Cognitive Functional Independence Measure Scores Research Articles

Abstract W P136: Aiding Stroke Rehabilitation with the Modified Atkins Diet: A Pilot Trial

Introduction: The Modified Atkins Diet (MAD) is a low carbohydrate, ketogenic diet. Animal studies suggest ketogenic diets enhance functional stroke recovery by activating transcriptional programs associated with brain protection and repair. The safety of use of the MAD in the elderly stroke population is however unknown. We here expand the use of MAD in a new patient population. Setting: Inpatient Stroke Rehabilitation Unit Methods: 18 first time ischemic stroke patients were randomized to receive either the MAD or their respective regular diet. Laboratory studies were obtained upon admission and every 5 days until discharge. Functional outcome measures included the Upper Extremity Fugl Meyer Motor Score (FMMS), Functional Independence Measure (FIM) and Montreal Cognitive Assessment (MOCA). Urine was tested daily for presence of ketones. A registered dietician monitored patients daily. All patients received cholesterol-lowering medication. Results: 10 patients received the MAD and 8 respective control diets. Age, gender, and interval post stroke did not differ significantly between groups. No significant difference existed between groups in admission cognitive, motor and total FIM scores, FMMS and MOCA scores. 4 patients withdrew prematurely from the MAD group due to low palatability of a pureed diet with nectar thick liquids. No significant medical events were encountered in either group. The MAD did not induce significant changes in LDL (-13.8±29.7 vs. -7.5±19.2;p=0.59), cholesterol (-9.2±36.5 vs. -10.8±25.22;p=0.92) and glucose levels (14±28.5 vs. -0.38±20.5;p=0.4).The MAD and Control group had similar changes in total (30.9,±12.3 vs. 25.9±11.9;p=0.5), motor (18.8±14.5 vs. 18.5±13.1;p=0.62), cognitive FIM (4.5,±2.3 vs. 5±3.5;p=0.4),FMMS(15.2±5.01 vs. 17.8±11.6;p=0.65),and MOCA scores (6.2±5.2 vs. 4.6±2.96;p=0.57). Conclusion: The Modified Atkins Diet is a safe and feasible intervention to aide stroke recovery. No adverse effects on lipid and glucose profile were noted, and the diet was overall well tolerated. A larger, multi-center trial will be needed to test for efficacy. The study also highlights the advantages of the rehab setting for implementing dietary interventions post stroke and verifying compliance.

Abstract T P125: Does the Stroke Impact Scale-16 (SIS-16) PositivelyCorrelate with the Functional Independence Measure ( FIM) During AcuteInpatient Rehabilitation Following Stroke?

Background and Purpose: For patients who require acute inpatient rehabilitation after stroke, affect and level of motivation are important for successful outcomes. Conversely, patients who have decreased insight into their deficits are more likely to have negative rehabilitation outcomes, including poorer function and longer hospital stay. Previous research has shown a significant correlation between Stroke Impact Scale(SIS) and Functional independence Measure(FIM) scores in patients undergoing rehabilitation 3 to 6 months after stroke. There is no data on whether these scores correlate immediately after stroke. The purpose of this study is to determine if SIS-16 scores positively correlate with FIM scores after stroke, during acute rehabilitation. Methods: Using a self-reported survey methodology, 70 adult patients with a primary medical diagnosis of stroke who were admitted to an inpatient rehabilitation hospital were surveyed using the Stroke Impairment Scale-16 at the time of admission and again at discharge. During the same time intervals, patients were assessed using the Functional Independence Measure. Data of the two assessment tools were analyzed using a Pearson Correlation Coefficient. Results: Based on the data analysis, the data demonstrated good correlation between SIS-16 average and FIM total motor scores on admission(r = .66) and discharge(r = .67). Additionally, The SIS-16 score change, showed good correlation with the total FIM score change(r = .31) and motor FIM change(r = .34). Interestingly, the degree of functional cognitive ability did not correlate to the same level of perceived impairment.(r = .17/.06) Conclusions: As found in previous research involving patients 3-6 months status post stroke, this study found that the SIS-16 and FIM demonstrate a direct correlation in patients within the inpatient rehabilitation hospital setting. Future research into interventions to improve the correlation between SIS-16 and the cognitive FIM scores are warranted.

