Rehabilitation Discharge Research Articles

Unmet Social Needs of Older Adults With Mobility Limitations Following Inpatient Rehabilitation Discharge in Nigeria: A Qualitative Narrative Inquiry Study.

Approximately, 30% to 60% of older adults experience functional decline following hospitalization, which has implications for their ability to meet social needs after discharge. Exploring the unmet social needs of older adults following discharge is warranted to rethink the elements of hospital discharge in low-resource countries. This study explored the unmet social needs of older adults with mobility limitations following discharge from an inpatient rehabilitation unit in a state hospital in Northern Nigeria. This narrative qualitative study is based on the social constructivism paradigm guided by the 3-Dimensional Narrative Inquiry Space (3-D NIS) methodology. We purposively selected and conducted telephone interviews with 12 older adults, aged 55years and older, with mobility limitations and discharged from inpatient rehabilitation units. The 3-D NIS guided the thematic analysis of the data. Two author coders independently conducted a thematic analysis of the transcripts. Reflexivity was maintained throughout the research process. Two related themes [6 sub-themes] emerged: "limitations in social functioning" [leisure activity, religious engagement, and instrumental activities of daily living modifications]; and "accepting the status quo" [Care/support from relatives, friends, and strangers, regrets and aspirations, and adaptation to psychological needs]. Seven tensions from the participants' transcripts were embedded in emotions, focused on belief, well-being, and spirituality, COVID-19 pandemic impact, desire to be "normal," limited finance, non-age-friendly homes and community settings, and undetailed rehabilitation discharge planning. This study highlights the substantial unmet social needs of older adults with mobility limitations following discharge from inpatient rehabilitation units in Northern Nigeria, underscoring the importance of a holistic approach to hospital discharge planning. Future research in low-resource countries should delve deeper into developing comprehensive discharge strategies that integrate social workers and rehabilitation professionals to effectively address these multifaceted social needs.

Functional capacity at rehabilitation discharge predicts physical activity characteristics twenty-four weeks later for people with total knee arthroplasty: a secondary analysis of a randomized controlled trial.

To determine the association between performance-based and patient-reported functional capacity at the conclusion of 12-week rehabilitation with average daily step counts and peak walking cadence 38 weeks following total knee arthroplasty (TKA). Secondary analysis of an RCT. Veterans Affairs Medical Center. 87 U.S. military Veterans (age: 67±7 years, 87% male). 12-week rehabilitation beginning two weeks post-TKA plus random assignment to either a telehealth-based physical activity behavior change intervention (PABC) or control group. Performance-based (Timed Up-and-Go (TUG), 30-second sit-to-stand) and patient-reported measures (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Veterans Rand 12-Item Health Survey (VR12)) were assessed at rehabilitation discharge (14-weeks post-TKA). Physical activity was measured using thigh-mounted accelerometry 38 weeks post-TKA. Relationships between participant characteristics (age, sex, BMI, group assignment), functional capacity at discharge, and long-term physical activity outcomes (average daily step count and peak walking cadence) were evaluated using single- and multiple-variable linear and logistic regressions. Univariate analyses: TUG time (r= -0.33, p=0.002) and VR12 physical health subscore (r= 0.23, p=0.036) were correlated to average daily step count at week 38. TUG time (r= -0.31, p=0.006) was correlated to peak walking cadence. Multivariate analyses: Multiple linear regression controlling for age, sex, and BMI identified TUG (B= -301.25, p=0.039) and VR12 physical health (B= 93.1; p=0.049) as predictors of daily step count. TUG time (B= -1.5, p=0.012) and assignment to PABC intervention (B= 13.7, p<0.001) predicted peak walking cadence. No significant predictors of attaining a 7500 steps/day threshold were identified. Functional capacity at discharge is related to physical activity characteristics 38 weeks post-TKA. While behavior-change interventions are needed to address physical activity deficits post-operatively, the link between functional capacity and activity suggests additional need to address functional capacity limitations during TKA rehabilitation.

Predicting Discharge Destination from Inpatient Rehabilitation Using Machine Learning.

Predicting discharge destination for patients at inpatient rehabilitation facilities is important as it facilitates transitions of care and can improve healthcare resource utilization. This study aims to build on previous studies investigating discharges from inpatient rehabilitation by employing machine learning models to predict discharge disposition to home versus non-home and explore related factors. Fifteen machine learning models were tested. A total of 4922 patient encounters from 4401 patients undergoing inpatient rehabilitation at a Midwestern academic center's inpatient rehabilitation facilities were included. Input variables included demographic and hospital encounter-specific data. The total dataset contained 3687 discharges to home, and 1235 discharges to non-home destinations. A bagging classifier utilizing a decision tree base classifier utilizing random undersampling and without feature selection performed the best in terms of area under the receiver operating characteristic curve with a score of 0.722. Shapley value analysis suggested that length of stay, intravenous medication administration, urinary dysfunction, age, abnormalities white blood cell count or plasma sodium, and fatigue were the factors with the greatest impact on model output. Machine learning can help predict inpatient rehabilitation discharge disposition and identify factors associated with home or non-home discharges.

Should Femoral Nerve Blocks and Adductor Canal Blocks Be Used in Pediatric or Adolescent Anterior Cruciate Ligament Reconstruction?: A Systematic Review.

Achieving adequate pain control is vital for proper rehabilitation, satisfaction, and earlier discharge after anterior cruciate ligament reconstruction. Opioids have traditionally been used for this purpose, however, can be associated with various negative outcomes. As such, multimodal analgesia was introduced to reduce postoperative opioid use. Regional nerve blocks constitute one modality of multimodal analgesia, with femoral nerve blocks (FNBs) and adductor canal blocks (ACBs) being standard. This review sought to evaluate the utility and adverse effects of FNBs and ACBs relative to controls, alternative regional anesthesia options, and each other in pediatric or adolescent anterior cruciate ligament reconstruction (ACLR). Three databases were searched on January 31, 2024. The authors adhered to the PRISMA and R-AMSTAR guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The definition of pediatric was considered to be a mean age of 18 years or younger. Data on demographics, operative and anesthetic details, strength and functional outcomes, postoperative opioid consumption, revision rates and return to sport (RTS) rates, and Visual Analogue Scale (VAS) scores were extracted. Eleven studies (1 level I, 10 level III) comprising 5453 patients were included in this review (54.1% female), with a mean age of 16.3 (range of means: 15.0 to 16.9) years. Two studies compared FNB with and without a sciatic-nerve block (SNB), finding lower opioid consumption (P=0.007) and VAS scores (P<0.0001) in the postanesthesia care unit (PACU) in the FNB + SNB group. Three studies compared FNB or ACB with controls, with no studies reporting a benefit in rates of RTS, isokinetic quadriceps or hamstrings strength, or functional test performance. There were minimal differences when comparing continuous and single nerve blocks and FNB with ACB. There is inconclusive evidence investigating the role of FNB and ACB in pediatric or adolescent ACLR. The addition of a SNB to FNB may result in improvements in opioid consumption and VAS scores in the early postoperative period. There was minimal evidence in support of continuous blocks over single-shot blocks. Future studies should compare the use of ACB, FNB, and no blocks for pediatric or adolescent ACLR, with primary endpoints of acute pain control, postoperative opioid use, and the presence of longer-term motor deficits. Level III.

Combinations of Independent Motor Functional Independence Measure Items Associated With Home Discharge in Stroke Patients in Post-acute Rehabilitation Wards: An UpSet Plot Analysis.

Objectives Home discharge is a crucial goal for stroke patients in convalescent rehabilitation wards. While previous studies have identified relationships between Functional Independence Measure (FIM) scores and home discharge outcomes using conventional statistical methods, these analyses have limitations in visualizing combinations of independent FIM items. This study aimed to identify combinations of independent motor FIM items associated with home discharge in stroke patients using UpSet plots. Methods We analyzed 205 stroke patients admitted to a convalescent rehabilitation ward between April 2018 and March 2021. Independence in motor FIM items was defined as a score of 6 or higher. We used UpSet plots to visualize combinations of independent motor FIM items at discharge and identified major combinations (occurring in >7% of cases) in the home discharge group. Results Among 136 patients discharged to home, four major combinations of independent motor FIM items were identified: independence in all 13 items (22 patients, or 16.2%), independence in 12 items excluding stairs (18 patients, or 13.2%), independence in 10 items excluding bathing, tub transfer, and stairs (14 patients, or 10.3%), and dependence in all items (11 patients, or 8.1%). These combinations accounted for 47.8% of home discharge cases. Conclusions The visual analysis using UpSet plots revealed that, while higher levels of activities of daily living (ADL) independence increased the likelihood of home discharge, complete independence was not required. Dependence on specific items, such as bathing, tub transfer, and stairs, could be compensated through care services and environmental modifications. These findings provide practical insights for developing rehabilitation strategies and discharge planning.

