FIM Gain Research Articles

Poster 24: Prognostic Indicators in Metastatic Spinal Cord Compression: Using FIM and Tokuhashi Scale to Optimize Rehabilitation Planning

Objectives: To determine if patients with metastatic spinal cord compression (MSCC) make significant functional gains through rehabilitation; to study survival and predictors of survival in MSCC; and to explore predictive factors for high or low functional gains in MSCC. Design: Retrospective, descriptive study. Setting: Inpatient neuro-oncology rehabilitation ward, Henderson General Hospital, Hamilton, Canada. Participants: Clinical records were examined for 63 inpatients with MSCC. Main Outcome Measures: Demographics, treatment of MSCC, length of rehabilitation, admission, and discharge FIM scores, Tokuhashi score, and survival data were collected. Statistical analyses included nonparametric comparisons, Kaplan-Meier analyses, Cox regression, and exploratory logistic regression. Results: FIM score improved from 83 to 102 (P<.001). Estimated median survival from time of rehabilitation was 10 months. Kaplan-Meier analysis showed longer survival in patients with high Tokuhashi scores (9–15) compared to low scores (0–8) (P<.005); and high FIM change (413) compared to low FIM change (p13) (P<.02). Cox regression revealed that high FIM gain and high Tokuhashi score were prognostic factors. Logistic regression showed Tokuhashi score (odds ratio [OR]¼=1.30, 95% confidence interval [CI]¼, 1.04–1.62), and length of rehabilitation (OR¼=1.04, 95% CI¼, 1.01–1.07) were associated with high FIM gain. Conclusions: Rehabilitation improves functional outcomes in MSCC. Patients who had a high Tokuhashi score and achieved high functional gains after rehabilitation had longer survival. Tokuhashi score and length of rehabilitation were associated with high FIM gain. The Tokuhashi score can help identify patients with good prognosis and potential for improvement during rehabilitation.

Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery

The purpose of the study was to evaluate patient and system outcomes regarding older community-residing adults who participated in a rehabilitation program following HF surgery. The health care professionals on the rehabilitation unit in this feasibility study had never cared for such patients who were so frail, with multiple co-morbidities including cognitive impairment (CI). After an innovative model of care was developed and the staff trained in the novel approach to care, the unit opened for all patients living within the community who had fractured their hip, regardless of their CI. Of the 31 elderly patients consecutively admitted post-HF in this retrospective study, 18 were found to have CI postoperatively as determined by a Mini-Mental State Examination (MMSE) score ≤23. There were no differences in length of stay (LOS), rehabilitation efficiency, and motor FIM gain scores between the two groups of patients. This feasibility retrospective study suggests that staff can learn how to care for patients with CI in rehabilitation settings, and that such clients can achieve outcomes comparable to those without CI in a setting dedicated to caring for patients with a HF.

Team Training and Stroke Rehabilitation Outcomes: A Cluster Randomized Trial

Strasser DC, Falconer JA, Stevens AB, Uomoto JM, Herrin J, Bowen SE, Burridge AB. Team training and stroke rehabilitation outcomes: a cluster randomized trial. ObjectiveTo test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes. DesignA cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups. SettingThirty-one Veterans Affairs medical centers. ParticipantsA total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention. InterventionThe intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process. Main Outcome MeasuresThree patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS). ResultsFor both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge. ConclusionsStroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).

REHABILITATION OF A CENTENARIAN.

