Discharge Functional Independence Measure Research Articles

Relationship Between Performance Improvement in Activities of Daily Living and Energy Intake in Older Patients With Hip Fracture Undergoing Rehabilitation.

ObjectiveTo analyze whether sufficient energy intake (EI) improves performance of activities of daily living (ADL) in patients with hip fracture admitted to rehabilitation hospitals. The adequate amount of EI for improving performance of ADL in patients with hip fracture remains unknown.MethodsThis retrospective cohort study included all patients with hip fracture (n=234) admitted to rehabilitation hospitals in Japan. The inclusion criteria for this study were age >65 years and body mass index <30.0 kg/m2. Patients who were transferred to an acute hospital and those with missing case data were excluded. According to the amount of EI, the patients were classified into energy sufficiency and shortage groups (EI/total energy expenditure ≥1.0 and <1.0, respectively). The Functional Independence Measure (FIM) and FIM gain were used to evaluate the patient disability level and change in patient status in response to rehabilitation. Finally, FIM gain was calculated as the discharge FIM score minus the admission FIM score.ResultsThe final analysis targeted 202 patients—53 (26.2%) were in the energy shortage group and 149 (73.8%) were in the energy sufficiency group. The energy sufficiency group had a greater FIM gain than the energy shortage group (mean, 25.1±14.2 vs. 19.7±16.4; p=0.024). Furthermore, sufficient EI in the first week since admission (β=0.165; 95% confidence interval, 0.392–5.230; p=0.023) was an independent factor of FIM gain.ConclusionAmong elderly patients with hip fracture admitted to rehabilitation hospitals in Japan, the amount of EI during the first week after admission was an independent factor of FIM gain.

Body weight supported treadmill vs. overground gait training for acute stroke gait rehabilitation.

The purpose of this study was to evaluate the clinical efficacy of body weight supported treadmill training for acute post-stroke rehabilitation, relative to conventional therapy. Forty individuals were randomized to receive either body weight supported treadmill training or conventional therapy as part of standard care at an acute rehabilitation facility. As part of normal care patients were evaluated using the Functional Independence Measure; gait units and length of stay were also recorded. Within 48 hours of discharge, participants were evaluated using a Qualisys motion capture system to measure spatiotemporal gait parameters. Participants allocated to the body weight supported treadmill training group had a significantly lower admission Functional Independence Measure, but had a longer length of stay, and did not have significantly different discharge Functional Independence Measure scores. Gait speed was the only spatiotemporal outcome that was significantly different at discharge, and was lower for the body weight supported treadmill training group. As seen in previous literature, the clinical efficacy of body weight supported treadmill training seems to be similar to that of conventional overground therapy. Accounting for difference in admission scores the body weight supported treadmill training and conventional therapy groups, both methods performed comparably.

Evaluating Effectiveness of an Acute Rehabilitation Program in Hospital-Associated Deconditioning.

Acute hospitalization can result in significant decline in functional ability, known as hospital-associated deconditioning. Older adults are most vulnerable, with resultant functional difficulties and increased risk of institutionalization. This study evaluates the effectiveness of a multidisciplinary acute rehabilitation program in hospital-associated deconditioning on routinely collected outcome data to examine its impact to determine whether a controlled trial is warranted. We conducted a retrospective review of the hospital database for the national rehabilitation clinical registry for 2013 and 2014. We analyzed responses from patient feedback questionnaires over a 2-year period to assess patient experience of the rehabilitation program. The analysis included 289 patients referred to our acute rehabilitation program. Most patients were aged 81-90 years, representing 47% (n = 137) of all admissions. The main impairment group was deconditioning (54%). The median entry time to the acute rehabilitation program for this impairment group was 5 days from admission and length of stay in the rehabilitation program was 9 days. Many of these patients (57%) were directly discharged home, with only 21% needing transfer for inpatient rehabilitation. The average Functional Independence Measure score gain was 22 for the patients directly discharged home, with an average discharge Functional Independence Measure score of 94/126. Of the patient feedback responses received (response rate: 24%), 96% rated the program as very good or good. We observed improved functional outcomes among program participants, with the majority directly discharged home, reduced transfer to rehabilitation hospitals, and patient acceptance of this acute rehabilitation program. These promising results suggest that a more rigorous evaluation of this acute rehabilitation program in the management of hospital-associated deconditioning is warranted.

