Use of the Barthel Index and the Functional Independence Measure during early inpatient rehabilitation after single incident brain injury

Survival and predictive factors of clinical outcome in patients with severe acquired brain injury

BACKGROUND

Despite the many tools available to modern medicine, predicting the neurological and functional status of patients after severe brain injury remains difficult.

AIM

This analysis evaluates the outcomes of patients with the most severe degree of cerebral function impairment.

DESIGN

Retrospective cohort study.

SETTING

Patients hospitalized in the long-term Intensive Care Unit (ICU) department in the Military University Hospital in Prague between 2015-2022.

POPULATION

We analyzed patients with severe acquired brain damage from five distinct etiologies whose initial Glasgow Coma Scale (GCS) score was eight or less upon admission to ICU due to neurological damage.

METHODS

Several parameters reflecting the patients' clinical status were evaluated. Overall survival after discharge from the ICU was calculated according to the Kaplan-Meier model with comparison between traumatic (TR) and non-traumatic (non-TR) etiologies.

RESULTS

The analyzed cohort of 221 patients consisted of 116 patients of TR and 105 of non-TR etiology. There was no significant difference in overall survival between TR and non-TR groups. The length of hospitalization in the ICU was similar in both groups with a median of 94 days. The majority of patients had an improvement of GCS during the hospitalization with a median improvement of five points. GCS improvement occurred in the vast majority of patients regardless of TR or non-TR etiology.

CONCLUSIONS

We did not observe a statistically significant difference in mortality or log-term neurological status between patients with severe brain injury of traumatic or non-traumatic etiology for the duration of our follow-up. The majority of patients had improved GCS, were successfully decannulated, but remained disabled with severe limitations of functional independence.

CLINICAL REHABILITATION IMPACT

The return of the patient to normal life is a rehabilitation challenge, regardless of the etiology of brain injury, and is extremely influenced by the level of development of neurorehabilitation programs in individual institutions, the severity of brain injury, and the individual motivation of the patient.

Electroencephalographic spectrogram-guided total intravenous anesthesia using dexmedetomidine and propofol prevents unnecessary anesthetic dosing during craniotomy: a propensity score-matched analysis

BACKGROUND

The bispectral index (BIS) may be unreliable to gauge anesthetic depth when dexmedetomidine is administered. By comparison, the electroencephalogram (EEG) spectrogram enables the visualization of the brain response during anesthesia and may prevent unnecessary anesthetic consumption.

METHODS

This retrospective study included 140 adult patients undergoing elective craniotomy who received total intravenous anesthesia using a combination of propofol and dexmedetomidine infusions. Patients were equally matched to the spectrogram group (maintaining the robust EEG alpha power during surgery) or the index group (maintaining the BIS score between 40 and 60 during surgery) based on the propensity score of age and surgical type. The primary outcome was the propofol dose. Secondary outcome was the postoperative neurological profile.

RESULTS

Patients in the spectrogram group received significantly less propofol (1585 ± 581 vs. 2314 ± 810 mg, P < 0.001). Fewer patients in the spectrogram group exhibited delayed emergence (1.4% vs. 11.4%, P = 0.033). The postoperative delirium profile was similar between the groups (profile P = 0.227). Patients in the spectrogram group exhibited better in-hospital Barthel's index scores changes (admission state: 83.6 ± 27.6 vs. 91.6 ± 17.1; discharge state: 86.4 ± 24.3 vs. 85.1 ± 21.5; group-time interaction P = 0.008). However, the incidence of postoperative neurological complications was similar between the groups.

CONCLUSIONS

EEG spectrogram-guided anesthesia prevents unnecessary anesthetic consumption during elective craniotomy. This may also prevent delayed emergence and improve postoperative Barthel index scores.

Minimal clinically important difference of the functional independence measure in older adults with hip fracture

PURPOSE

To investigate the responsiveness and minimal clinically important difference (MCID) of the Functional Independence Measure (FIM) from a clinician's perspective in hip-fractured elderly undergoing inpatient rehabilitation.

MATERIALS AND METHODS

Data of 701 hip-fractured elderly admitted to our rehabilitation institute were retrospectively collected. Ten a priori hypotheses were formulated.

RESULTS

The effect size of the FIM scores after treatment were large (total = 1.38, motor = 1.78). Moderate correlations were found between the change total score of FIM and Barthel Index (BI, rs = 0.51), Functional Ambulation Categories (FAC, rs = 0.52) and a checklist regarding participants' independence in transfers (rs = 0.59). The area under the receiving operating characteristics were 0.82, 0.81, and 0.85 when BI, FAC and checklist were used as anchors, respectively. Based on these findings, the FIM showed high responsiveness (9/10 hypotheses met). Triangulation of findings showed that MCIDs of 22 and 21 points were the most appropriate for the FIM total and motor score, respectively.

CONCLUSIONS

The FIM scale is appropriate for assessing independence and functional recovery in hip-fractured elderly. Improvements of 22 and 21 points at the total and motor FIM were identified as indicators of minimal clinical change in those admitted to a rehabilitation facility with an FIM total score between 40 and 80.

The structure of the Early Rehabilitation Barthel Index (ERBI) should be modified: evidence from a Rasch analysis study

BACKGROUND

The Early Rehabilitation Barthel Index (ERBI) comprises seven items of the Early Rehabilitation Index and ten items of the Barthel Index. The ERBI is usually used to measure functional changes in patients with severe acquired brain injury (sABI), but its measurement properties have yet to be extensively assessed.

AIM

To study the unidimensionality and internal construct validity (ICV) of the ERBI through Confirmatory Factor Analysis (CFA), Mokken Analysis (MA), and Rasch Analysis (RA).

DESIGN

Multicenter prospective study.

SETTING

Inpatients from five intensive rehabilitation centers.

POPULATION

Two hundred and forty-seven subjects with sABI.

METHODS

ERBI was administered on admission and discharge to study its unidimensionality through CFA and MA and its ICV, reliability, and targeting through RA.

RESULTS

The preliminary analyses showed a lack of unidimensionality (RMSEA=0.460 >0.06; SRMR=0.176 >0.06; CFI=1.000 >0.950; TLI=1.000 >0.950). According to CFA, "Confusional state" and "Behavioral disturbance" items showed low factor loadings (<0.40), whereas these two items composed a separate scale within the MA. Furthermore, the baseline RA showed that three items misfitted ("Mechanical ventilation," "Confusional state," "Behavioral disturbances") and a lack of conformity of several ICV requirements. After deletion of three misfitting items and further non-structural modifications (i.e., testlets creation to absorb local dependence between items and item misfit), the solution obtained showed adequate ICV, adequate reliability for measurements at the individual level (PSI>0.85), although with a frank floor effect. This final solution was successfully replicated in a total sample of the subjects. After post-hoc modifications of the score structure of two out of three misfitting items, the subsequent CFA (RMSEA=0.044 <0.06; SRMR=0.056 <0.06; CFI=1.000 >0.950 TLI=1.000 >0.950) and MA showed the resolution of the unidimensional issues.

CONCLUSIONS

Although the ERBI is a potentially valuable tool for measuring functioning in the coma-to-community continuum, our analyses suggested its lack of ICV, partly due to an incorrect scoring design of some items. A new perspective multicenter study is proposed to validate a modified version of the ERBI that overcomes the problems highlighted in this analysis.

CLINICAL REHABILITATION IMPACT

Our results do not support the use of the original structure of the ERBI in clinical practice and research, as a lack of ICV was highlighted.

Citicoline on the Barthel Index: Severe and moderate brain injury

INTRODUCTION

Traumatic brain injury (TBI) is a paramount factor in mortality and morbidity. The clinical trials conducted to investigate the efficacy of neuroprotective agents, such as citicoline, as a therapeutic alternative for TBI have presented divergent findings. Therefore, this study aimed to evaluate and compare citicoline's effect on the Barthel Index in patients with severe and moderate brain injury.

