Lower FIM Scores Research Articles

Abstract TP160: What Matters Most? Predictors of Poststroke Functional Outcomes From Inpatient Rehabilitation Facilities Across the United States

Introduction: Stroke is one of the leading cause of disability and death in the United States (Benjamin et al., 2018). Inpatient rehabilitation is the gold standard treatment for post-acute care (Weinstein et al., 2016). Data indicate a discharge to inpatient rehabilitation facilities (IRFs) following the acute stroke phase has increased (Buntin, Colla, & Escarce, 2009). The inpatient milieu provides a unique opportunity to examine predictors of functional outcomes using a captive sample. Thus, the current study aim is to identify factors associated with poststroke functional outcomes throughout inpatient rehabilitation. Method: This is a cross-sectional and retrospective analysis of data extracted from an administrative database during years 2005-2016 from 244,286 stroke patients across 30% of IRFs in the U.S. Inclusion criteria were patients at or above the age 18 with stroke as an admitting diagnosis using ICD 9/10 codes 430-438/I60-I69. Dependent variables were: admission Total FIM, Total FIM efficiency, discharge Total FIM, and length of stay (LOS). Results: Using separate regression analyses, marital status, admit year, type of admission, race/ethnicity, insurance type, sex, age, number of complications, number of comorbidities, and stroke type, emerged as significant predictors of functional outcomes throughout inpatient rehabilitation. Moreover, those with greater comorbidities and complications were associated with lower admission FIM total score, less total FIM efficiency, lower discharge FIM total score, and a longer LOS. Compared to NHWs, racial/ethnic people were associated with lower FIM scores throughout inpatient rehabilitation and a longer length of stay. Discussion: In this robust national dataset, data indicate clinical and sociodemographic factors are significantly associated with poststroke functional outcomes throughout inpatient rehabilitation. Implications are discussed within a framework of social determinants of health.

Spatial neglect, rather than asymmetrical physical impairment, impedes rehabilitation outcome

Spatial neglect (SN) is 1) the failure to report stimuli in the contra-lesional space, or 2) the lack of initiation or ineffective movement toward or within the contra-lesional space. Because patients with SN often have hemiplegia or hemiparesis, some hypothesize that asymmetrical physical impairment, rather than SN, is the leading predictor of poor rehabilitation outcome. We developed the Movement and Mobility Scale (MMS) to assess upper and lower extremities in left versus right voluntary movement and mobility. Inter-rater reliability was examined by having two physical therapists (PT) independently assessed 13 patients. With a good inter-rater reliability, kappa = .75, seven PTs were trained to use the MMS. They then assessed patients admitted with a first stroke or traumatic brain injury (TBI) within 100 days post-injury to the inpatient rehabilitation facility. All patients also received the FIM (admission and discharge) and the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (admission). Seventy-six patients were tested (61 with stroke; 15 with TBI). Median age was 69 years old (IQR = 55–79). 43 patients (56.6%) had SN. Patients with SN had lower FIM scores at discharge than those without SN (M = 71.2 vs. 89.2). Controlling for admission FIM and age, there was a significant main effect of SN, F (1,72) = 19.71, P < .001. To examine the a priori hypothesis, we additionally controlled for MMS, which provided indices for asymmetrical movement in upper and lower extremities and asymmetrical mobility in left versus right space. The main effect of SN remained robust, F (1,69) = 17.71, P < .001. As reported in previous studies, SN impedes rehabilitation outcome in individuals with acquired brain injury. Additionally, we confirmed that such finding cannot be attributed to asymmetrical physical abilities. SN must be addressed effectively in rehabilitation care in order to improve outcome.