Weight gain is associated with improvement in activities of daily living in underweight rehabilitation inpatients: a nationwide survey

We retrospectively analysed large-scale, nationwide data from the Kaifukuki (convalescent) Rehabilitation Ward (KRW) survey of 2015. Patients were classified into two groups based on changes in body mass index (BMI) during their KRW stay: increased BMI and non-increased BMI. The primary outcome was motor functional independence measure (FIM) score at discharge, and the secondary outcomes were motor FIM gain and full oral intake at discharge. We analysed 4605 patients (64% women; mean age, 79.3 years). Of these patients, 1128 and 3477 were classified into the increased and non-increased groups, respectively. Multivariate analysis showed that BMI increases were independently associated with motor FIM scores at discharge (partial regression coefficient = 1.165; 95% confidence interval, 0.671-1.659) and motor FIM gains, although BMI increase was not associated with full oral intake. Thus, increasing body weight might lead to activities of daily life improvement in underweight patients undergoing post-acute rehabilitation.

Outcomes of Acute Inpatient Rehabilitation of Patients With Left Ventricular Assist Devices and Subsequent Stroke.

The aim of the study was to examine the functional outcomes and medical complications of patients with left ventricular assist device implantation and subsequent stroke during comprehensive inpatient rehabilitation. Retrospective cohort study of 21 patients admitted to an inpatient rehabilitation facility between 2009 and 2015. Main outcome measurements include admission and discharge Functional Independence Measure, length of stay, and Functional Independence Measure efficiency. The study included 17 male and 4 female patients aged 32-75 yrs. Eleven patients (52%) required transfer to an acute care hospital for evaluation. Fifteen patients completed inpatient rehabilitation with median [interquartile range] length of stay 26 [13.5-34] days (range = 7-59 days), median [interquartile range] Functional Independence Measure gain of 18 [12.5-32], and median [interquartile range] Functional Independence Measure efficiency of 1.0 [0.6-1.44]. Patients who required transfer to acute care during their course but ultimately completed inpatient rehabilitation (n = 5) demonstrated larger median [interquartile range] Functional Independence Measure gain (40 [23-42]) and longer median [interquartile range] length of stay (35 [35-42]) compared with patients who completed inpatient rehabilitation without transfer (Functional Independence Measure gain = 15 [9.25-26.5]; length of stay = 14.5 [11.5-26.25]). Patients with left ventricular assist device implantation and subsequent stroke demonstrate functional gains during acute inpatient rehabilitation programs. A large percent of patients required transfer to acute care.

Association between anticholinergic drug prescription changes and rehabilitation outcome in post-acute hip fractured patients

Purpose: To follow changes in anticholinergic drug prescriptions throughout hip fractured patients’ rehabilitation; to assess whether a change in anticholinergic burden affects rehabilitation outcome.Methods: Retrospective study of 869 hip fractured patients admitted between January 2011 to October 2015, performed in a post-acute geriatric rehabilitation center. The Anticholinergic Cognitive Burden Scale quantified the anticholinergic burden. Main outcome measures: Functional Independence Measure, motor Functional Independence Measure, Montebello Rehabilitation Factor Score on motor Functional Independence Measure and length of stay. Multiple linear regression analysis tested for independent association between admission anticholinergic burden and anticholinergic burden change during rehabilitation, and rehabilitation outcomes.Results: One hundred and sixty two (18.7%) patients were prescribed additional anticholinergic medications upon discharge; 76 (8.7%) were prescribed fewer. Patients with high admission anticholinergic burden presented with a significantly higher rate of higher education, less likely to reside at home, less independent pre-fracture, exhibited a significantly lower admission and discharge Functional Independence Measure score, a lower Functional Independence Measure score change and a lower Montebello Rehabilitation Factor Score. Admission anticholinergic burden, but not changes in anticholinergic burden during rehabilitation, was found to be independently associated with rehabilitation outcome (discharge FIM score).Conclusions: High admission anticholinergic burden is associated with lower functional ability in hip fractured patients. Changes in anticholinergic drug prescription during rehabilitation were not associated with rehabilitation outcomes.Implications for rehabilitationClinicians should make an effort to reduce AC drug use in hip fractured patients on admission to post-acute rehabilitation.AC burden should be carefully monitored throughout the rehabilitation period and reduced whenever possible.When functional ability does not improve as expected, AC burden should be considered as an intervening factor.

Posterior cord syndrome: Demographics and rehabilitation outcomes

Context/Objectives: To describe demographics, clinical characteristics, and functional outcomes of patients with incomplete spinal cord injuries and posterior cord syndrome (PCS). Design: Five-year retrospective case series. Setting: Spinal cord injury (SCI) rehabilitation unit at a Level 1 tertiary university medical center. Participants: 9 patients with incomplete cord injuries diagnosed with PCS admitted to rehabilitation within the past 5 years. Outcome measures: Functional Independence Measure (FIM) motor scores, length of stay (LOS), discharge disposition. Results: Incidence of PCS was 2% with an average age of 62.0 years. The most common etiology for PCS was spinal cord compression from localized tumors (78%). Seven (78%) patients had paraparesis. All patients had an American Spinal Injury Association impairment scale (AIS) classification of AIS D. SCI-related complications most commonly included: neuropathic pain (78%), spasticity (44%), and neurogenic bladder (78%). Average LOS on the rehabilitation unit was 28 days. Average admission and discharge FIM motor scores were significantly improved (P = 0.001) from 41 to 65, respectively. Two-thirds (67%) of patients were able to walk at least 150 feet with a rolling walker prior to discharge. Most (78%) patients were discharged to home. Continence improved from admission to discharge from 22% vs 56% (bladder) and 67% vs 78% (bowel). Conclusions: We can conclude that PCS most often results in paraparesis due to tumor compression. Typical SCI-related medical complications are encountered. These patients often experience significant functional improvements during SCI rehabilitation with the majority also having bladder and bowel continence allowing them to return home at discharge.

Discharge Destination from a Rehabilitation Unit After Acute Ischemic Stroke.

We reviewed numerous variables for ischemic stroke patients admitted to a rehabilitation unit to determine those that were statistically associated with discharge destination. A retrospective chart review of patients with ischemic stroke discharged from the rehabilitation unit between January 1, 2005 and December 31, 2015. Variables were examined for their association with discharge destination (home versus long-term care (LTC)). Univariable relationships with discharge destination were assessed, and a multivariable logistic regression model was built. Univariate predictors of discharge to LTC: advanced age, decreasing admission and discharge functional independence measure (FIM) scores, increasing change in FIM score from admission to discharge, dependency, residence outside of home before the stroke, absence of a caregiver, urinary and bowel incontinence, low Berg balance score at admission and discharge, low Montreal Cognitive Assessment scores, smoking, chronic heart failure, and an inability to transfer. Multivariable logistic regression: five factors remained significant predictors with LTC disposition: advanced age, bowel incontinence, residence outside of the home prior to stroke, right hemisphere site of the stroke, and absence of a caregiver. Several easily measured variables were significantly associated with discharge to LTC versus home following stroke rehabilitation.

