Inpatient Rehabilitation Unit Research Articles

Discharge Rehabilitation Measures Predict Activity Limitations in Patients With Stroke 6 Months After Inpatient Rehabilitation.

The aim of this study was to identify rehabilitation measures at discharge from acute inpatient stroke rehabilitation that predict activity limitations at 6 mos postdischarge. This is a retrospective analysis of a prospective, longitudinal, observational cohort study. It was conducted in an acute inpatient rehabilitation unit at an urban, academic medical center. Activity limitations in patients ( N = 141) with stroke of mild-moderate severity were assessed with the activity measure for post-acute care at inpatient stroke rehabilitation discharge and 6-mo follow-up. Rehabilitation measures at discharge were investigated as predictors for activity limitations at 6 mos. Measures of balance (Berg Balance Scale), functional limitations in motor-based activities (functional independence measure-motor subscore), and motor impairment (motricity index), in addition to discharge activities measure for post-acute care scores, strongly predicted activity limitations in basic mobility and daily activities at 6 mos (51% and 41% variance explained, respectively). Functional limitations in cognition (functional independence measure-cognitive subscore) and executive function impairment (Trail Making Test-part B), in addition to the discharge activities measure for post-acute care score, modestly predicted limitations in cognitively based daily activities at 6 mos (12% of variance). Standardized rehabilitation measures at inpatient stroke rehabilitation discharge can predict future activity limitations, which may improve prediction of outcome post-stroke and aid in postdischarge treatment planning.

Community Reintegration of Long-Stay Hospitalised Mental Health Consumers During COVID-19 Pandemic

ABSTRACT Mandatory restrictions on social activities and access to services during the COVID-19 pandemic prevented discharge into the community of consumers from an extended-stay, hospital-based rehabilitation program. This article describes a revised discharge process that overcame the pandemic-related restrictions by replacing the graded and slow discharge process with a one-stage, full-time transition that facilitated the discharge of 16 adult consumers. No adverse mental health outcomes occurred during the process. The change of practice with its positive results reflected therapeutic risk-taking. The COVID-19 pandemic provided scope for creativity and innovation in mental health care and psychiatric rehabilitation. IMPLICATIONS Innovation and collaboration by service providers can promote consumers’ positive risk-taking to return to a life in mainstream society after a prolonged stay in an inpatient rehabilitation unit. Community reintegration of consumers with enduring severe mental illness can occur under adverse public health and social situations like the COVID-19 pandemic with innovative hospital discharge planning.

Improving WeeFIM score completion rates: An interdisciplinary inpatient rehabilitation unit quality improvement project.

The WeeFIM is a tool commonly used in pediatric rehabilitation settings to measure objective patient progress while receiving comprehensive therapy services on inpatient rehabilitation units. This Quality Improvement (QI) project aimed for 95% of inpatients to have complete, on-time documented and displayed WeeFIM scores upon admission and discharge by 12/2017. An interdisciplinary team examined historic WeeFIM completion rates. Using Plan-Do-Study-Act cycles, a unified flowsheet was developed in the electronic health record (EHR) to revamp workflow and identify opportunities for improvement, data accuracy, and finally sustainability. Progress was monitored in real time via an automated data visualization tool which monitored score timeliness and completeness. On-time admission completion rates increased from 0% to 95% during the intervention period. On-time discharge completion rates increased from 0% to 89% during the intervention period. This change has been sustained over two years with on-time admission and discharge scores averaging 79.4% and 77.9% respectively, and 96.4% of scores completed. Changes in the completion rate of WeeFIMs are sustainable, evidenced by ongoing maintenance of our initial gains over the course of multiple months. The incorporation of WeeFIM documentation into the workflow increased on-time and overall completion rates. The success of this project shows that integrating new tasks into provider workflows helps drive completion.