MATERIALS AND METHODS

The study is a randomized clinical trial. Patients in the case group (35 patients) were treated with citicoline and the control group (34 patients) received a placebo. Data were analyzed using SPSS 16 software.

RESULTS

The results showed that changes in the Glasgow Coma Scale, changes in quadriceps muscle force score, Barthel Index score changes, achieving the status without intubation, and spontaneous breathing in patients treated with citicoline were not a statistically significant difference in the two groups (P > 0.05).

CONCLUSION

Findings revealed that citicoline did not impact the recovery process of severe and moderate TBI patients.

Predictive model for early functional outcomes following acute care after traumatic brain injuries: A machine learning-based development and validation study

INTRODUCTION

Few studies on early functional outcomes following acute care after traumatic brain injury (TBI) are available. The aim of this study was to develop and validate a predictive model for functional outcomes at discharge for TBI patients using machine learning methods.

PATIENTS AND METHODS

In this retrospective study, data from 5281 TBI patients admitted for acute care who were identified in the Beijing hospital discharge abstract database were analysed. Data from 4181 patients in 52 tertiary hospitals were used for model derivation and internal validation. Data from 1100 patients in 21 secondary hospitals were used for external validation. A poor outcome was defined as a Barthel Index (BI) score ≤ 60 at discharge. Logistic regression, XGBoost, random forest, decision tree, and back propagation neural network models were used to fit classification models. Performance was evaluated by the area under the receiver operating characteristic curve (AUC), the area under the precision-recall curve (AP), calibration plots, sensitivity/recall, specificity, positive predictive value (PPV)/precision, negative predictive value (NPV) and F1-score.

RESULTS

Compared to the other models, the random forest model demonstrated superior performance in internal validation (AUC of 0.856, AP of 0.786, and F1-score of 0.724) and external validation (AUC of 0.779, AP of 0.630, and F1-score of 0.604). The sensitivity/recall, specificity, PPV/precision, and NPV of the model were 71.8%, 69.2%, 52.2%, and 84.0%, respectively, in external validation. The BI score at admission, age, use of nonsurgical treatment, neurosurgery status, and modified Charlson Comorbidity Index were identified as the top 5 predictors for functional outcome at discharge.

CONCLUSIONS

We established a random forest model that performed well in predicting early functional outcomes following acute care after TBI. The model has utility for informing decision-making regarding patient management and discharge planning and for facilitating health care quality assessment and resource allocation for TBI treatment.

Analysis of the effect of patients' health status on efficiency: Application of data envelopment analysis in healthcare

The effective and efficient operation of public healthcare systems is more and more important as a consequence of the increasing amount of money spent on their operation. For this reason, accurate and science-based efficiency information is needed for managers and healthcare policy makers. The evaluation of the efficiency in this sector is particularly difficult because several measures and indicators are used. Data envelopment analysis (DEA) can provide aggregate and overall measures of efficiency. The purpose of this paper is the examination of the efficiency of in-patient rehabilitation units curing musculoskeletal disorders in Hungary. The research presented focuses on rehabilitation units which attend to patients recovering from stroke or other acquired brain injuries. Output-oriented, slack-based DEA models are applied for the evaluation of in-patient rehabilitation units using data of a national survey. The novelty of the method presented is the consideration of the change in patients' functional status when efficiency is evaluated using DEA.

Neuroprotective effects of intraoperative dexmedetomidine versus saline infusion combined with goal-directed haemodynamic therapy for patients undergoing cranial surgery: A randomised controlled trial

BACKGROUND

By inhibiting neuroinflammation dexmedetomidine may be neuroprotective in patients undergoing cranial surgery, but it reduces cardiac output and cerebral blood flow.

OBJECTIVE

To investigate whether intra-operative dexmedetomidine combined with goal-directed haemodynamic therapy (GDHT) has neuroprotective effects in cranial surgery.

DESIGN

A double-blind, single-institution, randomised controlled trial.

SETTING

A single university hospital, from April 2017 to April 2020.

PATIENTS

A total of 160 adults undergoing elective cranial surgery.

INTERVENTION

Infusion of dexmedetomidine (0.5 μg kg-1 h-1) or saline combined with GDHT to optimise stroke volume during surgery.

MAIN OUTCOME MEASURES

The proportion who developed postoperative neurological complications was compared. Postoperative disability was assessed using the Barthel Index at time points between admission and discharge, and also the 30-day modified Rankin Scale (mRS). Postoperative delirium was assessed. The concentration of a peri-operative serum neuroinflammatory mediator, high-mobility group box 1 protein (HMGB1), was compared.

RESULTS

Fewer patients in the dexmedetomidine group developed new postoperative neurological complications (26.3% vs. 43.8%; P = 0.031), but the number of patients developing severe neurological complications was comparable between the two groups (11.3% vs. 20.0%; P = 0.191). In the dexmedetomidine group the Barthel Index reduction [0 (-10 to 0)] was less than that in the control group [-5 (-15 to 0)]; P = 0.023, and there was a more favourable 30-day mRS (P = 0.013) with more patients without postoperative delirium (84.6% vs. 64.2%; P = 0.012). Furthermore, dexmedetomidine induced a significant reduction in peri-operative serum HMGB1 level from the baseline (222.5 ± 408.3 pg ml-1) to the first postoperative day (152.2 ± 280.0 pg ml-1) P = 0.0033. There was no significant change in the control group. The dexmedetomidine group had a lower cardiac index than did the control group (3.0 ± 0.8 vs. 3.4 ± 1.8 l min-1 m-2; P = 0.0482) without lactate accumulation.

CONCLUSIONS

Dexmedetomidine infusion combined with GDHT may mitigate neuroinflammation without undesirable haemodynamic effects during cranial surgery and therefore be neuroprotective.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02878707.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Influencing factors of Barthel index scores among the community-dwelling elderly in Hong Kong: a random intercept model

Background

Barthel Index (BI) is one of the most widely utilized tools for assessing functional independence in activities of daily living. Most existing BI studies used populations with specific diseases (e.g., Alzheimer’s and stroke) to test prognostic factors of BI scores; however, the generalization of these findings was limited when the target populations varied.

Objectives

The aim of the present study was to utilize electronic health records (EHRs) and data mining techniques to develop a generic procedure for identifying prognostic factors that influence BI score changes among community-dwelling elderly.

Methods

Longitudinal data were collected from 113 older adults (81 females; mean age = 84 years, SD = 6.9 years) in Hong Kong elderly care centers. Visualization technologies were used to align annual BI scores with individual EHRs chronologically. Linear mixed-effects (LME) regression was conducted to model longitudinal BI scores based on socio-demographics, disease conditions, and features extracted from EHRs.

Results

The visualization presented a decline in BI scores changed by time and health history events. The LME model yielded a conditional R² of 84%, a marginal R² of 75%, and a Cohen’s f² of 0.68 in the design of random intercepts for individual heterogeneity. Changes in BI scores were significantly influenced by a set of socio-demographics (i.e., sex, education, living arrangement, and hobbies), disease conditions (i.e., dementia and diabetes mellitus), and EHRs features (i.e., event counts in allergies, diagnoses, accidents, wounds, hospital admissions, injections, etc.).

Conclusions

The proposed visualization approach and the LME model estimation can help to trace older adults’ BI score changes and identify the influencing factors. The constructed long-term surveillance system provides reference data in clinical practice and help healthcare providers manage the time, cost, data and human resources in community-dwelling settings.

Exercise Interventions With Trained Home Helpers for Preventing Loss of Autonomy and Falls in Community-Dwelling Older Adults Receiving Home Heath Physical Therapy T4H: A Randomized Controlled Pilot Study

BACKGROUND AND PURPOSE

Older adults at risk for falls live independently in the community in their own home and have rehabilitation needs. However, little is known about whether home coaching of older adults can decrease falls at home. We sought to determine whether a novel program for preventing falls and a loss of exercise capacity, the T4H program, in which home helpers act as exercise coaches by using an information technology (IT) device, was acceptable and feasible.