Abstract WP202: Race/ethnicity Matters: Differences in Stroke Inpatient Medical Rehabilitation Outcomes for Communities of Color

Introduction: Stroke is a leading cause of disability and death in the United States. Racial/ethnic people with stroke demonstrate lower functional independence measure (FIM) scores before and after inpatient medical rehabilitation compared to non-Hispanic Whites. Racial/ethnic differences in FIM scores have implications for discharge. Method: This is a cross-sectional and retrospective analysis of data extracted and pooled across years 2002-2018. Inclusion criteria were: 1) stroke as a primary diagnosis and 2) non-Hispanic White (NHW), Hispanic, non-Hispanic Black (NHB), and non-Hispanic Asian (NHA) patients. Per systematic review evidence, ICD codes 430-438/I60-I69 were used to identify stroke diagnoses. Dependent variables were: length of stay (LOS), admission FIM Cognitive and Motor Total, FIM efficiency, FIM change per day, discharge FIM Cognitive and Motor Total, and discharge to home. NHWs were used as the reference group. Results: There were 3,911 patients across the study period. Age, gender, and admission year were used as covariates. There were racial/ethnic differences in LOS, F (3, 3853) = 2.658, p = .047, partial η2 = .002, with NHAs having longer LOS. Racial/ethnic differences in admission FIM scores were found, F (6, 7750) = 6.727, p &lt; .001, Wilks' λ = .989, partial η2 = .006, with NHAs and Hispanics showing lower cognitive and motor scores. There were no racial/ethnic differences in cognitive or motor efficiency. Racial/ethnic differences in FIM change per day emerged, F (3, 3854) = 4240, p = .005, partial η2 = .003, with Hispanics and NHBs having lower change per day. Racial/ethnic differences in discharge FIM scores were noted, F (6, 7704) = 4.865, p &lt; .001, Wilks' λ = .992, partial η2 = .004, with NHAs and Hispanics having lower total cognitive scores but only Hispanics had lower motor scores. Lastly, Hispanics had higher odds of being discharged home compared to other racial/ethnic groups ( OR = 1.246, 95% CI = 1.046-1.485, p = .014). Discussion: Controlling for covariates, there were significant racial/ethnic differences in stroke inpatient medical rehabilitation outcomes, particularly for Hispanics. Factors involved in creating/maintaining post-stroke rehabilitation disparities for Hispanics (and others) are discussed.

Rehabilitation Outcomes in Patients with Guillain–Barré Syndrome Caused by Zika Virus

Introduction: Zika virus (ZIKV) is transmitted by the bite of the Aedes species mosquito. Infected patients may present flu-like symptoms or even neurological deficits. In Puerto Rico (PR), an increased number of cases of ZIKV were noted in 2016 and a surveillance system was established for monitoring. As of August 2018, a total of 36,097 symptomatic cases of ZIKV had been reported in PR by the Centers for Disease Control and Prevention of the United States. One of the neurological complications secondary to ZIKV was Guillain–Barre syndrome (GBS). The surveillance system reported that 66% of patients with GBS who were tested were positive for ZIKV. This study aims to identify the functional outcomes of GBS patients related to ZIKV as compared to patients with GBS nonrelated to ZIKV during inpatient rehabilitation using functional independence measure (FIM) score. Materials and Methods: A retrospective case–control study design was used. Patients with a diagnosis of GBS admitted to an inpatient rehabilitation unit between January 1, 2016, and August 15, 2017, were deemed eligible. Patients were divided in two groups: (1) GBS-positive ZIKV (experimental) group and (2) GBS-negative ZIKV (control) group. A total of 21 patients were identified; 16 qualified for the study. The primary outcome was the admission and discharge FIM score. Results: A total of 11 (69%) patients were ZIKV positive or presumptive positive and 5 (31%) were ZIKV negative. One hundred (100%) of the patients had significantly improved FIM scores upon discharge. No significant differences between the ZIKV groups were noted on admission or discharge FIM scores. Conclusion: This study demonstrated that all GBS patients benefit from inpatient rehabilitation facility admission and therapy regardless of ZIKV status. Rehabilitation outcome is not determined by ZIKV status.