COVID and Cognition: Preliminary Findings of a NYC Inpatient Rehabilitation Unit

Research ObjectivesTo investigate the impact of COVID-19 on cognition and independence with functional tasks of patients admitted to an inpatient rehabilitation unit (IRU).DesignCross-sectional observational study with assessments at admission and discharge of 94 COVID-19 patients admitted to an urban inpatient rehabilitation unit (IRU) between March 2020 - August 2020.SettingThis study took place in an urban acute care hospital 22-bed IRU.Participants94 individuals admitted to the IRU with a diagnosis of COVID-19. 77 patients received an admission cognitive assessment, 45 also received discharge cognitive assessment. All received admission and discharge Quality Indicator for Self-Care (QI SC) Score.InterventionsNot applicable.Main Outcome MeasuresMontreal Cognitive Assessment (MoCA) administered to identify cognitive impairment. The Uniform Data System (UDS) Quality Indicators (on Self-Care (QI-SC) scored for functional status.Results75/77 (97%) patients received an admission cognitive assessment coded as independent with ADL and cognitive tasks prior to admittance. 62/77 (80.5%) patients demonstrated cognitive deficits on the MoCA at admission: 39/77 (50.6%) mildly impaired, 20/77 (26%) moderately impaired, and 3/77 (3.9%) severely impaired. 32/45 patients discharge scores improved and met the MoCA minimally clinically important difference (MCID); however, 35/45 continued to score in the impaired range. Patients who met the MoCA MCID demonstrated significantly greater QI-SC score gains than those that did not meet the MCID. 70/77 (91%) were discharged home with recommendation for continued therapy services.ConclusionsCognitive impairment is common amongst patients requiring prolonged hospitalization and acute inpatient rehabilitation for COVID-19. Most patients admitted to the IRU demonstrated intact independence and cognition prior to disease onset and hospitalization. Although most patients on the IRU showed improvements in cognition according to the MoCA; these patients were recommended for continued therapy and/or assistance for functional tasks post discharge. Since cognitive deficits were still present at discharge, the need for standardized assessment and follow-up is indicated, especially given the association with functional outcome.Author(s) DisclosuresNone.

SLP Outcomes and Experiences from an Inpatient Rehabilitation Unit on the COVID-19 Front Lines

Research ObjectivesTo contribute to COVID-19 data by reporting experiences from Speech Language Pathologists (SLPs) working at the height of the COVID-19 pandemic in New York City. We report incidence of dysphagia, cognitive impairments, and/or dysphonia in patients at acute inpatient rehabilitation facility (IRF), and summarize facility changes implemented to meet patient needs while maintaining requirements of an IRF.DesignThis is a retrospective study; data obtained through retroactive chart reviews of electronic medical records.SettingData gathered at Rusk Rehabilitation NYU Langone Orthopedic Hospital (LOH) in New York City. In March 2020, NYU LOH converted 75 orthopedic surgical beds to acute COVID-19 medicine beds. Simultaneously, rehabilitation unit shifted to managing rehabilitation needs of patients with COVID-19 related debility post-ICU/acute care.ParticipantsSubjects include 61 patients, ages 18+, who received SLP services during inpatient rehabilitation with primary diagnosis of COVID-19-acute respiratory failure, ARDS, or COVID-19 related debility. Admissions occurred April 1st-June 30th 2020. Reported demographics include age, gender, and discharge destination. Patients excluded if primary diagnosis was neurological with incidental positive COVID-19.InterventionsPatients received daily SLP intervention per IRF requirements. Intensity of daily services (30 vs 60 minute sessions) determined by therapy team based on individual patient needs/tolerance.Main Outcome MeasuresDysphagia outcomes are reported using the Functional Oral Intake Scale (FOIS) for admitting and discharge diets. Data for other disorders presented as incidence findings.ResultsData presents strong evidence for presence of dysphagia, cognitive impairments and dysphonia following COVID-19. 31.2% demonstrated dysphagia, 57.3% of patients demonstrated cognitive impairments, and 52.4% of patients demonstrated dysphonia. Practice reflections include: importance of PPE, reducing infection spread, establishing safe objective swallowing assessments, and inclusion of virtual modalities.ConclusionsThere is a high occurrence of dysphagia, cognitive impairments, and dysphonia in patients with severe cases of COVID-19. Standard practice of rehabilitation for patients with COVID-19 illness should include SLP contribution to help patients achieve highest level of function.Author(s) DisclosuresAll authors work full-time and are currently employed by the facility where this research occurred. No other financial or non-financial connections/conflicts to disclose.