Background & Purpose: The population over the age of 100 is increasing. Individuals are living longer with chronic conditions. At present, there is little published on this group. This decreases our ability to design effective plans for these patients. Physical therapists must be aware of these patients'functional potential. This case description attempts to document this potential in a patient in this age group. Case Description: The subject is a 100 year old female residing in an assisted living facility (ALF) prior to admission to acute care with shortness of breath. PMH included degenerative joint disease, hypertension, congestive heart failure (CHF), spinal stenosis, dementia, and functional decline. Eleven days after admission, she transferred to an inpatient rehabilitation facility (IRF) and began physical therapy (PT) for debility due to decompensated CHF and an electrolyte imbalance. She received 19 PT treatments for a total of 810 minutes over a period of 15 days. She also received occupational therapy. Upon the IRF PT assessment, she demonstrated an increased risk for falls (Tinetti score 13/28), gross strength UEs 3+/5 and LEs 4−/5, and decreased functional status (total Functional Independence Measure [FIM] score =57). On admission the FIM score for transfers=2, walking=1, toilet transfers=3 and tub transfers=0. Her mental status was 27/30 as measured by the Mini Mental State Exam. She was able to walk 30 feet with a rolling walker and minimum assistance. She required maximum assistance to move in bed, and maximum assistance for transfers (supine to/from sit). Interventions included education and training for gait, transfers, balance, endurance, and strength. Outcomes: At discharge, the patient needed supervision for bed mobility. Transfers required minimal assistance (FIM =4). She was able to ambulate 60 feet (twice in a 45 minute session) with a rolling walker and supervision (FIM =2). She was able to transfer to/from a toilet and a tub with minimal assistance (FIM =4). At discharge, her total FIM score was 83, representing a gain of 26 points. The adjusted national average for admission FIM during the same quarter the patient was treated was 58.1, and the national average discharge FIM was 86.9, resulting in an average FIM gain of 28.8 (national data from Uniform Data Systems). The patient was discharged back to her ALF with home health PT, nursing, and an aide. Discussion: This patient presented with multiple comorbidities and significant functional decline. Despite these challenges, she made functional gains similar to those of the national average. It is important to note that these averages include a younger population. This case report demonstrates that patients among the oldest old (100 years old) can improve in functional areas measured by the FIM. Results in this case are only slightly lower than national averages for the same time period. These patients can benefit from the intensity of services provided in an inpatient rehabilitation facility. This level of service allowed this patient to return home environment and avoid institutionalization.

Poster 43: Inpatient Rehabilitation Trends in the Morbidly Obese Population

Objective: To evaluate the hypothesis that inpatient rehabilitation patients with morbid obesity have lower FIM instrument gains and longer lengths of stay (LOS) than patients without morbid obesity. Design: Retrospective chart review. Setting: Regional rehabilitation center in a tertiary care center in eastern North Carolina. Participants: Patients admitted to an acute rehabilitation center between January 2002 and November 2006 with morbid obesity as a diagnosis code (278.01). This group was compared with the population of patients admitted to the same rehabilitation center without morbid obesity as a diagnosis code. Interventions: Not applicable. Main Outcome Measures: All medical records of patients admitted to inpatient rehabilitation with a morbid obesity diagnostic code of 278.01 (n=383) were reviewed and compared with medical records of patients without a morbid obesity code (n=5384). A simple t test was used to compare the 2 groups. Admission FIM scores, discharge FIM scores, FIM gain, LOS, and LOS efficiency. Results: On average, the morbidly obese group had an admission FIM score of 66.8 and a FIM gain of 17.96. The nonobese (control) population had an admission FIM score of 64.02 and a FIM gain of 17.90. The morbidly obese group had an LOS of 17 days and an LOS efficiency of 1.08. The control group had an LOS of 14 days and an LOS efficiency of 1.25. Statistical analysis showed a significant difference in LOS (P=.025) but no significant difference in FIM gain or LOS efficiency. Conclusions: Morbidly obese rehabilitation patients require a greater LOS to achieve FIM gains comparable to that of the non–morbidly-obese population.

The Impact of Previous Strokes on the Rehabilitation of Elderly Patients Sustaining a Hip Fracture

Mizrahi EH, Fleissig Y, Arad M, Adunsky A. The impact of previous strokes on the rehabilitation of elderly patients sustaining a hip fracture. Objective To evaluate whether a previous stroke may affect the functional outcome gain of elderly patients undergoing rehabilitation for a hip fracture. Design A retrospective cohort study. Setting The division of geriatric medicine with rehabilitation wards at a university-affiliated referral hospital. Participants Patients with hip fractures (N=460) undergoing a standard rehabilitation course. Interventions Not applicable. Main Outcome Measures The functional outcome of previous stroke- and nonprevious stroke (NPS)–affected patients assessed by the FIM instrument at admission and discharge from the rehabilitation facility. Data were analyzed by t tests, Pearson correlation, chi-square tests, and linear regression analysis. Results Both admission and discharge total FIM scores were significantly higher in NPS compared with previous stroke patients (63.53±19.89 vs 52.19±19.37, P<.001) and (84.23±24.93 vs 71.37±25.03, P=.001), respectively. However, changes in total FIM (20.70±11.68 vs 19.17±13.32, P=.38) and in motor FIM (19.84±10.63 vs 17.96±11.21, P=.23) at discharge were not statistically significant between the 2 groups. A linear regression analysis showed that a previous stroke was not predictive of a worse total FIM gain at discharge ( P=.58). Conclusions NPS hip fracture elderly patients show higher admission and discharge FIM scores compared with previous stroke patients. Nevertheless, both groups achieve similar FIM gains during rehabilitation period. A previous stroke should not be considered as adversely affecting the rehabilitation of such patients.