Adverse effects of admission blood alcohol on long-term cognitive function in patients with traumatic brain injury.

Alcohol is known to be protective in patients with traumatic brain injury (TBI); however, its impact on the long-term cognitive function is unknown. We hypothesize that intoxication at the time of injury is associated with adverse long-term cognitive function in patients sustaining TBI. We performed a 2-year retrospective study of all trauma patients with isolated TBI presenting to our Level I trauma center and discharged to a single rehabilitation facility. Patients with moderate-to-severe TBI (head Abbreviated Injury Scale [AIS] score ≥ 3), measured admission blood alcohol concentration, and measured cognitive function on hospital discharge and rehabilitation center discharge were included. Cognitive function was assessed using Functional Independence Measure (FIM) scores. Delta cognitive FIM was defined as the difference between rehabilitation center discharge and hospital discharge cognitive FIM scores. Multivariate linear regression was performed. A total of 64 patients were included. Mean (SD) age was 51.8 (23) years, median head AIS score was 3 (IQR, 3-5), and median Glasgow Coma Scale (GCS) score was 11 (IQR, 3-15). Mean (SD) cognitive FIM score on hospital discharge was 17 (6), and mean (SD) cognitive improvement was 8.6 (4.7). Sixty percent (n = 39) were under the influence of alcohol on admission, and the mean (SD) admission blood alcohol concentration was 132 (102).On multivariate linear regression analysis, admission blood alcohol concentration (β = -0.4; 95% confidence interval, -6.7 to -0.8; p = 0.01) and age (β = -0.13; 95% confidence interval, -0.2 to -0.04; p = 0.04) were negatively associated with improvement in long-term cognitive function. Alcohol intoxication at the time of injury is associated with lower improvement in long-term cognitive function. Older intoxicated patients are likely to have a lower cognitive improvement. Prognostic and epidemiologic study, level III.

Disability Impacts Length of Stay in General Internal Medicine Patients

Disability is prevalent among patients treated in Internal Medicine (IM), but its impact on length of inpatient stay (LOS) is unknown. Current systems of patient management and resource allocation are disease-focused with scant attention paid to functional impairment. Earlier studies in selected cohorts suggest that disability prolongs LOS. To investigate the relationship of disability with LOS in IM, controlling for comorbidity. Prospective cohort study. We charted 448 patients from an IM team admitted between 2008 and 2012 for sociodemographic, disease, biochemical and functional characteristics. Each IM team is on duty for one month annually, and patients were hence recruited for one month each year. Disability was measured using the Functional Independence Measure (FIM) recorded at discharge. Comorbidity was measured using the Charlson Comorbidity Index (CCI). Of the 448 patients, 57.4 % were male with mean age 68.6 years. The mean LOS was 9.58 days. The mean motor and cognitive FIM scores were 57.1 and 25.7, respectively. The mean CCI score was 2.69. Thirty-four percent had major social issues impacting discharge plans. The five most common diagnoses for admission were pneumonia (8.9 %), urinary tract infection (7.8 %), cellulitis (7.6 %), heart failure (7.1 %) and falls (6.0 %). Both cognitive and motor FIM scores were negatively correlated with longer LOS (P < 0.001). On multivariate analysis, variables independently associated with longer LOS included the motor FIM score (P < 0.001), presence of social issues such as caregiver unavailability (P < 0.001), non-realistic patient expectations (P = 0.001) and administrative issues impeding discharge (P = 0.016). Disability predicts LOS in IM patients, and thus their comprehensive care should involve functional assessment. As social and administrative factors were also independently associated with LOS, there is a need to involve social workers and administrators in a multidisciplinary approach towards optimizing LOS.

A videoendoscopic swallowing examination using a scoring system for prediction of successful oral intake after discharge from an acute care hospital

It is often difficult to decide whether to restart an oral diet during acute hospitalization. We investigated retrospectively the predictive factors for successful oral intake after discharge from an acute care hospital or transfer to a recovery rehabilitation hospital. A total of 45 inpatients were enrolled, presenting with dysphagia due to various diseases during hospitalization in an acute care hospital. Between October 2011 and December 2012 the patients were examined with a videoendoscopic examination of swallowing (VE). We classified the feeding procedure after discharge from the hospital into three groups-the first group (group 1) had no oral intake limitation, the second group (group 2) had limited oral intake, and the third group (group 3) had no oral intake ability. We then assessed the factors of age, sex, VE score, and functional independence measure (FIM) score to compare the activities of daily living (ADL) between group 1 and group 2 + 3. FIM score consists of motor and cognitive scores. We observed a statistically significant difference in age, VE score, motor FIM score and cognitive FIM score in a univariate analysis (p = 0.03, p = 0.0036, p = 0.0019, p = 0.0125). The VE score also showed a statistically significant difference in a multivariate analysis (p = 0.0396), indicating that the VE score was an independent variable related to prediction of the feeding procedure. A VE score of 4 as the cut-off point between group 1 and group 2 + 3 provided a specificity of 0.944 and a positive predictive value of 0.923. On the other hand, a VE score of 9 as the cut-off point between group 3 and group 1 + 2 provided a specificity of 0.969 and a positive predictive value of 0.857. These results indicate that the VE score is a useful tool for the prediction of successful oral intake after discharge from an acute care hospital. In addition, age and ADL are also useful predictive factors for the feeding procedure.

Changes in cognition and continence as predictors of rehabilitation outcomes in individuals with severe traumatic brain injury.

The study objective was to examine postacute changes in bowel and bladder continence and cognition after severe traumatic brain injury (TBI) in persons with long-term functional recovery to full independence. This case series included nine patients initially admitted to inpatient rehabilitation (IR) with severe TBI who had returned to prior responsibilities and functional independence by 8 to 15 mo. Patients had initial Glasgow Coma Scale scores of 3 to 6, posttraumatic amnesia durations of 18 to 70 d, time-to-follow-commands of 16 to 56 d, initial abnormal brain computed tomography scans, and initial pupil abnormalities. IR Functional Independence Measure (FIM) cognitive and sphincter score improvements were compared with national TBI FIM data from Uniform Data Systems for Medical Rehabilitation (UDSMR) for 2010 (n = 16,368). All patients had IR improvements in cognitive and sphincter FIM scores approximately twice the national UDSMR data for 2010. All patients had combined IR discharge sphincter FIM scores that were 12 or greater, indicating independence to modified independence with bowel and bladder function with no incontinence. Five participants (55%) were admitted to IR with sphincter FIM scores of 11 to 12, indicating recovery of continence during acute care. These findings suggest potential usefulness of IR cognitive FIM score changes and of the recovery of bowel and bladder continence for predicting favorable functional outcomes following severe TBI.

Clinical usefulness of indoor life-space assessment in community-dwelling older adults certified as needing support or care.

This study aimed to develop a questionnaire to evaluate indoor life-space mobility and assess its validity in community-dwelling older adults certified as needing support or care. The participants included 37 community-dwelling older adults undergoing home-visit rehabilitation (mean age: 78.5±7.0 years). We developed a questionnaire to assess the degree of indoor life-space mobility (home-based life-space assessment (Hb-LSA)), evaluating the functional status (life-space assessment (LSA), time spent away from bed, functional independence measure (FIM), bedside mobility scale (BMS)), physical function (hand grip power (HGP), 30-second chair stand (CS-30), one-leg standing (OLS)) and cognitive status (mental status questionnaire (MSQ)). The average Hb-LSA score was 56.3±24.3 (minimum 4 to maximum 102.5). The test-retest reliability was high (intraclass correlation coefficients: (1, 1)=0.986, (1, 2)=0.993). The Hb-LSA scores were significantly associated with the LSA (r=0.897), time spent away from bed (r=0.497), FIM (r=0.786), BMS (r=0.720), HGP (r=0.388), CS-30 (r=0.541) and OLS (r=0.455). There were no significant associations between the Hb-LSA scores and the FIM cognitive subscores (r=0.180) or MSQ scores (r=-0.240). The Hb-LSA scores were significantly higher among the participants able to move independently indoors (75.8±18.8 points) than in those who required help to move (45.7±20.2 points). The Hb-LSA is a useful, reliable and valid tool for assessing the degree of indoor physical mobility in the life-space. The Hb-LSA score is related to the degree of independence of indoor mobility.

