Functional Independence Measure Change Research Articles

Factors affecting the efficiency of walking independence in patients with subacute stroke following robot-assisted gait training with conventional rehabilitation.

Factors affecting the efficiency of walking independence in patients with subacute stroke following robot-assisted gait training (RAGT) and conventional treatment (RAGT-CT) were examined. This retrospective cohort study included 37 patients with stroke [ n = 11 ischemic; n = 26 hemorrhagic; median poststroke interval, 28 days (interquartile range, IQR, 24-42)] who underwent RAGT using Welwalk for a median of 3 weeks (IQR, 2-4) followed by conventional training (median, 129 days; IQR, 114-146). The primary outcome was the change in functional independence measure (FIM)-walk item score from before to after RAGT (FIM-walk efficiency). The secondary outcome was the FIM-walk score at discharge. The independent variables included sensorimotor function [lower extremity (LE) motor and sensory scores and trunk function from the Stroke Impairment Assessment Set (SIAS) and Berg Balance Scale (BBS)] and cognitive function (FIM-cognitive, MMSE and Cognitive-related Behavioral Assessment) before RAGT-CT and RAGT dose duration per session, total steps and average treadmill speed at week 1, and number of sessions). We first determined the bivariate associations of each independent variable with the FIM-walk efficiency at the end of the RAGT period as decided by the therapists and with the FIM-walk score at discharge. Hierarchical multiple regression revealed that only the FIM-cognitive score was a significant predictor of the FIM-walk efficiency at the end of the RAGT period ( β = 0.47; P < 0.01, adjusted R2 = 0.21) after accounting for age, days post-stroke, SIAS-total lower extremity (SIAS-LE) motor score, and number of RAGT sessions (all nonsignificant). Furthermore, only the SIAS-trunk score was a significant predictor of the FIM-walk score at discharge ( β = 0.52; P < 0.01; adjusted R2 = 0.65) after accounting for age, days post-stroke, FIM-cognitive score, SIAS-LE motor score, and average treadmill speed at week 1 (all nonsignificant). Although patients with better cognition at the start of locomotor training achieved the pragmatic targets for terminating RAGT and proceeding with conventional therapy at a faster rate, the outcome at discharge is mainly dependent on early trunk function.

Process mining and customer journey mapping in healthcare: Enhancing patient-centred care in stroke rehabilitation.

Patient-centred care and enhancing patient experience is a priority across Australia. Stroke rehabilitation has multiple consumer touchpoints that would benefit from a better understanding of customer journeys, subsequently impacting better patient-centred care, and contributing to process improvements and better patient outcomes. Customer journey mapping through process mining extracts process data from event logs in existing information systems discovering patient journeys, which can be utilized to monitor guideline compliance and uncover nonconformance. Utilizing process mining and variant analysis, customer journey maps were developed for 130 stroke rehabilitation patients from referral to discharge. In total, 168 cases from the Australasian Rehabilitation Outcomes Centre dataset were matched with 6291 cases from inpatient stroke data. Variants were explored for age, gender, outcome measures, length of stay and functional independence measure (FIM) change. The study illustrated the process, process variants and patient journey map in stroke rehabilitation. Process characteristics of stroke rehabilitation patients were extracted and represented utilizing process mining and results highlighted process variation, attributes, touchpoints and timestamps across stroke rehabilitation patient journeys categorized by patient demographics and outcome variables. Patients demonstrated a mean and median duration of 49.5 days and 44 days, respectively, across the patient journeys. Nine variants were discovered, with 78.46% (n = 102) of patients following the expected sequence of activities in their stroke rehabilitation patient journey. Relationships involving age, gender, length of stay and FIM change along the patient journeys were evident, with four cases experiencing stroke rehabilitation journeys of more than 100 days, warranting further investigation. Process mining can be utilized to visualize and analyse patient journeys and identify gaps in service quality, thus contributing to better patient-centred care and improved patient outcomes and experiences in stroke rehabilitation.

The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada.

Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown. The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change. A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines. A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care. None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target.

Association of Baseline Skeletal Muscle Mass Index With Adverse Events and Rehabilitation Outcomes in Patients Admitted for Rehabilitation

ObjectiveTo assess the associations of baseline skeletal muscle mass index (SMI) with adverse events and rehabilitation outcomes in patients admitted for rehabilitation. DesignA retrospective cohort study. ParticipantsThe subjects were 409 patients (mean age, 79 years; men, 167 [41%]) undergoing rehabilitation because of neurologic disease, musculoskeletal disorders, or hospital-associated deconditioning. Patients were divided into 2 groups according to the definition of sarcopenia by the Asian Working Group for Sarcopenia: those with low SMI (<7.0 kg/m2 in men and <5.7 kg/m2 in women) and those with high SMI (≥7.0 kg/m2 in men and ≥5.7 kg/m2 in women). InterventionsNot applicable. Main Outcome MeasuresThe primary outcomes were adverse events including death and acute illness requiring transfer to other hospitals for specialized treatments. The secondary outcomes were rehabilitation outcomes including the efficiency scores (changes in functional independence measure [FIM] score divided by length of stay) of FIM for motor function (FIM-M) and FIM for cognitive function (FIM-C). ResultsOf the 409 patients, 299 (73%) had a low SMI. The adjusted hazard ratio (95% confidence interval) of the low SMI group relative to the high SMI group for adverse events was 2.79 (1.06-7.34). There were no significant differences between the 2 groups in FIM-M efficiency scores [mean ± SD, low SMI group: 0.4 (0.58) vs high SMI group: 0.47 (0.54), P=.3] and FIM-C efficiency scores [mean ± SD, 0.05 (0.14) vs 0.06 (0.2), P=.4]. Multiple linear regression models did not show significant associations between the low SMI group and FIM-M efficiency or FIM-C efficiency scores (β=0.064, P=.3; β=−0.05, P=.4, respectively). ConclusionLow baseline SMI was significantly associated with adverse events but not with rehabilitation outcomes in patients undergoing rehabilitation.

Assessing functional recovery for individuals with spinal cord injury post-discharge from inpatient rehabilitation

Objective To determine the associations between trauma variables, acute phase-related variables, and patient-level characteristics with functional recovery during the first-year post-discharge from inpatient rehabilitation facilities (IRF) for individuals with spinal cord injury (SCI). Design Retrospective cohort analysis. Setting Two SCI Model Centers in Pennsylvania, United States. Methods We were able to link 378 individuals with traumatic SCI between the Pennsylvania Trauma Systems Outcomes Study and the National SCI Model Systems databases. Nineteen individuals with SCI were excluded due to missing data. We estimated functional recovery based on changes in functional independence measure (FIM) total motor score during the first-year post-discharge from IRF in 359 individuals with SCI, who did not have any missing data, using ordinary least squares regression (OLS). Results After discharge from IRF the majority of individuals with SCI improved over the first-year post-injury. Individuals with cervical A-C (injury severity group) who were older had a slight decrease in motor FIM at 1-year post-injury. Regression analysis indicated that lower functional recovery was associated with being of Black and Hispanic race and ethnicity, higher injury severity group, occurrence of non-pulmonary infection during acute care, and longer length of stay at IRF (R 2 = 0.36). Conclusions Patient-level characteristics, trauma variables, and acute phase-related variables were associated with functional recovery post-discharge from IRF. Further research is necessary to collect and assess post-rehabilitation and socio-economic factors that play a critical role in continued functional recovery in the community.

The impact of dementia on rehabilitation outcomes following hip fracture.

To compare clinical outcomes between patients for whom their participation in inpatient rehabilitation was and was not impacted by dementia through matching patients reporting dementia (dementia group) with those not reporting dementia (non-dementia group). Prospectively collected data held by the Australasian Rehabilitation Outcome Centre (AROC) were analyzed for patients aged 65 years or older receiving inpatient rehabilitation in public hospitals in Australia following a hip fracture and discharged between July 1, 2014, and June 30, 2019. Patients reported as having dementia impacting their rehabilitation program were matched to patients not reporting dementia based on age, admission motor Functional Independence Measure (FIM) score, and accommodation prior to rehabilitation. The matched cohorts were compared in relation to clinical outcomes (motor and cognitive FIM improvement, FIM efficiency, length of stay, and discharge destination) following participation in hospital-based rehabilitation using univariate analysis. Patients with dementia had significantly lower cognitive FIM scores on commencing rehabilitation (17.6 and 26.9, respectively, P < 0.001) and their median length of stay was 2 days shorter than those without dementia (21 and 23 days, respectively, P < 0.001). Relative change in FIM score and FIM efficiency (per week) were lower in the dementia group [relative FIM score change of dementia vs non-dementia, respectively, 26.2% vs. 44.0% (P < 0.001) and FIM efficiency, 6.5 vs. 8.9 (P < 0.001)]. Discharge destination between the two groups was statistically different, with 35.7% of patients with dementia being discharged to residential aged care facilities (RACFs) compared to 21.7% of those without dementia (P < 0.001). More patients with dementia had carers in their private residence in the post-rehabilitation phase, 82.2% vs. 57.6% (P < 0.001). Patients with dementia who sustain a fractured hip benefit from inpatient rehabilitation, although their clinical outcomes are not as good as those without dementia. FIM change and FIM efficiency were lower in the dementia group. Length of stay in the hospital for patients with dementia was shorter due to earlier recognition for the need for placement in either an RACF or at home with carer support. Theneed for placement in an RACF or carer support in a private residence was significantly greater in the dementia group.

A Systematic Review of Testosterone Therapy in Men With Spinal Cord Injury or Traumatic Brain Injury.

Spinal cord injuries (SCI) and traumatic brain injuries (TBI) increase the risk of testosterone deficiency and result in adverse changes in body composition and poor functional outcomes. The current systematic review aims to provide insights into the use of testosterone therapy for treating men with SCI and TBI. The PubMed and EMBASE databases were systematically reviewed using appropriate terms, and resulting manuscripts were screened using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The patient population included male patients with SCI or TBI. Further inclusion criteria were: a) human participants 18 years of age or older; b) manuscript published in English; c) study included an intervention with exogenous testosterone; and d) articles published in peer-reviewed journals with full text available. Two reviewers independently extracted data regarding injury type, intervention, and outcomes. Following screening for inclusion/exclusion criteria, a total of 12 primary research studies conducted over the last 30 years were included. Men with SCI were investigated in 11 articles. The combination of testosterone patches and resistance training with functional electrical stimulation (FES) for 16 weeks in men with SCI and an average baseline testosterone level above the cutoff for testosterone deficiency increased muscle mass, strength, bone quality, and basal metabolic ratewhile testosterone patches without exercise for 16 weeks produced no significant changes in these parameters. Testosterone patches for 12 months in men with SCI and testosterone deficiency also increased lean tissue mass (LTM) and resting energy expenditure (REE). In one study, men with TBI and testosterone deficiency receiving testosterone gel for eight weeks showed a non-statistically significant greater absolute change in functional independence measure (FIM) and grip strength compared to a placebo group. Testosterone therapy with exercise may help improve muscle mass, bone health, strength, energy expenditure, and cardiac health in men with SCI without major side effects. It is difficult to draw conclusions regarding the effects of testosterone therapy in men with TBI based on the limited available evidence. Further investigation is warranted to explore the relationship between testosterone therapy and recovery after SCI and TBI.

