Inpatient Rehabilitation Facility Admission Research Articles

Predictive utility of self-efficacy in early stroke rehabilitation

ABSTRACT Introduction A biopsychosocial approach entailing person-centered factors provides valuable insight to post-stroke rehabilitation potential. The consideration of an individual’s belief in their capabilities, known as self-efficacy, may prove especially informative in the inpatient rehabilitation setting where motor learning often occurs. Objective To assess the predictive utility of self-efficacy in functional independence status change during inpatient rehabilitation. Methods Individuals with stroke admitted to an inpatient rehabilitation facility (IRF) completed an assessment battery near IRF admission and discharge involving motor assessments, participant-reported self-efficacy (Stroke Self-Efficacy Questionnaire), and functional independence status evaluation (sum of self-care and mobility Quality Indicators (QI) from the IRF-Patient Assessment Instrument). Linear regression was performed to determine the predictive performance of self-efficacy on QI change during IRF stay while accounting for age, time post-stroke, and IRF length of stay. Regression procedures were repeated for separate subgroups based on initial motor impairment level. Results Thirty individuals with stroke (14 females, age = 67.0 ± 9.80 years, 10.4 ± 3.46 days post-stroke) were enrolled. Self-efficacy at IRF admission explained a significant percentage of variance in QI Change for the cohort (R2 = 30.7%, p = .001) and for the moderate to severe motor impairment subgroup (n = 12; R2 = 49.9%, p = .010). After accounting for confounders, self-efficacy remained a significant predictor for the cohort (n = 30) model. Discussion Findings generated from this work support the predictive utility of self-efficacy in early post-stroke motor recovery. The inclusion of self-efficacy in a multi-faceted evaluation framework may therefore optimize rehabilitation outcomes by providing therapists with additional knowledge to better tailor an individual’s care.

Wireless wearable sensors can facilitate rapid detection of sleep apnea in hospitalized stroke patients.

To evaluate wearable devices and machine learning for detecting sleep apnea in patients with stroke at an acute inpatient rehabilitation facility (IRF). A total of 76 individuals with stroke wore a standard home sleep apnea test (ApneaLink Air), a multimodal, wireless wearable sensor system (ANNE), and a research-grade actigraphy device (ActiWatch) for at least one night during their first week after IRF admission as part of a larger clinical trial. Logistic regression algorithms were trained to detect sleep apnea using biometric features obtained from the ANNE sensors and ground truth apnea rating from the ApneaLink Air. Multiple algorithms were evaluated using different sensor combinations and different apnea detection criteria based on the Apnea-Hypopnea Index (AHI≥5, AHI≥15). Seventy-one (96%) participants wore the ANNE sensors for multiple nights. In contrast, only forty-eight participants (63%) could be successfully assessed for OSA by ApneaLink; 28 (37%) refused testing. The best-performing model utilized photoplethysmography (PPG) and finger temperature features to detect moderate-severe sleep apnea (AHI≥15), with 88% sensitivity and a positive likelihood ratio (LR+) of 44.00. This model was tested on additional nights of ANNE data achieving 71% sensitivity (10.14 LR+) when considering each night independently and 86% accuracy when averaging multi-night predictions. This research demonstrates the feasibility of accurately detecting moderate-severe sleep apnea early in the stroke recovery process using wearable sensors and machine learning techniques. These findings can inform future efforts to improve early detection for post-stroke sleep disorders, thereby enhancing patient recovery and long-term outcomes.

Identifying Racial and Ethnic Disparities in Acute Inpatient Rehabilitation

ObjectiveTo investigate whether racial, ethnic, and linguistic disparities exist at discharge from an acute inpatient rehabilitation facility (IRF) by examining change in Functional Independence Measure (FIM) scores and discharge destination. DesignThis is a retrospective study using our IRF's data from the Uniform Data System for Medical Rehabilitation from 2013-2019. FIM scores and discharge destination were compared between race, language, and ethnic groups, with adjustment for patient characteristics. SettingAn urban hospital with a level 1 trauma center, comprehensive stroke center, and IRF with Commission on Accreditation of Rehabilitation Facilities (CARF) certification. Participants2518 patients admitted to the IRF from 2013-2019 (N=2518). InterventionsNot applicable. Main Outcome MeasuresChange in FIM score and discharge destination. ResultsAfter adjusting for covariates, non-White patients and patients with limited English proficiency had significantly lower functional recovery, as measured by smaller changes in FIM scores from IRF admission to discharge. Additionally, both groups were more likely to be discharged home with home health care than to a skilled nursing facility, compared with White and English-speaking patients. Disparities in discharge destination persisted within patients with noncommercial insurance (Medicaid or Medicare) and a stroke diagnosis but not within those who had commercial insurance or a nonstroke diagnosis. ConclusionsRacial and linguistic disparities were identified within our CARF certified IRF; however, the organization is committed to reducing health care disparities. Next steps will include investigating interventions to reduce disparities.

Role of Inpatient Rehabilitation Facility Quality Measures to Predict Community Discharge After Stroke

<h3>Research Objectives</h3> Main objective: Examine the association between National Institutes of Health Stroke Scale (NIHSS) scores measured during the acute care stay and inpatient rehabilitation facility (IRF) admission functional status, measured by the IRF-Patient Assessment Instrument (IRF-PAI) self-care and mobility quality measures, to deduce if quality measures can serve as a proxy for stroke severity. The self-care and mobility quality measures are indicators of physical function. Secondary objective: Investigate the predictive power of the NIHSS and IRF-PAI admission physical function quality measures to predict community discharge from IRF after stroke. <h3>Design</h3> Retrospective cohort study using electronic health records and Uniform Data System Medical Record file data from January 1, 2018 to December 30, 2019. <h3>Setting</h3> Academic hospital-based IRF. <h3>Participants</h3> 544 patients transferred from acute care hospital to IRF after an ischemic or hemorrhagic stroke. Exclusion criteria: transient ischemic attack, discharged against medical advice, died during IRF stay, or re-admitted to acute care within 48 hours of IRF admission. Cases with incomplete data (missing IRF-PAI, NIHSS scores) were excluded from analyses. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Community discharge status from IRF. <h3>Results</h3> Of 544 patients, 76.6% had community discharge; the median age was 64.7 years. NIHSS scores were available for 434 patients, with the majority of patients classified as minor to moderate stroke (n=294). NIHSS scores were significantly associated with IRF-PAI admission self-care scores across each NIHSS stroke category (n=433). There was no association between NIHSS and IRF-PAI admission mobility score. IRF admission self-care and mobility scores were each a significant predictor of successful discharge to the community (n=430; OR=1.09, 95% CI: 1.03 – 1.17, OR=1.1, CI: 1.03 – 1.18, respectively). NIHSS scores from acute care were not a significant predictor of community discharge (OR = 0.70 CI 0.47-1.04) from IRF. <h3>Conclusions</h3> IRF-PAI self-care quality measure is associated with the NIHSS and can serve as a proxy for stroke severity. IRF-PAI self-care and mobility measures each predict community discharge status. <h3>Author(s) Disclosures</h3> No disclosures or conflicts of interest.

Longitudinal Trends in Severe Traumatic Brain Injury Inpatient Rehabilitation.

The goal of this study is to describe national trends in inpatient rehabilitation facility (IRF) discharges for the most severely disabled cohort of patients with traumatic brain injury (TBI). Data from the Uniform Data System for Medical Rehabilitation for patients discharged from an IRF between January 1, 2002, and December 31, 2017, with a diagnosis of TBI and an admission Functional Independence Measure of 18, the lowest possible score, were obtained and analyzed. Of the 252 112 patients with TBI discharged during the study period, 10 098 met the study criteria. From 2002 to 2017, the number of patients with an IRF admission Functional Independence Measure of 18 following TBI discharged from IRFs annually decreased from 649 to 488, modeled by a negative regression (coefficient = -2.97; P = .001), and the mean age (SD) increased from 43.0 (21.0) to 53.7 (21.3) years (coefficient = 0.70; P < .001). During the study period, the number of patients with the most severe disability on admission to IRF who were discharged annually as a proportion of total patients with TBI decreased from 5.5% to 2.5% (odds ratio = 0.95; P < .001) and their mean length of stay decreased from 41.5 (36.2) to 29.3 (24.9) days (coefficient = -0.83; P < .001]. The number and proportion of patients with the most severe disability on IRF admission following TBI who are discharged from IRFs is decreasing over time. This may represent a combination of primary prevention, early mortality due to withdrawal of life-sustaining treatment, alternative discharge dispositions, or changes in admitting and reimbursement practices. Furthermore, there has been a decrease in the duration of IRF level care for these individuals, which could ultimately lead to poorer functional outcomes, particularly given the importance of specialized rehabilitative care in this population.

Predictors of cognitive gains during inpatient rehabilitation for older adults with traumatic brain injury.

Traumatic brain injury (TBI) among older adults is increasing and can affect cognition. To effectively meet the rehabilitation needs of older adults, a clearer picture is needed of patient-, clinical-, and facility-level characteristics that affect cognitive recovery during inpatient rehabilitation facility (IRF) stays. To identify patient, clinical, and facility factors associated with cognitive recovery among older adults with TBI who received IRF care. Secondary data analysis. Uniform Data System for Medical Rehabilitation-participating IRFs in the United States. Patients were 65 to 99 years of age at IRF admission for TBI. Participants received IRF care between 2002 and 2018 (N=137,583); 56.3% were male; 84.2% were white; mean age was 78.7 years. Change in Functional Independence Measure Cognitive Score (FIM-Cognitive) from IRF admission to discharge, categorized as favorable (FIM-cognitive score gains ≥3 points) or poor (FIM-cognitive score gains <3 points) cognitive outcomes. Not applicable. Patients had greater odds of favorable cognitive recovery if they were female (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.05-1.08), had higher motor functioning at IRF admission (aOR 1.03, 95% CI 1.03-1.04), longer length of stay (aOR 1.07, 95% CI 1.06-1.07), or received care at a freestanding IRF (vs. hospital rehab unit) (aOR 1.57, 95% CI 1.52-1.61). Patients who were older (aOR 0.99, 95% CI 0.98-0.99), Black (aOR 0.79, 95% CI 0.75-0.83), Hispanic or Latino (aOR 0.97, 95% CI 0.91-1.02), or were part of another racial or ethnic group (aOR 0.85, 95% CI 0.81-0.90) (vs. White), had high-cost comorbid conditions (aOR 0.71, 95% CI 0.65-0.76), or who had higher cognitive functioning at IRF admission (aOR 0.90, 95% CI 0.90-0.91) had lower odds of favorable cognitive recovery. Patient (age, sex, race, ethnicity), clinical (level of functioning at IRF admission, length of stay) and facility (e.g., freestanding IRF) factors contributed to the cognitive recoveries of older adults during IRF stays.

Sex and Racial/Ethnic Differences in Within-Stay Readmissions During Inpatient Rehabilitation Among Patients With Traumatic Brain Injury.

The aim of the study was to determine the association of sex and race/ethnicity with acute hospital readmissions ("within-stay readmissions") during inpatient rehabilitation facility care versus patients discharged home without a within-stay readmission among traumatic brain injury patients. The study used a secondary analysis ( N = 210,440) of Uniform Data System for Medical Rehabilitation data using multiple logistic regression. Within-stay readmissions occurred for 11.79% of female and 11.77% of male traumatic brain injury patients. Sex-specific models identified insurance, comorbidities, and complications factored differently in likelihood of within-stay readmissions among female than male patients but association of all other factors were similar per group. Within-stay readmissions differences were more pronounced by race/ethnicity: White, 11.63%; Black, 11.32%; Hispanic/Latino, 9.78%; and other, 10.61%. Descriptive bivariate analysis identified racial/ethnic patients with within-stay readmissions had greater days from traumatic brain injury to inpatient rehabilitation facility admission (White, 17.66; Black, 21.70; Hispanic/Latino, 23.81; other, 20.66) and lower admission cognitive and motor function. Factors differed across models predicting within-stay readmissions for race/ethnic groups; age, admission motor and cognitive function, complications, and length of stay were consistent across groups. This study demonstrates disparities by race/ethnicity for inpatient rehabilitation facility within-stay readmissions among traumatic brain injury patients and factors predictive of this potentially preventable outcome by sex and race/ethnicity. Findings could inform care planning and quality improvement efforts for TBI patients.

Abstract TP70: Preliminary Associations Between Quality Indicators, Motor Status, And Self-efficacy In Early Stroke Rehabilitation

Introduction: Recent changes in reimbursement policies for inpatient rehabilitation facility (IRF) providers prompted the adoption of Quality Indicators (QI) on the IRF Patient Assessment Instrument leading to the discontinuation of the Functional Independence Measure (FIM). Given that the FIM has shown associations with motor assessments and self-efficacy measures during early stroke recovery, the purpose of this study was to confirm if similar associations exist with QI. Methods: Participants with acute ischemic and hemorrhagic stroke completed a battery of assessments at the time of IRF admission and discharge: Total QI (summation of self-care and mobility items), Upper Extremity Fugl-Meyer (UEFM), Action Research Arm Test (ARAT), and Stroke Self-Efficacy Questionnaire (SSEQ). We determined associations between QI and these measures by computing correlation coefficients with an alpha value=.01 denoting significance following a Bonferroni correction. Results: Fourteen individuals (7 females, age=65.9±9.0 years, 8.1±3.5 days post-stroke) with moderate-severe motor deficit completed study procedures. Table 1 summarizes admission and discharge scores and associations with QI. Conclusions: Significant associations between motor assessments and QI from this ongoing study parallel similar associations involving the FIM. The implementation of QI in IRFs necessitates additional work to validate our findings and to determine psychometric properties of QI to enhance clinical research in stroke rehabilitation.

Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries Discharged Home After a Stroke: Findings From the COMPASS Trial

ObjectivesTo examine the effect of a comprehensive transitional care model on the use of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke. DesignCluster randomized pragmatic trial SettingForty-one acute care hospitals in North Carolina. Participants2262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (SD) age of 74.9 (10.2) years and a mean ± SD National Institutes of Health stroke scale score of 2.3 (3.7). InterventionComprehensive transitional care model (COMPASS-TC), which consisted of a 2-day follow-up phone call from the postacute care coordinator and 14-day in-person visit with the postacute care coordinator and advanced practice provider. Main Outcome MeasuresTime to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission. ResultsOnly 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (hazard ratio, 1.20, with a range of 0.95-1.52) compared to usual care. This estimate was robust to additional covariate adjustment (hazard ratio, 1.23) (0.93-1.64). Both clinical and non-clinical factors (ie, insurance, geography) were predictors of SNF/IRF use. ConclusionsCOMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.

Time at home among nonvalvular atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants versus warfarin

Abstract Background Clinical trials and real-world database studies have shown the benefits of non-vitamin K antagonist oral anticoagulants (NOACs) compared to warfarin; however, measures of functional outcomes are critical in evaluating a patient's quality of life. Previous measures of time spent out of hospital in a home setting and time spent receiving disease-related care among non-valvular atrial fibrillation (NVAF) patients are lacking in the current literature. Purpose This analysis was based on the previously published ARISTOPHANES study, and used multiple data sources to evaluate the amount of time spent at a patient's home among NVAF patients who were prescribed NOACs versus warfarin. Methods This retrospective observational study used US data from CMS Medicare and four commercial databases to select adult NVAF patients who initiated apixaban, dabigatran, rivaroxaban, or warfarin (01JAN2013–30SEP2015). Time at home and time at home without external AF-related care were measured during the 180 days after the index date (OAC prescription). Time at home was defined as days from index date without any of the following: an inpatient, skilled nursing facility or nursing facility, hospice, or inpatient rehabilitation facility admission. Time at home and without external AF-related care was defined as days away from home and days with a claim for bleeding, stroke/systemic embolism, AF, or an INR test. Each day a claim was observed was counted as one day. In each database, three 1:1 NOAC-warfarin propensity-score-matched (PSM) cohorts were created before pooling the results. After PSM, a subgroup of patients who were alive and had ≥180 days of follow-up was created. Poisson regression was conducted in each NOAC-warfarin matched cohort to compare time at home and time at home without external AF-related care. Results After matching, a total of 100,977 apixaban-warfarin, 36,990 dabigatran-warfarin, and 125,068 rivaroxaban-warfarin patient pairs were selected. Of those patients, 38–46% had 180 days of follow-up available. Across treatment cohorts, approximately 75% of patients were at home for the 180-day follow-up. Apixaban, dabigatran, and rivaroxaban patients had 1.3, 0.9, and 0.8 more days at home, respectively, compared to warfarin patients. Patients treated with apixaban had 13.4 more days at home without AF-related care compared to warfarin, while dabigatran and rivaroxaban had 11.6 and 11.7 more days at home without AF-related care compared to warfarin. A greater proportion of warfarin patients than NOAC patients had an INR test (81–82% vs 14–21%), and days with INR testing were the main driver for external AF-related care for warfarin patients. Conclusion Among NVAF patients treated with OACs, NOACs were associated with a longer time at home and time at home without external AF-related care compared to warfarin. These results can help inform healthcare providers and patients regarding the impact of NOAC treatment in NVAF patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer Inc.

Time at home among nonvalvular atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants: an ARISTOPHANES analysis

Abstract Background Patient-centered outcomes, such as home time, are becoming increasingly important quality-of-life measures. There are limited data on the impact of oral anticoagulants (OACs) on home time among patients with non-valvular atrial fibrillation. Purpose This analysis, based on the previously published ARISTOPHANES study, used five US insurance claims databases (CMS Medicare and four commercial databases) to compare home time among NVAF patients who were prescribed non-vitamin K antagonist OACs (NOACs). Methods Adult NVAF patients who were newly prescribed apixaban, dabigatran, or rivaroxaban (01JAN2013–30SEP2015) were selected. Time at home was calculated as the number of days from the index date (NOAC prescription) without any of the following: an inpatient, skilled nursing facility (SNF) or nursing facility, hospice, or inpatient rehabilitation facility admission. Time at home and without external AF-related care was defined as days from index date without any events from the home time endpoint or any days with a claim for bleeding, stroke/systemic embolism (S/SE), AF, or an INR test. Time at home and without external AF-related care were measured during the 180 days of follow-up; patients were required to have been alive and have 180 days of follow-up post index. In each database, three 1:1 NOAC-NOAC propensity-score-matched (PSM) cohorts were created before combining the databases. For each NOAC-NOAC matched cohort, Poisson regression was conducted to compare time at home and time at home without external AF-related care. Results After PSM, 37,314 apixaban-dabigatran, 107,236 apixaban-rivaroxaban, and 37,693 rivaroxaban-dabigatran patient pairs were created of which 37–44% had 180 days of follow-up available. Across the NOAC cohorts, approximately 21–25% of patients had an admission to a hospital, SNF, nursing facility, rehabilitation center, or hospice during the 180-day follow-up. The time at home was generally consistent between the NOAC cohorts (177 days); however, apixaban patients had 0.5 more days at home compared to rivaroxaban patients. Across all NOAC cohorts, 7–8% had a claim for a S/SE, 11–15% had a claim for bleeding, and 15–22% had an INR test, while 87–89% of all patients had an AF-claim during the 180-day follow-up. Patients prescribed apixaban had 1 more day at home without external AF-related care compared to dabigatran, and 1.5 more days at home without external AF-related care compared to rivaroxaban. Dabigatran had &amp;lt;1 more day at home without external AF-related care compared to rivaroxaban. Conclusion Among NVAF patients treated with NOACs, there were small differences in the time at home and time at home without external AF-related care during the first 6 months of NOAC treatment. As NVAF is a chronic condition, it is important to understand the impact of NOAC treatment on these patient-centered outcomes. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer Inc.

Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization.

ObjectiveThe aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post–COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions.DesignFor this clinical descriptive retrospective study, data were extracted from post–COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1–June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned.ResultsThe COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data.ConclusionsThe COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation After Stroke.

The aim of the study was to identify causes for readmission to acute care of patients admitted to inpatient rehabilitation facility after stroke. The institutional Uniform Data System for Medical Rehabilitation database was used to identify stroke patients who experienced readmission to acute care and an equal number of age-/sex-matched group of patients who successfully completed their inpatient rehabilitation facility stay during 2005-2018. Retrospective chart review was used to extract clinical data. The two study groups were compared using univariate and multivariate analyses. The rate of readmission to acute care was 4.7% (n = 89; age = 65 ± 14 yrs; 37% female; 65% White; 73% ischemic stroke). The most common indications for transfer were neurological (31%) and cardiovascular (28%). Compared with control group, the readmission to acute care group had statistically higher rates of comorbid conditions, lower median (interquartile range) Functional Independence Measure score on inpatient rehabilitation facility admission (55 [37-65] vs. 64 [51-78], P < 0.001), and a higher rate of sedative/hypnotic prescription (82% vs. 23%, P < 0.001). Readmission to acute care is not common in our cohort. Patients who experienced readmission to acute care had higher medical complexity and were prescribed more sedative/hypnotic medications than the control group. Practitioners should be vigilant in patients who meet these criteria.

Low-Frequency Oscillations Are a Biomarker of Injury and Recovery After Stroke.

Background and Purpose- Low-frequency oscillations reflect brain injury but also contribute to normal behaviors. We examined hypotheses relating electroencephalography measures, including low-frequency oscillations, to injury and motor recovery poststroke. Methods- Patients with stroke completed structural neuroimaging, a resting-state electroencephalography recording and clinical testing. A subset admitted to an inpatient rehabilitation facility also underwent serial electroencephalography recordings. The relationship that electroencephalography measures (power and coherence with leads overlying ipsilesional primary motor cortex [iM1]) had with injury and motor status was assessed, focusing on delta (1-3 Hz) and high-beta (20-30 Hz) bands. Results- Across all patients (n=62), larger infarct volume was related to higher delta band power in bilateral hemispheres and to higher delta band coherence between iM1 and bilateral regions. In chronic stroke, higher delta power bilaterally correlated with better motor status. In subacute stroke, higher delta coherence between iM1 and bilateral areas correlated with poorer motor status. These coherence findings were confirmed in serial recordings from 18 patients in an inpatient rehabilitation facility. Here, interhemispheric coherence between leads overlying iM1 and contralesional M1 was elevated at inpatient rehabilitation facility admission compared with healthy controls (n=22), declining to control levels over time. Decreases in interhemispheric coherence between iM1 and contralesional M1 correlated with better motor recovery. Conclusions- Delta band coherence with iM1 related to greater injury and poorer motor status subacutely, while delta band power related to greater injury and better motor status chronically. Low-frequency oscillations reflect both injury and recovery after stroke and may be useful biomarkers in stroke recovery and rehabilitation.

Abstract TMP42: Coherent Neural Oscillations Inform Early Stroke Motor Recovery

Introduction: Neural oscillations may contain valuable information for stroke rehabilitation. The objective of this study was to examine the predictive performance of neural oscillations in early stroke motor recovery using dense array electroencephalography (EEG). Since past work theorizes that neural oscillations underlie behavior, we hypothesized that coherent oscillations with ipsilesional primary motor cortex (M1) across a 1-30 Hz band would significantly predict early motor recovery post-stroke. Methods: Individuals with stroke admitted to an inpatient rehabilitation facility (IRF) completed a three-minute resting EEG recording and structural MRI around the time of IRF admission and motor testing (Functional Independence Measurement motor subscale (FIM-motor)) at IRF admission and discharge. We examined how well FIM-Motor change was predicted using EEG power and coherence with ipsilesional M1 across delta (1-3 Hz), theta (4-7 Hz), alpha (8-12 Hz), low beta (13-19 Hz), and high beta (20-30 Hz) frequency bands, along with corticospinal tract (CST) injury, in a lasso regression with K-fold cross-validation for deviance estimation. Results: Twenty-seven subjects (20 males, 58.3±14.6 years, 8-17 days post-stroke) with predominantly mild-moderate motor impairment participated. EEG ipsilesional M1 coherence with 16 leads overlying both hemispheres predicted 61.8% of FIM-motor change from IRF admission to discharge, with higher frequencies (alpha, high beta) positively relating to motor recovery. Lower frequencies overlying contralesional parietal (theta) and frontal (delta) regions inversely and positively related to motor recovery respectively. Coherence outperformed EEG power and CST injury measurements. Ipsilesional M1 coherence also predicted 55.2% of the variance in residuals derived from a predictive model containing only CST injury, suggesting that EEG coherence and CST injury contain unique information for motor recovery prediction. Conclusions: Early after stroke, coherence of neural oscillations with ipsilesional M1 across the entire brain through a wide frequency spectrum is best at predicting functional gains from inpatient rehabilitation and may be feasible as a bedside biomarker of motor recovery.

Abstract TMP47: Impact of Medicare Reform on Inpatient Rehabilitation Facility Access for Hemorrhagic Stroke Patients

Introduction: There is growing evidence that ICH patients make larger &amp; faster recovery gains compared to ischemic stroke patients. Inpatient rehabilitation facility (IRF) care can significantly facilitate improvement. In 2010, changes to IRF admission criteria potentially restricted access. We hypothesize the Centers for Medicare and Medicaid Services (CMS) 2010 IRF Prospective Payment System Rule decreased IRF access &amp; increased skilled nursing facility (SNF) utilization in ICH patients. Methods: The proportion of ICH survivors discharged to IRF, SNF or home was estimated using GWTG-Stroke data between 1/1/2008 &amp; 12/31/2015 (n=265,444). Two binary hierarchical models determined the association between the 1/1/2010 CMS admission criteria change for IRFs and discharge setting, adjusting for patient &amp; hospital characteristics. Subgroup analyses evaluated the effects of age, region &amp; hospital type. Sensitivity analyses used complete NIHSS data (≈49%). Results: The prevalence of the 3 discharge destinations changed significantly over time (CMH row-mean-score P&lt;0.0001; Figure 1). IRF rehab odds decreased and SNF rehab odds increased for ICH patients compared to home after the CMS 2010 IRF PPS Rule (Figure 2a &amp; 2b). Decreased IRF rehab odds were found in patients age&lt;65, Western US location or at non-teaching hospitals (Figure 2a). Increased SNF rehab odds were found in patients age≥65, Midwest location or at teaching hospitals (Figure 2b). Conclusions: IRF Rehab odds decreased and SNF rehab odds increased during the time period after CMS 2010 IRF PPS Rule implementation in ICH patients. The impact of such legislative changes on patient outcomes warrants further study.

Abstract TP164: Impact of Early Admission to Inpatient Rehabilitation Facilities on Functional Outcome With Stroke

