Intensive Interdisciplinary Rehabilitation Research Articles

The Effects of an Intensive Rehabilitation Program on the Nutritional and Functional Status of Post-COVID-19 Pneumonia Patients.

Most hospitalized COVID-19 pneumonia patients are older adults and/or have nutrition-related issues. Many are bedridden in intensive care units (ICU), a well-documented cause of malnutrition, muscle wasting, and functional impairment. Objectives: To assess the effectiveness of an intensive rehabilitation program over the nutritional/functional status of patients recovering from COVID-19 pneumonia. Post-COVID-19 pneumonia patients underwent a 30-day intensive interdisciplinary rehabilitation program including a personalized nutritional intervention designed to achieve a minimum intake of 30 kcal/kg/day and 1 g protein/kg/day. The nutritional and functional status was assessed in each patient at three different moments. Each assessment included Body Mass Index (BMI), Mid Upper Arm Circumference (MUAC), Mid Arm Muscle Circumference (MAMC), Tricipital Skinfold (TSF), Hand Grip Strength (HGS), and Mini Nutritional Assessment (MNA®). The study included 118 patients, with ages in the range 41–90 years old. BMI increased linearly over time (0.642 units, F-test = 26.458, p < 0.001). MUAC (0.322 units, F-test = 0.515, p = 0.474) and MAMC status (F-test = 1.089, p = 0.299) improved slightly, whereas TSF decreased (F-test = 1.885, p = 0.172), but all these arm anthropometry trends did not show significant variations, while HGS (4.131 units, F-test = 82.540, p < 0.001) and MNA® (1.483 units, F-test = 217.726, p < 0.001) reported a meaningful improvement. Post-COVID-19 pneumonia patients presented malnutrition and functional impairment. An interdisciplinary rehabilitation program, including personalized nutritional intervention, was effective for post-hospital COVID-19 pneumonia nutritional/functional rehabilitation.

Experiences of an intensive interdisciplinary rehabilitation for people with early-stage Parkinson's disease

Background There has been little research on the experiences of individuals in the early stages of Parkinson’s disease (PD) when they participate in intensive interdisciplinary rehabilitation programs emphasising self-management. In addition, little is known about such individuals’ transition back to everyday life following rehabilitation. This paper seeks to provide insights into such experiences. Methods A qualitative approach was utilised in the study on which this paper is based. Semi-structured interviews were conducted with seven individuals approximately three months after they had completed a 3-week interdisciplinary rehabilitation program. Following transcription, the interviews were analysed on the basis of Brown & Clarke’s six stage framework for thematic analysis. Results Analysis of the data yielded three core themes: being oneself during rehabilitation; believing in oneself again; and managing one’s everyday life following rehabilitation. Conclusions Our results demonstrate how an intensive interdisciplinary rehabilitation program can contribute to improved physical function and self-esteem for individuals in an early phase of PD. The results also reveal ambivalence regarding relational aspects of the rehabilitation program and point to the need for more emphasis on including emotional, mental and family aspects into the program.

Interdisciplinary Pain Management Improves Pain and Function in Pediatric Patients with Chronic Pain Associated with Joint Hypermobility Syndrome.

The relation between chronic musculoskeletal pain and joint hypermobility in a small percentage of the pediatric population is well described. However, literature discussing the treatment of chronic pain associated with joint hypermobility in pediatrics is limited. The present study examines the impact of interdisciplinary treatment on chronic pain in pediatrics with joint hypermobility syndrome. To determine if pediatric patients with chronic pain related to joint hypermobility can be effectively treated with an intensive, interdisciplinary pain management program, as measured by changes in pain, psychosocial and physical functioning, as well as parental coping. Retrospective cohort study. Urban academic tertiary intensive outpatient interdisciplinary pain management clinic. The study involved 30 patients who met the criteria for a diagnosis of joint hypermobility and chronic pain and completed an interdisciplinary pain management program. All patients were treated in an intensive pediatric interdisciplinary pain management program for a duration of 6 to 8 weeks. The program provided physical therapy, occupational therapy, psychological counseling, and weekly pediatric rehabilitation medicine follow-up. Outcome measures included numeric rating scale pain scores, the Bath Adolescent Pain Questionnaire, and the Bath Adolescent Pain-Parent Impact Questionnaire. Changes from pre- to post-treatment were analyzed using paired-samples t tests. Patients endorsed pre- to post-treatment improvements in pain, depression, general anxiety, pain-related anxiety, social functioning, and physical functioning (P < .05). The patients' parents showed significant improvements in depression, anxiety, catastrophic thinking, self-blame and helplessness, leisure functioning, and parental behavior (P < .05). The present findings suggest that an intensive interdisciplinary rehabilitation pain management program yields short-term improvements in pain, emotional and physical function, and daily activity in a pediatric population diagnosed with joint hypermobility. Parents also experienced benefits from the program. A larger prospective study with longer-term follow-up is needed. III.