Association of inpatient rehabilitation with functional outcome in patients with stroke receiving mechanical thrombectomy

ABSTRACT Introduction Patients with ischemic strokes that have undergone mechanical thrombectomy (MT) can still have poor functional outcomes. Limited research exists on factors that impact functional outcomes in these patients who are discharged to inpatient rehabilitation. We examined patient characteristics correlated with 90-day outcomes in ischemic stroke patients having undergone MT and undergo acute rehabilitation. Methods This is a retrospective study of patients (≥18 years) who were consecutively admitted to inpatient rehabilitation after undergoing MT following an ischemic stroke event from 2015 through 2018. Functional outcomes at 90-days were determined by the modified Rankin Score (mRS). Binary logistic regression models were used to measure the association of meaningful Functional Independence Measure (FIM) change with poor-outcome (mRS >2). Results Out of 56 stroke patients undergoing MT, 36 had poor outcome (mRS >2) at 90-days. One unit increase in discharge FIM significantly decreased the likelihood of poor outcome by 4% [aOR = 0.96; 95% CI = 95% CI = 0.92, 0.99]. Admission FIM [aOR = 0.95; 95% CI = 0.90, 1.00] and change in FIM [aOR = 0.97; 95% CI = 0.93, 1.02] were not significantly associated poor outcome in the adjusted models. Conclusion Patients with ischemic stroke who received MT who have a worse disability, particularly at discharge, while undergoing inpatient rehabilitation have higher odds of having poor future functional outcomes. This was regardless of age, sex, or race. Future research is needed to understand the mechanisms that can improve functional performance in our patient population at the IRF.

Effects of dynamic body weight support on functional independence measures in acute ischemic stroke: a retrospective cohort study

BackgroundStroke remains a major public health concern in the United States and a leading cause of long-term disability in adults. Dynamic body weight support (DBWS) systems are popular technology available for use in clinical settings such inpatient rehabilitation. However, there remains limited studies in such inpatient settings that compare DBWS to standard of care (SOC) using real world outcome measures. For survivors of acute ischemic stroke, we determine if incorporating a dynamic body weight support (DBWS) system into inpatient therapy offers greater improvement than standard of care (SOC).MethodsA retrospective chart review included 52 individuals with an acute ischemic stroke admitted to an inpatient rehabilitation facility. Functional Independence Measure (FIM) data, specifically changes in FIM at discharge, served as the primary outcome measure. Patient cohorts received either therapies per SOC or therapies incorporating DBWS. Regardless of cohort group, all patients underwent therapies for 3 h per day for 5 days a week.ResultsFor both groups, a statistically and clinically significant increase in total FIM (P < 0.0001) was observed at discharge compared to at admission. Improvements for the DBWS group were significantly greater than the SOC group as evidenced by higher gains in total FIM (p = 0.04) and this corresponded to a medium effect size (Cohen’s d = 0.58). Among FIM subscores, the DBWS group achieved a significant increase in sphincter control while all other subscore changes remained non-significant.ConclusionsThis preliminary evidence supports the benefit of using DBWS during inpatient rehabilitation in individuals who have experienced an acute ischemic stroke. This may be due to the greater intensity and repetitions of tasks allowed by DBWS. These preliminary findings warrant further investigations on the use of DBWS in inpatient settings.

Muscular Echo-Intensity of the Quadriceps by Ultrasound Is More Related to Improvement of Gait Independence than Muscle Thickness in Older Inpatients.

This study aimed to examine whether the decrease in muscular echo-intensity of the quadriceps by ultrasound in older inpatients is related to the improvement of gait independence than the increase of muscle thickness. Longitudinal study. Hospital-based study. This study included 171 inpatients aged ≥ 65 years (median age: 84.0 [77.0-88.0], 56.1% female). Patients who were able to walk independently at hospital admission were excluded from the study. Improvement of gait independence during hospital stay was assessed using the change in Functional Independence Measure (FIM) gait score (i.e., FIM gait score at hospital discharge minus FIM gait score at hospital admission) and FIM gait score at hospital discharge. Muscular echo-intensity and muscle thickness of the quadriceps were assessed at hospital admission and discharge using ultrasound images, respectively. Muscular echo-intensity has been shown to be mainly related to intramuscular adipose tissue. Multiple linear regression analysis was performed to identify the factors independently associated with the change in FIM gait score and FIM gait score at discharge. Change in quadriceps echo-intensity was independently and significantly associated with the change in FIM gait score (β = -0.22, p = 0.017) and FIM gait score at hospital discharge (β = -0.21, p = 0.017). In contrast, change in quadriceps thickness was not independently and significantly associated with the change in FIM gait score (β = 0.16, p = 0.050) and FIM gait score at hospital discharge (β = 0.15, p = 0.050). Our study indicates that a decrease in muscular echo-intensity of the quadriceps by ultrasound is more related to the improvement of gait independence than an increase of muscle thickness in older inpatients. Intervention for intramuscular adipose tissue of the quadriceps may be important for improving gait independence in older inpatients.

