Inpatient Multidisciplinary Rehabilitation Program Research Articles

Outcomes among older people in a post-acute inpatient rehabilitation unit

Purpose: Designated multidisciplinary rehabilitation units have been shown to provide several benefits for the frail older population. The aim of this research was to evaluate changes in strength, mobility, balance, endurance, frailty and quality of life (QoL) following a 6-week multidisciplinary inpatient rehabilitation programme. Method: This was a prospective, observational study performed in a post-acute multidisciplinary geriatric inpatient rehabilitation service. A consecutive sample of heterogenous frail older adults (n = 32) participated. Subjects were assessed on admission to the rehabilitation service (T1) and following 6 weeks of rehabilitation (T2). A range of outcome measures were used to assess function and QoL: Berg Balance Scale (BBS), Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Barthel Index (BI), EuroQol-Visual Analogue Scale (EQ-VAS), Clinical Frailty Scale (CFS), lower limb and grip dynamometry. Results: The majority were female (n = 25), the mean age was 82.9 years (SD 6.35). The median length of stay was 49 days. Patients improved significantly between T1 and T2 assessments in the BBS (p ≤ 0.0001); TUG (p ≤ 0.0001); 6MWT (p ≤ 0.0001); BI (p ≤ 0.0001); EQ-VAS (p = 0.002); CFS (p ≤ 0.0001); and in some aspects of grip and lower limb strength. Conclusion: This study has demonstrated that positive outcomes occurred in a range of measures in an older, frail inpatient rehabilitation population.Implications for RehabilitationElderly inpatients undergoing rehabilitation programmes improve across a range of measures looking at impairment, activity, participation and quality of life.However, gains were modest and patients did not attain their baseline level of performance after a 6-week programme of inpatient rehabilitation.Using outcome measures in clinical rehabilitation practice can facilitate comparison between units and can form the basis for future research in this population.

Effects of whole body vibration in patients with chronic obstructive pulmonary disease – A randomized controlled trial

To date endurance and strength training are established and evidence-based exercise methods in patients with chronic obstructive pulmonary disease (COPD). There is an unmet need for further research in new and complementary exercise modalities. Additional whole body vibration training during pulmonary rehabilitation may be such a new approach that has not yet been investigated in patients with COPD. Eighty-two patients (65±9 yrs, FEV(1) pred. 38±11%, female 51%) with COPD in GOLD stage III to IV assessed for a 3-week inpatient multidisciplinary rehabilitation program were on top randomly assigned to one of two intervention groups: (1) 3×3min of bilateral dynamic squat exercises on a side-alternating vibration platform at 24-26Hz three times per week (WBV) and (2) a control group (CON) with the same amount of exercise time without WBV. Thirty-six patients completed the study in each group. The improvement in 6-min walking distance was significantly higher in the WBV-group when compared to the CON-group (WBV: 64±59m, CON: 37±52m with a between-group difference of 27m [95% CI, 1-53], p=0.046). The time required for a sit-to-stand test also decreased more markedly in the WBV-group than in the CON-group (WBV: -4.0±4.8s, CON: -2.0±3.1s with a between-group difference of -1.9s [95% CI, -4.0 to 0.1], p=0.067). Improvements in health-related quality of life were similar in both groups. WBV training seems to be a promising new exercise modality for patients with COPD and may enhance the effects of a multidisciplinary rehabilitation program.

Neurorehabilitation of stroke

Despite ongoing improvements in the acute treatment of cerebrovascular diseases and organization of stroke services, many stroke survivors are in need of neurorehabilitation, as more than two-thirds show persisting neurologic deficits. While early elements of neurorehabilitation are already taking place on the stroke unit, after the acute treatment, the patient with relevant neurologic deficits usually takes part in an organized inpatient multidisciplinary rehabilitation program and eventually continues with therapies in an ambulatory setting afterwards. A specialized multidisciplinary neurorehabilitation team with structured organization and processes provides a multimodal, intense treatment program for stroke patients which is adapted in detail to the individual goals of rehabilitation. There are many parallels between postlesional neuroplasticity (relearning) and learning in the development of individuals as well as task learning of healthy persons. One key principle of neurorehabilitation is the repetitive creation of specific learning situations to promote mechanisms of neural plasticity in stroke recovery. There is evidence of achieving a better outcome of neurorehabilitation with early initiation of treatment, high intensity, with specific goals and active therapies, and the coordinated work and multimodality of a specialized team. In this context, interdisciplinary goal-setting and regular assessments of the patient are important. Furthermore, several further potential enhancers of neural plasticity, e.g., peripheral and brain stimulation techniques, pharmacological augmentation, and use of robotics, are under evaluation.