Psychological Distress, Quality of Life, and Burden in Caregivers During Community Reintegration After Spinal Cord Injury

ObjectivesTo examine relations between psychological distress, health-related quality of life (HR-QOL), and burden among caregivers of people with traumatic spinal cord injury (SCI) over time, and to determine whether the data are more consistent with a wear and tear or adaptation trajectory. DesignProspective longitudinal cohort study with measurements at 4 time points (6wk prior to discharge from subacute inpatient rehabilitation and 6wk, 1y, and 2y postdischarge to community). SettingRehabilitation units. ParticipantsParticipants (N=44; spouses, parents, others) nominated as a primary caregiver by the person with SCI. InterventionsNot applicable. Main Outcome MeasuresGeneral Health Questionnaire-28 (GHQ-28), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Caregiver Strain Index (CSI) assessed the extent of psychological distress, HR-QOL, and burden, respectively, among caregivers. Functional status and community participation/care needs of the persons with SCI were assessed by the FIM and Craig Handicap Assessment and Reporting Technique, respectively. ResultsMultilevel piecewise models showed that psychological distress (GHQ-28 score) decreased significantly after discharge (slope estimate =−.03, P<.008). At the predischarge time point, the caregivers’ mental component summary score on the SF-36 was significantly lower than Australian national norms. The scores improved from predischarge to 6 weeks postdischarge (slope estimate =.39, P<.001), but they did not change significantly across the following 2 time points (slope estimate =.02, P=.250). At all 3 postdischarge time points, the mental component summary scores were not significantly different to national norms. In contrast, the physical component summary score of the SF-36 did not significantly change across the predischarge and 6-week postdischarge time points (slope estimate =−.14, P=.121) and the 3 postdischarge time points (slope estimate <.01, P=.947). Scores at all 4 time points were not significantly different to the national norms. Caregiver burden showed no significant change over the study period (predischarge to 6wk postdischarge slope estimate =.02, P=.426; 3 postdischarge time point slope estimates <−.01, P=.334). Reflecting this, 42% of caregivers met CSI caseness criterion at the first time point, and 46% met the criterion at the fourth (2y) time point. Higher burden was significantly correlated with increased hours of care being provided by the caregiver and lower FIM scores and lower community participation (for the person with SCI) at each time point. Psychological distress correlated with caregiver burden at 6 weeks and 1 year postdischarge but not at 2 years postdischarge. ConclusionsThe trajectory of scores for psychological distress and HR-QOL was consistent with caregiver adaptation to the challenge of providing support to a person with SCI in the early postdischarge period. Caregiver burden did not display similar reductions but did not worsen over the study period.

Long-Term Outcomes of Joint Replacement Rehabilitation Patients Discharged From Skilled Nursing and Inpatient Rehabilitation Facilities

DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh C-H, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities. Objective To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design Postdischarge follow-up interview study at 7.5 months after admission. Setting Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs. Participants Patients (N=856): 561 with knee replacement and 295 with hip replacement. Interventions None. Main Outcome Measures FIM and Short-Form 12-Item Health Survey (SF-12). Results Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12–related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes. Conclusions At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.

Comparing Consequences of Right and Left Unilateral Neglect in a Stroke Rehabilitation Population

This article details right and left unilateral neglect (UN) in a stroke rehabilitation population. This prospective observational cohort study documented hemipersonal neglect and hemispatial neglect in 309 of 325 stroke rehabilitation patients consecutively admitted over a 28-month period. Shoulder-hand complications, safety concerns, length of stay, discharge function, and discharge destination were documented. Of the 85 with right UN and 113 with left UN, 17.7% had expressive aphasia, and 17.7% had mixed or receptive aphasia. Hemispatial neglect was associated with hemianopsia (29.2% and 31.8% for right and left, respectively). Having both hemipersonal neglect and hemispatial neglect was related to greater safety risk (46.9% vs. 24.3%), greater incidence of shoulder-hand complications (28.3% vs. 9.9%), lower FIM scores (>10 points lower), longer length of stay (8 days), and less likelihood of discharge to home (67.3% vs. 87.4%) than subjects without UN. Results were similar for those with right and left UN. Right and left UN occur after stroke, can be detected even in the presence of aphasia, and are associated with shoulder-hand problems, lower discharge function, and lower likelihood of discharge home. Having both hemispatial neglect and hemipersonal neglect impacts people more than having either type of UN alone.