The Effect of Medicare's Prospective Payment System on Patient Satisfaction

To examine the impact of Medicare's Prospective Payment System (PPS) on patient satisfaction at four inpatient rehabilitation hospitals. Prospective study using a satisfaction survey to examine the effects of Medicare's PPS for rehabilitation hospitals. Surveys were conducted at four affiliated rehabilitation hospitals in the Midwest. Patient characteristics varied only slightly pre- to post-PPS, and several characteristics were related to overall satisfaction, including motor functional gain, discharge to home, and respondent (patient or proxy). A 12-point increase on a 12-item motor function scale resulted in 1.13 greater odds (95% CI: 1.04, 1.24) of reporting excellent satisfaction. Patient respondents were 1.27 times more likely (95% CI: 1.07, 1.50) than proxies to report excellent satisfaction, and patients discharged home were 1.65 times more likely (95% CI: 1.31, 2.07) to report excellent satisfaction than patients discharged elsewhere. We found an increase in observed satisfaction from 60.3 to 63.4% (P < 0.05) after PPS implementation, despite a decrease in motor FIM gain. Patient characteristics such as motor FIM gain, discharge status, and respondent type were significantly associated, although only slightly, with patient satisfaction in inpatient rehabilitation. Percentage of excellent satisfaction improved at these four facilities after PPS implementation, despite declines in motor FIM gain. The improvement may be the result of numerous ongoing quality-improvement initiatives directed at improving patient satisfaction at these facilities.

Functional outcome of ischemic stroke: A comparative study of diabetic and non-diabetic patients

Background and purpose. Diabetes is associated with more ischemic strokes and diabetic patients have up to a three-fold increased risk for suffering a stroke, compared with non-diabetics. The aim of this study is to evaluate whether diabetes mellitus may also affect the functional outcome of patients with acute ischemic stroke, undergoing post-acute care rehabilitation.Methods. A retrospective charts analysis of consecutive older patients with acute ischemic stroke admitted for rehabilitation at a tertiary hospital with post-acute care geriatric rehabilitation wards. Functional outcome of diabetics and non-diabetics was assessed by the Functional Independence Measurement scale (FIM™) at admission and discharge. Data were analysed by t-tests, Pearson correlation, and Chi-square test, as well as by linear regression analysis.Results. A total number of 527 patients were admitted, of whom 39% were diabetics. Compared with non-diabetics, diabetic stroke patients were slightly younger (p = 0.0001) but had similar admission FIM scores. FIM gain parameters (total FIM gain, motor FIM gain, daily total and motor FIM gains) upon discharge were similar in both groups. A linear regression analysis showed that higher MMSE scores (β = 0.08; p = 0.01) and higher admission total FIM scores (β = 0.87; p < 0.001) predicted higher total FIM scores upon discharge. Diabetes mellitus was not interrelated, whatsoever, with better total FIM scores upon discharge (β = −0.03; p = 0.27).Conclusions. The findings suggest that there is no difference in the functional outcome of diabetic and non-diabetic patients, presenting for rehabilitation after acute ischemic stroke. Diabetes should not be considered as adversely affecting rehabilitation of such patients.

Comparison of functional results in non-traumatic and traumatic spinal cord injury