Effectiveness of in-patient rehabilitation in obesity-related orthopedic conditions.

The aim of the present paper is to provide initial evidence that in-patient multidisciplinary rehabilitation is effective in minimizing the obesity-related disability and enhancing functional capacities in obese patients with motor disability. Four hundred and sixty-four obese patients with orthopedic conditions admitted to our Rehabilitation Unit for multidisciplinary rehabilitation were enrolled in this study. At admission and discharge (after 4 weeks), the following outcome measures were computed: body weight (BW) (kg), body mass index (BMI) (kg/m2), Functional Independence Measure (FIM) motor and cognitive, Obesity-related disability test (TSD-OC), Visual Analogue Score (VAS) for functioning, Timed-Up-Go (TUG). Intensive rehabilitation addressed to obese patients with orthopedic conditions and motor difficulties consisted of a 4-week and 3-h daily multidisciplinary program covering nutritional, motor and psychological aspects. All of the outcomes measured, except the FIM cognitive score, improved significantly after in-patient rehabilitation. The obesity-specific disability scale appears sensitive to changes among groups with different grades of disability and the percentage of change does not differ among groups. Younger obese individuals generally showed to benefit more from rehabilitation interventions than the older ones. In-patient rehabilitation interventions appear effective in reducing both mild and severe disabilities related to obesity with orthopedic co-morbidities. This paper provides initial evidence that in-patient multidisciplinary intensive rehabilitation is effective in minimizing the obesity-related disability and initial support to the indications of the Italian Ministry of Health for such rehabilitation pathway. The disability grading could help the decision making of allocating patients to appropriate rehabilitation settings.

Relationship of speech-language pathology inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Background/objectiveDescribe associations of patient characteristics and speech–language pathology (SLP) interventions provided during impatient rehabilitation for spinal cord injury (SCI) to outcomes at discharge and 1-year post-injury.MethodsSpeech–language pathologists at six inpatient rehabilitation centers documented details of treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary. Cognitive, participation, and mood outcomes for a subsample of patients with traumatic brain injury (TBI) and cognitive-communication limitations (CCLs) were examined.ResultsSLP treatment factors explain a small amount of variation in cognitive Functional Independence Measure (FIM), participation, and mood. Variation explained by treatment factors for cognitive outcomes at the time of discharge increased when the patient group was more homogeneous (patients with TBI and CCLs). More time in SLP cognitive-communication interventions had a negative relationship, while longer length of stay was positive. The added explanatory power was not seen for similar outcomes at 1-year post-injury.ConclusionPatients with SCI who have the greatest need for interventions to address cognitive limitations due to TBI receive the most SLP cognitive-communication treatment and show the greatest amount of improvement during rehabilitation. Their cognitive functioning remained impaired at discharge; this likely accounts for the consistent finding that more hours of SLP cognitive-communication treatment is associated with lower cognitive FIM scores at discharge. Future research on individuals with dual SCI and TBI should include more comprehensive assessment of individual differences in cognitive performance in order to better examine the complex relationships between SLP treatments and outcomes.NoteThis is the fifth of nine articles in this SCIRehab series.

