Motor Recovery After Rehabilitation and Long‐Term Clinical Outcomes

Abstract

To the Editor: We read with interest the paper by Boyd et al.1 about functional recovery in older patients discharged from the hospital after an acute medical illness. The authors found that those discharged with a new disability in activities of daily living showed poor functional recovery at 1-year follow-up. We would like to contribute to this topic with personal data, primarily focusing on the motor aspects of functional recovery. For this purpose, the clinical data of a population of elderly patients, consecutively discharged from a Rehabilitation and Aged Care Unit (RACU) from January 2006 to November 2007, were retrospectively reviewed. Like Boyd and colleagues, only patients aged 70 and older discharged from local hospitals and transferred to the RACU after an acute medical or surgical illness were selected. Exclusion criteria were RACU admission after elective surgery and living in nursing home before hospital admission. All patients underwent a multidimensional assessment on RACU admission, including sociodemographic (age, sex, living arrangement), cognitive (Mini-Mental State Examination, Geriatric Depression Scale), functional (Instrumental activities of daily living, Barthel Index), and physical (Cumulative Illnesses Rating Scale severity, albumin serum level) status. To evaluate the degree of motor recovery, three motor items were selected from the Barthel Index (transfer, walking, and climbing stairs),2 and difference between patients' pre-admission (1 month before the acute medical event) and RACU discharge scores were calculated. Two groups were therefore created, according to patients' change in motor abilities. Patients who completely returned to their premorbid condition were classified in the full motor recovery (FMR) group, and those who did not recover completely were classified in the poor motor recovery (PMR) group. Two hundred eleven patients were eligible for the analysis; 87 displayed FMR at discharge, and 124 displayed PMR (Table 1). Groups were comparable for age, sex, and comorbidity, although patients in the FMR group were more likely to live alone, were less cognitively impaired, and had higher albumin serum levels than those in PMR. Patients did not differ on the Barthel preadmission total score, but there was a significant difference in functional status between groups on admission and at discharge. Motor performance was different between groups at pre-admission, on admission, and at discharge, with patients in the PMR group having the poorest scores. At the 1-year follow up, information about patient survival; institutionalization; and ability to transfer from the bed to a chair, walk, and climb stairs independently were gathered in telephone interviews with proxies. Sixteen subjects died or were institutionalized at 1 year, with only one of these in the FMR group. Moreover, patients in the PMR group were more likely to have a 1-year decline in motor abilities, defined as a loss of 27 or more points at the Barthel Index motor scores, than those in the FMR group. These results support Boyd's findings, showing that poor motor recovery from pre-admission to RACU discharge is associated with further functional decline and a higher rate of death or institutionalization at the 1-year follow-up. It could be hypothesized that PMR membership could reflect a condition of frailty that can lead to a loss of homeostatic capacity and therefore to long-term adverse outcomes; the lower albumin serum levels and the poorer cognitive and functional performances at baseline in the PMR group than in their counterparts indirectly suggest this, although the data also suggest that postacute rehabilitation should maximize its efforts, where possible, to fully reinstate patient's motor abilities, because evidence indicates that intensive exercise programs have positive effects on reducing disability in elderly persons in the middle to long term (∼1 year).3, 4 The authors would like to acknowledge Drs. Fabio Guerini, Salvatore Speciale, Alessandra Marrè, and Renato Turco for their contribution to data collection. All have provided written consent for this acknowledgment. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Bellelli and Trabucchi: study concept and design, analysis and interpretation of data, and preparation of manuscript. Morghen and Tirelli: acquisition of subjects and data and preparation of manuscript. Sponsor's Role: No sponsor.