The relationship between patient satisfaction and functional status in inpatient rehabilitation: a comparison over time

Introduction: The purpose of this study was to compare patient satisfaction over time in the context of major changes in service delivery in acute rehabilitation (sicker patients admitted earlier and staying fewer days). We hypothesized that patient satisfaction is significantly correlated with patient functional goal achievement. Methods: Data was collected on two cohorts: Patients receiving inpatient rehabilitation for at least two weeks at a University Hospital during a two year period (Group A, n=210) or a second two year period (Group B, n=280). Patient progress is measured with the Functional Independence Measure (FIM) in areas A thru M at admission, discharge, and goals established at admission. Patients are considered to have met their goals if their discharge FIM score is within 10 points of their predicted goal. Three months post discharge all patients were contacted by telephone interview about their satisfaction with their rehabilitation. Results: Two hundred and four in Group A patients reported satisfaction, but only 185 met their FIM goals. Of the six who reported dissatisfaction, three met their FIM goals. Two hundred and sixty eight Group B patients reported satisfaction, and 251 met their FIM goals of the 12 who reported dissatisfaction, 10 met their FIM goals. The average length of stay for Group A was three times longer than Group B. Chi Square analyses of the differences between satisfied and dissatisfied patients in the two groups was significant for Group A (p<.01), meaning satisfaction correlated with functional goal achievement. There is no correlation between functional achievement and satisfaction for Group B. Medical complications were noted to be higher in Group B. Conclusion: Current trends in rehabilitation as in Group B patients (sicker patients admitted earlier and staying fewer days) have not affected patient satisfaction. There was a correlation between functional goal attainment and patient satisfaction in Group A but not with Group B.

Perbedaan Skor Functional Independence Measure (FIM) pada Pasien Rawat Inap dengan Stroke Iskemik dan Stroke Hemoragik di Rumah Sakit di Kota Bengkulu Tahun 2018

Stroke is one of the most common causes of disability in the world. Patients with ischemic stroke have different functional improvements from patients with hemorrhagic stroke. The tool is the Functional Independence Measure (FIM) questionnaire. This study aims to determine the difference in FIM scores in hospitalized patients with ischemic stroke and hemorrhagic stroke at hospitals in Bengkulu City. This research is an observational analytic research with cross-sectional design. The study involved stroke patients who hospitalized at RS Bhayangkara Bengkulu City, RSUD Bengkulu City, and RSUD dr. M. Yunus Bengkulu City from January-April 2018 with total sample 22 ischemic stroke patients and 22 hemorrhagic stroke patients who met the inclusion criteria. FIM scores as independent variables, while the type of stroke as dependent variables. The difference between the two variables was analyzed by unpaired t test and Mann-Whitney test. Patients with ischemic stroke had admission FIM score higher than patients with hemorrhagic stroke (26 vs 13,5; p=0.006). There were no differences in discharge FIM score in patients in both types of stroke (1,67 vs 1,58; p=0,081). There was no difference in FIM score gain between patients with ischemic stroke and patients with hemorrhagic stroke (4,12 vs 4,36; p=0,444). Patients with ischemic stroke had higher admission FIM score compared to patients with hemorrhagic stroke, but there was no significant difference in FIM score gain during hospitalization between ischemic stroke and hemorrhagic stroke patients at hospitals in Bengkulu City.

Early Functional Outcomes for Pediatric Patients Diagnosed with Anti-N-Methyl-D-Aspartate Receptor Encephalitis during Inpatient Rehabilitation.