Quality Improvement Project: Reduce Waiting Time for Inpatient Spinal Cord Injury Rehabilitation Transfer from Orthopedic and Neurosurgery to Rehabilitation Unit

<h3>Research Objectives</h3> Spinal cord injury (SCI) is a disabling condition for which early rehabilitation is important to improve patient's mobility and ability to perform daily activities. SCI patients who are accepted for inpatient rehabilitation would be transferred to a designated Rehabilitation unit as soon as possible so they can receive highly specialized SCI care provided by a designated Rehabilitation Team. However, the average waiting time for SCI patients is 8 days. Long waiting times result in delay of initiation of the rehabilitation program and risk of developing complications from prolonged hospital stay. As such, we conducted this Quality Improvement (QI) project to reduce the waiting time for inpatient rehabilitation transfer for SCI patients. We aim to reduce the waiting time for Spinal cord injury inpatient rehabilitation transfer. <h3>Design</h3> A QI team was formed to discuss the root causes which lead to long waiting times for inpatient rehabilitation transfer. Fishbone diagram was applied. Based on the root causes identified, weighted voting from the team members identified the main cause(s) to target. <h3>Setting</h3> Hospitalised care. <h3>Participants</h3> Patients with SCI and suitable to transfer to Rehabilitation Unit for inpatient rehabilitation. <h3>Interventions</h3> Pareto chart was applied to identify the main cause(s) to target. The main causes to target at PDSA cycle one were as follows: 1) Lack of knowledge of Rehab physicians; 2) No standard bed booking process. Based on the issues identified, Plan, Do, Study, Act (PDSA) cycle was carried out. The plan for PDSA cycle one was to form a designated SCI Inpatient Rehabilitation team to review SCI referrals and arrange transfer once a decision to take over is made. <h3>Main Outcome Measures</h3> The average waiting time for SCI patients to transfer to inpatient rehabilitation unit. <h3>Results</h3> A run chart was carried out and it showed the waiting time for transfer was reduced. <h3>Conclusions</h3> A designated SCI Inpatient Rehabilitation team to review SCI referrals and arrange transfer is an effective way to reduce waiting time for inpatient rehabilitation unit transfer for SCI patients. <h3>Author(s) Disclosures</h3> All authors listed on the abstract have no disclosures.

Outcomes of Early Rehabilitation in Traumatic Brain Injury

<h3>Research Objectives</h3> To determine the functional outcomes and the associated clinical predictors of early rehabilitation of patients with all TBI severity. <h3>Design</h3> Retrospective analysis. <h3>Setting</h3> Acute inpatient rehabilitation (AIR) unit. <h3>Participants</h3> A total of 491 patients with head trauma were screened and reviewed between 1 November 2010 and 30 October 2012 within 72 hours of admission to the neurosurgical ward in an acute tertiary hospital. Patients who fulfilled the following criteria were then recommended and transferred to AIR: (1) presence of impairments or disabilities which could benefit from a comprehensive inpatient rehabilitation programme, (2) potential to participate in a goal-oriented rehabilitation programme and (3) medical stability to participate in a rehabilitation setting. One hundred and sixteen patients were directly transferred to AIR. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Rehabilitation Length of Stay (RLOS); Functional Independence Measure (FIM); FIM gain and FIM efficiency. <h3>Results</h3> The median age of the patients transferred to AIR was 72.0 (IQR 58.3-79.8). Most sustained a mild injury (75.9%). The total functional and motor gains after AIR were significant (p< 0.001). The median total FIM gain was 12.00 (IQR 2.00-41.00) points. The median FIM efficiency was 0.55 (IQR 0.67-1.58) points/day. The median RLOS (days) was 20.50 (IQR 12.25-30.50). Increased age, complications, high motor admission FIM (AFIM) and long RLOS were associated with lower FIM gain and lower FIM efficiency. <h3>Conclusions</h3> Our study showed majority of the patients selected for AIR were mild TBI and older patients. There was functional improvement in patients with TBI receiving early rehabilitation. Increased age, presence of complications, high motor AFIM and increased RLOS were associated with lower FIM gain and lower FIM efficiency. <h3>Author(s) Disclosures</h3> Nil.