Purpose. This study was conducted primarily to be a descriptive study about non-traumatic (NT) spinal cord injury (SCI) patients, in terms of their demographic and neurological features, and to investigate the complications and efficient results of rehabilitation in this group. The second aim of the study was to conduct a comparison between non-traumatic SCI patients and traumatic SCI patients.Materials and methods. The design was a retrospective study at a Physical Medicine and Rehabilitation Training and Research center. The study was carried out with 194 patients, of whom 63 had non-traumatic SCI and 131 had traumatic SCI. Main outcome measures were: Demographics, etiology, Functional Independent Measure score, and level of injury.Results. A total of 32.47% (n = 63) of the patients in the study had a non-traumatic SCI. In traumatic SCI group, the proportion of male patients were significantly more than the proportion of female patients (p = 0.002). Admission FIM score of non-traumatic SCI group was better than the traumatic SCI group (p = 0.004). The comparison of discharge FIM scores between traumatic SCI and non-traumatic SCI groups did not yield any significant results (p = 0.303). However, the comparison of FIM gain between the two groups showed a significant difference (p = 0.03). The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (39.68%).Conclusions. The present study showed that there are certain differences between NT and traumatic SCI patients. Therefore, not all SCI patients should be considered to be falling under a single category, and should be divided into groups on the basis of the etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program.

Toward Benchmarks for Stroke Rehabilitation in Ontario, Canada

Canadian benchmarking data do not exist for stroke rehabilitation services. This study used the FIM-function-related group (FIM-FRG) classification system to group patients and to describe the outcomes within each group. The intent was to begin to develop benchmarks for persons recovering from stroke in Canadian rehabilitation facilities. 561 patients were stratified into the nine categories of the FIM-FRG system. Length of stay (LOS), total FIM gain, total FIM at discharge, and discharge location were described for each category. Mean waiting time to rehabilitation admission was 29.7 days. Mean LOS was 49.2 days. Mean admission and discharge total FIM ratings were 78.1 and 103.1, respectively. FIM gain ranged from 8 to 37. Seventeen percent of patients were discharged to nursing homes, with rates ranging from a low of 0% (FRG 8 and 9) to a high of 60% (FRG 2). For the nine FIM-FRG groups, LOS was considerably longer in the Canadian facility than in the United States, and total FIM score at discharge was higher in Canada. This is likely related to differences in the healthcare systems of the two countries and confirms the need to develop benchmarks based on Canadian data.

Ideal timing to transfer from an acute care hospital to an interdisciplinary inpatient rehabilitation program following a stroke: an exploratory study.

BackgroundTimely accessibility to organized inpatient stroke rehabilitation services may become compromised since the demand for rehabilitation services following stroke is rapidly growing with no promise of additional resources. This often leads to prolonged lengths of stays in acute care facilities for individuals surviving a stroke. It is believed that this delay spent in acute care facilities may inhibit the crucial motor recovery process taking place shortly after a stroke. It is important to document the ideal timing to initiate intensive inpatient stroke rehabilitation after the neurological event. Therefore, the objective of this study was to examine the specific influence of short, moderate and long onset-admission intervals (OAI) on rehabilitation outcomes across homogeneous subgroups of patients who were admitted to a standardized interdisciplinary inpatient stroke rehabilitation program.MethodsA total of 418 patients discharged from the inpatient neurological rehabilitation program at the Montreal Rehabilitation Hospital Network after a first stroke (79% of all cases reviewed) were included in this retrospective study. After conducting a matching procedure across these patients based on the degree of disability, gender, and age, a total of 40 homogeneous triads (n = 120) were formed according to the three OAI subgroups: short (less than 20 days), moderate (between 20 and 40 days) or long (over 40 days; maximum of 70 days) OAI subgroups. The rehabilitation outcomes (admission and discharge Functional Independence Measure scores (FIM), absolute and relative FIM gain scores, rehabilitation length of stay, efficiency scores) were evaluated to test for differences between the three OAI subgroups.ResultsAnalysis revealed that the three OAI subgroups were comparable for all rehabilitation outcomes studied. No statistical difference was found for admission (P = 0.305–0.972) and discharge (P = 0.083–0.367) FIM scores, absolute (P = 0.533–0.647) and relative (P = 0.496–0.812) FIM gain scores, rehabilitation length of stay (P = 0.096), and efficiency scores (P = 0.103–0.674).ConclusionOAI does not seem to affect significantly inpatient stroke rehabilitation outcomes of patients referred from acute care facilities where rehabilitation services are rapidly initiated after the onset of the stroke and offered throughout their stay. However, other studies considering factors such as the type and intensity of the rehabilitation are required to support those results.

Acute Inpatient Rehabilitation of 55 Patients After Liver Transplantation

Acute rehabilitation for patients who have had liver transplants is often necessary to restore functional mobility, but no studies, except for case reports, have documented the complications, outcomes, or predictors of success of an acute inpatient rehabilitation program. Our objective was to examine each of these areas related to rehabilitation after liver transplantation. We performed a chart review of 55 patients who received a liver transplant and were treated on our acute rehabilitation service. We examined several factors, including age, reason for transplant, length of acute hospital stay, length of acute inpatient rehabilitation stay, FIMtrade mark scores, albumin levels, medical complications, and discharge disposition. Patients undergoing rehabilitation after liver transplantation required multiple medical interventions, including liver biopsy, ultrasound, blood transfusions, and dialysis. Several patients (15%) were transferred to the acute care hospital for medical problems. Both a low albumin and a long length of stay in the acute care hospital correlated with a longer stay in rehabilitation and less efficient rehabilitation. Longer rehabilitation stays correlated positively with FIM gain (P < 0.001, r = 0.534). Significant improvements in FIM scores (P < 0.001) during acute inpatient rehabilitation were noted in patients who were discharged to home. We also found that age, albumin level, and length of stay in the hospital did not predict discharge disposition. Patients who have had liver transplants can achieve significant functional gains in acute rehabilitation. Rehabilitation professionals should be aware of potential complications and factors that may affect the rehabilitation of this patient population.

Abstract 25: Aneurysmal Subarachnoid Hemorrhage and Traumatic Brain Injury: A Comparison of Rehabilitation Outcomes

Objective: To compare short-term functional outcome in persons with diffuse brain injury of different etiologies, aneurysmal subarachnoid hemorrhage (SAH) versus traumatic brain injury (TBI). Design: Cohort study with matched group comparison. Setting: Acute inpatient interdisciplinary brain injury rehabilitation unit of a level I trauma center. Participants: Included a total of 48 patients with brain injury during the study period (2002–2004). 24 consecutive admissions with nontraumatic SAH were identified. A matched cohort of 24 patients with TBI were selected from 133 TBI admissions during this period on the basis of age, acute hospital length of stay (LOS), gender, and total admission FIM score. As intended by the design, the groups were found equal on all matching variables (all P>.05). Interventions: Not applicable. Main Outcome Measures: Total discharge FIM score, rehabilitation LOS (RLOS), FIM gain, and FIM efficiency defined as FIM gain/RLOS. Results: The TBI group had a shorter RLOS (18.7d vs 25.9d, P=.04) along with a greater FIM efficiency (2.17 vs 1.37, P=.01). The TBI group displayed better efficiency on both the FIM motor scale (1.83 vs 1.19, P=.01) and the FIM cognitive scale (.33 vs .17, P=.03). No between-group difference was found for either total discharge FIM or FIM gain (both, P>.05). Conclusions: This study demonstrated that a group of patients with TBI receiving inpatient rehabilitation made more rapid functional gains than a group of SAH patients matched for age, gender, acute LOS, and admission functional level. Rehabilitation programs should anticipate slower recoveries in aneurysmal SAH patients compared with TBI patients of similar prognostic markers.

Low Ejection Fraction

To determine the effect of low ejection fraction (<or=35%) on the rehabilitation progress and outcome of stroke patients and compare these variables with patients with high ejection fraction (>35%). A retrospective chart review of the 332 stroke patients admitted to the inpatient rehabilitation unit of an acute tertiary general hospital during a 36-mo period. A total of 262 (79%) of these patients (126 men and 136 women) had an ejection fraction study performed and are the subjects of this analysis. They were classified into two groups: low ejection fraction (n = 36) and high ejection fraction (n = 226). The main outcome measures included discharge total FIM score, FIM gain, FIM efficiency, length of stay, and discharge disposition. Patients with low ejection fraction had lower discharge FIM scores (82.9 vs. 89.1, t = 2.09, P < 0.04), lower FIM gain (15.9 vs. 19.3, t = 1.99, P < 0.05), and lower FIM efficiency (1.2 vs. 1.7, t = 232, P < 0.03), and they were less likely to return home (69% vs. 85%, chi 2= 5.25, P < 0.04) as compared with patients with high ejection fraction. Lengths of stay were not significantly different between the two groups. Compared with patients in the high ejection fraction cohort, the low ejection fraction subjects had lower discharge FIM scores, FIM gains, and FIM efficiency. However, almost 70% progressed well enough to be discharged to home. Low ejection fraction in stroke patients may well serve as an indicator of a patient population with greater medical and social needs.