The aims of the current study were to characterize the demographic and clinical presentation of pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis who require inpatient rehabilitation, to examine early functional outcomes, and to investigate predictors of early recovery. A retrospective chart review was conducted for 27 pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis who received intensive inpatient neurorehabilitation. On average, patients were 10.6 yrs of age (range, 2-18 yrs) at the time of symptom onset. Average time to treatment from symptom onset was 27.2 days (range, 5-91 days). Patients displayed significant improvements between admission and discharge Functional Independence Measure for Children (WeeFIM) Developmental Functional Quotient (DFQ) scores across patients (P < 0.01). Mean Functional Independence Measure for Children Total Developmental Functional Quotient score at admission was 28.6 (range, 15.0-62.6) and at discharge was 54.3 (range, 14.2-91.9). Younger age at onset, seizures, and number of treatments received were associated with worse functional outcomes at discharge. Time to initiate treatment was not found to be associated with early functional outcomes. Pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis displayed significant functional gains during inpatient rehabilitation, despite persistent functional deficits at discharge, suggesting the need for ongoing monitoring and intervention. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to (1) Recognize the clinical presentation of anti-N-methyl-D-aspartate receptor encephalitis in pediatric patients, (2) Appreciate the role of rehabilitation in the care of the pediatric patient with anti-N-methyl-D-aspartate receptor encephalitis, and (3) Identify demographic and clinical variables that predict poor functional outcomes after rehabilitation in pediatric patients with anti-N-methyl-D-aspartate receptor encephalitis. Advanced. The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Prospective evaluation of frailty and functional independence in older adult trauma patients

BackgroundThe aim of our study was to assess the association between frailty and functional status in geriatric trauma patients. Methods3-year(2013–2015) prospective analysis and included all geriatric trauma patients(≥65y) discharged to a single rehabilitation center from our level-I trauma center. Frailty was measured using Trauma-Specific-Frailty-Index(TSFI) while Functional status was assessed using functional-independence-measure(FIM) at admission and discharge from rehabilitation center. Multivariate linear regression analysis was performed. Results267 patients were enrolled. Mean age was 76.9 ± 7.1y, 63.6% were males. Overall, 22.8% were frail, and 37.4% were pre-frail. On linear regression, higher motor-FIM, higher cognitive-FIM scores at admission, and longer length-of-stay at rehab were independently associated with increased discharge FIM score. While, ISS(injury-severity-score), pre-frail and frail status were negatively correlated with FIM gain. ConclusionFrail patients were less likely to recover to their baseline functional status compared with non-frail patients. Early focused intervention in frail elderly patients is warranted to improve functional status in this population.

Use of Oral Hydration Protocols for Dysphagic Patients Following Stroke

The aim of the study was to describe the use of oral hydration protocols for dysphagic patients following stroke. We reviewed inpatient records for patients able to take food and liquids orally within 30 days of an ischemic stroke. Orders were hierarchically defined with three levels of liquid consistency modification (LCM) and six levels of augmented hydration orders (AHOs). Change from admission to discharge in hydration and functional independence measure (FIM) scores across LCM and AHO groups was assessed. Length of stay, admission FIM, discharge FIM, and change in FIM scores were all significantly related to LCM and AHO group assignment. Need for supplemental intravenous hydration was low (6.9%) over the 2-year study period and was significantly related to both LCM and AHO group assignment. The association of LCM and AHO interventions with functional outcomes and need for intravenous fluids helps to validate their clinical utility.

Association of Urinary Incontinence with Cognition, Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

BackgroundAcute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination. ObjectiveTo examine if urinary incontinence is associated with inpatient-rehabilitation (IR) outcomes in cognition, transfers, and discharge destinations. DesignRetrospective observational study of 303 of 579(52%) acute-stroke patients admitted to IR 2012-2015 with complete urinary incontinence (total assistance for bladder management). Discharge Functional Independence Measure (FIM) scores were correlated for continence, cognition, transfers-(bed/chair/wheelchair), and discharge destination. ResultsPatients were admitted to IR on average 7.4 days after acute stroke. Average length-of-stay in IR was 14 days. At discharge 118 of 303(39%) remained urinary incontinent (total assistance). Continence/bladder-management FIM scores at discharge were associated with cognition FIM scores at discharge (chi square =105.8; P < .0001), and associated with transfer FIM scores at discharge (chi square = 153.1; P < .0001). Patients total to moderate assistance for continence at discharge included greater percentage that were dependent to moderate assistance for cognition and transfers than those minimal assistance to independent for continence. Continence/bladder-management FIM scores at discharge were associated with discharge disposition destinations (chi square = 29.98; P < .002). Patients total to moderate assistance for continence at discharge included greater percentage of acute care transfers, and skilled-nursing-facility dispositions, than patients that recovered to minimal assist to independent for continence. Urinary-incontinence recovery to minimal assistance to independent was associated with a home/community disposition rate of 82%. Conclusions52% stroke patients were total assistance with bladder management for urinary incontinence on IR admission. Partial to complete continence recovery occurred in 61%. Continence/bladder-management FIM scores at discharge were associated with cognition and transfer FIM scores, and discharge destinations.

Nutritional Status Changes and Activities of Daily Living after Hip Fracture in Convalescent Rehabilitation Units: A Retrospective Observational Cohort Study from the Japan Rehabilitation Nutrition Database

BackgroundSeveral studies have suggested that malnutrition impedes functional recovery in patients with hip fracture, but there are few reports on improvement in nutritional status and return to activities of daily living (ADL) in these patients. ObjectiveThis study was conducted to evaluate the relationship between change in nutritional status and recovery of ADL in malnourished patients after hip fracture and to identify predictors of functional recovery among the characteristic features of undernutrition. DesignThis was a retrospective observational cohort study. Participants/settingData for patients aged ≥65 years with hip fracture and malnutrition (Mini Nutritional Assessment–Short Form [MNA-SF] score ≤7) at the time of admission to convalescent rehabilitation units were obtained from the Japan Rehabilitation Nutrition Database between November 2015 and August 2017. Main outcome measuresThe main outcome measures were Functional Independence Measure (FIM) at discharge and the proportion of patients discharged home. Statistical analyses performedPatients were divided into two groups based on MNA-SF scores at discharge: improvement in nutritional status (>7, IN group) and non-improvement in nutritional status (≤7, NN group). Clinical characteristics and outcomes were compared between the groups. Multivariable regression analysis was performed to adjust for confounders including age, sex, comorbidity, pre-fracture ADL level, and FIM score on admission. ResultsOf 876 patients, 110 met the eligibility criteria (mean age, 85 years; 78.2% female); 77 of the patients were assigned to the IN group and 33 to the NN group. The patients in the IN group were younger and had higher FIM and MNA-SF scores on admission than those in the NN group. At discharge, the median FIM score was significantly higher in the IN group than in the NN group (110 vs 83, P<0.001). Multivariable analysis revealed a significant association between improvement in nutritional status and higher FIM score at discharge (B=7.377 [B=partial regression coefficient], P=0.036) but no association with discharge to home. Mobility, neuropsychological impairment, and weight loss subscores of MNA-SF were independently associated with discharge FIM score (R2=0.659). ConclusionsIn older patients with hip fracture and malnutrition, improvement in nutritional status was independently associated with improved performance of ADL during inpatient rehabilitation. Weight loss may be an important nutritional indicator for these patients.

Functional outcomes in patients with co-occurring traumatic brain injury and spinal cord injury from an inpatient rehabilitation facility’s perspective

ObjectiveTo examine the occurrence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI), i.e. dual diagnosis (DD), and to describe differences in functional outcomes between persons with DD and SCI only from an inpatient rehabilitation facility (IRF) perspective.DesignRetrospective clinical chart review.SettingAcute Midwest SCI inpatient rehabilitation facility.Participants256 persons age 18-80 years with acute traumatic SCI (AIS A-E, C1-S3 level of injury) from 2002-2012.InterventionsNeuroimaging and electronic medical records were reviewed to identify those with co-occurring TBI. Outcomes were then compared between the SCI only and DD groups.Outcome MeasuresLength of stay (LOS), discharge location and functional independence measures (FIM)ResultsForty-one percent of persons with traumatic SCI experienced co-occurring TBI. Rehabilitation LOS for the DD groups did not differ significantly from the SCI only group. Those with Moderate-Severe DD had significantly lower Total admission FIM (P < 0.001), Cognitive admission and discharge FIM (both P < 0.001) and Motor FIM efficiency scores (P = 0.03) compared to those with SCI only and were significantly less likely to discharge home (P = 0.05).ConclusionsPersons admitted to IRFs with Moderate-Severe DD compared to those with SCI only are less efficient in obtaining motor skills and may require ongoing rehabilitation to safely return home. It is therefore imperative to initiate early discharge planning and educate rehabilitation team members and families on the additional time and resources necessary to achieve more successful outcomes in those with Moderate-Severe DD.