Poster 44 The Utility of the Modified Mini-Mental State Examination in Inpatient Rehabilitation for Traumatic Brain Injury

The Modified Mini-Mental State Examination (3MS) could provide useful information about cognitive status in traumatic brain injury (TBI), yet has not been validated in this population. We studied the association of the 3MS with inpatient rehabilitation functional status compared to the Mini-Mental State Examination (MMSE), and the ability of the 3MS to assist with predicting length of stay (LOS). Patients receiving inpatient rehabilitation for TBI were consecutively approached to participate. Participants were administered the 3MS, MMSE, and Functional Independence Measure (FIM) at admission and discharge. Inpatient rehabilitation facility. Male and female patients receiving inpatient rehabilitation services for TBI. Not applicable. 3MS, MMSE, FIM, LOS. The admission 3MS had stronger correlations with admission FIM total, cognitive, and motor scores (r = .72, .76, .56, respectively; all p < .005) than the MMSE. The discharge 3MS had stronger correlations with discharge FIM total, cognitive, and motor scores (r = .86, .73, .68, respectively; all p < .001) than the MMSE. Prediction of LOS was significantly improved with admission 3MS included as a predictor with admission FIM (R^2 change from .53 to .64). Construct validity of the 3MS in a TBI sample was illustrated through significant correlations with the FIM. The 3MS can provide clinicians with more specific information about patterns of cognitive deficits than the cognitive FIM items, which could inform treatment. The improved accuracy in predicting LOS by combining admission 3MS scores with admission FIM scores can be useful for resource planning.

Severe TBI Outcome Prediction: Usefulness of FIM Scores during Inpatient Rehabilitation (P01.187)

Objective: The goal of this study is to examine possible clinical predictors related to exceptional long-term functional outcomes in severe truamatic brain injury(STBI). Background Long-standing impairments are commonplace following STBI. There is plentiful literature on clinical predictors following STBI, but cases of greater than expected recovery following STBI have not as yet been a focus for research. Design/Methods: Case report series of three female participants with STBI initially admitted to inpatient rehabilitation(IR). Participants had initial Glascow Coma Scale scores of 3, post-traumatic amnesia durations of 18-115 days, time to follow commands of 16-100 days, abnormal initial brain CT scans, and initial pupil abnormalities. Outpatient rehabilitation ranged from three to six months. All resumed major life roles (gainful employment, ability to drive, ability to live independently). Participant IR Functional Independence Measure(FIM) score improvements were compared to national normative STBI FIM data from National Data Systems (NDS) for 2010 (n = 15,808). Results: All three participants were involved in gainful employment, resumed driving, and were living independently by 12 months post-injury. Initial FIM scores ranged from 12 to 42 (χ = 28; NDS = 51.8) with discharge scores ranging from 39 to 76 (χ = 59; NDS = 79.3). Total FIM gain from IR admission to discharge ranged from 27 to 34 points (χ = 31; NDS = 27.5). Cognitive FIM rating improved an average of 13.7 points, compared to 5.9 points for NDS. Sphincter (bowel and bladder) FIM rating improved an average of 5 points, compared to 3 points for NDS. Conclusions: IR FIM score changes may be useful in long-term STBI outcome prediction All three participants demonstrated marked improvements in FIM scores during inpatient rehabilitation and subsequent resumption of major life domains. Further research is necessary to validate whether sphincter and cognitive FIM score changes may be useful in long-term STBI outcome prediction. Disclosure: Dr. Kushner has nothing to disclose. Dr. Johnson-Greene has nothing to disclose.

Physical Therapy Activities in Stroke, Knee Arthroplasty, and Traumatic Brain Injury Rehabilitation: Their Variation, Similarities, and Association With Functional Outcomes

The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown. The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups. This was a prospective observational cohort study. The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities. All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome. The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities. All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.