Poster 244: Stroke Rehabilitation: Does Dysphagia Make a Difference for Outcomes?

Objective: To investigate the effects dysphagia may have on outcome measures during inpatient rehabilitation for stroke patients. Setting: Freestanding inpatient rehabilitation hospital. Participants: Consecutive stroke admissions over 24 months. Interventions: Not applicable. Main Outcome Measures: FIM gain, length of stay (LOS), cost of care, and discharge destination. Results: A total of 4551 patients were admitted over 24 months. Of those, stroke admissions represented 19.93% (908/4551) of all admissions.

Poster 248: Rehabilitation of Stroke Patients: The Turkish Experience

Objectives: To examine the demographic and clinical characteristics of stroke patients admitted for inpatient rehabilitation, to study medical problems that occurred during rehabilitation and to document functional outcome and possible factors influencing outcome. Design: Consecutive case series. Setting: A national rehabilitation hospital in Turkey. Participants: A sample of 83 patients with confirmed stroke. Interventions: Not applicable. Main Outcome Measures: FIM instrument, FIM gain, and length of stay (LOS). Results: The mean age of this cohort (53 men, 30 women) was 58±12 years, and the mean LOS was 45.7±23 days. The most common medical comorbidity was hypertension (65%) followed by heart disease (42%) and diabetes mellitus (22%). LOS was related to the number of medical comorbidities (r=−.24, P<.05). Almost all patients experienced several medical problems during rehabilitation stay (average, 7.2 events/patient). Shoulder dysfunction (80.7%), symptomatic blood pressure fluctuations (72.3%), and psychosocial problems (57.8%) were among the most common problems. There was a statistically significant improvement in total FIM scores from admission to discharge (56.5 vs 74.6), with a mean gain of 18.1. FIM gain correlated significantly with LOS (r=.50, P<.001) and the number of previous strokes (r=−.23, P<.05) but not with age, onset to admission interval, comorbidities, and the presence of medical problems. Discharge total FIM scores correlated significantly only with the admission total FIM scores (r=.72, P<.001) and the onset to admission interval (r=−.23, P<.05). Conclusions: Significant functional improvements were documented in this cohort of stroke patients after an interdisciplinary rehabilitation approach. Discharge functional status was best correlated with admission functional status. Medical problems are common among patients undergoing stroke rehabilitation. In our patients, functional outcomes were not significantly influenced by the occurrence of medical problems.

Association of Hemoglobin Levels, Acute Hemoglobin Decrease, Age, and Co-Morbidities with Rehabilitation Outcomes After Total Knee Replacement

A study was undertaken to assess the association of preoperative and postoperative hemoglobin levels with rehabilitation outcomes, age, and selected co-morbidities Charts of 49 patients admitted to rehabilitation after total knee arthroplasty due to degenerative joint disease were reviewed. Outcome measures included rehabilitation admission and discharge motor FIMtrade mark scores, motor FIM gain, and rehabilitation length of stay. Patients with higher preoperative hemoglobin levels had higher rehabilitation admission motor FIM scores (r=0.38, P<0.01) and lower motor FIM gains (r=-0.45, P<0.001). Patients who had higher hemoglobin levels at rehabilitation admission had higher admission motor FIM scores and shorter length of stay. Patients with diabetes had lower preoperative hemoglobin levels. Patients with hypertension had longer length of stay. Older patients had lower admission and discharge motor FIM scores and longer length of stay. Patients admitted to rehabilitation after total knee replacement have the potential to improve motor function, regardless of their preoperative and rehabilitation admission hemoglobin levels and the decrease in hemoglobin levels. However, those admitted to rehabilitation with lower hemoglobin levels, those with lower admission motor FIM scores, those who are older, and those who have hypertension may expect longer hospital stays to reach their functional goals.