Return to the Primary Acute Care Service of Glioblastoma Multiforme Acute Inpatient Rehabilitation Patients

<h3>Research Objectives</h3> 1) Determine the transfer rate to the primary acute care service of patients with World Health Organization (WHO) Grade IV Glioblastoma Multiforme (GBM) from acute inpatient rehabilitation (IPR). 2) Determine reasons for transfer back to the primary acute care service from IPR <h3>Design</h3> Retrospective Chart Review. <h3>Setting</h3> National Cancer Institute Comprehensive Cancer Center Acute Inpatient Rehabilitation Unit. <h3>Participants</h3> 140 unique GBM patients admitted to the acute inpatient rehabilitation unit from 4/1/2016 - 3/31/2020. Only first admissions to IPR were analyzed. <h3>Interventions</h3> Patients underwent acute inpatient rehabilitation. <h3>Main Outcome Measures</h3> Transfer to the acute care service. <h3>Results</h3> 107/140 (76.4%) of patients were discharged home from acute inpatient rehabilitation. 16/140 (11.4%) were transferred to the primary acute care service (1/16 was a planned transfer), 12/140 (8.6%) transferred to SNF, and 5/140 (3.6%) transferred to hospice. Of those transferred to primary service, 6/14 were transferred back to IPR, 5/14 to hospice, 4 to home, 2 to SNF. One patient transferred back for planned neurosurgical brain tumor resection. 6/14 were transferred back for unplanned neurosurgical complications. 3/14 were transferred back for respiratory decline (2/14 requiring immediate ICU transfer) due to pneumonia (1/14) and PE (2/14), 4/14 transferred to neuro-oncology for neurologic decline due to swelling or tumor progression. <h3>Conclusions</h3> The rate of transfer to the primary acute care service of GBM IPR patients is relatively low compared to other oncologic IPR populations and similar when compared to stroke and traumatic brain injury populations. <h3>Author(s) Disclosures</h3> Not Applicable.

Sleep Quality in an Acute Inpatient Rehabilitation Setting: The Importance of Prior Sleep Disorders

<h3>Research Objectives</h3> To assess whether demographic and clinical factors might impact sleep quality during inpatient stay in a rehabilitation setting. <h3>Design</h3> Patients were assessed for their sleep quality at admission and discharge. Demographic and clinical data were collected (i.e., age, Body Mass Index-BMI, gender, race, cause of hospitalization, pre-hospital setting and prior diagnosis of sleep disorders). The levels of anxiety and depression were also assessed. <h3>Setting</h3> acute inpatient rehabilitation unit of Casa Colina Hospital and Centers for Healthcare (Pomona, California). <h3>Participants</h3> Thirty five patients participated to this study (age=61±16 years old; BMI=30±7kg/m2; 18 females, 18 Caucasians). The average length of hospitalization was 18±8 days. Cause of hospitalization included stroke (20%), spinal cord injury (28%), orthopedic (28%) and other (23%). In this sample, 23% had prior sleep disorders (mostly, sleep apnea) and 60% came from an acute care unit. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> the Pittsburgh Sleep Quality Index (PSQI), the Beck Anxiety Inventory (BAI) and the Patient Health Questionnaire-9 (PHQ-9). <h3>Results</h3> ANOVAs with repeated measures were performed on the outcome measure (PSQI) controlling for BMI and age. Among the demographic and clinical variables considered, prior sleep disorders had a strong effect on changes in PSQI total scores [F(1,33)= 14.74, p < .001]. The PSQI decreased only in patients with prior diagnosis of sleep disorders [F(1,33)= 5.86, p < .05]. The pre-hospital setting trended toward significance for the group without sleep disorders [F(1,33)= 3.55, p=.07]. Changes in BAI [F(1,33)= 5.02, p < .05] and PHQ-9 [F(1,33)= 5.47, p < .05] total scores were related to changes in PSQI. Finally, our dataset did not reveal an effect of race or gender. <h3>Conclusions</h3> Sleep quality of patients with sleep disorders can deteriorate over inpatient stay and should be addressed in order to optimize recovery during rehabilitation. <h3>Author(s) Disclosures</h3> None.