Functional Level During the First Year After Moderate and Severe Traumatic Brain Injury: Course and Predictors of Outcome

Background : The objective of this study was to describe the functional level during the first year after moderate and severe traumatic brain injury (TBI), and to evaluate the predictive impact of pre-injury and injury-related factors. Methods : A cohort of 65 patients with moderate (N = 21) or severe (N = 44) TBI were examined with FIM (Functional Independence Measure) at admission and discharge from the rehabilitation clinic (on average two months after injury) and at 12 months, and with GOSE (Glasgow Outcome Scale Extended) at 12 months after injury. Possible predictors were analyzed in a regression model using FIM total score at 12 months as outcome. Results : All mean FIM scores improved significantly from injury to discharge from sub-acute rehabilitation. In the later period from discharge to 12 months after injury, the mean FIM motor score improved in severe TBI but not in moderate TBI patients. The mean FIM cognitive scores did not improve in any of the groups. At 12 months, 95% with moderate TBI had a FIM score from 109 - 126 (functionally independent) compared to 74% with severe TBI. Functional global outcome as assessed by GOSE was “good recovery” in 52% with moderate TBI versus 33% in severe TBI, “moderate disability” in 33% with moderate TBI versus 31% in severe TBI, and “severe disability” in 14% with moderate TBI versus 36% in severe TBI. Predictors such as PTA duration (B = -0.209), GCS admission rehabilitation (B = 5.058) and LOS rehabilitation (B = 0.458) explained 47% of the FIM variance 12 months post injury. Conclusions : The greatest improvement after moderate and severe TBI was in the sub-acute phase during the stay in a specialized rehabilitation unit. Residual disability was reported in 47% of moderate TBI patients as measured by GOSE at 12 months post injury indicating the importance of post-acute rehabilitation for these patients. Longer stays at the rehabilitation unit, a short PTA period and a high GCS score at admission to rehabilitation were positive predictors of functional level (FIM) at 12 months follow-up demonstrating that these factors are common predictors of early and late TBI phases. doi:10.4021/jnr20w

Time to Inpatient Rehabilitation Hospital Admission and Functional Outcomes of Stroke Patients

To study the association of time to inpatient rehabilitation hospital (IRH) admission and functional outcomes of patients who have had a stroke. A retrospective cohort study. A regional IRH. Moderately (n = 614) and severely (n = 1294) impaired patients who had a stroke who were admitted to the facility between 2002 and 2006. Not applicable. Change in total, motor, and cognitive Functional Independence Measure (FIM) scores between IRH admission and discharge. After controlling for patient demographics and initial medical conditions and functional status, shorter periods from stroke onset to IRH admission were significantly associated with greater functional gains for these patients during IRH hospitalization. Moderately impaired patients achieved a greater total FIM gain when admitted to an IRH within 21 days of stroke. Severely impaired patients showed a gradient relationship between time to IRH admission and total FIM gain, with significantly different functional gain if admitted to an IRH within 30 and 60 days after stroke diagnosis. Results of multiple regression analysis also showed that age, race/ethnicity, side of stroke, history of a previous stroke, functional measures at IRH admission, IRH length of stay, and selected medications were associated with total, motor, and cognitive FIM score changes. In addition, certain factors such as older age, diagnosis of a hemorrhagic stroke or a previous history of stroke, and initial functional status were associated with longer periods between diagnosis and admission to an IRH after the stroke occurred. Our findings are consistent with the hypothesis that earlier transfer to an IRH may lead to better functional improvement after stroke. However, certain factors such as age, race/ethnicity, initial medical conditions and functional status, and length of stay at an IRH contributed to functional gain. Factors affecting the time to IRH admission also were addressed.

Functional Level During the First Year After Moderate and Severe Traumatic Brain Injury: Course and Predictors of Outcome