Effect of cranioplasty on FIM in patients with severe cerebral infarction after cerebral decompression.

The functional effects of cranioplasty were measured in patients with severe cerebral infarction who had undergone cerebral decompression by comparing the functional independence measure (FIM) during convalescent rehabilitation before and after cranioplasty. The study design was a single-center retrospective cohort study. Fifty-five patients underwent cerebral decompression after cerebral infarction at our hospital, six of whom were included in this study. Two patients who exhibited cranial depression had no changes in FIM one month prior to cranioplasty. However, the FIM increased one month postoperatively. These patients showed a large increase in the scores for movement and transfer. Cranioplasty may play a role in improving ability during convalescent rehabilitation in patients with severe cerebral infarction who undergo cerebral decompression, especially in movement and transfer items.

Abstract WP68: Clinical Characteristics And Inpatient Rehabilitation Outcomes In Patients With Posterior Circulation Strokes

Introduction: Posterior circulation strokes (PCS) are considered to have poor outcomes with high mortality and morbidity, but comparisons of functional outcome with anterior circulation strokes (ACS) have yielded conflicting results. Differences in demographics, cardiovascular risk factors and stroke etiology have been proposed, with ischemic PCS patients tending to be younger, more often male, and more frequently diabetic. Objectives: Describe the clinicodemographic profile and functional outcomes in PCS patients admitted to inpatient rehabilitation (IPR), and identify factors associated with functional change. Methods: A retrospective review of a database maintained on consecutive stroke patients admitted to IPR at Memorial Hermann-TIRR between 2017 and 2019 was conducted. Demographics, Functional Independence Measure (FIM) scores, and discharge disposition of 806 patients were assessed. Table 1 displays significance testing by univariate analysis. Baseline characteristics, pre-stroke mRS, NIHSS, admit FIM, and length of stay (LOS) in IPR were adjusted in regression models. Results and Conclusions: Results are summarized in Table 1. Diabetes and prior stroke or TIA occurred in higher percentages of patients with PCS, or concurrent ACS/PCS. NIHSS was higher in ACS patients with a mean of 9.6 (SD 7.1, p&lt;0.001) and median of 6 with IQR of 11. Total FIM score on admission to IPR was 53.3 (SD 16.5) for PCS compared to 46.6 (SD 16.9, p&lt;0.001) in ACS patients. Motor FIM score change was 28.6 (SD 12.2) in PCS compared to 27.2 (SD 12.8) in ACS. Adjusting for baseline variables of admit FIM, NIHSS and LOS, we found no significant differences in total or motor FIM change between the groups from admission to discharge. There was no greater odds for improvement on total or motor FIM for ACS compared to PCS. In summary, patients with PCS and ACS respond similarly to rehab therapy as captured on the FIM score, with a higher amount of therapy associated with better improvement.

The Impact of Body Mass Index Classification on Outcomes After Stroke Rehabilitation: A Retrospective Study.