Postacute Rehabilitation for Survivors of COVID-19 in an Inpatient Rehabilitation Setting: A Case Series

Research ObjectivesTo investigate the rehabilitation outcomes of patients with COVID-19, admitted to an in-hospital inpatient rehabilitation unit.DesignCase series method. All patients were followed up by phone call six months after discharge.SettingIn-hospital Inpatient Rehabilitation Unit.ParticipantsSubjects included three male patients in the age range of 55-65 with underlying medical conditions after COVID-19 infection with a mean acute hospital stay of 39 days.InterventionsAll three patients received services from an interdisciplinary team led by a physical medicine and rehabilitation specialist. Interventions were focused on managing ongoing medical issues, weaning off of supplemental oxygen, restorative and compensatory training to improve independence with functional mobility, activities of daily living, assessment and treatment of dysphagia, speech/voice, and cognitive-communication deficits.Main Outcome MeasuresSix-minute Walk Test, 10-meter Walk Test, GG codes, Berg Balance Scale, MRC sum score, Montreal Cognitive Asessment, Dynamometry and 9-hole Peg Test.ResultsThe average length of stay at the rehabilitation unit was 21 days. The distance on six-minute walk has improved from being unable to walk for six minutes on admission to an average of 921 feet at a speed of 1.05m/s. Two out of three patients remained at medium risk of falls requiring use of assistive devices for mobility. Persisting dysphagia and dependence on supplemental oxygen was an issue for one patient. All three patients discharged home with support from family members and no episode of readmission to hospital within six months after discharge.ConclusionsOngoing fatigue, cognitive impairment and reduced endurance demonstrates the impact of COVID-19 on multiple organ systems in the body. Intensive inpatient rehabilitation is beneficial to accelerate recovery process, while managing ongoing medical issues.Author(s) DisclosuresRussell ME: Speakers Bureau for Allergan and Merz.LIjo, Hamilton, Wren: Nothing to disclose.

Exploring Animal-Assisted Therapy for Creating Rich Communicative Environments and Targeting Communication Goals in Subacute Rehabilitation.

This study continues our research examining the use of animal-assisted therapy (AAT) for patients with acquired neurogenic communication disorders. AAT pairs an animal/handler team with a licensed therapist during sessions to target discipline-specific goals. Our original study focused on dog/handler teams paired with occupational and physical therapists during inpatient rehabilitation sessions. We documented multiple ways that AAT enriched the communicative environment, increasing the amount, complexity, and voluntariness of patient participation. This study focuses on speech-language pathology sessions, comparing communicative environments during AAT and traditional sessions. We also examined the speech-language pathologists' (SLPs') experiences in learning to plan for and target communication goals for patients during AAT sessions. This interpretive design combines ethnographic methods with participatory action research. We recruited 10 patients from an inpatient rehabilitation unit and two SLPs. We video-recorded 20 speech-language pathology sessions (one AAT and one traditional for each patient) and conducted 26 interviews. We consulted with SLPs on how to incorporate AAT into their treatment during their preparation time and used self-report measures to track changes in their planning time and confidence across the 6-week study. Across participants, AAT sessions provided richer communicative environments than traditional speech-language pathology sessions as measured by participant talk time, mean length of turns, and use of interactional discourse resources such as narrative use and playful language. The SLPs were rapidly able to adapt their clinical practice to incorporate AAT and displayed rapid and marked decreases in their initial planning time and increases in confidence. AAT sessions created meaningful, rich, and complex communicative environments in a clinical space for participants to align with others around a shared interest.

Factor structure of the Modified Mini Mental State (3MS) exam among participants in inpatient neurorehabilitation

ABSTRACT Objective: To evaluate the factor structure of the Modified Mini Mental State (3MS) Exam and its suitability as a cognitive screening tool among individuals admitted to an inpatient rehabilitation unit for new-onset neurological injury/illness. Method: A retrospective chart review was conducted. Of the 187 individuals meeting the inclusion criteria, 116 had a diffuse pattern of neurological injury/illness; 71 had a focal injury/illness. Confirmatory and exploratory factor analyses (CFA; EFA) were conducted for the whole sample and separately by group. Results: The CFA suggested poor fit indices. The EFA of the total sample suggested a three-factor solution (Orientation/Awareness; Learning/Recall and Executive Functioning; Psychomotor Ability). The EFA of the diffuse subsample suggested a three-factor solution (Attention and Learning/Recall; Psychomotor Ability; Expressive Language). The Orientation/Awareness, Learning/Recall, Executive Functioning, Psychomotor Ability, and Expressive Language four-factor solution observed among the focal subsample was considered invalid. Conclusion: The 3MS provides information about the pattern of cognitive performance among individuals in neurorehabilitation; clinicians are advised to interpret total scores with caution. Among individuals with focal injuries/illnesses, clinicians might use the 3MS to compare the pattern of cognitive ability to expectations for performance and to support strengths-based approaches to participation in rehabilitation therapies.