Background : The objective of this study was to describe the functional level during the first year after moderate and severe traumatic brain injury (TBI), and to evaluate the predictive impact of pre-injury and injury-related factors. Methods : A cohort of 65 patients with moderate (N = 21) or severe (N = 44) TBI were examined with FIM (Functional Independence Measure) at admission and discharge from the rehabilitation clinic (on average two months after injury) and at 12 months, and with GOSE (Glasgow Outcome Scale Extended) at 12 months after injury. Possible predictors were analyzed in a regression model using FIM total score at 12 months as outcome. Results : All mean FIM scores improved significantly from injury to discharge from sub-acute rehabilitation. In the later period from discharge to 12 months after injury, the mean FIM motor score improved in severe TBI but not in moderate TBI patients. The mean FIM cognitive scores did not improve in any of the groups. At 12 months, 95% with moderate TBI had a FIM score from 109 - 126 (functionally independent) compared to 74% with severe TBI. Functional global outcome as assessed by GOSE was “good recovery” in 52% with moderate TBI versus 33% in severe TBI, “moderate disability” in 33% with moderate TBI versus 31% in severe TBI, and “severe disability” in 14% with moderate TBI versus 36% in severe TBI. Predictors such as PTA duration (B = -0.209), GCS admission rehabilitation (B = 5.058) and LOS rehabilitation (B = 0.458) explained 47% of the FIM variance 12 months post injury. Conclusions : The greatest improvement after moderate and severe TBI was in the sub-acute phase during the stay in a specialized rehabilitation unit. Residual disability was reported in 47% of moderate TBI patients as measured by GOSE at 12 months post injury indicating the importance of post-acute rehabilitation for these patients. Longer stays at the rehabilitation unit, a short PTA period and a high GCS score at admission to rehabilitation were positive predictors of functional level (FIM) at 12 months follow-up demonstrating that these factors are common predictors of early and late TBI phases. J Neurol Res. 2011;1(2):48-58 doi: https://doi.org/10.4021/jnr20w

Clinical practice improvement approach in multiple sclerosis rehabilitation: a pilot study

The objective of this study was to explore methods examining patient complexity and therapy interventions in relation to functional outcomes from an inpatient multiple sclerosis (MS) rehabilitation program. Retrospective and prospective data for 24 consecutive inpatients at a tertiary rehabilitation facility assessed (i) impairment/disability - Expanded Disability Status Scale, Neurological Impairment Set, (ii) complexity of intervention - Rehabilitation Complexity Scale, Northwick Park Therapy Dependency Assessment (NPTDA), the type and duration of therapy, (iii) Function - Barthel Index (BI), functional independence measure (FIM), (iv) hospital length of stay, discharge destination. The mean length of stay was 20 days (SD=15.7); male : female ratio was 10 : 14; 11 (46%) had Expanded Disability Status Scale scores more than 6.5, and all discharged to community. Over one-half had 'moderate-severe' scores for fatigue, and deficits in motor function and mood that resulted in significant functional limitation. Rehabilitation Complexity Scale scores showed substantial complexity with two-thirds requiring specialized nursing. The NPTDA score (median 22 interquartile range 20-23) showed moderate dependency on admission in the following domains: physical, cognitive and psychosocial programs and preparing for discharge. The mean physiotherapy and occupational therapy received was 45.76 and 24.04 min/day, respectively. Functional gains from admission to discharge for FIM and BI were significant (P<0.001). There were strong correlations between the total NPTDA and FIM motor scores (Spearman's ρ -0.80) and BI (ρ -0.83), but only weak correlations with the FIM cognitive score (ρ -0.33). In conclusion, this pilot study provided information about the complex interplay of patient and process factors, and their interrelationships that impact functional outcomes in MS rehabilitation. A prospective study is now planned using appropriate tools to understand the 'black box' of rehabilitation.

Functional Outcome after Stroke in Patients with Aphasia and Neglect: Assessment by the Motor and Cognitive Functional Independence Measure Instrument