The Link Between Cerebrovascular Hemodynamics and Rehabilitation Outcomes After Aneurysmal Subarachnoid Hemorrhage

The aim of the study was to assess the relation between cerebrovascular function early after aneurysmal subarachnoid hemorrhage onset and functional and rehabilitation outcomes. Observational cohort study of subarachnoid hemorrhage patients (n = 133) admitted to rehabilitation (n = 49), discharged home (n = 52), or died before discharge (n = 10). We obtained hemodynamic markers of cerebral autoregulatory function from blood flow velocities in the middle cerebral artery and arterial pressure waveforms, recorded daily on days 2-4 after symptom onset, and functional independence measure (FIM) scores and FIM efficiency for those admitted to acute rehabilitation. Compared to those discharged home, the range of pressures within which autoregulation is effective was lower in patients admitted to rehabilitation (4.6 [0.2] vs. 3.9 [0.2] mm Hg) and those who died (2.7 [0.4], P = 0.04). For those admitted to rehabilitation, autoregulatory range and the ability of cerebrovasculature to increase flow were related to discharge FIM score (R = 0.33 and 0.43, P < 0.01) and efficiency (R = 0.33 and 0.47 P < 0.01). The latter marker, along with subarachnoid hemorrhage severity and admission FIM, explained 84% and 69% of the variability in discharge FIM score and efficiency, respectively, even after accounting for age. Early cerebrovascular function is a major contributor to functional outcomes after subarachnoid hemorrhage and may represent a modifiable target to develop therapeutic approaches. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Define cerebral autoregulation; (2) Explain the importance of the integrity of cerebral autoregulation for longer-term functional and rehabilitation outcomes after aneurysmal subarachnoid hemorrhage; and (3) Theorize why treatment strategies that may be effective in reducing large-vessel vasospasms after an aneurysmal subarachnoid hemorrhage might not always translate into improved functional outcomes. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Association between Anticholinergic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study.

Anticholinergic (AC) drugs are associated with significant impairment in cognitive and physical function which may affect rehabilitation in older people. We aimed to evaluate whether AC burden is associated with rehabilitation achievement in post-acute hip-fractured patients. A retrospective cohort study carried out in a post-acute geriatric rehabilitation center on 1019 hip-fractured patients admitted from January 2011 to October 2015. The Anticholinergic Cognitive Burden Scale (ACB) was used to quantify the AC burden. Main outcome measures included the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM, and length of stay (LOS). The study population was divided into two groups: individuals with low admission AC burden (ACB≤1) and those with high admission AC burden (ACB≥2). The relationship between the admission AC burden and clinical, demographic and comorbidity variables was assessed using the Mann-Whitney and Chi square tests. A multiple linear regression model was used to estimate the association between admission AC burden and discharge FIM score after controlling for sociodemographic characteristics and chronic diseases. Patients with a high admission AC burden had a significantly higher rate of high education, a significantly lower rate reside at home, they waited a longer period of time from surgery to rehabilitation, were less independent pre-fracture, and presented with a higher rate of vascular disorders and depression compared with patients with a lower admission AC burden. These patients also exhibited a significantly lower FIM score on admission and at discharge, a lower FIM score change, and a lower achievement on the MRFS compared with patients with a lower admission AC burden. A multiple linear regression analysis showed that admission AC burden was significantly associated with the discharge FIM score after adjustment for confounding variables. High admission AC drug burden is significantly associated with less favorable discharge functional status in post-acute hip-fractured patients, independent of relevant risk factors.