METHODS

Between February 2015 and October 2015, we performed a cluster randomized controlled trial in which home helpers either assisted older adults 75 years and over, to participate in the T4H program, or provided standard home help over 3 months. We assessed levels of acceptability and satisfaction among the older adults and home helpers with regard to the exercise program and the technologies used. To measure efficacy, the main outcome measures for the older adults were the absence of falls requiring medical or paramedical care, unplanned hospitalizations, walking ability in a Timed Up and Go test (TUG), and self-care ability by the Barthel Index at the 3-month follow-up visit.

RESULTS AND DISCUSSION

Overall, 35 older adults were included, aged 89 years and with 68.6% women. Eighty-five percent of the respondents were pleased or very pleased to have participated in the T4H exercise program, 70% were satisfied with the IT devices, and 92% were satisfied with their home helper's level of involvement. Two of the 4 home helper respondents were satisfied or very satisfied with the exercise program, and 2 were moderately satisfied. The proportions of older adult participants with no falls or no unplanned hospitalizations were higher in the T4H group (92.3% and 85.7%, respectively) than in the control group (81.8% and 71.4%, respectively), although these intergroup differences were not statistically significant. The T4H and control groups did not differ significantly with regard to the TUG time (median [IQR]: 27.6 seconds [17.9-58.6] vs 30.7 seconds [19.7-57.2], respectively) or the Barthel Index (median [IQR]: 90 [75-95] and 90 [75-95], respectively).

CONCLUSIONS

The novel T4H home help model was feasible and was associated with a high level of participant satisfaction. We observed a trend toward fewer falls and hospitalizations and better quality of life in the older adults.

Comparison Between Conventional Intervention and Non-immersive Virtual Reality in the Rehabilitation of Individuals in an Inpatient Unit for the Treatment of COVID-19: A Study Protocol for a Randomized Controlled Crossover Trial

Background: The new human coronavirus that leads to COVID-19 (coronavirus disease 2019) has spread rapidly around the world and has a high degree of lethality. In more severe cases, patients remain hospitalized for several days under treatment of the health team. Thus, it is important to develop and use technologies with the aim to strengthen conventional therapy by encouraging movement, physical activity, and improving cardiorespiratory fitness for patients. In this sense, therapies for exposure to virtual reality (VR) are promising and have been shown to be an adequate and equivalent alternative to conventional exercise programs.

Aim: This is a study protocol with the aim of comparing the conventional physical therapy intervention with the use of a non-immersive VR software during COVID-19 hospitalization.

Methods: Fifty patients hospitalized with confirmed diagnosis of COVID-19 will be divided in two groups under physiotherapy treatment using conventional or VR intervention: Group A: participants with COVID-19 will start the first day of the protocol with VR tasks in the morning and then in the second period, in the afternoon, will perform the conventional exercises (n = 25) and Group B: participants with COVID-19 will start the first day with conventional exercises in the morning and in the second period, in the afternoon, will perform activity with VR (n = 25). All participants will be evaluated with different motor and physiologic scales before and after the treatment to measure improvements.

Conclusion: Considering the importance of benefits from physical activity during hospitalization, VR software shows promise as a potential mechanism for improving physical activity. The results of this study may provide new insights into hospital rehabilitation.

Trial Registration:ClinicalTrials.gov, identifier: NCT04537858. Registered on 01 September 2020.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

The Effectiveness and Safety of Manual Acupuncture Therapy in Patients with Poststroke Cognitive Impairment: A Meta-analysis

Background. Poststroke cognitive impairment (PSCI) is a common cause of disability among patients with stroke. Meanwhile, acupuncture has increasingly been used to improve motor and cognitive function for stroke patients. The aim of the present study was to summarize and evaluate the evidence on the effectiveness of acupuncture in treating PSCI. Methods. Eight databases (PubMed, The Cochrane Library, CNKI, WanFang Data, VIP, CBM, Medline, Embase databases) were searched from January 2010 to January 2020. Meta-analyses were conducted for the eligible randomized controlled trials (RCTs). Assessments were performed using Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Barthel Index (BI), or modified Barthel Index (MBI). Results. A total of 657 relevant RCTs were identified, and 22 RCTs with 1856 patients were eventually included. Meta-analysis showed that acupuncture appeared to be effective for improving cognitive function as assessed by MMSE ( $\text{mean}\text{difference}\left(\text{MD}\right)=1.73$ , 95% confidence interval (CI) (1.39, 2.06), $P<0.00001$ ) and MoCA ( $\text{MD}=2.32$ , 95% CI (1.92, 2.73), $P<0.00001$ ). Furthermore, it also suggested that acupuncture could improve the activities of daily life (ADL) for PSCI patients as assessed by BI or MBI ( $\text{SMD}=0.97$ , 95% CI (0.57, 1.38), $P<0.00001$ ). Conclusions. Compared with nonacupuncture group, acupuncture group showed better effects in improving the scores of MMSE, MoCA, BI, and MBI. This meta-analysis provided positive evidence that acupuncture may be effective in improving cognitive function and activities of daily life for PSCI patients. Meanwhile, long retention time of acupuncture may improve cognitive function and activities of daily life, and twist technique may be an important factor that could influence cognitive function. However, further studies using large samples and a rigorous study design are needed to confirm the role of acupuncture in the treatment of PSCI.

First-Hand Experience of Severe Dysphagia Following Brainstem Stroke: Two Qualitative Cases

BACKGROUND

Dysphagia has profound effects on individuals, and living with dysphagia is a complex phenomenon that touches essential areas of life. Dysphagia following a brainstem stroke is often more severe and the chances of spontaneous recovery are less likely as compared with dysphagia following a hemispheric stroke.

OBJECTIVE

To explore how two individuals with brainstem stroke experienced severe dysphagia during their inpatient neurorehabilitation and how they experienced their recovery approximately one month following discharge.

METHODS

An explorative study was conducted to evaluate the first-hand perspective on severe eating difficulties. A qualitative case study was chosen to collect data during two face-to-face semi-structured interviews. Phenomenological perspectives shaped the interview-process and the processing of data.

RESULTS

Analysis of the empirical data generated the following main themes regarding experiences of: (i) the mouth and throat; (ii) shared dining; and (iii) recovery and regression related to swallowing-eating-drinking.

CONCLUSION

Participants expressed altered sensations of the mouth and throat, which affected their oral intake and social participation in meals. Good support for managing and adapting their problems of swallowing, eating, and drinking in daily activities is essential. Knowledge and skills of professionals in relation to dysphagia is a significant requirement for recovery progress in settings within the municipality.

Recovery in cognitive motor dissociation after severe brain injury: A cohort study

OBJECTIVE

To investigate the functional and cognitive outcomes during early intensive neurorehabilitation and to compare the recovery patterns of patients presenting with cognitive motor dissociation (CMD), disorders of consciousness (DOC) and non-DOC.

METHODS

We conducted a single center observational cohort study of 141 patients with severe acquired brain injury, consecutively admitted to an acute neurorehabilitation unit. We divided patients into three groups according to initial neurobehavioral diagnosis at admission using the Coma Recovery Scale-Revised (CRS-R) and the Motor Behavior Tool (MBT): potential clinical CMD, [N = 105]; DOC [N = 19]; non-DOC [N = 17]). Functional and cognitive outcomes were assessed at admission and discharge using the Glasgow Outcome Scale, the Early Rehabilitation Barthel Index, the Disability Rating Scale, the Rancho Los Amigos Levels of Cognitive Functioning, the Functional Ambulation Classification Scale and the modified Rankin Scale. Confirmed recovery of conscious awareness was based on CRS-R criteria.