Association Between Racial Marginalization with Direct Healthcare Expenditure, Time at Home and Rehabilitation Access Following Moderate to Severe Traumatic Brain Injury.

To determine the association between residence in racialized neighborhoods with direct healthcare expenditure and days at home (DAH) after moderate to severe traumatic brain injury (TBI). Differences in ethno-racial background have been associated with health outcome disparities. Much of this prior research was conducted in settings without universal healthcare coverage. The influence of ethno-racial background on health outcomes after TBI in universal healthcare settings remains unclear. This retrospective multicenter cohort study utilized linked administrative health data to identify adults sustaining moderate to severe TBI between 2009-2021. The primary exposure was an area-level index corresponding to the degree of racialized and immigrant populations within neighborhoods of residence (Q1-least racialized; Q5-most racialized). Co-primary outcomes were direct healthcare expenditure and DAH365days after injury. Secondary outcomes included discharge to rehabilitation and functional independence measure (FIM) scores at rehabilitation discharge. 6,188 patients met inclusion criteria. Patients in the most racialized neighborhoods incurred higher crude and adjusted direct healthcare costs compared to those in the least racialized neighborhoods. This effect was driven predominantly by physician claims and acute care costs. There were no significant differences in crude or adjusted DAH across quintiles. Access to rehabilitation and discharge FIM scores were comparable for patients residing different racialized neighborhood quintiles. Despite differences in healthcare expenditure, this study found similar home time, access to rehab and discharge FIM scores for TBI patients according to racialized neighborhood residence. Recognizing the limitations of area-level indices, our findings suggest equitable care delivery in a publicly funded universal care environment.

Translating acceptability to sustained delivery: Clinician and manager perspectives on implementing modified constraint-induced movement therapy in an early-supported discharge rehabilitation service.

Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite up to one-third of stroke survivors being eligible, clinical uptake remains poor. To address this, a multi-modal behaviour change intervention was implemented across a large seven-site early-supported discharge (ESD) rehabilitation service. This study investigated the acceptability of mCIMT implementation within this ESD service and identified adaptations required for sustained delivery. This qualitative study was nested within a mixed-methods process evaluation of mCIMT implementation. Four focus groups (n= 24) comprising therapists (two groups), therapy assistants (one group), and allied health managers (one group) were conducted. Data were analysed using reflexive thematic analysis and mapped to the Theoretical Domains Framework (TDF). Consumers were not directly involved in this study; however, lived experience research partners have helped shape the larger mixed-methods implementation study. Four themes were generated and mapped to the TDF. Factors related to acceptability included interdisciplinary practice in sharing workloads (belief about capabilities), practice opportunities across a range of UL presentations (skills), clinician attitudes influencing patient engagement (optimism), time constraints (belief about consequences), and cognitive overload from multiple systems and processes (memory, attention, and decision-making processes). Factors facilitating sustained delivery included improving stroke survivor education (knowledge), sharing success stories across teams (reinforcement), manager facilitation (social/professional role and identity), and the perception that the ESD setting was optimal for mCIMT delivery (social influences). mCIMT was acceptable in the ESD service, with clinicians feeling a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhanced patient and carer engagement. Successful implementation and sustained delivery of mCIMT in the ESD service could enhance UL function and reduce the burden of care for potentially hundreds of stroke survivors and their carers. Modified constraint-induced movement therapy (mCIMT) helps improve arm movement after a stroke. However, many stroke survivors do not get this therapy. To fix this, we started a program in a large home-based rehabilitation service. This study looked at how well mCIMT could fit into this service. We also wanted to know what changes were needed to make sure it was regularly provided. We held four group discussions with therapists, therapy assistants, and health managers. A total of 24 people took part. From these discussions, we found several important points. Therapists needed to work together as a team. They also needed to practice mCIMT to get better at delivering it. Therapists having a positive attitude would encourage more stroke survivors to take part. For long-term success, stroke survivors need better education about mCIMT. Managers need to encourage therapists to provide mCIMT. The rehabilitation service should also share their success stories about this therapy to encourage therapists to deliver it and stroke survivors to ask for it. Therapists enjoyed delivering mCIMT in the rehabilitation service. It worked better than other therapies to improve a stroke survivor's arm function. Because of this, they also felt it was their duty to offer mCIMT. Having ongoing training and better resources would help keep mCIMT going. If mCIMT can be provided regularly in this service, it could lead to better arm function and less care needed for many stroke survivors and their carers.