Day-of-Injury Computerized Tomography, Rehabilitation Status, and Development of Cerebral Atrophy in Persons with Traumatic Brain Injury

To compare day-of-injury (DOI) computerized tomography (CT) findings with acute injury severity markers, disability at acute hospital admission and discharge from inpatient rehabilitation, injury severity markers, and degree of postacute cerebral atrophy on magnetic resonance imaging (MRI). Retrospective chart review of 240 consecutive traumatic brain injury (TBI) admissions (mean age 31.7 +/- 15.8 yrs) with moderate-to-severe initial brain injury. All DOI CT abnormalities were qualitatively rated. Disability was assessed using the Disability Rating Scale (DRS) and the FIM measure. In a representative subset, cerebral atrophy was determined by the ventricle-to-brain ratio (VBR) method and quantified from MRI scans 25 or more days postinjury. CT classification resulted in nonsignificant differences in DRS and FIM ratings at the time of discharge from the rehabilitation unit, except in brainstem injury subjects who had significantly higher DRS and lower FIM scores at rehabilitation discharge. At 25 or more days postinjury, presence of any DOI CT abnormality was associated with larger VBR. Increased VBR, as an index of cerebral atrophy, was associated with worse rehabilitation discharge DRS and FIM ratings. Other than brainstem injury, DOI CT findings relate poorly to rehabilitation outcome. Presence of DOI CT abnormalities were associated with the development of cerebral atrophy, which was associated with poorer rehabilitation discharge DRS and FIM scores.

Sex and Age Effects on Outcomes of Total Hip Arthroplasty After Inpatient Rehabilitation

Vincent HK, Alfano AP, Lee L, Vincent KR. Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation. Objective To retrospectively examine the effects of sex and age on the inpatient rehabilitation outcomes of patients after total hip arthroplasty (THA). Design Exploratory, retrospective study. Setting A university-affiliated rehabilitation hospital. Participants Male and female THA patients (N=332) were stratified into age brackets (<65y, 65–84y, ≥85y). All patients completed interdisciplinary inpatient rehabilitation. Interventions Not applicable. Main Outcome Measures Length of stay (LOS), FIM instrument scores, FIM efficiency (FIM/LOS), hospital costs, and discharge disposition location were collected by chart review. Results Regardless of age, women had lower FIM scores at admission and discharge than men ( P<.05). FIM efficiency was 22% to 53% lower for women in primary THA and 16% to 85% lower in revision THA than men ( P=.001). Women accrued higher total hospital charges than men ($13,099 vs $11,141; P<.05), and were discharged home less frequently than men (84.4% vs 90.9%; P<.05). Admission FIM scores were 10.6% and 8.9% lower and discharge FIM scores were 7.3% and 9.2% lower in patients 85 years or older than those less than 65 or 65 to 84 years ( P<.01). FIM efficiency was 25% to 38% higher in patients less than 85 years than those 85 years and older ( P=.015), and 37% higher in men than women ( P=.001). Patients 85 years and older were discharged less frequently to home than patients less than 85 years ( P<.05). Conclusions All patients made functional improvement after inpatient rehabilitation, but women and patients 85 years and older had longer LOS and lower FIM efficiency, incurred greater hospital charges, and were less likely to be discharged to home than men and younger counterparts.

Applying the Clinical Practice Improvement Approach to Stroke Rehabilitation: Methods Used and Baseline Results

Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. Objectives To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP). Design Prospective observational cohort study. Setting Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand. Participants Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs). Interventions Not applicable. Main Outcome Measures Change in FIM score, change in severity of illness, and discharge destination. Results For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4. Conclusions This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.

Influence of medical comorbidities and complications on FIM change and length of stay during inpatient rehabilitation.