Objective: To determine whether early admission of patients with stroke into an inpatient rehabilitation facility (IRF) results in motor function improvement during hospitalization. Methods: Data were extracted from the Japan association of rehabilitation database for 2,760 patients admitted to IRFs at 28 centers. Early IRF admission was defined as 14 days from stroke onset to IRF admission. Variables surveyed were age; sex; stroke type; length of stay; period from stroke onset to IRF admission; motor functional independence measure (mFIM) and cognitive FIM at admission and discharge; and modified Rankin Scale score before onset, at admission, and at discharge. In addition, the difference between mFIM at admission and at discharge per day (ΔmFIM/day) was calculated by dividing by the length of stay. The average rehabilitation intensity per day was calculated as the total units of rehabilitation during hospitalization divided by the length of hospital stay. We defined intensive rehabilitation as rehabilitation conducted at the first quartile (&gt;2.27 hour/day). Multiple regression analysis and instrumental variable analysis were performed to examine the association of early rehabilitation with activities of daily living (ADL) at discharge. Results: ΔmFIM/day was higher in early and intensive rehabilitation. The multiple regression analysis showed that significant improvements in ΔmFIM/day were observed for intensive rehabilitation (partial regression coefficient: 1.56; 95% confidence interval: 0.34-2.8), after controlling for various confounding variables. The instrumental variable analysis showed that ΔmFIM/day was associated with early IRF admission (partial regression coefficient: 0.1; 95% confidence interval: 0.05-0.14). Conclusion: Patients with stroke experience greater improvement in ADL if admitted to an IRF within 14 days after stroke onset.

Contextualized Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

ObjectiveTo evaluate the effect of providing a greater percentage of therapy as contextualized treatment on acute traumatic brain injury (TBI) rehabilitation outcomes. DesignPropensity score methods are applied to the TBI Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data. SettingAcute inpatient rehabilitation. ParticipantsPatients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received their first inpatient rehabilitation facility admission in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation. InterventionsNot applicable. Main Outcome MeasuresParticipation Assessment with Recombined Tools-Objective (PART-O)-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. ResultsIncreasing the percentage of contextualized treatment during inpatient TBI rehabilitation leads to better outcomes, specifically in regard to community participation. ConclusionsIncreasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used.

Abstract TMP46: EEG is a Useful Biomarker of Motor Recovery in Early Stroke Rehabilitation

Introduction: The application of biomarkers to study and monitor stroke recovery mechanisms can potentially advance rehabilitation practice and research. This study examined the utility of dense-array electroencephalography (EEG) for predicting and capturing changes in brain function in early stroke rehabilitation. Hypothesis: Changes in EEG measures involving ipsi- and contralesional motor cortices (iM1 and cM1) in delta (1-3Hz) and high beta (20-30Hz) frequency bands [1] parallel and [2] predict motor recovery. Methods: Individuals with recent ischemic or hemorrhagic stroke admitted to an inpatient rehabilitation facility (IRF) completed a 3-minute resting-state EEG recording and behavioral testing (Upper Extremity Fugl-Meyer (FM) and Functional Independence Measurement motor subscale (FIM-motor)) during hospitalization and 90-days post-stroke. EEG power and coherence (connectivity) measures were computed from leads overlying iM1 and cM1. Results: Twenty-seven subjects (20 males, age 58.3±14.6 years, 14.7±12.8 days post-stroke) participated. Greater decrease in iM1-cM1 coherence in the delta band correlated significantly with larger (a) FIM-motor score improvement from IRF admission to discharge (r=-0.70, p=0.001, n=18) and (b) FM score improvement from IRF admission to 90-days post-stroke (r=-0.57, p=0.02, n=17). Baseline EEG measures did not predict motor recovery when examined across the entire group. Performance of biomarkers varies according to stroke severity, and so prediction was further examined in relation to baseline FM. In subjects with moderate-severe impairment (FM≤40), delta iM1-cM1 coherence at baseline correlated with FIM-motor gains (r=0.72, p=0.03, n=9), and delta power in leads over iM1 positively correlated with FM gains (a) from IRF admission to discharge (r=0.75, p=0.03, n=8) and (b) from IRF admission to 90-days post-stroke (r=0.73, p=0.04, n=8). Conclusions: Bedside EEG recording in the IRF provides neurophysiological insights that predict and parallel motor recovery, and so may be a valuable bedside tool in early stroke rehabilitation. EEG measures can predict motor recovery in individuals with moderate-severe motor impairment.

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

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