RESULTS

CMD patients were significantly associated with better functional outcomes and potential for improvement than DOC. Furthermore, outcomes of CMD patients did not differ significantly from those of non-DOC. Using the CRS-R scale only; approximatively 30% of CMD patients did not recover consciousness at discharge.

INTERPRETATION

Our findings support the fact that patients presenting with CMD condition constitute a separate category, with different potential for improvement and functional outcomes than patients suffering from DOC. This reinforces the need for CMD to be urgently recognized, as it may directly affect patient care, influencing life-or-death decisions.

Value of the Barthel scale in prognostic prediction for patients with cerebral infarction

Background

This study aims to evaluate the ADL(activity of daily living) of patients with acute cerebral infarction through BI scoring, in order to observe its predictive value in the prognosis of these patients.

Methods

According to the inclusion and exclusion criteria, patients with acute anterior circulation cerebral infarction were included in the present study. Then, the BI scoring was analyzed through five grades, in order to further investigate the dose-response relationship between BI scoring and mortality risk in patients with cerebral infarction. The receiver operating characteristic (ROC) curves for BI-scored patients were drawn, and the predictive authenticity of the Barthel scale in prognostic prediction for patients with cerebral infarction was estimated.

Results

The difference in BI scores between the survival group and death group were statistically significant (t = 10.029, P < 0.05), in which the score was lower in the death group than in the survival group. According to the linear trend ײ-test, the decrease in BI score indicates an increase in mortality risk in patients with cerebral infarction. The area under the curve (AUC) of the ROC curve was 0.794 with a P–value of < 0.05.

Conclusion

BI scoring is a highly valuable scoring system for the prognostic prediction of patients with acute cerebral infarction.

Is Barthel Index Suitable for Assessing Activities of Daily Living in Patients With Dementia?

OBJECTIVES

To evaluate application of the Barthel Index (BI) in assessing basic activities of daily living (ADL) of patients with dementia using Rasch analysis.

DESIGN

A multi-country cross-sectional study.

SETTING AND PARTICIPANTS

Nineteen long-term care facilities located in China, Japan, South Korea, and Thailand. A total of 644 patients with dementia were included.

METHODS

Unidimensionality, global and item fit, local dependence, person-item targeting, threshold disordering, and differential item functioning (DIF) were examined. Negative correlations between scores for DIF items and Neuropsychiatric Inventory Nursing Home version (NPI-NH) were evaluated.

RESULTS

Item reliability (1.0) and person reliability (.88) were acceptable. The Rasch dimension explained 72.9% of the variance (Eigenvalue = 27), while the first contrast explained 6.6% (Eigenvalue = 2.4). The "mobility" was misfitting to the Rasch model (infit mean square = 1.86). The overall difficulty of the BI exceeded patients' ability (person location = -2.27 logits). The "stairs climbing" and "mobility" showed narrow category thresholds (< 1.4 logits). The location of "controlling bladder" and "toilet use" overlapped. Removing "stairs climbing", collapsing categories with narrow threshold widths in "mobility", and combining "controlling bowel" and "controlling bladder" into one item, improved unidimensionality, and item fit of the scale. Only three items ("grooming", "dressing", and "toilet use") were free from DIF across countries. The scores for "feeding" were negatively related to scores for "disinhibition" (r = -0.46, P < 0.01), and scores for "controlling bowel" were negatively related to scores for "disinhibition" (r = -0.44, P < 0.01), "agitation" (r = -0.32, P < 0.05), and "aggression" (r = -0.27, P < 0.01) in Japanese samples.

CONCLUSIONS AND IMPLICATIONS

The performance of the BI for assessing patients with dementia might be compromised by misfit items, person-item mistargeting, measurement gaps, redundant items, narrow threshold width, and item bias. Mobility ability might not be helpful for determining capability of basic ADL in the patients. Comparisons of BI scores between countries should be undertaken with caution due to item bias. Neuropsychiatric symptoms might interact with basic ADL abilities of the patients. We will not suggest using the instrument in patients with dementia, without future refining to improve its performance.

Effect of verticalization with Erigo® in the acute rehabilitation of severe acquired brain injury

The recovery of the orthostatism after a severe acquired brain injury (sABI) is an essential objective to pursue in order to avoid the occurrence of secondary complications resulting from prolonged immobilization to which the patient is subjected during the acute phase. This randomized controlled trial aims to evaluate the effect of verticalization with the lower limb robot-assisted training system Erigo® versus conventional neurorehabilitation in 44 adult subjects affected by sequelae of sABI in the acute rehabilitation phase, related to cardiorespiratory signs and measures of impairment and activity. At the end of the study (20 treatment sessions, 5 sessions per week), in both groups of patients, there were no dropouts nor adverse events. In subject verticalized with Erigo®, there were no episodes of (pre)syncope from orthostatic hypotension nor postural orthostatic tachycardia and cardiorespiratory signs remained stable; moreover, there were no increase in muscle tone nor reduction in range of motion at lower limbs. Results obtained show improved outcomes on the whole and in a similar way in both groups; however, the improvement in scores of the National Institutes of Health Stroke Scale, the Tinetti scale, and the Functional Independence Measure from the enrollment to the end of the treatment cycle being equal, the evaluation performed at the 10th session allows to establish that the improvement appears earlier in the intervention group and later in the control group. The more rapid recovery of impairments and some activities in subjects treated with Erigo® could allow a "time-saver" to devote to the rehabilitation of sensory-motor functions which are more complex and subordinated to the preliminary reacquisition of elementary postures and motor strategies.

Validity and responsiveness of Barthel index for measuring functional recovery after hemiarthroplasty for femoral neck fracture

INTRODUCTION

To investigate the validity of Barthel Index (BI) compared with de Morton Mobility Index (DEMMI), EuroQol-visual analog scale (EQ-VAS), 2-min walk test (2MWT), and timed get-up-and-go test (TUG), and to evaluate the responsiveness of all outcome measures for assessing functional recovery in older patients who underwent hemiarthroplasty after femoral neck fracture.

MATERIAL AND METHOD

Eighty-one femoral neck fracture patients who were enrolled in a study evaluating functional recovery after bisphosphonate therapy during 2013 to 2015, and who had data available at both baseline and 12 months after surgery were included in this study.

RESULTS

All scores improved significantly from baseline to the 1-year follow-up. BI had moderate to strong correlation with DEMMI, 2MWT, and TUG (r-value: 0.490-0.843), and mild to moderate correlation with EQ-VAS (r-value: 0.278-0.323). All outcome measurements had high effect estimates. The minimal clinically important difference (MCID) of BI at 12 months was 9.8 points.

CONCLUSION

Since BI was shown to have good validity (moderate to strong correlation with DEMMI and performance-based tests, and mild to moderate correlation with EQ-VAS), BI can be used to accurately assess functional recovery in patients who undergo hemiarthroplasty after femoral neck fracture.

Effects of Early Exercise Rehabilitation on Functional Recovery in Patients with Severe Sepsis

PURPOSE

Severe sepsis is associated with functional disability among patients surviving an acute phase of infection. Efforts to improve functional impairment are important. We assessed the effects of early exercise rehabilitation on functional outcomes in patients with severe sepsis.

MATERIALS AND METHODS

A prospective, single-center, case-control study was conducted between January 2013 and May 2014 at a tertiary care center in Korea. Patients with severe sepsis and septic shock were enrolled and randomized to receive standard sepsis treatment or intervention. Intervention involved early targeted physical rehabilitation with sepsis treatment during hospitalization. Participants were assessed at enrollment, hospital discharge, and 6 months after enrollment. Functional recovery was measured using the Modified Barthel Index (MBI), Functional Independence Measure (FIM), and Instrumental Activities of Daily Living (IADL).

RESULTS

Forty participants (21 intervention patients) were included in an intention-to-treat analysis. There were no significant differences in baseline MBI, FIM, and IADL between groups. Intervention yielded greater improvement of MBI, FIM, and IADL in the intervention group at hospital discharge, but not significantly. Subgroup analysis of patients with APACHE II scores ≥10 showed significantly greater improvement of physical function at hospital discharge (MBI and FIM) in the intervention group, compared to the control group (55.13 vs. 31.75, p=0.048; 52.40 vs. 31.25, p=0.045). Intervention was significantly associated with improvement of MBI in multiple linear regression analysis (standardized coefficient 0.358, p=0.048).

CONCLUSION

Early physical rehabilitation may improve functional recovery at hospital discharge, especially in patients with high initial severity scores.

Brain Injury and Severe Eating Difficulties at Admission-Patient Perspective Nine to Fifteen Months after Discharge: A Pilot Study

The purpose of this pilot study was to explore and interpret the way that individuals with acquired brain injury, admitted to inpatient neurorehabilitation with severe eating difficulties, experienced eating nine to fifteen months after discharge. Four individuals with acquired brain injury were interviewed via qualitative semi-structured interviews. An explorative study was conducted to study eating difficulties. Qualitative content analysis was used. Four main themes emerged from the analysis: personal values related to eating, swallowing difficulties, eating and drinking, meals and social life. Three predominating experiences were: fed by tube, “relearning” to eat, and eating meals together. The preliminary results regarding the four participants suggest that the meaning of food and being able to eat and take part in meals may be nearly the same as before the injury; however, having the ability to eat reduced or lost completely, even temporarily, was unexpected and difficult, and caused strong emotional reactions, even 18 months after injury. Time spent using a feeding tube had a negative, but not persistent, impact on quality-of-life. The preliminary findings provide knowledge regarding the patient perspective of adapting to and developing new strategies for activities related to eating, however, further prospective, longitudinal research in a larger scale and with repeated interviews is needed.

Non-aneurysmal non-perimesencephalic subarachnoid hemorrhage: effect of rehabilitation at short-term and in a prospective study of long-term follow-up

BACKGROUND

A recently published prospective study identified an impaired outcome of patients with non-perimesencephalic (NPM) subarachnoid hemorrhage (SAH). Our objective was to analyze the long-term outcome of patients with subsequent rehabilitation after NPM SAH.

METHODS

A comparison of patients with NPM SAH receiving subsequent in-patient rehabilitation was done at discharge (using the modified Rankin scale (mRS)), short-term outcome after 6 months (mRS), and prospectively using a questionnaire (short-form health survey with 36 questions (SF-36)), which was sent to 66 patients.

RESULTS

Thirty-seven patients answered the SF-36, on average 6.3 years after ictus (range 1.5-14 years). After NPM SAH, the mRS is impaired. Patients with subsequent rehabilitation had a significant better improvement until short-term follow-up. Until long-term outcome, the psychological items were non-significantly reduced, whereas all physical items (physical functioning, role limitations because of physical health problems, bodily pain, and general health perceptions) were significantly decreased compared to the standard population. In patients with subsequent rehabilitation, all items were only non-significantly reduced. About 16% of the patients developed secondary neurological and/or psychiatric diseases.

CONCLUSIONS

The quality of life (QoL) is decreased after NPM SAH. In the long-term follow-up, a significant reduction in physical items was identified. Due to subsequent in-patient rehabilitation after NPM SAH, the impairment can be improved significantly until short-term follow-up. Whereas patients with NPM SAH had a significantly decreased QoL at long-term follow-up, for patients with rehabilitation, the QoL was only slightly (non-significantly) reduced. Therefore, patients should receive subsequent rehabilitation after NPM SAH to improve the functional short-term outcome (mRS) and long-term QoL. www.clinicaltrials.gov (Identifier No. NCT02334657).

A new prognostic scale for the early prediction of ischemic stroke recovery mainly based on traditional Chinese medicine symptoms and NIHSS score: a retrospective cohort study

Background

Ischemic stroke (IS) is a common disease, often resulting in death or disability. Previous studies on prognosis of stroke mainly focused on the baseline condition or modern expensive tests. However, the change of clinical symptoms during acute stage is considerably neglected. In our study, we aim to develop a new prognostic scale to predict the 90-day outcome of IS patients.

Methods

In this retrospective cohort study, a secondary data analysis was performed on 489 patients extracted from 1046 patients of 4 hospitals. A new prognostic scale was constructed to predict the recovery of IS mainly based on the National Institutes of Health Stroke Scale (NIHSS) score, traditional Chinese Medicine (TCM) symptoms & signs and the changes during the first 3 days of patients in the 3 TCM hospitals. Receiver Operating Characteristic (ROC) curve was used to determine the cutoff point for prediction. In the end, the scale was used to test the outcome of IS patients in Xuanwu hospital.

Results

The new prognostic scale was composed of 8 items including age degree (OR = 3.32; 95 % CI: 1.72–6.42), history of diabetes mellitus (DM) (OR = 2.20; 95 % CI: 1.19–4.08), NIHSS score (OR = 3.08; 95 % CI: 2.16–4.40), anxiety (OR = 3.17; 95 % CI: 1.90–5.29) and irritability (OR = 4.61; 95 % CI: 1.36–15.63) on the 1st day of illness onset, change in NIHSS score (OR = 2.49; 95 % CI: 1.31–4.73), and circumrotating (OR = 7.80; 95 % CI: 1.98–30.64) and tinnitus (OR = 13.25; 95 % CI: 1.55–113.34) during the first 3 days of stroke onset. The total score of the scale was 16.5 and the cutoff point was 9.5, which means patients would have poor outcome at 90 days of stroke onset if the score was higher than 9.5. The new scale was validated on the data of Xuanwu hospital, and the value of its sensitivity, specificity and overall accuracy were 69.6 %, 83.3 % and 75.0 % respectively.

Conclusions

The 8-item scale, mainly based on TCM symptoms, NIHSS score and their changes during the first 3 days, can predict the 90-day outcome for IS patients while it still needs to be further validated and optimized clinically.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0903-1) contains supplementary material, which is available to authorized users.

Sequence of Functional Loss and Recovery in Nursing Homes

PURPOSE OF THE STUDY

This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery.

DESIGN AND METHODS

We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits.

RESULTS

The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments.

IMPLICATIONS

Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.

Clinical effect size of an educational intervention in the home and compliance with mobile phone-based reminders for people who suffer from stroke: protocol of a randomized controlled trial

Background

Stroke is the third-leading cause of death and the leading cause of long-term neurological disability in the world. Cognitive, communication, and physical weakness combined with environmental changes frequently cause changes in the roles, routines, and daily occupations of stroke sufferers. Educational intervention combines didactic and interactive intervention, which combines the best choices for teaching new behaviors since it involves the active participation of the patient in learning. Nowadays, there are many types of interventions or means to increase adherence to treatment.

Objective

The aim of this study is to enable patients who have suffered stroke and been discharged to their homes to improve the performance of the activities of daily living (ADL) in their home environment, based on advice given by the therapist. A secondary aim is that these patients continue the treatment through a reminder app installed on their mobile phones.

Methods

This study is a clinical randomized controlled trial. The total sample will consist of 80 adults who have suffered a stroke with moderate severity and who have been discharged to their homes in the 3 months prior to recruitment to the study. The following tests and scales will be used to measure the outcome variables: Barthel Index, the Functional Independence Measure, the Mini-Mental State Examination, the Canadian Neurological Scale, the Stroke Impact Scale-16, the Trunk Control Test, the Modified Rankin Scale, the Multidimensional Scale of Perceived Social Support, the Quality of Life Scale for Stroke, the Functional Reach Test, the Romberg Test, the Time Up and Go test, the Timed-Stands Test, a portable dynamometer, and a sociodemographic questionnaire. Descriptive analyses will include mean, standard deviation, and 95% confidence intervals of the values for each variable. The Kolmogov-Smirnov (KS) test and a 2x2 mixed-model analysis of variance (ANOVA) will be used. Intergroup effect sizes will be calculated (Cohen’s d).

Results

Currently, the study is in the recruitment phase and implementation of the intervention has begun. The authors anticipate that during 2015 the following processes should be completed: recruitment, intervention, and data collection. It is expected that the analysis of all data and the first results should be available in early-to-mid 2016.

Conclusions

An educational intervention based on therapeutic home advice and a reminder app has been developed by the authors with the intention that patients who have suffered stroke perform the ADL more easily and use their affected limbs more actively in the ADL. The use of reminders via mobile phone is proposed as an innovative tool to increase treatment adherence in this population.

Trial Registration

ClinicalTrials.gov NCT01980641; https://clinicaltrials.gov/ct2/show/NCT01980641 (Archived by WebCite at http://www.webcitation.org/6WRWFmY6U).

Gait and Glasgow Coma Scale scores can predict functional recovery in patients with traumatic brain injury

Fifty-one patients with mild (n = 14), moderate (n = 10) and severe traumatic brain injury (n = 27) received early rehabilitation. Level of consciousness was evaluated using the Glasgow Coma Score. Functional level was determined using the Glasgow Outcome Score, whilst mobility was evaluated using the Mobility Scale for Acute Stroke. Activities of daily living were assessed using the Barthel Index. Following Bobath neurodevelopmental therapy, the level of consciousness was significantly improved in patients with moderate and severe traumatic brain injury, but was not greatly influenced in patients with mild traumatic brain injury. Mobility and functional level were significantly improved in patients with mild, moderate and severe traumatic brain injury. Gait recovery was more obvious in patients with mild traumatic brain injury than in patients with moderate and severe traumatic brain injury. Activities of daily living showed an improvement but this was insignificant except for patients with severe traumatic brain injury. Nevertheless, complete recovery was not acquired at discharge. Multiple regression analysis showed that gait and Glasgow Coma Scale scores can be considered predictors of functional outcomes following traumatic brain injury.

A prospective study of the responsiveness of the original and the short form Berg Balance Scale in people with stroke

OBJECTIVE

The study aim was to examine the responsiveness of the Berg Balance Scale (BBS) and that of its short form (SFBBS) at both the individual person level and the group level.

DESIGN

A repeated-measurements design.

SETTING

Hospital and home setting.

PARTICIPANTS

Patients with stroke.

RESULTS

Totals of 226, 202, and 168 patients with stroke were assessed with the BBS at 14, 30, and 90 days after stroke, respectively. The SFBBS data were extracted from the patients' responses on the BBS. At the group level, the BBS and the SFBBS had sufficient and similar responsiveness. For the Rasch scores, the effect sizes of the three change scores for the BBS and the SFBBS, respectively, had similar ranges between 0.38 and 0.88 and between 0.39 and 0.85, respectively. The standardized response means of the three change scores for the BBS and the SFBBS ranged from 0.74 to 1.33 and from 0.72 to 1.13, respectively. At the individual person level, the BBS detected significant balance improvement in about twice as many patients as the SFBBS detected.

CONCLUSION

The responsiveness of the BBS at the individual person level was better than that of the SFBBS in patients with stroke. The BBS is recommended as an outcome measure to better detect changes in individual patients.

[Subacute care of stroke-affected patients. Satisfaction and results]

OBJECTIVE

To determine the satisfaction of the stroke inpatients and their caregivers in Rehabilitation Service and to analyze the effectiveness, social risk, and discharge destination.

MATERIAL AND METHOD

Prospective longitudinal cohort multicenter study. An analysis was made of the social risk (Gijón Scale), co-morbidity (Charlson Index), disability (Barthel Index), effectiveness of the rehabilitation treatment, satisfaction (Pound Questionnaire) and discharge destination of 241 patients. An evaluation was also made on 119 caregivers 6 months post-stroke, recording age, family relationship, time care-giving, satisfaction with the information/training, and accessibility to the rehabilitation team.

RESULTS

The patient profile is a 71 year-old male, with low/intermediate social risk, high co-morbidity and total/severe dependence, with 27.1% living alone. Almost all (96.6%) of the patients claimed to be satisfied/very satisfied with the treatment, with satisfaction with the recovery being lower (80.3%). The effectiveness was 32.5 ± 20.4. Home was the discharge destination of 81.7% of the patients.The average age of the caregivers was 58.8 ± 12.3 years, and 73.9% were women. The time dedicated to care-giving was over 6 hours per day in the 62% of the cases. Being satisfied/very satisfied with the received information was recorded by 89.9% of the caregivers.

CONCLUSIONS

Patients admitted for stroke rehabilitation achieve significant functional gain during hospitalization and return to their homes in most cases. The satisfaction with the rehabilitation treatment and received information is high. The training of the caregiver is an aspect that needs improving.

Catechol-O-Methyltransferase Polymorphism Influences Outcome After Ischemic Stroke

Background. To explore whether a polymorphism in dopamine metabolism influences the effectiveness of neurological rehabilitation and the outcome after ischemic stroke. Methods. The Barthel Index (BI) and the Rivermead Motor Assessment (RMA) were assessed in 78 moderately affected stroke patients (1) after they had entered a neurological inpatient rehabilitation, (2) after 4 weeks of rehabilitation therapy, and (3) 6 months later. Polymorphisms of the gene encoding catechol- O-methyltransferase (COMT) were determined. BI and RMA results were analyzed with respect to the genetic profiles of COMT. Results. Carriers of COMT Val/Val alleles showed better results in BI and RMA than COMT Met/Met carriers at all 3 time points. Val/Met carriers exhibited results in between the homozygotes, suggesting a gene–dose relationship. Altogether, BI and RMA results were highly correlated. Conclusion. Stroke patients with COMT Val/Val alleles had higher motor functions and abilities of activities of daily living even at the beginning of the rehabilitation period. All patient groups improved during the rehabilitation period to a similar degree, suggesting that physical therapy is comparably effective in all polymorphism subtypes.

Reliability of the Clinical Dementia Rating with a traumatic brain injury population: a preliminary study

This study examined the inter-rater reliability (IRR) of the Clinical Dementia Rating (CDR) for patients with traumatic brain injury (TBI). The CDR is a commonly used rating of impairment, but there has been no research examining its utility in patients with TBI. It was hypothesized that the CDR would have good IRR when used with patients with TBI. Two hundred and fifty U.S. neuropsychologists were randomly selected from the National Academy of Neuropsychology's membership list and were mailed packets of information (e.g., CDR, patient vignette, mental status, neuropsychological test information, and history). Professionals were asked to complete the CDR for the described patient and return the information. IRR was calculated for the Global CDR score and each of the six CDR domains. Of those packets mailed, 53 were returned and completed as instructed (21.2% response rate). Clinician experience varied from 0 to 31 years. Global CDR score IRR was 73.6%. Domain IRRs were as follows: Orientation, 79.2%; Home and Hobbies, 71.7%; Personal Care, 71.7%; Memory, 56.6%; Judgment and Problem Solving, 49.1%; and Community Affairs, 54.7%. Results suggest the CDR Global score has acceptable IRR (>.70). Overall concordance (W = .527) among raters was significant with moderate-to-strong agreement. Further research to improve the utility of this instrument is discussed.

Measuring acute rehabilitation needs in trauma: preliminary evaluation of the Rehabilitation Complexity Scale

BACKGROUND

Injury severity, disability and care dependency are frequently used as surrogate measures for rehabilitation requirements following trauma. The true rehabilitation needs of patients may be different but there are no validated tools for the measurement of rehabilitation complexity in acute trauma care. The aim of the study was to evaluate the potential utility of the Rehabilitation Complexity Scale (RCS) version 2 in measuring acute rehabilitation needs in trauma patients.

METHODS

A prospective observation study of 103 patients with traumatic injuries in a Major Trauma Centre. Rehabilitation complexity was measured using the RCS and disability was measured using the Barthel Index. Demographic information and injury characteristics were obtained from the trauma database.

RESULTS

The RCS was closely correlated with injury severity (r=0.69, p<0.001) and the Barthel Index (r=0.91, p<0.001). However the Barthel was poor at discriminating between patients rehabilitation needs, especially for patients with higher injury severities. Of 58 patients classified as 'very dependent' by the Barthel, 21 (36%) had low or moderate rehabilitation complexity. The RCS correlated with acute hospital length of stay (r=0.64, p=<0.001) and patients with a low RCS were more likely to be discharged home. The Barthel which had a flooring effect (56% of patients classified as very dependent were discharged home) and lacked discrimination despite close statistical correlation.

CONCLUSION

The RCS outperformed the ISS and the Barthel in its ability to identify rehabilitation requirements in relation to injury severity, rehabilitation complexity, length of stay and discharge destination. The RCS is potentially a feasible and useful tool for the assessment of rehabilitation complexity in acute trauma care by providing specific measurement of patients' rehabilitation requirements. A larger longitudinal study is needed to evaluate the RCS in the assessment of patient need, service provision and trauma system performance.

Development of an assessment tool for the multidisciplinary evaluation of neurological dependency: preliminary findings

BACKGROUND

Multidisciplinary inputs are of vital importance in the comprehensive care management and rehabilitation of individuals with long-term neurological conditions. Although many ordinal measures of disability correlate with patient dependency and care, few are based on numbers of different health professionals required, or their skill-mix, for assistance associated with levels of dependency.

AIM AND OBJECTIVES

To develop an instrument to assess dependency in adult patients suffering from severe and complex neurological disability for use by multidisciplinary teams. Objectives were to establish content validity, construct validity, inter-rater reliability and internal consistency, and to demonstrate preliminary clinical utility from the perspective of professional staff.

DESIGN AND METHODS

A mixed methods design utilised qualitative and quantitative approaches. Stage I involved developmental fieldwork using focus groups (n = 3), questionnaires (n = 70), expert panel (n = 20) and direct observation (n = 12). In stage 2, intensive refinement through direct observation, construct validity and reliability testing (n = 100) of the instrument was completed. The research complied with the research governance and ethical standards set by the Department of Health (UK).

RESULTS

In the final format, an instrument was developed which comprised two sections. Section 1: an ordinal scaled basic care section, with 15 categories of dependency and level of descriptors based on numbers, grade and time taken by staff providing assistance. Factor analysis identified one dominant and four subsidiary factors which explained 67% of the total variance. Overall inter-rater agreement was 0.87 (kappa coefficient: range 0.67-1.0), and Cronbach's coefficient alpha was 0.733. Section 2: comprised a nominally measured specialist care section for inputs from nurses and therapists. The mean time taken to complete assessments was 12 minutes.

CONCLUSION

The instrument satisfied preliminary selective criteria for validity and reliability. Further research is necessary to satisfy other requirements of psychometric testing and clinical utility.

Management of skin-related adverse events during locomotor training with robotic-assisted body weight supported treadmill: A case report

The purpose of this case report is to describe attempts to prevent skin-related adverse events from occurring and protect the skin once breakdown occurred in a person with chronic stroke during locomotor training. There is scant literature in how to address skin during locomotor training with the Lokomat(®), particularly when a patient presents with sensory deficits and frail skin. The patient was a 75-year-old male survivor of stroke who participated in the Lokomat(®) group of a randomized clinical pilot study comparing locomotor training with the Lokomat(®) and conventional means. He had diminished sensation to light touch and proprioception on his left leg with skin on both lower legs presenting as thin, flaky, and virtually hairless. Although much effort was put towards prevention of skin breakdown, he developed numerous skin-related adverse events during his training. However, his skin healed completely with reduced training intensity and initiation of "pre-wrapping" his lower legs with Akton(®) viscoelastic polymer sheets and elastic bandages. Significant improvements were noted in his Functional Improvement Measure(™) locomotion score and Stroke Impact Scale domains of strength, participation/role function, and total recovery, though not in his 10-m walk test velocity or 6-min walk test. The Akton(®) sheets and team approach between study team, patient, and his wife allowed simultaneous safe continuation of locomotor training with the Lokomat(®) and healing of his skin breakdown.

[Early rehabilitation for neurologic patients]

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients' impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.

Over-ground and robotic-assisted locomotor training in adults with chronic stroke: a blinded randomized clinical trial

PURPOSE

The purpose was to compare the effectiveness of robotic-assisted body weight supported treadmill training using the Lokomat(®) to over-ground gait training (OGT) in adults with chronic stroke.

METHODS

Participants were randomly assigned to the Lokomat(®) or OGT interventions. Both protocols included 40 sessions over 8 weeks. Primary outcome measures were the 10-meter walk test and 6-minute walk distance. Secondary measures included the Functional Independence Measure(TM) locomotion score, Fugl-Meyer Lower Extremity Motor Score (FM-LE), Barthel Index, and Stroke Impact Scale. Blinded assessors tested the participants at baseline, post-intervention, and 3-month follow-up.

RESULTS

Eleven Lokomat(®) and nine OGT participants completed the study. Within group differences in the FM-LE score and Barthel Index occurred over time from baseline to post-intervention and baseline to 3-month follow-up. No other within group differences and no between group differences were observed.

CONCLUSIONS

Although walking measures did not show significant changes between groups, LE motor function and physical functional levels improved over time within both groups. The Lokomat(®) may allow aggressive locomotor training, particularly for the lower functioning patients who wish to improve walking ability due to apparent eased therapist physical burden, when compared to OGT, although an increased risk of skin breakdown is present.

A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of patients with hemorrhagic stroke

To investigate whether early rehabilitation has a positive impact on the recovery of the activities of daily living and motor function after intracerebral hemorrhagic stroke, 364 patients with hemorrhagic stroke were selected and randomly divided into a rehabilitation group and a control group. The rehabilitation group underwent a standardized, three-stage rehabilitation program. The control group was treated with standard hospital ward, internal medical intervention. The simplified Fugl-Myere assessment scale (FMA) and Modified Barthel Index (MBI) were administered at various time points. The magnitude of improvement was significantly higher in the rehabilitation group than in the control group for both the FMA (p<0.05) and MBI scores (p<0.05). The greatest improvement was observed in the first month post-stroke. Thus, our study shows that early rehabilitation can significantly improve the daily activities and motor functions of patients with stroke.

ACTIVLIM-Stroke: A Crosscultural Rasch-Built Scale of Activity Limitations in Patients With Stroke

Background and Purpose—

This study describes the development of a Rasch-built scale measuring activity limitations in stroke patients, named ACTIVLIM-Stroke.

Method—

This new Rasch-built measure was constructed based on stroke patients' perceptions of difficulty in performing daily activities. Patients were recruited from inpatient and outpatient rehabilitation departments in Belgium and Benin. A 73-item questionnaire was completed by 204 participants. A random subsample of 83 subjects was given the questionnaire a second time. Data were analyzed using RUMM2030 software.

Results—

After successive Rasch analyses, the ACTIVLIM-Stroke questionnaire, a unidimensional and linear 20-item measure of activity limitations, was constructed. All 20 items fulfilled Rasch requirements (overall and individual item fit, category discrimination, invariance, local response independence, and nonredundancy in item difficulty). This simple patient-based scale encompasses a large range of activities related to self-care, transfer, mobility, manual ability, and balance. The ACTIVLIM-Stroke questionnaire exhibited high internal validity, excellent internal consistency, and good crosscultural validity. The test–retest reliability of item difficulty hierarchy (intraclass correlation coefficient=0.99) and patient location (intraclass correlation coefficient=0.92) were both excellent. Furthermore, it showed good external construct validity using correlations with the Functional Independence Measure motor and the Barthel Index and a higher discriminating capacity than either of these widely used indices.

Conclusions—

The ACTIVLIM-Stroke questionnaire has good psychometric qualities and provides accurate measures of activity limitations in patients with stroke. It is recommended for evaluating clinical and research interventions in patients with stroke, because it provides a higher discrimination and might be more sensitive to change.

Assessments in Australian stroke rehabilitation units: a systematic review of the post-stroke validity of the most frequently used

PURPOSE

In Australia, stroke is the leading cause of adult disability. For most stroke survivors, the recovery process is challenging, and in the first few weeks their recovery is supported with stroke rehabilitation services. Stroke clinicians are expected to apply an evidence-based approach to stroke rehabilitation and, in turn, use standardised and validated assessments to monitor stroke recovery. In 2008, the National Stroke Foundation conducted the first national audit of Australia's post acute stroke rehabilitation services and findings identified a vast array of assessments being used by clinicians. This study undertook a sub-analysis of the audit's assessment tools data with the aim of making clinically relevant recommendations concerning the validity of the most frequently selected assessments.

METHOD

Data reduction ranked the most frequently selected assessments across a series of sub-categories. A serial systematic review of relevant literature using Medline and the Cumulative Index to Nursing and Allied Health Literature identified post-stroke validity ranking.

RESULTS

The study found that standardised and non-standardised assessments are currently in use in stroke rehabilitation. It recommends further research in the sub-categories of strength, visual acuity, dysphagia, continence and nutrition and found strengths in the sub-categories of balance and mobility, upper limb function and mood.

CONCLUSIONS

This is the first study to map national usage of post-stroke assessments and review that usage against the evidence. It generates new knowledge concerning what assessments we currently use post stroke, what we should be using and makes some practical post stroke clinical recommendations.

Comparison of the responsiveness of the Care Dependency Scale for rehabilitation and the Barthel Index

OBJECTIVE

The aim of this study is to compare the responsiveness of the Care Dependency Scale for Rehabilitation (CDS-R) and the Barthel Index in rehabilitation.

DESIGN

A longitudinal study was performed over six months (2007-8) where patients were assessed using the scales after admission and before discharge.

SETTING AND SUBJECTS

A convenience sample of 1,542 patients was recruited in an Austrian rehabilitation centre.

MEASURES

The CDS-R and the Barthel Index.

DATA ANALYSIS

Responsiveness was determined by descriptive analysis, significance tests and calculation of effect sizes.

RESULTS

For the 1,542 patients, the calculation according to Kazis yielded values of 0.10 for both instruments. For the group of patients who showed clinically relevant changes, values of 0.50 were obtained for the CDS-R and 1.06 for the Barthel Index. For the group 1,542 patients, the calculation according to Liang yielded values of 0.42 for the CDS-R and 0.34 for the Barthel Index. For the group of patients who showed clinically relevant changes, values of 1.47 were obtained for the CDS-R and 1.92 for the Barthel Index.

CONCLUSION

The Barthel Index seems to be slightly more responsive than the CDS-R, and both instruments seem to be appropriate for the assessment of patients' changes over time. Nevertheless, the exact level of responsiveness could not be clearly identified for both instruments. To confirm the level of responsiveness, further research is recommended.

Does functional change predict the course of improvement in geriatric inpatient rehabilitation?

OBJECTIVE

The evaluation of rehabilitation success as measured by different tools is becoming increasingly important in terms of time and money allocation. We wanted to know whether functional change in the first week predicts subsequent improvement in a geriatric inpatient rehabilitation clinic.

DESIGN

Observational longitudinal study.

SETTING

Geriatric inpatient rehabilitation clinic in Germany.

SUBJECTS

One hundred and sixty-one inpatients (117 women) with a median age of 82 years, capable of walking at baseline.

MAIN MEASURES

Weekly assessments of physical function were performed from admission until three weeks later. We used a self-rated tool (the function component of the Short Form - Late Life Function and Disability Index), a proxy-rated tool (the Barthel Index) and a performance-based tool (gait speed). We set up linear regression models to estimate the predictive capacity of change in physical function within the first week on change in physical function within the following two weeks.

RESULTS

Positive correlations were found between functional change within the first week and total change within three weeks. However, correlations of the same periods of change with subsequent change were negative. Correlations were highly significant for both analysis with P-values <0.0001 when the same measures for prediction and outcome were used. Correlations were inconsistent when prediction and outcome were different.

CONCLUSIONS

Improvement within the first week of inpatient rehabilitation is negatively correlated with subsequent functional change.

Development and validation of the Utrecht Scale for Evaluation of Clinical Rehabilitation (USER)

OBJECTIVE

The Utrecht Scale for Evaluation of Rehabilitation (USER) is a measure of functional independence that covers physical functioning (mobility, self-care), cognitive functioning and additional domains of pain, fatigue and mood. USER is implemented in the Netherlands as a generic rehabilitation outcome measure. This article reports the development and psychometric characteristics of USER.

DESIGN

(1) Inter-rater reliability study and (2) responsiveness study with measurements at admission and at discharge from clinical rehabilitation.

SETTING

Three rehabilitation facilities in the Netherlands.

PATIENTS

Rehabilitation inpatients (N = 319).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Effect size (ES) and standardized response mean (SRM) of USER scales were compared to those of the Barthel Index, Functional Independence Measure (FIM) and to relevant scales of the SF-36.

RESULTS

Inter-rater reliability of USER was satisfactory to good. Strong correlations were found between the physical and cognitive functioning scores of USER, the Barthel Index and FIM (0.84-0.94). Correlations between USER pain, fatigue and mood scores and SF-36 scores were also strong (0.58-0.84). Responsiveness of USER physical functioning (1.0-1.2) was very good and slightly better than responsiveness of the Barthel Index (0.9-1.1) and the FIM motor score (0.8-1.1). Responsiveness of the USER cognitive score was below standard (0.2-0.3), but better than responsiveness of the FIM cognitive scores (0.1-0.2).

CONCLUSIONS

USER is a reliable, valid and responsive measure of functional independence that can be used as an alternative for the FIM. The pain, fatigue and mood scores were adapted after this study and need additional validation.

Severe disease activity and complications of immunosuppressive therapy: a challenge for acute hospital-based rehabilitation in rheumatology

Acute rehabilitation refers to the multidisciplinary rehabilitative treatment of patients in continuing need of integrated acute and rehabilitative longterm care. As a result of the advances in acute rheumatology and improved emergency services, an increasing number of patients survive episodes of severe disease and complications of immunosuppressive therapy. These patients require not only treatment of their acute medical problems but also specialized multidisciplinary acute rehabilitation starting as early as possible during their hospital stay. We describe 4 typical cases from the major fields of rheumatology. (1) Acute rehabilitation of a 63-year-old woman with rheumatoid arthritis after replacement of both preexisting knee endoprostheses in one session and removal of the left hip endoprosthesis due to infection and sepsis. (2) Rehabilitation of a 29-year-old man with a 7-year history of ankylosing spondylitis who lived in an adjustable easy chair for 2 years due to severe pain prior to admission. (3) A 61-year-old woman with active refractory Wegener's granulomatosis who developed respiratory insufficiency due to aspergillus and pseudomonas pneumonia. (4) The acute rehabilitation of a 21-year-old woman with systemic lupus erythematosus and a history of 14 laparotomies due to severe acute pancreatitis and multiple gut perforations. Acute rehabilitation was complicated by a large defect of the abdominal wall and significant critical illness polyneuropathy. Our report points out differences between acute, postacute, and longterm rehabilitation, describes the mobilization of patients in acute rheumatology units, and defines specific problems encountered in acute hospital-based rehabilitation of rheumatological patients.