Resting energy expenditure during spinal cord injury rehabilitation and utility of fat-free mass-based energy prediction equations: a pilot study

Study designLongitudinal observational study. Measurements were undertaken between weeks 4–6 post-spinal cord injury (SCI), repeated at week 8 and every 4 weeks thereafter until week 20 or rehabilitation discharge, whichever occurred first.ObjectivesObserve variation in measured resting energy expenditure (REE) and body composition in males undergoing SCI rehabilitation, compare REE with SCI-specific prediction equations incorporating fat-free mass (FFM), and explore the prevalence of clinical factors that may influence individual REE.SettingSpinal Injuries Unit, Brisbane, Queensland, Australia.MethodsIndirect calorimetry was used to measure REE and bioimpedance spectroscopy to assess body composition. Four SCI-specific FFM-based REE and basal metabolic rate (BMR) prediction equations were compared to measured REE. A clinically significant change in REE was defined as +/− 10% difference from the week 4–6 measurement. Clinical factors that may affect REE variations were collected including infection, pressure injuries, autonomic dysreflexia, spasticity, and medications.ResultsFifteen people participated (mean age 35 ± 13 years, 67% paraplegic). There was no statistically significant change in mean REE, weight, or body composition, and the Chun and Nightingale BMR prediction equations performed best (rc > 0.8 at all time points). One-third of participants had >10% change in REE on 11 occasions, with clinical factors not consistently associated with the observed changes.ConclusionDuring SCI rehabilitation, mean REE, weight, and body composition remain unchanged, and FFM-based BMR prediction equations may be an acceptable alternative to indirect calorimetry. Future research designs should avoid single indirect calorimetry measures as snapshot data may not represent typical REE in this population.

Mortality and Place of Residence One Year Post Stroke in an Irish Cohort

Abstract Background Transition from hospital to community post stroke is a critical period in a patient's recovery. Understanding where post-stroke patients are living a year after discharge can provide valuable insights into the effectiveness of discharge planning and rehabilitation strategies. We aimed to identify location of patients one year post stroke and examine the influences on that location. Methods We performed a retrospective cohort study of stroke patients admitted to an acute hospital over a one-year period. Data on demographics, function, length of stay, stroke severity, mortality and discharge location were obtained from the in-hospital stroke registry. Patients were interviewed one year post stroke and follow up data on place of residence obtained. Results 260 strokes occurred during the 1-year period. 11% died as inpatients and 5% were uncontactable leaving 206 stroke patients included in this study. Twenty-five patients (12%) died between discharge and 1 year follow up. 150 (73%) returned home post discharge rising to 157 (76%) one year post stroke. 32 (16%) were discharged to nursing homes falling to 22 (11%) at one year. Patients in nursing homes were older (80 vs 68 years, p = 0.001), had longer inpatient stays (37 vs 9 days, p = 0.000) and had higher Modified Rankin Scores (5 vs 2, p=0.0001). Conclusion Almost one in four stroke patients died within the first year of stroke consistent with international data. Mortality was highest in the acute post stroke period, but half of all deaths occurred post hospital discharge highlighting the importance of secondary vascular prevention and advanced care planning in this population. Older age, higher functional dependence and longer length of hospital stay were all associated with nursing home admission. Post stroke morbidity and mortality remains high after hospital discharge. Further study is needed to understand cause of death in the post discharge period in this population.