With improving stroke mortality rates, more individuals are living with the consequences of stroke. Obesity is a known risk factor for stroke, but its effect on functional outcomes poststroke is less clear. The aim of this study was to determine the association between body mass index classification (underweight, normal weight, overweight, and obese) and functional outcomes, as measured by Functional Independence Measure change, Functional Independence Measure efficiency, and rehabilitation length of stay after inpatient stroke rehabilitation. A retrospective cohort study of individuals with a diagnosis of stroke admitted to a high-intensity inpatient rehabilitation program was performed. Patients were divided into 4 groups based on body mass index category using normal body mass index as the reference. Overall, 34 individuals (4.5%) were classified as underweight, 303 (40.1%) had body mass indices within the normal range, 269 (35.6%) were overweight, and 149 (19.7%) were obese. Ischemic stroke was the most common stroke type across all body mass index categories. Patients in the overweight and obese groups tended to be younger. There were no statistically significant differences in rehabilitation length of stay, Functional Independence Measure change, or Functional Independence Measure efficiency with all groups demonstrating significant functional improvements. Based on these findings, patients admitted for inpatient rehabilitation after stroke can be expected to make similar functional improvements regardless of BMI class.

Accuracy of the Australian National Sub-Acute and Non-Acute Patient Classification in predicting rehabilitation length of stay for stroke survivors who are ≥65 years of age and have lateropulsion

ABSTRACT Background Lateropulsion is a common impairment after stroke. Regardless of stroke severity, functional recovery is slower in people with lateropulsion, resulting in requirement for longer rehabilitation duration. In Australia, inpatient rehabilitation funding is determined via the Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP). AN-SNAP class is determined using age, diagnosis, weighted Functional Independence Measure (FIM) motor score, and FIM cognitive score. Objectives To explore accuracy of the AN-SNAP to predict length of stay (LOS) for people with poststroke lateropulsion. Methods A retrospective database audit was undertaken. AN-SNAP predicted LOS for each participant was calculated based on 2019 calendar year national benchmarks. A multivariable linear regression model estimated mean differences in reported LOS and AN-SNAP predicted LOS after adjusting for lateropulsion severity (Four Point Pusher Score). A separate logistic regression model assessed whether FIM change during admission was associated with reported LOS exceeding AN-SNAP predicted LOS. Results Data were available from 1126 admissions. Reported LOS exceeding AN-SNAP predicted LOS was associated with greater lateropulsion severity on admission. Where AN-SNAP predicted LOS was longer, those with no lateropulsion on admission showed shorter reported than predicted LOS. Greater improvement in FIM during rehabilitation was associated with increased odds of reported LOS exceeding AN-SNAP predicted LOS (OR 1.02, 95%CI 1.01–1.03, p < .001). Conclusions Inclusion of a measure of poststroke lateropulsion in the AN-SNAP classification model would result in more accurate LOS predictions to inform funding. Costs of longer rehabilitation LOS may be countered by optimized long-term physical function, reducing requirement for ongoing care.

A terapia do espelho melhora a recuperação motora do membro superior e o nível de independência após AVC: um ensaio clínico randomizado

Abstract Introduction In stroke survivors, the prevalence of upper motor disability remains high. There has not been much report on the success of post-stroke mirror therapy, especially in developing countries. Objective The focus of this research is to see how mirror therapy, in addition to standard rehabilitation for hand paresis, affects upper limb motor recovery and level of independence in self-care after stroke at an Indonesian teaching hospital. Method This was a randomized controlled trial with no assessor blinding. The study included 18 subacute stroke patients who did not have cognitive or visual impairment. The mirror group received a 20-minute mirror therapy session in addition to conventional rehabilitation, while the control group received only the standard program for 5 weeks (2 times per week). The Brunnstrom score and self-care level of independence elements of the Functional Independence Measure (FIM) were used as outcome measures. Results Baseline comparisons of lesion type and Brunnstrom score showed significant between-group differences. The ANACOVA test showed the difference had no effect on the FIM change in scores (P &gt; 0.05). One patient (mirror group) was dropped out from the study. After 5 weeks (n=17), the mirror group showed improvement in both the Brunnstrom and FIM scores (P &lt; 0.05) compared to the control group. Conclusions Mirror treatment improves upper limb motor recovery and level of independence in self-care after stroke when combined with standard hand paresis rehabilitation 2 times a week for 5 weeks.

