The impact of a structured rehabilitation program for uninsured individuals

PURPOSE/OBJECTIVE

Health disparities in rehabilitation have been identified in brain injury (BI), spinal cord injury (SCI), stroke, and amputee populations. A free clinic was established to serve such uninsured individuals. The purpose of this exploratory study was to characterize the sample of patients attending a free rehabilitation clinic by investigating their demographics, access to care, trends in quality of life, and satisfaction with the rehabilitation program.

METHOD/DESIGN

This is a retrospective chart review of data from 15 individuals admitted to the free clinic program who were administered an admission questionnaire, the abbreviated World Health Organization Quality of Life assessment (WHOQOL-BREF), and a postcare assessment survey.

RESULTS

A majority of patients reported not having a primary care provider nor a checkup within the past 5 years. This sample also reported extensive physical needs at admission. Seventy-three percent of the sample improved on the WHOQOL-BREF physical domain by discharge with a large effect size. The psychological, social, and environmental domain scores did not show a reliable pattern of change in this sample. Conclusions/Implication: These results support previously noted gaps in care among individuals with BI, SCI, stroke, and amputation and suggest that a monthly clinic can improve physical quality of life. This exploratory study aims to lay the foundation for future research that is needed to understand the factors that exclude these individuals from the health care system and to help key stakeholders to advocate for these patients and improve their early access to rehabilitation care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Testosterone replacement in hypogonadal men during inpatient rehabilitation following traumatic brain injury: Results from a double-blind, placebo-controlled clinical pilot study

BACKGROUND

Endocrinopathy, including hypogonadism, is common following traumatic brain injury (TBI). Prior evidence suggests hypogonadism is associated with poorer function.

OBJECTIVE

Determine the feasibility, safety, and efficacy of testosterone (T) therapy in hypogonadal men following TBI in acute rehabilitation.

DESIGN

Randomized, double blind, placebo-controlled pilot trial.

SETTING

Inpatient rehabilitation brain injury unit.

PARTICIPANTS

Men ages 18 -65, post moderate to severe TBI receiving inpatient rehabilitation.

INTERVENTIONS

Transdermal T gel or placebo.

MAIN OUTCOME MEASURES

Revised FIM™ score, strength, adverse events.

RESULTS

Of 498 screened, 70 participants were enrolled, and 22 meeting all criteria were randomized into placebo (n = 10) or physiologic T therapy (n = 12). There was no significant difference between groups in rate of improvement on the FIM™ (intercepts t = -0.31, p = 0.7593, or slopes t = 0.61, p = 0.5472). The Treatment group demonstrated the greatest absolute improvement in FIM™ scores and grip strength compared to Placebo or Normal T groups. There was no difference in adverse events between groups. Percentage of time with agitation or aggression was highest in the Placebo group.

CONCLUSIONS

Although there were no significant differences in rates of recovery, treatment group subjects showed greater absolute functional and strength improvement compared to the Placebo or Normal T groups.

Breakthrough instruments and products steady-state and time-resolved photoluminescence using the FluoTime 300 spectrometer with a FluoMic add-on

This report highlights the combination of the FluoTime 300 photoluminescence spectrometer with a FluoMic add-on as a powerful tool for photophysical research and applications, yielding spectral, temporal, and spatial information on a wide range of samples. The steady-state and time-resolved measurement capabilities of this combination are demonstrated reflecting a broad range of applications.

Oculomotor Treatment in Traumatic Brain Injury Rehabilitation: A Randomized Controlled Pilot Trial

IMPORTANCE

Vision impairments are common after traumatic brain injury (TBI). Little evidence exists to assist clinicians with effective interventions for impaired oculomotor skills in people with TBI.

OBJECTIVE

To pilot a randomized controlled trial (RCT) of oculomotor treatment in TBI rehabilitation.

DESIGN

An impairment-based oculomotor protocol was compared with an activity-based standard of care in a two-group RCT. Participants were masked to assignment.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

For 1 yr, 138 people with TBI, ages 18-65 yr, were screened. Twenty-six were eligible; 6 declined. Inclusion criteria: oculomotor impairment. Exclusion criteria: inpatient stay <6 wk, blind, no functional arm use, unable to follow a three-step command, attention <30 min, or in another clinical trial.

INTERVENTION

Participants were randomized into an experimental group (n = 10) receiving the Six Eye Exercises protocol or a control group (n = 10) receiving a standard-of-care protocol for 30 min/day, 5 days/wk, for 4 wk. Oculomotor and related functional impairments were measured at baseline and posttreatment.