Effects of a short‐term rehabilitation program on airway inflammation in children with cystic fibrosis

Respiratory therapy in cystic fibrosis (CF) consists of airway clearance, infection control, and reduction of airway inflammation. It is well recognized that physical activity as well as daily chest physiotherapy, enhance airway clearance. We investigated the effects of pulmonary rehabilitation, including physical activity and chest physiotherapy, on airway inflammation in children with CF. Eighteen children with stable CF (six females), aged 8.2-16.2 years, participating in a 3-week multidisciplinary inpatient rehabilitation program were recruited. Assessment at the beginning and the end of the program included clinical score, pulmonary function test, exhaled breath condensate (EBC) and sputum analysis. Sputum supernatant and EBC were analyzed for interleukin (IL)-1b, 6, 8, 10, 12, tumor necrosis factor-alpha (TNF-alpha) and LTB4. Median (IQR) symptom scores decreased from 19 [23] to 16 [21], P = 0.005. Vital capacity and FVC increased significantly (P < 0.05). However no difference was found for the total sputum cells and sputum as well as EBC cytokines between the two visits. Significant correlations were found for sputum IL-1 (+), IL-6 (-), and IL-8 (+) to total sputum cell count and neutrophils and for IL-8 to TNF-alpha. We have shown that a short-term inpatient rehabilitation for children with stable CF with intensive physical activity mainly improve subjective clinical symptoms and measures of lung function such as VC and FVC but does not influence airflow obstruction and airway inflammation as assessed by sputum and EBC analysis.

Effectiveness of an Inpatient Multidisciplinary Rehabilitation Program for People With Parkinson Disease

In the outpatient setting, it can be difficult to effectively manage the complex medical and rehabilitation needs of people with Parkinson disease (PD). A multidisciplinary approach in the inpatient rehabilitation environment may be a viable alternative. The purposes of this study were: (1) to investigate the effectiveness of an inpatient rehabilitation program for people with a primary diagnosis of PD, (2) to determine whether gains made were clinically meaningful, and (3) to identify predictors of rehabilitation outcome. Sixty-eight subjects with a diagnosis of PD were admitted to an inpatient rehabilitation hospital with a multidisciplinary movement disorders program. Subjects participated in a rehabilitation program consisting of a combination of physical therapy, occupational therapy, and speech therapy for a total of 3 hours per day, 5 to 7 days per week, in addition to pharmacological adjustments based on data collected daily. A pretest-posttest design was implemented. The differences between admission and discharge scores on the Functional Independence Measure (FIM) (total, motor, and cognitive scores), Timed "Up & Go" Test, 2-Minute Walk Test, and Finger Tapping Test were analyzed. An analysis of data obtained for the 68 subjects admitted with a diagnosis of PD revealed significant improvements across all outcome measures from admission to discharge. Subjects with PD whose medications were not adjusted during their admission (rehabilitation only) (n=10) showed significant improvements in FIM total, motor, and cognitive scores. Improvements exceeded the minimal clinically important difference in 71% of the subjects. Prior level of function at admission accounted for 20% of the variance in the FIM total change score. The results suggest that subjects with a diagnosis of PD as a primary condition benefited from an inpatient rehabilitation program designed to improve functional status.

COPD-Schulung im Rahmen der stationären Rehabilitation verbessert Lebensqualität und Morbidität

Pulmonary rehabilitation is recommended for the treatment of COPD in international guidelines. However, patient education as an important part of pulmonary rehabilitation has not been addressed sufficiently to show its benefit. The aim of this study was to find out whether education improves the effectiveness of rehabilitation with regard to quality of life (QoL) and morbidity in the year following rehabilitation. COPD patients of multidisciplinary pulmonary inpatient rehabilitation programme participated in this prospective, randomised and controlled trial. To the education group we offered a programme of patient education (4 x 1.5 hours) and an individual action plan on how to cope with exacerbations. Pulmonary function tests and QoL as measured by the Saint George Respiratory Questionnaire (SGRQ) were tested at baseline and at follow-up after 1 year. 90 patients were randomly assigned to the multidisciplinary rehabilitation programme with the usual care (control group, CG) and 94 patients received additional patient education (education group, EG). In both groups the total number of hospital admissions was diminished after 1 year (CG: 24.7% to 11.5%, p = 0.02; EG: 30.8% to 9.9%, p = 0,001). Only the EG needed less intensive care (11.8 days to 2.2, p = 0.02), received less home emergency medical service (18.3 to 5.5%, p = 0.01) and had less emergency hospital admissions (19.6% to 8.7%, p = 0.03). One year after rehabilitation, patients of the EG had a higher chance of improved quality of life (OR = 2.5; CI 1.07-5.84), and they could maintain a longer duration of weekly exercise training (more than 1 hour/week: EG n = 58, CG n = 34, p < 0.01). Patient education for COPD has been shown to improve the effectiveness of an inpatient rehabilitation programme regarding quality of life. It also reduces morbidity and supports a change of lifestyle. Therefore, education should be an essential component of rehabilitation in COPD.

Invited commentary

Invited commentary

Trägerübergreifendes Projekt zur Früherkennung von Rehabilitationsbedarf bei Versicherten mit muskuloskelettalen Beschwerden durch Auswertung von Arbeitsunfähigkeitsdaten: Ergebnisse einer randomisierten, kontrollierten Evaluationsstudie

In Germany medical rehabilitation has to be initiated by members of statutory pension fund and health insurances. This often leads to delays in the application for and provision of rehabilitation services. Since January 2000 a regional statutory pension fund for blue collar workers (LVA Schleswig-Holstein), 4 statutory health insurances and their medical service MDK have been evaluating a pro-active system to offer rehabilitation to certain member groups. Its acceptance, performance and outcomes were evaluated within a randomized controlled study. Over one year actively insured (i. e. working) members of the a. m. institutions were screened for longer work disability due to musculoskeletal disorders (ICD-10: M05 - 25, M40 - 54, M60 - 99). Based on further inclusion criteria eligible persons were randomized either to an intervention (invitation, counselling, application support) or control (usual care) group. At baseline and six and 12 months all participants completed a postal questionnaire enquiring about various health status aspects (secondary outcomes). Information on sick leave (cases, days), hospital treatment and disability pension was based on administrative data (primary outcomes). Analyses were run on an intention to treat-, per protocol-, as actual-, and matched pairs-basis. 230 persons gave written informed consent (IG: n = 134, KG: n = 96). Within 6 months after study entry 69% of the IG- and 20 % of the KG-members participated in a 3 week in-patient multidisciplinary rehabilitation program. Compared to 6 months prior to the study the occurrence of sick leave due to musculoskeletal disorders was clearly reduced during follow-up between month 6 and 12, however with no significant difference between the two groups. Additionally, IG and CG did not differ in any other primary and secondary outcomes. Contrary to our expectations the IG-members do not seem to benefit from the PETRA-programme including inpatient rehabilitation.

Exercise capacity before and after an 8-week multidisciplinary inpatient rehabilitation program in lung cancer patients: A pilot study

Although lung cancer is a highly prevalent type of cancer, the effects of an inpatient multidisciplinary rehabilitation program on pulmonary function and exercise capacity have never been studied in these patients. Pulmonary function, 6-min walking distance and peak exercise capacity of 10 patients with a severely impaired pulmonary function following treatment of lung cancer were assessed in this pilot study before and after an 8-week inpatient multidisciplinary rehabilitation program. At baseline, patients had a restrictive pulmonary function and an apparent exercise intolerance (median 6-min walking distance: 63.6% predicted; median peak cycling load: 58.5% predicted). Despite the lack of change in median pulmonary function [FEV1: -0.01L, p = 0.5469], functional exercise capacity [145 m; 43.2% of the initial values, p=0.0020] and peak exercise capacity [26 W; 34.4% of the initial values, p = 0.0078] improved significantly compared to baseline. Future trials have to corroborate the present findings. Nevertheless, patients with lung cancer have a clear indication to start a comprehensive rehabilitation program following intensive treatment of their disease. In fact, based on the results of the present pilot study it appears that these patients are good candidates for pulmonary rehabilitation programs.

Does Age Predict Outcome in Stroke Rehabilitation? A Study of 878 Chinese Subjects

Background: The predicting value of age on stroke rehabilitation has been controversial. There is a lack of large-scale studies in the Chinese population to examine the effect of age on stroke rehabilitation outcomes. This study examines the predictors of a good outcome after rehabilitation in Chinese stroke patients with special attention to age as a factor. Patients andMethods: This retrospective cohort study includes stroke patients receiving a standard inpatient multidisciplinary rehabilitation program in a neuro-rehabilitation ward of a convalescence hospital in Hong Kong from January 2000 to December 2003. Functional independence measure (FIM) ≧90 was used to define a good outcome. Multivariate regression analysis was used to assess the independent predictors of a good outcome. Results: There were important differences in clinical characteristics and complications of stroke among patients of three age groups: <65, ≧65 and <80, and ≧80 years. The total FIM scores both upon admission and at discharge were lower in the older age groups. No significant difference was observed in the changes in FIM scores across these age groups. Age was not an independent predictor for a good outcome. FIM upon admission was an independent predictor for a good outcome (discharge FIM ≧90) in all patients and in individual age groups. Having employment before stroke was a predictor for good outcome in all patients. Living at home prior to stroke was a predictor for the total population and the ≧65 and <80 years group. The length of stay predicted a good outcome in the group ≧80 years. Conclusions: Admission functional status, employment and living at home before stroke but not age per se are predictors of a good outcome following stroke rehabilitation. As older patients show comparable improvement during rehabilitation, intensive rehabilitation should not be withheld in stroke patients simply because of advanced age.

Perceived self-efficacy gained from, and health effects of, a rehabilitation program after hip joint replacement

To examine whether a routine multidisciplinary inpatient rehabilitation program can increase patient self-efficacy, and to investigate the effects of high self-efficacy at admission, and increases in self-efficacy, on health changes in patients who undergo such rehabilitation after hip joint replacement. Participants in this longitudinal study were 1,065 patients who underwent inpatient rehabilitation after hip joint replacement. Questionnaires were administered at admission, discharge, and 6-month followup. The main outcome variables were disability, pain, depressive symptomatology, and self-efficacy to cope with disability and pain. Significant improvements from admission to discharge from the inpatient rehabilitation program in disability, pain, depressive symptoms, and self-efficacy were found. In addition, higher levels of self-efficacy at admission and larger increases in self-efficacy over the course of the program predicted larger health changes (i.e., greater decreases in disability, pain, and depressive symptoms). Results were generally similar for health changes from discharge to 6-month followup. A routine multidisciplinary inpatient rehabilitation program after hip joint replacement can result in enhanced self-efficacy.

Evaluation of a Multidisciplinary Inpatient Rehabilitation Programme for Adolescents With Chronic Fatigue Syndrome

Objective: To examine the hypothesis that chronic fatigue syndrome (CFS) is associated with significant psychological and physical issues that can be improved by a multidisciplinary inpatient rehabilitation programme. Methods: A battery of psychometric instruments was administered to 39 adolescents with CFS. These instruments were administered prior to a 4 week inpatient admission as well as on discharge. The instruments were also administered to 19 adolescents at 6 month follow up. Results: The sample included 35 girls and four boys. The Beck Depression Inventory demonstrated high depression scores that improved after the 4 week programme (p &lt; 0.001) and these improvements were maintained after 6 months (p &lt; 0.038). Coopersmith self-esteem scores showed low self-esteem, which improved following the programme (p &lt; 0.001) but there was some fall off at the 6 month follow up. Physical functioning scores improved significantly after the 4 week programme (p &lt; 0.001) and were maintained at 6 months (p &lt; 0.001); clinician ratings of functioning matched patient ratings. On Achenbach profiles the teenagers presented with internalizing problems, which significantly improved following admission (p &lt; 0.001). Parents reported similar findings. Conclusion: These findings confirm the effectiveness of a multidisciplinary approach to the management of adolescents with CFS with improvements in emotional and physical functioning. Most of the improvements were maintained at 6 months follow up.

Prognose der sozialmedizinischen Entwicklung ein Jahr nach teilstationärer oder stationärer Rehabilitation wegen Dorsopathie*

In a one-year prospective study of patients participating in a multidisciplinary outpatient or inpatient rehabilitation program (OPR/IPR) for chronic back pain the following issues were investigated: (i) the frequency of low labour force participation (LFP), i. e., work loss due to the disease or total duration of sick leave (SL) of 6 weeks or more; (ii) prognostic indicators at the beginning of the rehabilitation program (T1) for low LFP after one year (T2); (iii) the significance of the type of rehabilitation IPR vs. OPR in relation to the identified prognostic indicators for LFP. A total of 413 patients participating in OPR (n = 299) or IPR (n = 114) for chronic back pain returned a postal questionnaire after one year. Low LFP was found in 30 % of all patients without significant differences between OPR (32 %) and IPR (25 %). Compared to the year before T1 the proportion of patients without SL between T1 and T2 increased from 12 % to 48 % after OPR, from 15 % to 47 % after IPR, respectively. In multivariate logistic regression analyses adjusted for type of rehabilitation the following prognostic indicators of T1 for low LFP were identified (p </= 0,05): SL of 6 weeks or more in the year before T1 with an odds ratio (OR) of 11.1; intended termination of employment (OR = 3.2), household income of less than 3300 DM per month (OR = 2.2); reduced social functioning (SF-36) (OR = 2.0). Regarding LFP no significance of the type of rehabilitation (IPR vs. OPR) was found in relation to the identified prognostic indicators or after adjustment for differences (i) in the characteristics of the patients at T1, and (ii) in the duration and number of single measures of the rehabilitation program. One year after IPR or OPR the rate of return to work is similar (about seven out of ten patients). The identified prognostic indicators may stimulate further research of the improvement of the rehabilitation processes. No evidence was found against the expansion of OPR.

A multidisciplinary TBI inpatient rehabilitation programme for active duty service members as part of a randomized clinical trial

Objective : To design and describe an effective rehabilitation programme for use in an ongoing trial on the efficacy of multidisciplinary brain injury rehabilitation for moderately head injured military service members. Design : Treatment arm of a randomized control trial. Setting : US military tertiary care hospital inpatient rehabilitation programme. Patients : Sixty seven active duty military with moderate to severe TBI who were randomized to the treatment arm of the protocol. Intervention : Eight week rehabilitation programme combining group and individual therapies with an inpatient milieu-oriented neuropsychological focus. Group therapies included fitness, planning and organization, cognitive skills, work skills, medication, and milieu groups, and community re-entry outings. Individual therapy included neuropsychology, work therapy, occupational therapy, and speech and language pathology. Main outcome measures : Successful return to work and return to duty. Results : At 1 year follow-up, 64 patients returned to work (96%) and 66% (44/67) returned to duty. Conclusion : The described rehabilitation programme demonstrates one successful effort to rehabilitate active duty military service members with TBI who have the potential to return to duty.

A1-Year Longitudinal Study of Severe Traumatic Brain Injury in Australia Using the Sickness Impact Profile

Objective: To document outcome and to investigate patterns of physical and psychosocial recovery in the first year following severe traumatic brain Injury (TDI) In an Australian patient sample. Design: A longitudinal prospective study of a cohort of patients, with data collection at 3, 6,9, and 12 months post injury. Setting: A head injury rehabilitation unit in a large metropolitan public hospital. Patients: A sample of 55 patients selected from 120 consecutive admissions with severe TBI. Patients who were more than 3 months post injury on admission, who remained confused, or who had severe communication deficits or a previous neurologic disorder were excluded. Interventions: All subjects participated in a multidisciplinary inpatient rehabilitation program, followed by varied participation in outpatient rehabilitation and community-based services. Main Outcome Measures: The Sickness Impact Profile (SIP) provided physical, psychosocial, and total dysfunction scores at each follow-up. Outcome at 1 year was measured by the Disability Rating Scale. Results: Multivariate analysis of variance indicated that the linear trend of recovery over time was less for psychosocial dysfunction than for physical dysfunction (F(l, 51)=5.87, P<.02). One year post injury, 22% of subjects had returned to their previous level of employability, and 42% were able to live independently. Conclusions: Recovery from TBI in this Australian sample followed a pattern similar to that observed in other countries, with psychosocial dysfunction being more persistent. Self-report measures such as the SIP in TBI research are limited by problems of diminished self-awareness.