Functional and Mental Health Status of United Kingdom Military Amputees Postrehabilitation

ObjectivesTo evaluate the functional and mental health status of severely injured traumatic amputees from the United Kingdom military at the completion of their rehabilitation pathway and to compare these data with the published normative data. DesignRetrospective independent group comparison of descriptive rehabilitation data recorded postrehabilitation. SettingA military complex trauma rehabilitation center. ParticipantsAmputees (N=65; mean age, 29±6y) were evaluated at the completion of their rehabilitation pathway; of these, 54 were operationally (combat) injured (23 unilateral, 23 bilateral, 8 triple) and 11 nonoperationally injured (all unilateral). InterventionsContinuous ∼4-week inpatient, physician-led, interdisciplinary rehabilitation followed by ∼4-weeks of patient-led, home-based rehabilitation. Main Outcome MeasuresThe New Injury Severity Score at the point of injury was used as the baseline reference. The 6-minute walk test, Amputee Mobility Predictor with Prosthesis, Special Interest Group in Amputee Medicine, Defence Medical Rehabilitation Centre mobility and activity of daily living scores as well as depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7), mental health support, and pain scores were recorded at discharge and compared with the published normative data. ResultsThe mean New Injury Severity Score was 40±15. After 34±14 months of rehabilitation, amputees achieved a mean 6-minute walk distance of 489±117m compared with age-matched normative distances of 459 to 738m. The 2 unilateral groups walked (544m) significantly further (P>.05) than did the bilateral amputee (445±104m) and triple amputee (387±99m) groups. All groups demonstrated mean functional mobility scores consistent with scores of either active adults or community ambulators with limb loss. In total, 85% could walk/run independently and 95% could walk and perform activities of daily living independently with an aid/adaptation. No significant difference in mental health outcome was reported between the groups (P>.05). At discharge, 98% of patients were able to control their pain. ConclusionsSeverely injured military amputees who completed intensive interdisciplinary rehabilitation achieved levels of physical function comparable with those in age-matched healthy adults. Mental health outcomes were indicative of preparedness for full integration back into society.

The influence of anxiety reduction on clinical response to pediatric chronic pain rehabilitation.

This study investigates the relationship between anxiety reduction and functional outcomes in children and adolescents receiving intensive interdisciplinary rehabilitation services for chronic pain (CP). Specifically, we evaluated whether: (1) anxiety changes over the course of treatment; (2) anxiety covaries with functional outcomes to rehabilitation; and (3) change in anxiety predicts change in functional outcomes from rehabilitation for CP. Using 3 separate measures assessing anxiety-related constructs, we hypothesized that anxiety would be associated with functioning, both before and following intensive rehabilitation for CP. Further, we hypothesized that a decrease in anxiety-related symptoms following rehabilitation would predict a positive change in functional outcomes. Our sample consisted of 119 children and adolescents treated for CP in an interdisciplinary rehabilitation program between 2007 and 2012. Children completed 3 measures related to anxiety (general anxiety, pain-specific anxiety, pain catastrophizing) and 2 functional outcome measures (eg, Bath Adolescent Pain Questionnaire, PedsQL) as part of clinical care. Measures of anxiety-related constructs were significantly correlated with measures of impairment and functioning, both at admission and at 1-month postdischarge. Regression analyses demonstrated that, after controlling for age, sex, and pain level at admission, a decrease in anxiety significantly predicted between 14% and 40% unique variance in functional outcomes. The findings of this study support existing research on anxiety and CP, specifically the relationship between anxiety and pain-related disability. This study also supports the benefit of intensive interdisciplinary rehabilitation for both reducing anxiety and increasing functional outcomes, suggesting a possible link in children's response to intervention. Study limitations and future directions for related research are discussed.

Rehabilitation outcomes following autologous human stem cell transplantation in a chronic complete C4 tetraplegic - the first 12 months: A case report

