Ambulatory Rehabilitation Program Research Articles

Changes in new cardiovascular risk factors during a 3-month ambulatory cardiac rehabilitation programme

Changes in new cardiovascular risk factors during a 3-month ambulatory cardiac rehabilitation programme

Repetitive Bilateral Arm Training and Motor Cortex Activation in Chronic Stroke

Reorganization in central motor networks occurs during early recovery from hemiparetic stroke. In chronic stroke survivors, specific rehabilitation therapy can improve upper extremity function. To test the hypothesis that in patients who have chronic motor impairment following stroke, specific rehabilitation therapy that improves arm function is associated with reorganization of cortical networks. A randomized controlled clinical trial conducted in a US ambulatory rehabilitation program with 21 patients (median [IQR], 50.3 [34.8-77.3] months after unilateral stroke). Data were collected between 2001 and 2004. Patients were randomly assigned to bilateral arm training with rhythmic auditory cueing (BATRAC) (n = 9) or standardized dose-matched therapeutic exercises (DMTE) (n = 12). Both were conducted for 1 hour, 3 times a week, for 6 weeks. Within 2 weeks before and after the intervention, brain activation during elbow movement assessed by functional magnetic resonance imaging (fMRI) and functional outcome assessed using arm function scores. Patients in the BATRAC group but not in the DMTE group increased hemispheric activation during paretic arm movement (P = .03). Changes in activation were observed in the contralesional cerebrum and ipsilesional cerebellum (P = .009). BATRAC was associated with significant increases in activation in precentral (P<.001) and postcentral gyri (P = .03) and the cerebellum (P<.001), although 3 BATRAC patients showed no fMRI changes. Considering all patients, there were no differences in functional outcome between groups. When only BATRAC patients with fMRI response were included (n = 6), BATRAC improved arm function more than DMTE did (P = .02). These preliminary findings suggest that BATRAC induces reorganization in contralesional motor networks and provide biological plausibility for repetitive bilateral training as a potential therapy for upper extremity rehabilitation in hemiparetic stroke.

Prognosis for Gross Motor Function in Cerebral Palsy: Creation of Motor Development Curves

When cerebral palsy (CP) is diagnosed, most often in the firm 18 months of life, the parents want to know how severe it is and, specifically, whether their child will ever walk. Neither the connection between reflexes andearly motor skills at age 2 nor the achievement of motor milestones up to age 4 years has reliably predicted walking ability at a later age. The present investigators longitudinally analyzed patterns of gross motor development by their degree of severity in a cohort study of 657 children, ranging in age from 1 to 13 years at the outset of study, who presented the full range of clinical severity seen in children with CP. The subjects, seen at 19 regional children's ambulatory rehabilitation programs in Ontario, Canada, were followed for up to 4 years. Severity of CP was classified using the five-level Gross Motor Function Classification System (GMFCS), and function was formally assessed using the Gross Motor Function Measure (GMFM). The children in this study received treatment representative of what is generally provided in the Western world. Based on 2632 GMFM assessments, five distinctive curves of motor development were distinguished, representing significantly different rates and limits of gross motor development: level I, walks without limits but more advanced gross motor skills are limited; level II, walking is possible without aids but is limited outdoors and in the community; level III, can walk with assistive devices; level IV, patients are mobile but limited, and they are transported or use powered mobility outdoors and in the community; level V, self-mobility is markedly limited even with assistive devices. As expected, the estimated limit of development declined as the severity of impairment increased. Children at levels III through V progressed significantly more rapidly than level I children, but those in levels I and II did not differ in rate of progression. A tendency was apparent for children with lower potential for motor development to reach their limit more quickly than those with greater potential, even within the same GMFCS level. Children who perform at a higher level than expected from the average level III curve were likely to level off sooner than their peers. Caregivers must not assume that further treatment is unneeded or will be ineffective when the curve appears to level off. In general, GMFCS levels remain stable over time, permitting reliable prognostic assessments. The curves describe patterns for groups of children, and it is important to recall that within each level there are variations in motor development emanating from other aspects of children's' functional status.