Discharge Destination, Mortality Outcomes and Rehabilitation Utilization, a One Year Follow Up of Frail Older Medical Inpatients

Abstract Background Patients with increasing frailty constitute a large proportion of acute hospital admissions. Deconditioning is a known complication of acute medical admission. This study reviews the outcomes for a population identified as frail during their admission, including utilisation of formal rehabilitation and discharge destination. Mortality rates at 6 and 12 months are also reviewed to assess if frailty could be used as a prognostication tool. Methods The patients selected were included in a hospital wide point prevalence study in 2023. Patients included were over 70 years of age and admitted under a medical team. Clinical frailty scale (CFS) score was recorded on all patients. The hospital electronic record provided information on transfer for formal rehabilitation, discharge home with home care package or discharge to long term care. The cohort were coded based on discharge destination. Mortality outcome at 6 and 12 months were also obtained via electronic record and RIP.ie. Results 233 patients were included, 177 (75.9%) were identified as frail. Only 8 (3.43%) of the group were discharged to formal rehabilitation. 52 (22.3%) were transferred directly to Long term care from hospital without a trial of formal rehabilitation. 8 of this group had specific rehab needs documents, all 8 were alive at 6 and 12 months. Approximately 40% of the total group had died within 12 months. Conclusion Rehabilitation benefits the individual patient and the health service as a whole, by impacting care needs and facilitating discharge home (Van Craen et al., 2010). This study has shown that approximately 1 in 4 patients over 70 were discharged directly to long term care without appropriate rehabilitation. Just over 3.4% of the group received formal rehabilitation outside of the acute hospital. This has highlighted the need to radically act on egress pathways to provide appropriate rehabilitation and care for our patients.

Unmet Needs Post Stroke: Level of Unmet Need According to Discharge Destination

Abstract Background Stroke survivors often face unmet needs after leaving acute and rehabilitation services (McKevitt et al., 2011). UK and Ireland stroke guidelines (2023) advise a 6-month health and social care review for all patients, yet resource access in hospital and community settings hinder this. Targeting those with the most unmet needs could improve service delivery. Consequently, we examined unmet needs of stroke patients post-rehabilitation, comparing those who were discharged to rehabilitation (RG) to the non-rehabilitation group (NRG). Methods Participants: All patients attending a post-stroke review clinic between March 2023 and April 2024. Groups: RG included patients discharged to Early Supported Discharge or inpatient rehabilitation; NRG included patients not discharged to these services. Data: Collected demographic information and assessed unmet needs using a modified Greater Manchester Stroke Assessment Tool. Analysis: Using Microsoft Excel, group comparisons were made using chi-squared tests and t-tests, with log transformation applied to non-normally distributed data. Results 251 patients attended during the data collection period (69 patients (27%) in RG, 182 patients (73%) in NRG). The average age was 68 in both groups. The RG had a longer mean length of stay (23 days) compared to the NRG (19 days) (p=0.0007). The RG also had a higher mean score on the clinical frailty scale (RG 4, NRG 3, p=0.05). In the RG, 97% reported no follow-up after discharge, compared to 78% in the NRG. A greater proportion of RG patients reported swallow difficulties (12% vs. 3%, p=0.03), mobility difficulties (46% vs. 30%, p=0.02), and falls (41% vs. 30%, p=0.008) compared to NRG patients. Conclusion Data from this exploratory study suggests substantial unmet needs among post-stroke patients with a significantly higher level of unmet needs among patients who were discharged to post-acute rehabilitation. Despite this, the majority of these patients were not seen by community services at the time of 6-month review.

Predictors of Psychiatric Hospitalization After Discharge From Inpatient Neurorehabilitation for Traumatic Brain Injury.

To examine, among persons discharged from inpatient rehabilitation for traumatic brain injury (TBI), the degree to which pre-TBI factors were associated with post-TBI hospitalization for psychiatric reasons. The authors hypothesized that pre-TBI psychiatric hospitalization and other pre-TBI mental health treatment would predict post-TBI psychiatric hospitalization following rehabilitation discharge, up to 5years post-TBI. Five Veterans Affairs Polytrauma Rehabilitation Centers. Participants with nonmissing rehospitalization status and reason, who were followed at 1 year (N=1006), 2years (N =985), and 5years (N =772) post-TBI. A secondary analysis of the Veterans Affairs TBI Model Systems, a multicenter, longitudinal study of veterans and active-duty service members with a history of mild, moderate, or severe TBI previously admitted to comprehensive inpatient medical rehabilitation. This study examined participants cross-sectionally at 3 follow-up timepoints. Psychiatric Rehospitalization was classified according to Healthcare Cost and Utilization Project multilevel Clinical Classifications diagnosis terminology (Category 5). Rates of post-TBI psychiatric hospitalization at years 1, 2, and 5 were 4.3%, 4.7%, and 4.1%, respectively. While bivariate comparisons identified pre-TBI psychiatric hospitalization and pre-TBI mental health treatment as factors associated with psychiatric rehospitalization after TBI across all postinjury timepoints, these factors were statistically nonsignificant when examined in a multivariate model across all timepoints. In the multivariable analysis, pre-TBI psychiatric hospitalization was significantly associated with increased odds of post-TBI psychiatric hospitalization only at 1-year post-TBI (adjusted odds ratio=2.65; 95% confidence interval, 1.07-6.55, P =.04). Posttraumatic amnesia duration was unrelated to psychiatric rehospitalization. Study findings suggest the limited utility of age, education, and pre-TBI substance use and mental health utilization in predicting post-TBI psychiatric hospitalization. Temporally closer social and behavior factors, particularly those that are potentially modifiable, should be considered in future research.

Cognitive Performance is Associated With 1-Year Participation and Life Satisfaction Outcomes: A Traumatic Brain Injury Model Systems Study.

To determine, in persons with traumatic brain injury (TBI), the association between cognitive change after inpatient rehabilitation discharge and 1-year participation and life satisfaction outcomes. Secondary analysis of prospectively collected TBI Model Systems (TBIMS) data. Inpatient rehabilitation and community. 499 individuals with TBI requiring inpatient rehabilitation who completed the Brief Test of Adult Cognition by Telephone (BTACT) at inpatient rehabilitation discharge (ie, baseline) and 1-year postinjury. Participation Assessment with Recombined Tools-Objective (PART-O) and Satisfaction with Life Scale (SWLS). Of 2,840 TBIMS participants with baseline BTACT, 499met inclusion criteria (mean [standard deviation] age=45 [19] years; 72% male). Change in BTACT executive function (EF) was not associated with 1-year participation (PART-O; β=0.087, 95% CI [-0.004, 0.178], P =.061) when it was the sole model predictor. Change in BTACT episodic memory (EM) was associated with 1-year participation (β=0.096, [0.007, 0.184], P =.035), but not after adjusting for demographic, clinical, and functional status covariates (β=0.067, 95% CI [-0.010, 0.145], P =.089). Change in BTACT EF was not associated with life satisfaction total scores (SWLS) when it was the sole model predictor (β=0.091, 95% CI [-0.001, 0.182], P =.0503). Change in BTACT EM was associated with 1-year life satisfaction before (β=0.114, 95% CI [0.025, 0.202], P =.012) and after adjusting for covariates (β=0.103, [0.014, 0.191], P =.023). In secondary analyses, change in BTACT EF was associated with PART-O Social Relations and Out and About subdomains before (Social Relations: β=0.127, 95% CI [0.036, 0.217], P =.006; Out and About: β=0.141, 95% CI [0.051, 0.232], P =.002) and after (Social Relations: β=0.168, 95% CI [0.072, 0.265], P <.002; Out and About: β=0.156, 95% CI [0.061, 0.252], P <.002) adjusting for functional status and further adjusting for covariates (Social Relations: β=0.127, 95% CI [0.040, 0.214], P =.004; Out and About: β=0.136, 95% CI [0.043, 0.229], P =.004). However, only the models adjusting for functional status remained significant after multiple comparison correction (ie, Bonferroni-adjusted alpha level=0.002). EF gains during the first year after TBI were related to 1-year social and community participation. Gains in EM were associated with 1-year life satisfaction. These results highlight the potential benefit of cognitive rehabilitation after inpatient rehabilitation discharge and the need for interventions targeting specific cognitive functions that may contribute to participation and life satisfaction after TBI.

PAIN RELIEF AFTER INSTRUMENTED SPINAL SURGERY

BackgroundOver 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques.MethodsPRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios.ResultsDifferences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented.ConclusionThe study is due to open in May 2024 and complete in 2026.Conflicts of InterestNo conflicts of interest declaredSources of FundingNIHR Health Technology Award – grant number NIHR153170Trial presentations so farAPOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024.