The Association Between Sarcopenia and Functional Improvement in Older and Younger Patients Who Completed Inpatient Rehabilitation: A Prospective Cohort Study.

Objective: To investigate the association between sarcopenia and functional improvement in patients older and younger than 65 years upon completion of an inpatient rehabilitation program.Design: Prospective cohort study.Participants: Adult consecutive patients who completed the inpatient rehabilitation program at a metropolitan tertiary referral hospital general inpatient rehabilitation unit.Methods: Sarcopenia status was determined using the European Working Group on Sarcopenia in Older People 2 algorithm, using muscle mass measured by BioImpedance Analysis and grip strength. Progress in rehabilitation was measured using change in the Functional Independence Measure and Goal Attainment Scaling score. To investigate the age group by sarcopenia status interaction we used quantile regression models with bootstrapped standard error estimation for functional improvement and linear regression model with robust standard error estimation for GAS score.Results: 257 participants [128 (50%) male, median age 63 years (IQR: 52–72)], 33(13%) with sarcopenia, completed inpatient rehabilitation [median length of stay 16 days (IQR: 11–27.5)]. Participants' median Functional Independence Measure change was 24 (IQR 15–33.5) and mean total Goal Attainment Scaling score was 57.6 (SD 10.2). Adjusting for admission Functional Independence Measure score, the median difference in Functional Independence Measure change between participants with and without sarcopenia was: −4.3 (95% CI: −10.6, 1.9); p = 0.17 in participants 65 years and younger, and 4.6 (95% CI: 1.0, 8.2); p = 0.01 in participants older than 65; age-by-sarcopenia interaction p = 0.02.Conclusions: Unlike younger people, older people with sarcopenia have greater functional improvement in inpatient rehabilitation than those without sarcopenia.

Metacognitive Strategy Training Is Feasible for People With Aphasia.

Metacognitive strategy training shows promise for reducing disability following stroke, but previous trials have excluded people with aphasia. Considering the high incidence of poststroke aphasia, it is important to determine whether people with aphasia can benefit from strategy training. The purpose of this study was to determine the feasibility of an adapted strategy training protocol for people with aphasia. We recruited 16 adults with mild-moderate aphasia from inpatient stroke rehabilitation. We examined recruitment and retention, intervention delivery and fidelity, participant engagement and communication, participant strategy mastery, and change in disability. Therapists demonstrated good fidelity to intervention elements. Participants demonstrated good engagement and fair communication. The sample achieved a mean Functional Independence Measure change of 21.8 (SD = 16.2, Cohen's d = .95), similar to matched controls without aphasia from previous trials. An adapted strategy training protocol appears feasible for people with aphasia in inpatient stroke rehabilitation. Future studies should examine the efficacy of this approach in larger samples.

Quality improvement outcomes from the introduction of a geriatrician into a rehabilitation setting.

Geriatrician impact on patient and system outcomes in formal rehabilitation settings has not been well described to date. We studied the effect of adding a geriatric medicine consultation service to a geriatric focused rehabilitation setting providing care to dialysis and non-dialysis patients. A pre- and post-retrospective observational cohort study from January 1, 2009 to June 30, 2019 on all consecutively admitted adults aged 65 and older to general rehabilitation program, and adults aged 60 and older to specialized dialysis rehabilitation program, within a 25 bed general rehabilitation unit in a large urban academic rehabilitation center in Toronto, Ontario. Data were analyzed with quality improvement methodology including Statistical Process Control charts (XmR and U charts). Addition of a geriatric medicine service providing automatic comprehensive geriatric assessment and co-management consultative services for all admitted patients from admission onwards who met criteria for the intervention. The intervention commenced on August 1, 2013. Outcome measures were length of stay (days), service interruption frequency, and average functional independence measure (FIM) change (discharge FIM minus admission FIM) which uses the validated FIM score, a marker of functional ability. A 22 point change in FIM score is clinically relevant. Patient characteristics: general rehabilitation patients (n=1395, mean age=79.7, 50.1% female) and dialysis rehabilitation patients (n=838, mean age=72.8, 41.8% female). The average FIM change following intervention improved from 20.8 to 29.3 in the general rehabilitation cohort (40.6% improvement, SD=5.51) and from 22.1 to 30.6 in the dialysis rehabilitation cohort (38.6% improvement, SD=5.88). Changes in length of stay (24.9%-28.1% reduction) and service interruption frequency (34.3%-49.7% reduction) were also observed. Introduction of a geriatric medicine service for rehabilitation inpatients was associated with significant FIM score improvements. Our results suggest this intervention contributes to important gains in functional independence in reduced time for older adults receiving inpatient rehabilitative care.