Síndrome de Guillain-Barré prolongado

Outcome in Guillain-Barré syndrome (GBS) in childhood is usually favorable although prolonged and severe forms may develop. We report the case of a 12-year-old boy with rapidly ascending, slowly-progressive GBS with severe cranial nerve and autonomic dysfunction. Diagnosis was based on clinical presentation, electromyography, cerebrospinal fluid analysis and plasmatic antiganglioside GM1 antibodies. Early treatment with an initial loading dose of 2 g/kg of intravenous gammaglobulins over 5 days was given with a significant but slow clinical improvement. A repeat infusion of gammaglobulins was given two months later. Response was satisfactory with motor, sensory and autonomic dysfunction recovery. A third course of immunoglobulins 28 days later produced little benefit. At the present time, 5 months after the onset of the disease, flaccid paralysis of the lower limbs and the distal portion of the upper limbs persists but autonomic instability has disappeared. The patient has been decannulated and is following an ambulatory rehabilitation program. Although repeated intravenous immunoglobulins may be useful in the treatment of prolonged GBS, the key issue is excellent intensive care unit management. Further research examining potentially more effective treatment such as beta-interferon and immunosuppressive agents is required.

Prognosis for gross motor function in cerebral palsy: creation of motor development curves.

Lack of a valid classification of severity of cerebral palsy and the absence of longitudinal data on which to base an opinion have made it difficult to consider prognostic issues accurately. To describe patterns of gross motor development of children with cerebral palsy by severity, using longitudinal observations, as a basis for prognostic counseling with parents and for planning clinical management. Longitudinal cohort study of children with cerebral palsy, stratified by age and severity of motor function and observed serially for up to 4 years during the period from 1996 to 2001. Nineteen publicly funded regional children's ambulatory rehabilitation programs in Ontario. A total of 657 children aged 1 to 13 years at study onset, representing the full spectrum of clinical severity of motor impairment in children with cerebral palsy. Severity of cerebral palsy, classified with the 5-level Gross Motor Function Classification System; function, formally assessed with the Gross Motor Function Measure (GMFM). Based on a total of 2632 GMFM assessments, 5 distinct motor development curves were created; these describe important and significant differences in the rates and limits of gross motor development among children with cerebral palsy by severity. There is substantial within-stratum variation in gross motor development. Evidence-based prognostication about gross motor progress in children with cerebral palsy is now possible, providing parents and clinicians with a means to plan interventions and to judge progress over time. Further work is needed to describe motor function of adolescents with cerebral palsy.

Partial inpatient cardiologic after-care

In Germany the in-hospital rehabilitation of patients with cardiac diseases is standard. Especially because of criticism of effectiveness and wasting of resources we evaluated in a pilot study a rehabilitation program with an in-hospital start, followed facultatively on ambulatory basis at the same institution, at the cardiac rehabilitation clinic. The aims of the study were to find out the acceptance of the the program by the patients, the safety and the impact of the facultative ambulatory rehabilitation program on cardiovascular risk factors. From January 1993 to December 1995 the primary enclosing criteria (cardiac disease suitable for rehabilitation, age < 70 years, lodging < 40 km) were fulfilled by 612 patients, 122 female. 268 (43.8%) were disclosed on medical grounds because of the rigid pilot character of the study, for 74 (12.1%) patients was the participation on organisational grounds not possible. Sixty-six of the remaining 270 patients preferred the facultative continuation of the rehabilitation on ambulatory basis for 1 or 2 weeks, the entire rehabilitation lasting up to 4 weeks. During the ambulatory phase the patients slept at home, otherwise these patients followed the same procedure as the in-hospital participants. Despite of severe medical concerns 4 further patients wished to participate on facultative ambulatory continuation of the rehabilitation, among these were 2 women, only 5 of the total 70 patients of the facultative ambulatory program group being female. There were no significant differences among 24 patients with CAD of both groups during the rehabilitation and in a control after 14.8 months (Table 3). The impact on serum total cholesterol and LDL cholesterol was positive (Table 2), albeit after 14.8 months no more significant. Over the control period there were a negative development of serum triglyceride level and significant negative effects on the body weight. There were no complications among the 66 patients during the facultative ambulatory phase of the rehabilitation, in contrast to those 37 of 268 patients who had to be disclosed because of medical concerns (Table 1). During the rehabilitation the drug therapy was optimized for many participants. The control after 14.8 months revealed that these remedies were followed with great accuracy by the physicians at home (Figure 1). In conclusion, a cardiac rehabilitation program with an in-hospital start of 2 weeks, going over to ambulatory rehabilitation for 1 to 2 weeks, is as effective and safe as an in-hospital cardiac rehabilitation. As known, amelioration of the long-term results has yet to be achieved.