Improving stroke care in Nova Scotia, Canada: a population-based project spanning 14 years

Stroke is a complex disorder that challenges healthcare systems. An audit of in-hospital stroke care in the province of Nova Scotia, Canada, in 2004–2005 indicated that many aspects of care...

18F-fluorodeoxyglucose positron-emitted tomography for predicting neurological outcome in hypoxic-ischemic encephalopathy

ABSTRACT Background : 18F-fluorodeoxyglucose positron-emitted tomography (FDG-PET) is a promising yet unexplored functional neuroimaging tool in the study and prognosis of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest or respiratory failure. The present study aimed to correlate clinical data and FDG-PET scans for both analysis and prognostic use. Methods : 24 patients from an intensive rehabilitation ward were retrospectively evaluated. Data collected included age, gender, cause of anoxic event, length of stay in acute and rehabilitation units, discharge destination, and evaluation at admission and discharge using three clinical scales to assess cognitive function, independence and disability. Subjects were identified as good and bad performers on the basis of quantitative analysis of FDG-PET scans with the Cortex ID software. The relation between glucose uptake reduction and neurological outcome was evaluated. Results : good and bad performers presented no statistically significant difference regarding demographical data and in-hospital length of stay. The two categories significantly differed for impairment and disability levels both at admission and at discharge from the inpatient rehabilitation unit. Conclusions : FDG-PET considerably facilitates the early identification of patients with HIE who will have poor neurological outcome and could inform planning for their rehabilitation and care.

Neurological complications in COVID-19: a single case study of rehabilitation treatment

Background/aims: COVID-19 is a global pandemic, which has seen over 198 million cases as of August 2021. This case study highlights the rehabilitation of a young patient with respiratory and neurologic sequalae of COVID-19 across the continuum of care, from the intensive care unit to the inpatient rehabilitation unit. Case description: A 45-year-old woman, with past medical history of fibromyalgia and morbid obesity, presented with complaints of shortness of breath. She tested positive for SARS-CoV-2, was transferred to the intensive care unit, and was intubated for 17 days. The day after extubation, she experienced worsened mental status; computed tomography and magnetic resonance imaging scans revealed bilateral strokes. On hospital day 21, she was transferred to the stroke step-down unit. On hospital day 24, she recovered some cognitive ability and movement of her lower extremities. On hospital day 30, she was admitted to the inpatient rehabilitation unit. Examination by occupational and physiotherapists found motor and sensory impairments of multiple peripheral nerves, including musculocutaneous, axillary and radial nerves. Interventions included passive range of motion, sitting balance, transfer training, rigid taping, upper extremity strengthening and functional training (gait, stair, activities of daily living). Her activities of daily living performance was limited by upper extremity weakness, sensory loss and pain. Conclusions This case highlights the medical, neurological and functional implications of COVID-19 on patients after prolonged hospitalisation. The plan of care was informed by collaboration between rehabilitation disciplines. Causes of her injuries are unclear but could include positioning, brachial plexus injuries, or post-critical illness syndrome. Further research on the evaluation and care of patients with COVID-19 that result in profound neurological impairments is warranted.

Stratified management of hemiplegic shoulder pain using an integrated care pathway: an 18-year clinical cohort analysis

Purpose Hemiplegic shoulder pain (HSP) is a common but heterogeneous complication of acquired brain injury. Integrated care pathways (ICPs) can support clinical decision-making, prompting timely intervention to improve quality of care. This 18-year cohort analysis of clinical data presents outcomes from an ICP for management of HSP in an inpatient rehabilitation unit. Materials & methods Consecutive data were extracted for all eligible patients admitted between 2000–2018 (n = 333). Patients were categorised according to presentation pattern (“Floppy-subluxed” (59%), “Painful-stiff” (21%) or Mixed/not categorised(20%)) to help guide early management. Pain was assessed using the Shoulder-Q with pain ratings/10 in three domains: rest, night-time and movement. Patients with pain reduction ≥3 points in any domain were designated ‘responders'. Results Mean baseline pain scores were 4.7 (95%CI 4.5,5.0). They were higher on movement (6.1(5.8,6.3)) than at rest (4.7(4.3, 5.0)) or at night (5.7(5.2,5.9)). Pain reduced significantly in all three domains (p < 0.0001) with a 65% overall response rate and complete resolution of pain 21–41%. There was a significant relationship between category of presentation pattern and management protocol used (X2 = 31.2, p < 0.0001). Conclusion These high pain-response rates compare favourably to the literature (14–27%), suggesting that this stratified and integrated approach to HSP guides more effective management in this heterogeneous clinical presentation. Implications for Rehabilitation Two-thirds of the patients demonstrated a clinically-significant reduction in pain when managed using the integrated care pathway. These results compare favourably with pain resolution rates of well under one-third cited in the literature and suggest that the integrated care pathway leads to reduced pain and improved patient outcomes. Hemiplegic shoulder pain can result from a range of different clinical problems. The diversity of presentation and the range of required treatments are confirmed in this 18-year cohort analysis. Heterogeneity in presentation of HSP poses a challenge for both management and the evaluation of outcome. The results of this study suggest that a stratified approach helps to guide more effective management.

Prescribing Patterns of Amantadine During Pediatric Inpatient Rehabilitation After Traumatic Brain Injury: A Multicentered Retrospective Review From the Pediatric Brain Injury Consortium.

To describe dosing practices for amantadine hydrochloride and related adverse effects among children and young adults with traumatic brain injury (TBI) admitted to pediatric inpatient rehabilitation units. Eight pediatric acute inpatient rehabilitation units located throughout the United States comprising the Pediatric Brain Injury Consortium. Two-hundred thirty-four children and young adults aged 2 months to 21 years with TBI. Retrospective data revie. Demographic variables associated with the use of amantadine, amantadine dose, and reported adverse effects. Forty-nine patients (21%) aged 0.9 to 20 years received amantadine during inpatient rehabilitation. Forty-five percent of patients admitted to inpatient rehabilitation with a disorder of consciousness (DoC) were treated with amantadine, while 14% of children admitted with higher levels of functioning received amantadine. Children with DoC who were not treated with amantadine were younger than those with DoC who received amantadine (median 3.0 vs 11.6 years, P = .008). Recorded doses of amantadine ranged from 0.7 to 13.5 mg/kg/d; the highest total daily dose was 400 mg/d. Adverse effects were reported in 8 patients (16%); nausea/abdominal discomfort and agitation were most common, each reported in 3 patients. The highest reported dose without an adverse effect was 10.1 mg/kg/d. During pediatric inpatient rehabilitation, amantadine was prescribed to children across a range of ages and injury severity and was most commonly prescribed to older children with DoC. Dosing varied widely, with weight-based dosing for younger/smaller children at both lower and higher doses than what had been previously reported. Prospective studies are needed to characterize the safety and tolerability of higher amantadine doses and optimize amantadine dosing parameters for children with TBI.

Cardiac arrhythmias six months following traumatic spinal cord injury

Objective To investigate the incidence of cardiac arrhythmias at six months following traumatic spinal cord injury (SCI) and to compare the prevalence of arrhythmias between participants with cervical and thoracic SCI. Design A prospective observational study using continuous twenty-four-hour Holter monitoring. Setting Inpatient rehabilitation unit of a university research hospital and patient home setting. Participants Fifty-five participants with acute traumatic SCI were prospectively included. For each participant, the SCI was characterized according to the International Standards for Neurological Classification of SCI by the neurological level and severity according to the American Spinal Injury Association Impairment Scale. Outcome measures Comparisons between demographic characteristics and arrhythmogenic occurrences as early as possible after SCI (4 ± 2 days) followed by 1, 2, 3, 4 weeks and 6 month time points of Holter monitoring. Results Bradycardia (heart rate [HR] <50 bpm) was present in 29% and 33% of the participants with cervical (C1–C8) and thoracic (T1–T12) SCI six months after SCI, respectively. The differences in episodes of bradycardia between the two groups were not significant (P < 0.54). The mean maximum HR increased significantly from 4 weeks to 6 months post-SCI (P < 0.001), however mean minimum and maximum HR were not significantly different between the groups at the six-month time point. There were no differences in many arrhythmias between recording periods or between groups at six months. Conclusions At the six-month timepoint following traumatic SCI, there were no significant differences in occurrences of arrhythmias between participants with cervical and thoracic SCI compared to the findings observed in the first month following SCI.

Patient-proxy agreement on change in acute stroke patient-reported outcome measures: a prospective study

ObjectivesResearch has indicated proxies overestimate symptoms on patients’ behalves, however it is unclear whether patients and proxies agree on meaningful change across domains over time. The objective of this study is to assess patient-proxy agreement over time, as well as agreement on identification of meaningful change, across 10 health domains in patients who underwent acute rehabilitation following stroke.MethodsStroke patients were recruited from an ambulatory clinic or inpatient rehabilitation unit, and were included in the study if they were undergoing rehabilitation. At baseline and again after 30 days, patients and their proxies completed PROMIS Global Health and eight domain-specific PROMIS short forms. Reliability of patient-proxy assessments at baseline, follow-up, and the change in T-score was evaluated for each domain using intra-class correlation coefficients (ICC(2,1)). Agreement on meaningful improvement or worsening, defined as 5+ T-score points, was compared using percent exact agreement.ResultsForty-one patient-proxy dyads were included in the study. Proxies generally reported worse symptoms and functioning compared to patients at both baseline and follow-up, and reported less change than patients. ICCs for baseline and change were primarily poor to moderate (range: 0.06 (for depression change) to 0.67 (for physical function baseline)), and were better at follow-up (range: 0.42 (for anxiety) to 0.84 (for physical function)). Percent exact agreement between indicating meaningful improvement versus no improvement ranged from 58.5–75.6%. Only a small proportion indicated meaningful worsening.ConclusionsPatient-proxy agreement across 10 domains of health was better following completion of rehabilitation compared to baseline or change. Overall change was minimal but the majority of patient-proxy dyads agreed on meaningful change. Our study provides important insight for clinicians and researchers when interpreting change scores over time for questionnaires completed by both patients and proxies.

Decompressive craniectomy is a life-saving procedure in malignant MCA infarction.

Objectives:To investigate the indications, timings, and outcomes of decompressive craniectomy (DC) performed for malignant middle cerebral artery (MCA) infarctions at our tertiary care center.Methods:This retrospective case series involved patients who underwent DC for malignant MCA infarction at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, between January 2012 and December 2018. Demographic, clinical, and radiological data were collected, and stroke- and surgery-related complications and discharge outcomes were assessed.Results:Eighteen patients (mean age: 50±10 years), of whom 13 (72%) were men, underwent DC during the study period. Of the patients, 9 (50%) had severe stroke (NIHSS 16–25), 10 (56%) had right MCA infarction, and 11 (61%) received either intravenous thrombolysis or endovascular thrombectomy or their combination. Indications for surgery included clinical deterioration as seen in 16 (89%) patients, ipsilateral pupillary dilatation as seen in 11 (61%) patients, and signs of raised intracranial pressure in 6 (33%) patients. Surgery was performed within 48 h in 14 (78%) patients. The mean Intensive Care Unit stay was 15±7 days. Seven (39%) patients were discharged home and 3 (17%) were transferred to an inpatient rehabilitation unit, and 2 (11%) patients died. All patients had stroke-related complications; one (6%) patient developed cerebrospinal fluid leak, 3 (17%) had sunken skin flap syndrome and wound infection each, and 2 (11%) developed epidural hematoma.Conclusion:The DC was life-saving in the our patients with malignant MCA infarction. Most of the patients had surgery within 48 hours. More than one-third of the patients were discharged home, while mortality occurred in only 2 patients. Moreover, stroke- and surgery-related complications were common in our cohort.