Mortality among Veterans following Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

Few studies have examined long-term mortality following traumatic brain injury (TBI) in a military population. This is a secondary analysis of a prospective, longitudinal study that examines long-term mortality (up to 10 years) post-TBI, including analyses of life expectancy, causes of death and risk factors for death in service members and veterans (SM/V) who survived the acute TBI and inpatient rehabilitation. Among 922 participants in the study, the mortality rate was 8.3% following discharge from inpatient rehabilitation. The mean age of death was 54.5 years, with death occurring on average 3.2 years after injury, and with an average 7-year life expectancy reduction. SM/V with TBI were nearly 4 times more likely to die compared with the US general population. Leading causes of death were external causes of injury, circulatory disease, and respiratory disorders. Also notable were deaths due to late effects of TBI itself and suicide. Falls were a significant mechanism of injury for those who died. Those who died were also more likely to be older at injury, unemployed, non-active duty status, not currently married, and had longer post-traumatic amnesia, longer rehabilitation stays, worse independence and disability scores at rehabilitation discharge, and a history of mental health issues prior to injury. These findings indicate that higher disability and less social supportive infrastructure are associated with higher mortality. Our investigation into the vulnerabilities underlying premature mortality and into the major causes of death may help target future prevention, surveillance, and monitoring interventions.

Predict Factors that Influence Stroke Recovery and Function Using FIM Score at Discharge in a Tertiary Hospital

Background: To assess the use of the National Institute of Health Stroke Scale (NIHSS) in predicting functional outcomes after hospital discharge using the functional independence measure (FIM) in patient’s post-stroke. Methods: This retrospective cohort study included 99 patients who were admitted to NGHA hospitals between January 2020 and January 2022 and had been discharged and scheduled for rehabilitation sessions in the hospital. All data were extracted from medical health records during the study period. Data on patient characteristics, NIHSS score, FIM admission and discharge scores, stroke type, rehabilitation sessions, smoking status, hypertension, and length of stay were collected. Results: Most patients had moderate stroke, and 88.9% of all the patients had ischemic stroke. There was a statistically significant improvement in the FIM score from admission to discharge [2.84 (+1.63) to 4.47 (+1.55), p= 0.01]. After adjusting for all other potential predictor variables, the NIHSS score for moderate stroke significantly predicted the FIM score upon discharge. Conclusion: This study showed the significance of using the NIHSS score for newly admitted patients with moderate stroke in predicting recovery. Conclusion: The study illustrated a significant improvement in the FIM scores from admission to discharge, demonstrating the importance of early and intensive rehabilitation post-stroke.

Reduced Functioning After Hospitalization for COVID-19 Infection

Background and Purpose: COVID-19 infection is associated with persistent physical problems, and approximately 2% of the &gt;100 million people in the United States with COVID-19 infection have required hospitalization. The purpose of this review is to identify problems with activity and participation persisting during the first 6 months after hospitalization for COVID-19. Methods: A comprehensive search of 5 bibliographic databases was performed for cohort studies examining activity limitations and participation restrictions assessed within 6 months of hospitalization in adults hospitalized with COVID-19 infection. Two reviewers screened titles, abstracts, and full text to determine eligibility. Study methodological quality was assessed using the SIGN Methodology Checklist 3. Study methods, design, and participant outcomes were extracted. Results were summarized in narrative synthesis, and meta-analysis was conducted for 6-minute walk test. Results: Titles (n = 2670) were screened, and 26 acceptable to high-quality studies satisfied all eligibility criteria. Within the first 6 months following hospitalization for COVID-19 people experienced activity limitations and participation restrictions, including 16% reduction in 6-minute walk test distance (compared to age and gender-matched norms) and 59% return to employment rate. Discussion and Conclusion: The first 6 months following hospitalization for COVID-19 infection are associated with significant reductions in exercise capacity and return to work. Problems associated with post-intensive care syndrome cannot be ruled out as contributing to these findings. Recognition of these problems is essential and should inform hospital discharge planning and rehabilitation services.

Factors linked to patient rehabilitation disposition following surgical treatment of bone-related complications.