Impact of osteoarthritis on the rehabilitation of patients following a stroke

To determine if functional gain for patients following stroke rehabilitation is adversely affected by osteoarthritis (OA). A retrospective cohort analysis was conducted using data collected between 1994 and 2001 from a large national registry of US rehabilitation inpatients. Outcome variables were functional status (the Functional Independence Measure [FIM Instrument]) at discharge and followup, FIM gain during and after rehabilitation, length of stay, and discharge setting. The primary predictor variable was the presence of OA. Covariates were age, sex, race, other comorbidities, type of stroke, length of stay, and time to followup. Analysis was by multivariable regression. Data from 3,094 patients with OA and 44,943 patients without OA admitted following a stroke to inpatient rehabilitation facilities were analyzed. In unadjusted analyses, OA was associated with significantly higher FIM ratings than patients without OA at admission (mean +/- SD 65.7 +/- 19.2 versus 63.1 +/- 20.5; P < 0.001) and discharge (mean +/- SD 89.2 +/- 21.8 versus 87.7 +/- 23.0; P < 0.001), but with lower FIM ratings at followup (mean +/- SD 97.7 +/- 24.7 versus 99.7 +/- 24.9; P < 0.001). In multivariate analyses, adjusting for potential confounders, OA was associated with a 1.62-day increase in length of stay (95% confidence interval [95% CI] 1.15, 2.08) and a 1.37 smaller improvement in FIM scores between admission and followup (95% CI 0.62, 2.12). This smaller increase in FIM instrument score was caused by less improvement in FIM after discharge. OA impairs recovery from stroke. This is compensated for by longer length of stay for inpatient medical rehabilitation. Reimbursement systems may need to consider the impact of OA as a comorbid condition in patients receiving stroke rehabilitation.

Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community

To examine the outcomes of patients with varying levels of cognitive impairment who received rehabilitation in skilled nursing facilities (SNFs). A retrospective analysis of the records of people admitted to SNFs for rehabilitation. Seven SNFs in Colorado. Community-dwelling persons (N=7159), 65 years of age and older, admitted for rehabilitation after a hospitalization or decline in function between May 1998 and May 2002. Interventions Not applicable. Cognitive impairment was assessed using a 4-level categorization of the FIM instrument cognitive score at admission. Functional gain was measured using the FIM. Community discharge was measured as the proportion of patients discharged to home, board and care, or assisted living facility. Rehabilitation progress was measured as the number of FIM points gained per day. Significant functional gains were made during rehabilitation in motor and cognitive FIM scores, regardless of cognitive impairment. The most cognitively impaired patients required more rehabilitation intervention, achieved less FIM gain, and were less likely to be discharged to the community. The strongest predictors of FIM gain were the amount of therapy hours and admission cognitive FIM score. The strongest predictors of discharge to the community were the discharge total FIM score and age. The strongest predictors of adequate rehabilitation progress were medical complexity and admission cognitive FIM score. Patients with cognitive impairment were able to recover function with rehabilitation intervention. Patients with a more serious cognitive impairment received more rehabilitation intervention than patients with less impairment. Outcomes were predicted by admission and rehabilitation measures that were qualitatively different from other discharge outcomes. Health care professionals need to consider these factors as they create a rehabilitation plan of care for patients with cognitive impairment.

Perceived Quality of Care and Outcomes Following Spinal Cord Injury: Minority Status In The Context Of Multiple Predictors

Objective: T o determine whether patients with spinal cord injury (SCI) who are members of minority groups experience a disadvantage with regard to quality of care, and investigate predictors of perceived quality of care and indicators of outcome.Design: Correlational analysis of longitudinal data.Sample: One hundred and forty-three individuals with SCI in the first year following injury (43.3 % tetraplegia, 56.7% paraplegia; 53.6% of total had complete injuries).Setting: Hospital and post discharge (usually outpatient) care at 3 SCI model systems.Main Outcome Measures: Perceived quality of acute, rehabilitative, and continuing care rated by patients according to standardformat. Objective indicators of amount of care (eg, length of stay [LOS], charges) and outcomes (eg, medical complications,Functional lndependence Measure [FIM] scores, a life satisfaction measure [the Diener Scale], and the Craig Handicap and Reporting Technique [CHART; a community participation scale]).Results: Minorities did not report statistically significant differences in perceived quality of care or other indicators (eg, amount ofcare, medical complications, FIM gain, life satisfaction, and CHART scores) compared with other groups. Severity ofinjury affected LOS and activity outcomes. Satisfaction with medical care before the injury significantly predicted perceived quality of acute hospital care, inpatient rehabilitation, and continuing ca re (P < 0.03, 0.02, and 0.02, respectively) .Conclusion: A number of factors may affect variations in perceived quality of care and outcomes, but ethnicity is not always the most important predictor. Asking patients about their satisfaction with previous care can assist in distinguishing satisfaction with currentcare from pre-existing biases.