OUTCOMES AND MEASURES

Measures were chosen before the start. Primary outcome measure: Craig Hospital Eye Evaluation Rating Scale for oculomotor status. Secondary measures for functional status: King-Devick Test, Delis-Kaplan Executive Function System Trail Making Test: Condition 1 Visual Scanning, Modified Nelson-Denny Reading Test, and Subjective Vision Symptom Scale.

RESULTS

Sixteen participants finished. Fatigue was the primary reason for withdrawal. No other negative effects were noted. Selected outcome measures captured positive improvements in both groups.

CONCLUSIONS AND RELEVANCE

Study findings suggest conducting an appropriately powered RCT to evaluate efficacy of oculomotor treatment in this population.

WHAT THIS ARTICLE ADDS

Oculomotor dysfunction seems to improve during inpatient TBI rehabilitation with remedial treatment. Best practice in occupational therapy has not yet been established. An appropriately powered RCT could positively contribute to the evidence available to clinicians.

Optimized Sleep After Brain Injury (OSABI): A Pilot Study of a Sleep Hygiene Intervention for Individuals With Moderate to Severe Traumatic Brain Injury

Background. Disrupted sleep is common after traumatic brain injury (TBI) particularly in the inpatient rehabilitation setting where it may affect participation in therapy and outcomes. Treatment of sleep disruption in this setting is varied and largely unexamined. Objective. To study the feasibility of instituting a sleep hygiene intervention on a rehabilitation unit. Methods. Twenty-two individuals admitted to a brain injury unit were enrolled and allocated, using minimization, to either a sleep hygiene protocol (SHP) or standard of care (SOC). All participants wore actigraphs, underwent serial cognitive testing, and had light monitors placed in their hospital rooms for 4 weeks. Additionally, participants in the SHP received 30 minutes of blue-light therapy each morning, had restricted caffeine intake after noon, and were limited to 30-minute naps during the day. SHP participants had their lights out time set according to preinjury sleep time preference. Both groups were treated with the same restricted formulary of centrally acting medications. Results. Of 258 patients screened, 27 met all study inclusion criteria of whom 22 were enrolled. Nine participants in each group who had at least 21 days of treatment were retained for analysis. The protocol was rated favorably by participants, families, and staff. Actigraph sleep metrics improved in both groups during the 4-week intervention; however, only in the SHP was the change significant. Conclusions. Sleep hygiene is a feasible, nonpharmacologic intervention to treat disrupted sleep in a TBI inpatient rehabilitation setting. A larger study is warranted to examine treatment efficacy. ClinicalTrials.gov Identifier: NCT02838082.

Near-real-time pulmonary shunt and dead space measurement with micropore membrane inlet mass spectrometry in pigs with induced pulmonary embolism or acute lung failure

The multiple inert gas elimination technique (MIGET) using gas chromatography (GC) is an established but time-consuming method of determining ventilation/perfusion (VA/Q) distributions. MIGET-when performed using Micropore Membrane Inlet Mass Spectrometry (MMIMS)-has been proven to correlate well with GC-MIGET and reduces analysis time substantially. We aimed at comparing shunt fractions and dead space derived from MMIMS-MIGET with Riley shunt and Bohr dead space, respectively. Thirty anesthetized pigs were randomly assigned to lavage or pulmonary embolism groups. Inert gas infusion (saline mixture of SF6, krypton, desflurane, enflurane, diethyl ether, acetone) was maintained, and after induction of lung damage, blood and breath samples were taken at 15-min intervals over 4 h. The samples were injected into the MMIMS, and resultant retention and excretion data were translated to VA/Q distributions. We compared MMIMS-derived shunt (MM-S) to Riley shunt, and MMIMS-derived dead space (MM-VD) to Bohr dead space in 349 data pairs. MM-S was on average lower than Riley shunt (- 0.05 ± 0.10), with lower and upper limits of agreement of - 0.15 and 0.04, respectively. MM-VD was on average lower than Bohr dead space (- 0.09 ± 0.14), with lower and upper limits of agreement of - 0.24 and 0.05. MM-S and MM-VD correlated and agreed well with Riley shunt and with Bohr dead space. MM-S increased significantly after lung injury only in the lavage group, whereas MM-VD increased significantly in both groups. This is the first work evaluating and demonstrating the feasibility of near real-time VA/Q distribution measurements with the MIGET and the MMIMS methods.

Psychological well-being in individuals living in the community with traumatic brain injury

BACKGROUND

Well-being and quality of life issues remain a long-term problem for many individuals with traumatic brain injury (TBI). Meaningful activity is key to developing life satisfaction and a sense of contribution to society, yet individuals with TBI are often unable to return to competitive employment.

OBJECTIVE

To describe the self-reported psychological well-being of a cohort of unemployed individuals living in the community at least 1 year post TBI with low life satisfaction.

METHODS

Seventy-four unemployed individuals with low life satisfaction at least 1 year post TBI were administered measures of psychological well-being and cognitive functioning.

RESULTS

This cohort of 74 participants demonstrated cognitive impairment and elevated levels of emotional distress. Significant bivariate relationships were noted among nearly all measures of well-being, and associations were in the directions as expected. Individuals reported low life satisfaction and well-being. Two newer measures of well-being correlated with established measures used with this population.

CONCLUSIONS

Individuals with TBI living in the community who are not employed but who seek to be productive reported low life satisfaction and well-being. This study highlights the need for interventions aimed at increasing productivity and meaning in life for individuals with TBI, and a broader understanding of psychological health after TBI.

Step Ergometer Training Augmented With Functional Electrical Stimulation in Individuals With Chronic Spinal Cord Injury: A Feasibility Study

Spinal cord injury (SCI) often results in loss of upright mobility and independence subsequently challenging rehabilitation practitioners for meaningful intervention strategies. The objective of this study was to evaluate the feasibility and potential impact on walking function of the stimulation and ergometer training protocol (STEP) in chronic SCI. Fourteen individuals with a chronic motor incomplete SCI (>1-year post injury) were enrolled in the study. The intervention consisted of a 12-week walking training program delivered three times per week from 20 up to 45 min in combination with 10 channels of FES on a step ergometer. Subsequent to this training, 30 min over ground walking training was performed. Ten out of the 14 participants completed the trial (71%). All participants who completed the intervention increased their walking speed by an average of 0.13 m/s (0.08) and walking endurance by an average of 117 ft (84 ft). For those who completed the trial, 50% demonstrated increases on the Walking Index for Spinal Cord Injury II by at least one level while 60% demonstrated an increase in lower extremity motor scores; all completing the Timed Up and Go Test at baseline demonstrated a reduction in time to complete during post-test evaluation. Recruitment objectives were attained. Overall retention was lower than anticipated with 29% withdrawing secondary to issues with lower extremity pain and exertional demands; however, no other adverse events occurred. Improvements in mobility outcomes generated by the STEP show promise in the context of feasibility and warrant further investigation to evaluate efficacy in comparison to other walking recovery interventions. The STEP was well-tolerated by participants who were >1 year and less than 10 years post SCI. Those completing the protocol exhibited improvements in commonly used SCI walking outcome measures.

Improving personal self-advocacy skills for individuals with brain injury: A randomized pilot feasibility study

OBJECTIVE

To investigate the feasibility of a self-advocacy intervention for individuals with acquired brain injury (ABI).

DESIGN

Two-arm, parallel-design, randomized feasibility study.

METHODS

Twelve participants, 1-year or more post-ABI (TBI and cerebral vascular accident (CVA)), were randomized into treatment/control groups. The treatment group received a group intervention and workbook; the control group received the workbook only. Outcome measures, taken at baseline, post-treatment and 6-weeks follow-up, included the General Self-Efficacy Scale (GSES), Satisfaction with Life Scale (SWLS) and Goal Attainment Scale (GAS) and two exploratory measures developed for the study: the Self Advocacy Scale (SAS) and the Personal Advocacy Activity Scale (PAAS).

RESULTS

Participants were successfully recruited and treated per protocol. The treatment group exhibited improvements from baseline to post-treatment on all measures; the control group improved on the GSES and declined on all others. Both groups exhibited improvement on all measures at follow-up, except the PAAS, which declined. There were no significant group differences on non-parametric analysis at any assessment points; however, the magnitude of change at post-treatment approached significance for the SAS and PAAS.

CONCLUSIONS

Initial feasibility for the methodology was demonstrated. Positive trends were noted. Further research could result in an evidence-based intervention to enhance self-advocacy post-ABI.

Virtual reality-based therapy for the treatment of balance deficits in patients receiving inpatient rehabilitation for traumatic brain injury

OBJECTIVE

To evaluate the feasibility and safety of utilizing a commercially available virtual reality gaming system as a treatment intervention for balance training.

DESIGN

A randomized controlled trial in which assessment and analysis were blinded.

SETTING

An inpatient rehabilitation facility.

INTERVENTION

Interventions included balance-based physical therapy using a Nintendo Wii, as monitored by a physical therapist, and receipt of one-on-one balance-based physical therapy using standard physical therapy modalities available for use in the therapy gym.

RESULTS

Participants in the standard physical therapy group were found to have slightly higher enjoyment at mid-intervention, while those receiving the virtual reality-based balance intervention were found to have higher enjoyment at study completion. Both groups demonstrated improved static and dynamic balance over the course of the study, with no significant differences between groups. Correlational analyses suggest a relationship exists between Wii balance board game scores and BBS scores for measures taken beyond the baseline assessment.

CONCLUSIONS

This study provides a modest level of evidence to support using commercially available VR gaming systems for the treatment of balance deficits in patients with a primary diagnosis of TBI receiving inpatient rehabilitation. Additional research of these types of interventions for the treatment of balance deficits is warranted.

Two approaches to manual wheelchair configuration and effects on function for individuals with acquired brain injury

OBJECTIVE

To determine whether manual wheelchair configuration impacts how well a person who has acquired brain injury (ABI) related hemiparesis performs functional tasks from his or her wheelchair.

DESIGN

Multi-treatment cross-over design.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Nineteen patients with ABI resulting in hemiparesis undergoing inpatient rehabilitation (average of 75 days post-injury (± 29.2 days); age range, 21-64; 9 with mechanical brain injury, 10 with cerebral vascular accident).

INTERVENTIONS

Participants in the study were placed in two different wheelchair configurations (position one and position two) and were randomized as to which position they were placed in first. All outcome measures were taken twice on each individual within each wheelchair configuration during two consecutive days.

MAIN OUTCOME MEASURES

Timed Forward Wheeling (TFW), Modified Functional Reach test (MFR), Visual Analogue Scale for Comfort (VAS), transfer score from the Functional Independence Measure (FIM), measurement of popliteal fossa to front of cushion.

RESULTS

The position two seating group's TFW was significantly faster than the position one seating group at both time points. There were no significant differences in the MFR scores, VAS comfort scale scores, and FIM transfer score between the two groups.

CONCLUSION

A wheelchair configuration with no seat slope, solid backrest mounted at 95 degree (± 3 degrees) seat to back angle, and use of a solid seat insert with a flat foam cushion (position two) results in greater efficiency in foot propulsion for individuals with ABI than a wheelchair configuration with one inch of seat slope, solid backrest mounted at 105 degree (± 3 degrees) seat to back angle, and no solid seat insert with a gel/foam contoured cushion (position 1).

Clinical outcomes of patients with adenocarcinoma in situ of the cervix treated by conization

OBJECTIVE

To describe the clinical outcomes of histologically confirmed adenocarcinoma in situ (AIS) of the cervix treated with cervical conization.

MATERIALS AND METHODS

A retrospective chart review of patients with histologically confirmed AIS from July 1998 to February 2011 included 52 patients. The rates of residual disease in subsequent excisions, the clinical recurrence rate, the average disease-free interval, and risk of progression to adenocarcinoma were described. The clinical outcomes of patients treated with cold knife cone (CKC) and loop electrosurgical excisional procedure (LEEP) were compared.

RESULTS

Fifteen LEEPs and 37 CKC procedures were performed as initial treatment and 26 patients (50%) had positive margins. There was no significant difference in rate of positive margins between LEEP and CKC (40% vs. 54%, respectively. p = 0.55). LEEPs and CKCs resulted in similar volumes of cervical tissue resected (4.98 cm3 vs. 5.04 cm3, p = 0.40). Of patients with positive margins, ten underwent immediate hysterectomy, six underwent a second cone biopsy, seven were managed expectantly, and four were lost to follow up. Residual AIS was found in 47% (eight of 17) of repeat cone biopsy and hysterectomy specimens performed for positive cone margins. Of the 26 patients with negative cone margins, no residual or recurrent disease was found after an average follow-up of 32 months.

CONCLUSIONS

A positive surgical margin was associated with residual disease in 47% of patients with AIS treated with conization. No patient with negative cone margins had recurrent or progressive disease. Cervical conization with negative margins appears to be a safe treatment option for patients with AIS but requires further investigation. CKC and LEEP were equally efficacious treatments in our study population.