e23061 Background: Cancer in the skeletal system, whether primary or metastatic, can cause fractures or impending fractures needing stabilization. Patients with pathologic fractures or impending fractures needing prophylactic fixation have lower home discharge rates than non-malignant hip fracture cases, a recognized quality metric. We initiated a single-center retrospective study to identify modifiable risk factors for improving home discharge rates in this population. Methods: We reviewed orthopedic surgery patients at Thomas Jefferson University Hospital (TJUH) from July 2020 to April 2023. We assessed demographics, living situation, admission-to-surgery time, surgery-to-physical therapy time, in-hospital complications, pathological fracture site, and weight-bearing status. Patients were stratified into discharge groups: home, subacute rehabilitation, and acute rehabilitation. Differences in rehabilitation facility versus home discharges were analyzed using pairwise two-sample t-tests and Fisher exact tests. Results: In this study, 102 cancer patients underwent orthopedic intervention at TJUH. The cohort comprised 57 women (55.9%), 67 non-Hispanic white individuals (63.7%), with median age of 66.6 (52.4-80.8). Living alone increased the likelihood of discharge to an acute rehabilitation facility compared to home (13 vs. 5, p&lt;.001). Lower median age correlated with home discharge compared to subacute and acute discharge (age 62.4 vs. 74.7, p&lt;0.001; 62.4 vs. 66.9, p&lt;0.05). Higher in-hospital complications, like sepsis, were associated with acute rehabilitation discharge versus home (24 vs. 17, p&lt;.05). Conclusions: These results link living alone, older age, and in-hospital complications to rehabilitation facility discharge. No modifiable risk factors for home discharge were identified. This study reinforces the importance of caregiver support for patient outcomes and high-quality care. In the future, we intend to investigate if the in-hospital complications were avoidable and, thus, modifiable. A larger patient cohort may be required to reveal potential areas for improvement. [Table: see text]

Utilization of early supported discharge and outpatient rehabilitation services following inpatient stroke rehabilitation

BackgroundStudies examining factors associated with patient referral to early supported discharge (ESD)/outpatient rehabilitation (OPR) programs and utilization of ESD/OPR services after discharge from inpatient stroke rehabilitation (IPR) are scarce. Accordingly, we examined utilization of ESD/OPR services following discharge from IPR and patient factors associated with service utilization.MethodsStroke patients discharged from IPR facilities in Alberta between April 2014 and March 2016 were included and followed for one year for ESD/OPR service utilization. Multivariable linear and negative binomial regressions were used to examine association of patients’ factors with ESD/OPR use.ResultsWe included 752 patients (34.4% of 2,187 patients discharged from IPR) who had 40,772 ESD/OPR visits during one year of follow-up in the analysis. Mean and median ESD/OPR visits were 54.2 and 36 visits, respectively. Unadjusted ESD/OPR visits were lower in females and patients aged ≥ 60 years but were similar between urban and rural areas. After adjustment for patient factors, patients in urban areas and discharged home after IPR were associated with 83.5% and 61.9%, respectively, increase in ESD/OPR visits, while having a right-body stroke was associated with 23.5% increase. Older patients used ESD/OPR less than their younger counterparts (1.4% decrease per one year of older age). Available factors explained 12.3% of variation in ESD/OPR use.ConclusionESD/OPR utilization after IPR in Alberta was low and varied across age and geographic locations. Factors associated with use of ESD/OPR were identified but they could not fully explain variation of ESD/OPR use.

Predictors of social risk for post-ischemic stroke reintegration

After stroke rehabilitation, patients need to reintegrate back into their daily life, workplace and society. Reintegration involves complex processes depending on age, sex, stroke severity, cognitive, physical, as well as socioeconomic factors that impact long-term outcomes post-stroke. Moreover, post-stroke quality of life can be impacted by social risks of inadequate family, social, economic, housing and other supports needed by the patients. Social risks and barriers to successful reintegration are poorly understood yet critical for informing clinical or social interventions. Therefore, the aim of this work is to predict social risk at rehabilitation discharge using sociodemographic and clinical variables at rehabilitation admission and identify factors that contribute to this risk. A Gradient Boosting modelling methodology based on decision trees was applied to a Catalan 217-patient cohort of mostly young (mean age 52.7), male (66.4%), ischemic stroke survivors. The modelling task was to predict an individual’s social risk upon discharge from rehabilitation based on 16 different demographic, diagnostic and social risk variables (family support, social support, economic status, cohabitation and home accessibility at admission). To correct for imbalance in patient sample numbers with high and low-risk levels (prediction target), five different datasets were prepared by varying the data subsampling methodology. For each of the five datasets a prediction model was trained and the analysis involves a comparison across these models. The training and validation results indicated that the models corrected for prediction target imbalance have similarly good performance (AUC 0.831–0.843) and validation (AUC 0.881 - 0.909). Furthermore, predictor variable importance ranked social support and economic status as the most important variables with the greatest contribution to social risk prediction, however, sex and age had a lesser, but still important, contribution. Due to the complex and multifactorial nature of social risk, factors in combination, including social support and economic status, drive social risk for individuals.