Effects of Home-Based Physical Exercise on Days at Home, Health Care Utilization, and Functional Independence Among Patients With Hip Fractures: A Randomized Controlled Trial

ObjectiveTo evaluate the effects of a physical exercise program on days lived at home, the use and costs of health care and social services, mortality, and functional independence among patients with hip fractures. DesignRandomized controlled trial with a parallel 2-group design consisting of a 12-month intervention and 12-month registry follow-up. SettingHome-based intervention. ParticipantsPatients aged ≥60 years (N=121) with operated hip fracture and who were living at home were randomized into physical exercise (n=61) and usual care (n=60) groups. InterventionsSupervised physical exercise twice a week. Main Outcome MeasuresThe primary outcome was the number of days lived at home over 24 months. Secondary outcomes were the use and costs of health care and social services, mortality over 24 months, and Functional Independence Measure (FIM) over 12 months. ResultsOver 24 months, there was no significant difference between the groups in terms of days lived at home (incidence rate ratio, 1.01; 95% confidence interval [CI], 0.90-1.14) or mortality (hazard ratio, 1.01; 95% CI, 0.42-2.43). The mean total costs of health care and social services did not differ between the groups. The costs per person-year were 1.26-fold (95% CI, 0.87-1.86) greater in the physical exercise group than in the usual care group over 12 months and 1.08-fold (95% CI, 0.77-1.70) over 24 months. The mean difference between the change in FIM of the groups over 12 months was 4.5 points (95% CI, 0.5-8.5; P=.029) in favor of the physical exercise group. ConclusionsLong-term home-based physical exercise had no effect on the number of days lived at home over 24 months among patients with hip fractures. The intervention was cost neutral over these 24 months. The FIM scores improved in both groups over 12 months, but the improvement was significantly greater in the physical exercise group than in the usual care group.

Lesion location may attenuate response to strategy training in acute stroke.

Strategy training, a rehabilitation intervention, reduces disability and improves functional skills associated with goal-directed behavior. Stroke lesions impacting selected ventromedial regions of interest associated with initiation of goal-directed behavior may attenuate intervention response. If so, strategy training may not be optimal for people with stroke lesions in these regions. To examine whether ventromedial regions of interest attenuate changes in disability status attributed to strategy training. Secondary analysis of data from two randomized controlled clinical trials. Inpatient stroke rehabilitation. People with acute stroke diagnosis and available diagnostic studies enrolled in inpatient rehabilitation randomized controlled studies between 2009 and 2017. Participants were randomized to strategy training or a control condition in addition to the usual care during inpatient rehabilitation. Diagnostic magnetic resonance imaging studies were retrieved from electronic medical records, and stroke lesion location was characterized by a neuroradiologist. Intervention response was defined by Functional Independence Measure change scores of 22 points or greater. Only 186 of 275 participants had diagnostic studies available; 13 patients showed no apparent lesion on their diagnostic study. Among 173 cases, 156 had complete data at discharge (strategy training n=71, control n=85). Twenty-five cases had a lesion within a region of interest (strategy training n=14, control n=11). Intervention response was attenuated in the strategy training group for those with lesions in regions of interest [χ2 (1, n=71)=4.60, P= .03], but not for those in the control group [Fisher exact test, n=85, P= .19). Lesions in the ventromedial regions of interest may attenuate response to strategy training.