Autologous Human Stem Cell Transplantation (AHESC) is emerging as one of several promising new cell-based treatments for chronic spinal cord injury (SCI). Since chronic SCI is generally deemed irreversible, treatment paradigms for post-intervention rehabilitation after many years of disability are limited, and a description of the impact of such intervention on the patients is hard to find. Here we describe, for the first time, the multi-disciplinary post-operative rehabilitation and outcome of a patient with chronic cervical SCI after autologous human embryonic stem cell transplant. We include the anatomical, physiological, functional and quality of life outcomes. METHODS: A 33 year old male, American Spinal cord Injury Association (ASIA) Grade A, C4 chronic SCI patient received glial scar resection and Autologous Human Embryonic Stem Cell (AHESC) transplant, 6 years after injury, and thereafter had intensive interdisciplinary rehabilitation comprising occupational, biokinetic and physiotherapy, for an average of 17 hours per week over the course of 12 months. Outcomes were measured with standardised outcome measures of physiological improvement, increased independence, and a questionnaire was designed to gain understanding of the changes in quality of life and well-being of the patient, from his perspective RESULTS: The patient progressed from ASIA Grade A to ASIA Grade C, over the first 12 post-operative months. Sensory recovery comprised awareness of deep pressure and light touch in all dermatomes, with accurate localisation to L1. Motor activation was restored to all major muscle groups of the right upper limb, and to a lesser extent in the left upper limb, with some recovery in thoracic, abdominal and spinal muscles. Gains have been made in areas of motor, sensory and vascular function, self-care, wheelchair use and safety, and leisure participation. The patient has found these changes meaningful in terms of quality of life CONCLUSION: Regenerative medicine approaches may create rehabilitation potential where none formerly existed, presenting unprecedented challenges to rehabilitation therapists. Our experience demonstrates the value of intensive multi-disciplinary rehabilitation programmes in this setting, and provides a template for functional restoration and retraining after many years of chronic disability. It also emphasises the need to debate the ethical questions surrounding the application of such interventions and highlights the impact that participation in rehabilitation can have on a patient's perception of quality of life and health status. Key words: Human therapeutic cloning, autologous human embryonic stem cells, spinal cord, spinal cord injury, quadriplegia, motor rehabilitation, motor retraining, mirror therapy, quality of life

The management of acute low back pain in adults: a guide for the primary care physician

To diagnose patients with acute low back pain (LBP), a focused physical examination needs to be conducted and a detailed history obtained. The patient should then be placed into one of three broad categories, namely nonspecific LBP, pain associated with radiculopathy or spinal stenosis, or back pain potentially associated with serious organic disease. The history should include an assessment of psychosocial risk factors that predict delayed healing and progression to chronic pain. Routine imaging is not required within the first three weeks of nonspecific LBP. Imaging should be performed for patients with severe or progressive neurological deficits, or when serious underlying pathology is suspected, based on the history and the physical examination. Patients should be advised of the benign course of nonspecific LBP and that over 90% of patients recover within a few weeks. Occasionally, the pain may last for a few months. Patients should be advised to remain active and should be provided with information on effective self-care options. Usually, first-line medication options are paracetamol or nonsteroidal anti-inflammatory drugs. To treat severe pain, a stronger drug approach that includes opioids may be considered, but only for a short time. Other therapies to be taken into account are spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, massage therapy, or progressive relaxation. Spinal surgery is an option in the event of progressive neurological fallout, severe persistent pain of more than three months and patient unresponsiveness to recommended treatment, or if there is acute cauda equina syndrome.

Clinical effectiveness of an interdisciplinary pain management programme compared with standard inpatient rehabilitation in chronic pain: A naturalistic, prospective controlled cohort study

To compare the effects of an interdisciplinary pain management programme with those of standard in-patient rehabilitation by comprehensive biopsychosocial self--assessment. In this naturalistic prospective controlled cohort study, 164 chronic pain patients who participated in the interdisciplinary pain programme and 143 who underwent standard rehabilitation were assessed using standardized instruments. Effect differences were compared bivariately and analysed by multivariate logistic regression to control for baseline differences in the outcome variables and confounders. On entry into the clinic, the interdisciplinary pain programme patients were younger and showed significantly worse mental and psychosocial health than the standard rehabilitation patients. At discharge, the interdisciplinary pain programme patients reported greater improvement on pain (multivariate p = 0.034), social functioning (bivariate p = 0.009), and in trend in catastrophizing and ability to decrease pain. At the 6-month follow-up, the effects experienced by the standard rehabilitation group were higher on physical functioning, social functioning, anxiety, and life control (multivariate p = 0.013-0.050). Intensive interdisciplinary rehabilitation with more behavioural therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation by the end of the stay, but not in the mid-term. Highly resource-consuming patients may benefit from subsequent, individually tailored outpatient care.

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

A Danish National Strategy for Treatment and Rehabilitation After Acquired Brain Injury

This study describes the establishment of a Danish national strategy for treatment and rehabilitation of acquired brain injury, particularly traumatic brain injury, in 1997. The vision was to create a system of tax-financed continuous treatment, restoration of function, and outpatient rehabilitation. Recommendations and their fulfillment are described. Focus is on the establishment and function of early intensive interdisciplinary rehabilitation after severe traumatic brain injury, centralized as 2 units since the year 2000, each with half the country as uptake area, corresponding to populations of around 2.5 million. Advantages gained by this centralization are increased focus on brain injury so that everybody gets specialized rehabilitation, regardless of the prognosis, the introduction of a database for severe brain injuries with unified measures of function and outcome, and the creation of a basis for method development and interdisciplinary research. Results for the first 3 years also indicate that outcome is improved after centralization.

