depressive symptoms may improve patients' well being and perception about quality of medical care.