The changing nature of ambulatory rehabilitation programs and services in a managed care environment

Rehabilitation providers have been experiencing the impact of managed care on their services for many years. However, the outpatient, or ambulatory, segments of rehabilitation and their inpatient counterparts are being reshaped differently by this payment source. Because most ambulatory patients do not originate from an inpatient setting, managed care contracts directly with providers rather than flowing contracts through the hospital setting. Thus, ambulatory rehabilitation, more than other elements of the rehabilitation industry, is dependent on contracting to ensure patient flow.

The changing nature of ambulatory rehabilitation programs and services in a managed care environment.

Rehabilitation providers have been experiencing the impact of managed care on their services for many years. However, the outpatient, or ambulatory, segments of rehabilitation and their inpatient counterparts are being reshaped differently by this payment source. Because most ambulatory patients do not originate from an inpatient setting, managed care contracts directly with providers rather than flowing contracts through the hospital setting. Thus, ambulatory rehabilitation, more than other elements of the rehabilitation industry, is dependent on contracting to ensure patient flow.

Improved exercise tolerance by cardiac rehabilitation after myocardial infarction in the elderly: Results of a preliminary, controlled study

Elderly patients are commonly excluded from cardiac rehabilitation after myocardial infarction (MI). The present controlled, non-randomized trial was undertaken as a preliminary study to compare some effects of cardiac rehabilitation between patients younger and older than 65 years without contraindications to physical exercise. Baseline total work capacity (TWC) was assessed by a maximal ergometric stress testing 4 weeks after MI. Patients were then prospectively enrolled into an 8-week ambulatory rehabilitation program (R-group: age < or = 65 N = 16; age > 65 N = 16). Those who refused or who could not participate in the program because of logistic difficulties served as controls (NR-group: age < or = 65 N = 16; age > 65 N = 14). In spite of non-randomized allocation, clinical characteristics did not differ between either treatment groups or age groups. TWC was re-assessed at 8 weeks from baseline evaluation in all patients. The number of completed training sessions in the R-group, and the proportion of sessions which were suspended for physiological or pathological (adverse events during exercise) causes were similar under and over 65 years. TWC increased (p < 0.001) in the R-group, the improvement being similar in the two age cohorts (< or = 65: +55% vs > 65: +65%, NS). A spontaneous enhancement of TWC (+37%, p < 0.001) occurred among younger controls as well. Only older controls did not improve their TWC; moreover, their +16% change was significantly (p < 0.05) less than the +65% increase obtained by the R-group of the same age.(ABSTRACT TRUNCATED AT 250 WORDS)

Outpatient treatment of patients with chronic pain: an analysis of cost savings.

To control costs, the University of Tennessee Center for Pain Management added an ambulatory pain rehabilitation program to its existing inpatient hospitalization program. The impact of this program was assessed by comparing the first 25 patients treated in 1985 (prior to the introduction of outpatient management) with the first 25 patients treated in 1987 (after outpatient management was established). Twenty of the 25 patients seen in 1985 required hospitalization, while in 1987 nine patients were hospitalized and 10 patients were placed in outpatient rehabilitation. The total cost for treating 25 patients in 1985 was $571,200 but decreased to $191,000 in 1987. Hospital charges were the greatest single cost factor in 1985 ($321,500) but were only $61,000 in 1987. Success rates as measured by a return to previous employment were not significantly changed (13 of 25 returned to work in 1985, and 11 of 25 returned to work in 1987).

Value of exercise testing for prediction of physical and psychosocial rehabilitation potential 3 months after acute myocardial infarction.

In 147 patients exercise tests were performed at the beginning and after 1 year of an ambulatory rehabilitation program. Measurements of both tests and the degree of functional improvement were correlated with patients' characteristics, the results of a psychological analysis using the Freiburger Personality Inventory and a patient's questionnaire for self-assessment. Among the major determinants for functional improvement were age, location of the infarct, rate of participation and greater initial functional impairment. High degree of psychosomatic impairment accompanied low levels of exercise capacity, the patients' self-assessment showed no correlation with exercise performance.