Poster 24: Rehabilitation outcome of 2 patients with neurologic complications from West Nile virus: a report of 2 cases

Setting: Inpatient rehabilitation. Patients: 2 patients with neurologic complications from West Nile virus (WNV). Case Description: A 42-year-old previously healthy man (patient 1) had an 82-day acute hospitalization with positive WNV serology and electromyography findings of severe generalized motor axonal and demyelinating polyneuropathy. Complications included flaccid quadraparesis, intubation, subsequent tracheostomy, pneumonia, and percutaneous endoscopic gastrostomy (PEG) placement. A 41-year-old man (patient 2), with remote history of traumatic brain injury, had a 5-day acute hospitalization with positive WNV serology, encephalitis, fever, mental status alteration, and mild quadraparesis. Assessment/Results: Patient 1 underwent a 57-day intensive interdisciplinary rehabilitation course notable for respiratory therapy, swallowing strategy instruction, and neurogenic bowel and bladder training. He showed improvement in grooming, feeding, and wheelchair ambulation. His tracheostomy and PEG were removed. He was discharged to an adult care facility with day rehabilitation follow-up at predominantly a dependent to maximum assistance level. At 7 months, he remained unchanged with the exception of a new tracheostomy placed due to respiratory failure from pneumonia. Patient 2 underwent a 6-day interdisciplinary rehabilitation course notable for cognitive neuropsychologic rehabilitation and physical and occupational therapy. He was discharged home at a modified independent level, which was his premorbid functional level. He remained at this level at 7-month follow-up. Discussion: Although WNV incidence increased in 2002, there have been few case reports on the rehabilitation management and outcomes of patients with complications resulting from WNV. These 2 patients with WNV required individualized rehabilitation approaches because of their varied neurologic and medical complications. They had significantly different functional outcomes. Conclusion: These 2 cases demonstrate the variable clinical presentations and outcomes resulting from complications attributed to WNV infections. Rehabilitation centers should recognize the need to personalize the rehabilitation process in WNV patients.

Functional outcome for African Americans and Hispanics treated at a traumatic brain injury model systems centre

Objective: To describe the demographics, incidence and functional outcome for African Americans and Hispanics treated at a traumatic brain injury (TBI) model systems centre. Design: Retrospective data analysis of patients admitted to an acute inpatient rehabilitation national TBI model systems centre. Setting: A tertiary care university medical centre participating in the NIDRR Traumatic Brain Injury Model Systems project. Subjects: Eighty-seven patients with TBI admitted to a Model Systems acute intensive interdisciplinary rehabilitation setting between 1989-1999. Information was extracted from the National TBI Model Systems data base for demographics such as age, race, education, gender, marital and employment status, sponsorship, injury aetiology and severity. Outcome measures: Functional outcome was determined using the Functional Independence Measure (FIM), and the Disability Rating Scale (DRS) at the time of admission and discharge. Results: Descriptive statistics were completed using SPSS. African American (94.3%) and Hispanic (5.7%) patients were injured most often as a result of motor vehicle accidents (48.8%). Males comprised 86.2% of this population, which had an average age of 34.5 years (SD = 13.1). On admission, average GCS score was 7.8 (SD = 3.6), average DRS was 13.5 (SD = 5.8), and average FIM total score was 49.8 (SD = 26.5). Average length of unconsciousness was 5.2 days (SD = 27.9), while average length of post-traumatic amnesia was 41.9 days (SD = 59.3). At the time of injury, 78.2% of the patients were not married. The majority of patients (97.7%) had private residences and 88.5% returned to their original home. Most patients had at least a high school education or passed a high school equivalent exam (49.4%) and were employed (70.1%) at the time of injury. Only 7% of the patients had a history of prior TBI. With regard to substance use, only 34.2% of patients reported pre-morbid illicit drug use. However, 50.5% met criteria for heavy or moderate alcohol use rates. Only 35.6% of patients reported a pre-morbid history of arrests, with the average number of arrests equal to 4.5 (SD = 10.2). Within this population, the number of drug or alcohol related arrests was 4.8 (SD = 13.5). Conclusions: Unmarried African American males, with an average age of 35 years, predominated at this institution. The primary mechanism of injury was motor vehicle accidents. The majority of patients had, at least, a high school education or passed an equivalency exam, were employed at the time of their injury and were discharged to their prior private residence. While half of the patients met criteria for moderate-to-heavy alcohol consumption, only one-third of the patients reported a history of premorbid illicit drug use. This descriptive analysis supports the need for further investigation of minority populations that sustain TBI and will enhance the accuracy of implications that minority status may have on functional outcome.