Background: The role of neuropsychological deficits in predicting functional outcome in patients with aphasia and neglect at the end of rehabilitation after stroke has been poorly investigated. This was the aim of this prospective study evaluated using a Functional Independence Measure (FIM) instrument. Methods: Patients with a primary diagnosis of cerebrovascular accident [125 patients with aphasia, 45 with neglect and 131 without either aphasia or neglect (WAN)] were enrolled. Backward multiple linear regression analysis was used to predict motor and cognitive FIM, discharge destination, and length of stay. The independent variables were age, gender, aphasia, stroke type, stroke lesion size, comorbidity, bladder catheter, stroke severity, trunk control test, initial motor FIM, and committed caregiver identified on admission to rehabilitation. Results: At the end of rehabilitation, patients with neglect had significantly lower final motor FIM scores and lower daily efficiency improvement in motor FIM scores compared with those with aphasia (both p < 0.001) and WAN (both p < 0.001). Patients with aphasia showed lower final cognitive FIM scores compared with those with neglect (p < 0.001) and those without deficits (p < 0.001). Neglect was a predictor of final motor FIM (β = –0.24) and efficiency in motor FIM (β = –0.29), while aphasia was a predictor of final cognitive FIM (β = –0.54). Neglect and aphasia did not differ and were not predictors of discharge destination and length of stay. Conclusions: Patients with neglect have lower motor FIM scores if compared with those with aphasia, while patients with aphasia have lower cognitive FIM scores. Neglect is a predictor of motor FIM, while aphasia is a predictor of cognitive FIM scores.

Prediction of Stroke Rehabilitation Outcome with Xenon-enhanced Computed Tomography Cerebral Blood Flow Study

Cerebral blood flow (CBF) of stroke patients in the chronic stage is supposed to reflect brain functions. We examined the relation between rehabilitation outcome and CBF values. The study group comprised 101 consecutive patients (mean age, 69±12 years) including 61 patients with cerebral infarction, 32 patients with cerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. Xenon-enhanced computed tomography was performed on 39 days on average after stroke onset. Regions of interest were in the cerebral cortices, putamen and thalamus, and CBF values were statistically compared with the functional independence measure (FIM). Furthermore, we performed a multivariate analysis for predictive factors. 1. The right mean CBF (mCBF) tended to be more closely correlated with the FIM total scores at discharge (r=0.495, P<.001) than the left mCBF (r=0.351, P<.001), in case of significance level 0.1 and statistical power 0.65. 2. The FIM total and motor scores at discharge showed the highest correlations to regional CBF (rCBF) in the right frontal cortex, and the FIM cognitive scores at discharge showed the highest correlation to rCBF in the left frontal cortex. 3. Right cerebral infarct subgroup (n=30) showed significant correlations between FIM total scores at discharge and mCBF values of the right (r=0.582, P<.001) and the left (r=0.563, P<.005) brain, respectively. 4. Rehabilitation outcome evaluated with the FIM total scores could be led by the formulae with the factors of age, gender, NIHSS, right/left hemispheric lesions and the right mCBF values (r=0.837, P<.001). The CBF of the right brain proved to be more influencing to rehabilitation results.

Rehabilitation Outcomes After Anoxic Brain Injury: A Case-Controlled Comparison With Traumatic Brain Injury

To investigate the functional outcomes of patients with anoxic brain injury (AnBI) compared with control patients with traumatic brain injury (TBI) during inpatient rehabilitation. Matched case-controlled design. Inpatient neurorehabilitation program. Fifteen patients with AnBI and 15 patients with TBI. Data of 15 patients with a primary diagnosis of AnBI were retrospectively reviewed and matched to 15 patients with TBI admitted within the same time frame on age, acute care length of stay, and functional status at admission. Functional outcome was assessed by the use of the Functional Independence Measure (FIM). Compared with the control patients with TBI, patients with AnBI achieved significantly lower FIM motor gain (16.3+/-15.6 versus 5.7+/-10.7, respectively) and efficiency scores (0.27+/-0.28 versus 0.06+/-0.13), discharge FIM cognition scores (25.9+/-5.9 versus 21.7+/-7.3), total FIM gain (22.5+/-19.6 versus 9.1+/-12.1), and total FIM efficiency scores (0.39+/-0.38 versus 0.10+/-0.16; all P<.05). Results suggest a slower rate of recovery for patients with AnBI compared with TBI, with physical recovery being slower than cognitive recovery as measured by the FIM during inpatient rehabilitation when matched according to preinjury characteristics and functional status at rehabilitation admission. Future studies on larger samples of patients with AnBI and TBI that use a case-controlled design and longer-term outcome measurement are warranted to further clarify the differences in functional outcomes between these groups and to assess whether optimal rehabilitation interventions differ for these groups.

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.