This study was performed to evaluate the influence of medical problems on functional outcome measures of patients admitted for comprehensive inpatient rehabilitation. In this retrospective database review of patients, demographic information, length of stay, FIM scores at admission and discharge, and FIM efficiency were collected and analyzed. Preexisting comorbidities and acute medical complications of all patients were identified, tabulated, and analyzed. A total of 175 patients were categorized into three major groups. In the postorthopedic surgery group, the presence of preexisting medical comorbidities did not significantly affect admission or discharge FIM scores. In contrast, traumatic brain injury patients with preexisting medical comorbidities had a tendency to be admitted and discharged with lower FIM scores. However, traumatic brain injury patients with acute medical complications still made reasonable functional improvement during their extended stay, so that their FIM efficiency was adequately maintained. In the cerebrovascular accident group, almost all patients had preexisting medical issues. The rehabilitation population is diverse, and functional outcome measures for distinct disease entities may be differentially affected by factors such as preexisting medical comorbidities and acute medical complications. Except for life-threatening medical emergencies, rehabilitation patients may benefit by staying on the acute rehabilitation unit, where both medical management and a comprehensive rehabilitation program are provided with continuity.

Rehabilitation of stroke patients: clinical profile and functional outcome.

To describe the nature of functional recovery of 67 Turkish survivors of first-episode stroke who were referred for inpatient rehabilitation and to identify the variables that best predict discharge functional status of these patients. A retrospective, descriptive study of the demographic and clinical profile and the functional status of patients with first-episode stroke. The mean age was 60 (11.8, SD) yr, and 35.8% were men. The mean onset-admission interval and length of stay were 62.9 and 97.1 days, respectively. The mean functional status score, as measured by the FIM instrument, at the time of admission was 75 compared with 86.7 at the time of discharge, showing a mean improvement of 11.7. Although rehabilitation gains were similar for the right- and left-side involved groups, patients with right-side paresis had lower FIM scores at the time of admission than did the left-side involved group. Significant predictors of functional status at the time of discharge were admission functional status score and onset-admission interval. Knowledge of these predictors can contribute to more appropriate treatment and discharge planning.

The relation of shoulder pain and range-of-motion problems to functional limitations, disability, and perceived health of men with spinal cord injury: A multifaceted longitudinal study

Ballinger DA, Rintala DH, Hart KA. The relation of shoulder pain and range-of-motion problems to functional limitations, disability, and perceived health of men with spinal cord injury: a multifaceted longitudinal study. Arch Phys Med Rehabil 2000;81:1575-81. Objectives: To determine if shoulder pain and range-of-motion (ROM) problems can be predicted by demographic, injury-related, body weight, and radiographic data over 3 years and to determine the relationships among these shoulder problems and functional limitations, disability, and perceived health. Design: A longitudinal, 2-panel study in which data were collected at 2 points in time, 3 years apart. Setting: The community. Participants: Eighty-nine adult men with traumatic spinal cord injury (SCI) in the Houston–Galveston, TX, area. Main Outcome Measures: The acromioclavicular (AC) and the glenohumeral (GH) joints were x-rayed on plain film in standard anteroposterior position. Functional limitations were determined with the FIM™ instrument; disability was measured with the Craig Handicap Assessment and Reporting Technique (CHART). Results: Thirty percent had shoulder pain and 22% had shoulder ROM problems. Men with shoulder pain had lived longer with SCI, were more likely to report shoulder ROM problems, had lower CHART mobility scores, and were more likely to rate their health as fair than those without shoulder pain. Shoulder ROM problems were more common among men who were older, had AC joint narrowing, had lower FIM scores, and reported poorer health. Conclusion: Shoulder pain and ROM problems were relatively prevalent. Demographic, injury-related, and radiographic variables were identified that were predictive of these problems over a period of at least 3 years. The shoulder problems were related to functional limitations, disability, and perceived health. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation