Medical Rehabilitation Settings Research Articles

Predicting Falls in Musculoskeletal Rehabilitation: A Retrospective Multisite Study.

Fall represents one of the highest concerns in the healthcare system, especially in medical rehabilitation settings. However, there is a lack of instruments for the assessment of risk falls in the context of musculoskeletal rehabilitation. This retrospective multisite study aimed to assess the sensitivity and specificity of four fall risk assessment tools (the Functional Independence Measure, the Fall Risk Assessment, the Schmid Fall Risk Assessment Tool, and the ePA-AC) in predicting falls in patients admitted to musculoskeletal rehabilitation in Swiss inpatient facilities. The data relative to 6970 individuals (61.5% females) were analyzed and 685 (9.83% of patients) fall events were registered. The area under the curve (AUC) relative to the Functional Independence Measure was 0.689, 0.66 for the Fall Risk Assessment, 0.641 for the Schmid Fall Risk Assessment Tool, and 0.675 for the ePA-AC. Among the four tools, the Functional Independence Measure had an acceptable discriminatory power in distinguishing between significant events (i.e., patients' falls) and non-events (no falls). None of the assessed tools showed highly satisfying levels of statistical sensitivity or sensibility. However, the Functional Independence Measure could be used to assess the fall risk assessment in musculoskeletal rehabilitation settings, although with some caution, since this questionnaire was not designed for this diagnostic purpose. We strongly suggest urgently designing a tool for risk assessment that is specific to this population and the rehabilitative setting.

Making the visible seen: The interactional competence of a person in a disordered state of consciousness

We examine a 12-min video-recorded interaction among a patient (KN) in a disordered state of consciousness (DOC) and a speech language pathologist clinician (CL) that takes place in a medical rehabilitation setting. The video is a demonstration of how caregivers could use a clinical assessment to observe their loved one's behavior to communicate potential behavioral changes to healthcare professionals. The purpose of this paper is to make visible the communication practices used by participants that may not be obvious to researchers, medical rehabilitation practitioners, and clinical assessment developers. We use phenomenological, linguistic and conversation analytic approaches to analyze the interaction. We found that KN demonstrates multiple conversational competencies, some (but not all) of which are acknowledged by CL, and most of which are not directly addressed by the assessment scoring criteria. For example, KN demonstrates conversational competency by responding non-verbally to CL's prompts from the assessment protocol and following along with the unspoken rules of discourse. He does this primarily through gaze, which broadcasts the focus of his attention and actively signals his participation in the conversation. Though KN does not always respond correctly to CL's questions, he nevertheless demonstrates implicit conversational competencies during turns of talk such as returning to ‘neutral’ position which signals the completion of a turn of talk. KN's conversational competencies may be missed by CL and the assessment protocol but we argue that they are important in understanding KN's capacity. Our analyses show that competency is not simply a performance by one person who appropriately and correctly responds to a series of questions in a prescribed time frame. Competence is a collaborative achievement among participants, co-produced in situ, and influenced by linguistic and cultural habits of talk and epistemic norms that privilege clinical knowledge and expertise.

Pain Catastrophizing Mediates the Association Between Mindfulness and Psychological Distress in Chronic Pain Syndrome.

Trait mindfulness has been found to be inversely associated with emotional distress such as depression and anxiety among patients suffering from pain. The current study investigated the putative mechanisms underlying these associations by examining whether pain catastrophizing mediates the association between mindfulness and psychological distress and whether this model differs in patients suffering from chronic pain compared to patients experiencing nonchronic pain in a medical rehabilitation setting. Forty-eight patients in their subacute stage of recovery participated in the study. Seventeen participants had a diagnosis of chronic pain. Trait mindfulness was assessed using the Mindful Attention Awareness Scale, pain catastrophizing was assessed using the Pain Catastrophizing Scale, depression symptoms were assessed using the Patient Health Questionnaire, and anxiety was assessed using the Generalized Anxiety Disorder scale. Two mediation models were used, with pain catastrophizing mediating the association between mindfulness and depression and anxiety. Catastrophizing significantly mediated the association between trait mindfulness and depression (P<0.05, confidence interval [CI]=-0.35, -0.05). Catastrophizing also mediated the relationship between trait mindfulness and anxiety (P<0.05, CI=-0.34, -0.04). Two moderated mediation models were tested, in which pain catastrophizing fully mediated the relationship between trait mindfulness and depression and anxiety, but only in patients with chronic pain. The negative association between trait mindfulness and psychological distress may thus be partly attributed to pain catastrophizing: individuals high in trait mindfulness engage in less catastrophic thinking and therefore experience less distress. Importantly, this was only observed in the patients with chronic pain. These results further underscore the need to cope with pain catastrophizing and encourage mindfulness among patients with chronic pain.

Application of virtual environments in a multi-disciplinary day neurorehabilitation program to improve executive functioning using the Stroop task.

Virtual reality (VR) technology has demonstrated usefulness in diagnosis, education, and training. Studies supporting use of VR as a therapeutic treatment in medical rehabilitation settings remain limited. This study examines the use of VR in a treatment capacity, and whether it can be effectively integrated into neurorehabilitation. To determine whether immersive VR treatment interventions improve executive dysfunction in patients with brain injury and whether performance is stronger on a VR version of the Stroop than traditional Stroop formats. 15 patients with brain injury admitted to day neurorehabilitation. reaction time, inhibition, and accuracy indices on VR Stroop; Automated Neuropsychological Assessment Metrics (ANAM) Stroop, Delis-Kaplan Executive Function System Stroop, Golden Stroop, and Woodcock-Johnson, 3rd Edition (WJ-III): Pair Cancellation. Participants demonstrated significantly reduced response time on the word-reading condition of VR Stroop and non-significantly reduced response time on the interference condition. Non-significant improvements in accuracy and inhibition were demonstrated on the color-naming condition of VR Stroop. Significantly improved accuracy under time pressure was found for the ANAM, after VR intervention. Implementation of immersive VR interventions during neurorehabilitation is effective in improving specific executive functions and information processing speed in brain-injured patients during the subacute period.

Calibration and validation of an item bank for measuring general physical function of patients in medical rehabilitation settings.

ObjectiveThe objective of this study was to report the item response theory (IRT) calibration of an 18-item bank to measure general physical function (GPF) in a wide range of conditions and evaluate the validity of the derived scores.MethodsAll 18 items were administered to a large sample of patients (n=2337) who responded to the items in the context of their outpatient rehabilitation care. The responses, collected 1997– 2000, were modeled using the graded response model, an IRT model appropriate for items with two or more response options. Inter-item consistency was evaluated based on Cronbach’s alpha and item to total correlations. Validity of scores was evaluated based on known-groups comparisons (age, number of health problems, symptom severity). The strength of a single, general factor was evaluated using a bi-factor model. Results were used to evaluate IRT assumption and as an indicator of construct validity. Local independence of item responses was also evaluated.ResultsResponse data met the assumptions of unidimensionality and local independence. Explained common variance of a single general factor was 0.88 (omega hierarchical =0.86). Only two of the 153 pairs of item residuals were flagged for local dependence. Inter-item consistency was high (0.93) as were item to total correlations (mean =0.61). Substantial variation was found in both IRT location (difficulty) and discrimination parameters. All omnibus known-groups comparisons were statistically significant (p<0.001).ConclusionItem responses fit the IRT unidimensionality assumptions and were internally consistent. The usefulness of GPF scores in discriminating among patients with different levels of physical function was confirmed. Future studies should evaluate the validity of GPF scores based on an adaptive administration of items.

Development of an Arabic inpatient satisfaction survey: application in acute medical rehabilitation setting in Saudi Arabia

BackgroundIn the management of chronic disease, evidence suggests that satisfied patients exhibit more loyalty to treatment providers and greater adherence to treatment regimens. This is particularly so in the rehabilitation setting. We aimed to develop a reliable and valid Arabic-language survey to objectively measure inpatient satisfaction in medical rehabilitation settings in Saudi Arabia.MethodsThe King Fahad Medical City Rehabilitation Hospital Patient Satisfaction Survey (RH PSS) is a self-administered survey that addresses four domains of rehabilitation care: access, structure, process, and outcomes. The RH PSS was developed through four steps. Step 1: An item-generation process utilizing input from patients, rehabilitation professionals, and the relevant literature. Step 2: Individual interviews and focus groups, conducted for cognitive testing of the survey and to examine content validity. Step 3: Assessment of internal consistency and construct validity. Step 4: Survey implementation wherein factor analysis and reliability and validity testing were conducted. The survey was conducted at an acute inpatient medical rehabilitation hospital in Saudi Arabia. A total of 709 rehabilitation inpatients participated.ResultsThe RH PSS demonstrated reasonable reliability and validity. Cronbach’s alpha for all the RH PSS subscales ranged from 0.81 to 0.89, and 0.96 for the entire survey. Factor analysis showed good correlation of the 33 survey items and the subscales. The RH PSS demonstrated a good level of predictive validity through the high correlation between the global item “intent to recommend” and overall satisfaction (R2 = 0.786, adjusted R2 = 0.783, p = 0.01).ConclusionsThe RH PSS is the first satisfaction survey with reported validity and reliability testing to address inpatient rehabilitation settings in Saudi Arabia. Further research involving multiple sites is recommended for nationwide validation.

Mediating Music and Culture in Medical Rehabilitation Settings

In this article, I highlight ways in which ethnomusicology-centered skills can be adapted for educational, practice-based, and research-based cross-disciplinary settings where topics of music and health intersect, by focusing on recurring issues that I have encountered and negotiated as an ethnomusicologist and music educator. These issues include determining the role of the ethnomusicologist in collaborative settings and developing awareness of cross-disciplinary considerations. Through discussion of project design and methodology, I explain how I have negotiated post-injury and program-based needs through practical applications of ethnomusicology to facilitate community integration through music in a community-based rehabilitation program for individuals recovering from traumatic brain injury.

The effectiveness of health education using the teach-back method on adherence and self-management in chronic disease: a systematic review protocol

Review question/objective What is the effect of using the teach-back method for health education to improve adherence to treatment regimen and self-management in chronic disease? Inclusion criteria Types of participants This review will consider all studies that include adult patients (aged 18 years and over) in any healthcare setting, either as inpatients (eg acute care, medical and surgical wards) or those who attend primary health care, family medical practice, general medical practice, clinics, outpatient departments, rehabilitation or community settings. Participants need to have been diagnosed as having one or more chronic diseases including heart failure, diabetes, cardiovascular disease, cancer, respiratory disease, asthma, chronic obstructive pulmonary disease, chronic kidney disease, arthritis, epilepsy or a mental health condition. Studies that include seriously ill patients, and/or those who have impairments in verbal communication and cognitive function will be excluded. Types of intervention This review will consider studies that investigate the use of the teach-back method alone or in combination with other supporting education, either in routine or research intervention education programs; regardless of how long the programs were and whether or not a follow-up was conducted. The intervention could be delivered by any healthcare professional. The comparator will be any health education for chronic disease that does not include the teach-back method. Types of outcomes Primary outcomes of interest are disease-specific knowledge, adherence, and self-management knowledge, behavior and skills measured using patient report, nursing observation or validated measurement scales. Secondary outcomes include knowledge retention, self-efficacy, hospital readmission, hospitalization, and quality of life, also measured using patient report, nursing observation, hospital records or validated measurement scales.

Comparison of Discharge Functional Status After Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients After Hip Fracture Repair

ObjectiveTo examine differences in rehabilitation outcomes across 3 post-acute care (PAC) rehabilitation settings for patients after hip fracture repair. DesignProspective, observational cohort study. SettingSix skilled nursing facilities (SNFs), 4 inpatient rehabilitation facilities (IRFs), and 8 home health agencies (HHAs) in 10 states. ParticipantsPatients (N=181) receiving PAC rehabilitation following hip fracture with internal fixation (n=116) or total hip replacement (n=64), or no surgical intervention (n=1). InterventionsNot applicable. Main Outcome MeasureSelf-care and mobility status at PAC discharge measured by the Inpatient Rehabilitation Facility Patient Assessment Instrument. ResultsIRF and HHA patients had lower self-care function at discharge relative to SNF patients controlling for patient characteristics, severity, comorbidities, and services. Adding length of stay (LOS) resulted in nonsignificant differences between IRFs and SNFs. In contrast, there was no setting-specific advantage in discharge mobility for patients with or without the addition of LOS. The average LOS of HHA patients was 2 weeks longer than that of SNF patients, whose average LOS was 9 days longer than that of IRF patients (average, 15d). IRF and SNF patients received about the same total minutes of therapy over their PAC stays (∼2100min on average), whereas HHA patients received only approximately 25% as many minutes. ConclusionsSetting-specific effects varied depending on whether self-care or mobility was the outcome of focus. It remains unclear to what extent rehabilitation intensity or natural recovery effects changes in functional status for patients with hip fracture. This study points to important directions for PAC setting comparative effectiveness studies in the future, including uniform measurement, limited consensus on factors affecting recovery, accounting for selection bias, and using end-point data collection that is at the same follow-up time periods for all settings.

Nurse practitioners in medical rehabilitation settings: A description of practice roles and patterns

To describe nurse practitioner (NP) roles in medical rehabilitation settings. Description of practice by rehabilitation NPs and physicians. NPs increasingly function in medical rehabilitation settings as independent or collaborative care providers. This article describes their roles at a large rehabilitation institute in acute care consultation/liaison, acute rehabilitation, and ambulatory settings. The organization has experienced greater physician efficiency and practice scope, without erosion of subjective or objective quality measures and outcomes. The authors provide specific examples of NP roles in intrathecal baclofen and cancer rehabilitation programs. Advanced practice nurses can provide efficacious care to people with disabilities, resulting in cost savings, improved outcomes, and high value. Patient care by NPs is beneficial for the physicians so that they may extend their clinical realm, spend more time doing research, and participate in medical leadership.

Predictors of Discharge to Acute Care after Inpatient Rehabilitation in Severely Affected Stroke Patients

This study aimed to determine the predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients. This was a retrospective study using data from the Uniform Data System for Medical Rehabilitation (UDSMR) between 2008 and 2009. The main outcome variable was discharge location, which included discharge to acute care or discharge to the community after inpatient rehabilitation. The study sample included 223 of the most severely affected stroke patients (Case-Mix Group 0110 of Medicare reimbursement classification), of whom 86 were discharged to acute care from after the inpatient medical rehabilitation setting; 137 similarly classified stroke patients were discharged to the community after inpatient medical rehabilitation. The variables examined were Functional Independence Measure ratings, co-morbid medical conditions, and four groups of stroke-related neurologic deficits (hemiparesis, dysphagia, language deficits, and other stroke-related neurologic deficits). The groups were devised based on International Classification of Diseases, 9th Revision codes. There were no significant demographic differences between the two groups-those discharged to the acute care hospital and those discharged to the community. There was a difference in admission Functional Independence Measure ratings, whereby patients discharged to acute care were significantly lower (P < 0.05) on admission motor and cognitive function than were patients discharged to the community. When controlling for 19 groups of co-morbid medical conditions and 4 groups of stroke-related neurologic deficits, there was no significant difference between patients being discharged to an acute care hospital and those discharged to the community. In the current study, controlling for impairment (stroke), severity of condition, demographic variables, inpatient rehabilitation admission day of the week and discharge day of the week, prehospitalization living setting, prehospitalization living with (alone, family, other), payer (secondary insurance coverage), onset days, co-morbid medical conditions, and classification of stroke-related neurologic deficits, the only variable predictive of discharge to the acute care hospital from an inpatient rehabilitation facility is function at admission, mainly the admission motor Functional Independence Measure rating. If clinicians routinely assess the functional status of patients during the preadmission screening process, it may aid in identifying whether the patient is at an increased risk of being readmitted to the acute care hospital.

Future of Outcomes Measurement: Impact on Research in Medical Rehabilitation and Neurologic Populations

Quatrano LA, Cruz TH. Future of outcomes measurement: impact on research in medical rehabilitation and neurologic populations. The National Institutes of Health (NIH) has embraced the investigation and development of health-related patient-reported outcomes (PROs) for their potential use in clinical trials, as well as in examining health care reimbursements and regulatory affairs. The NIH has 3 major programs to address this topic: the Patient-Reported Outcomes Measurement Information System (PROMIS), NIH Toolbox for Assessment of Neurological and Behavioral Function, and Quality of Life in Neurological Disorders (Neuro-QOL), a health-related quality-of-life assessment tool for adults and children with neurologic disorders. These initiatives are focused on developing, validating, and measuring aspects of health by using assessment tools that bridge disease type. Given that rehabilitation takes place across a variety of environments with differing levels of specialized equipment and skilled personnel, PROs may provide consistent measures over time and therefore are anticipated to have substantial impacts on the medical rehabilitation community. Despite their advantages, the widespread use of PROs in rehabilitation faces significant and diverse challenges. This article describes the background behind the NIH PRO initiatives and illustrates both potential benefits and challenges to PRO use in the medical rehabilitation setting.

A Comparison of Discharge Functional Status After Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients After Lower-Extremity Joint Replacement Surgery

Mallinson TR, Bateman J, Tseng H-Y, Manheim L, Almagor O, Deutsch A, Heinemann AW. A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery. Objective To examine differences in outcomes of patients after lower-extremity joint replacement across 3 post–acute care (PAC) rehabilitation settings. Design Prospective observational cohort study. Setting Skilled nursing facilities (SNFs; n=5), inpatient rehabilitation facilities (IRFs; n=4), and home health agencies (HHAs; n=6) from 11 states. Participants Patients with total knee (n=146) or total hip replacement (n=84) not related to traumatic injury. Interventions None. Main Outcome Measure Self-care and mobility status at PAC discharge measured by using the Inpatient Rehabilitation Facility Patient Assessment Instrument. Results Based on our study sample, HHA patients were significantly less dependent than SNF and IRF patients at admission and discharge in self-care and mobility. IRF and SNF patients had similar mobility levels at admission and discharge and similar self-care at admission, but SNF patients were more independent in self-care at discharge. After controlling for differences in patient severity and length of stay in multivariate analyses, HHA setting was not a significant predictor of self-care discharge status, suggesting that HHA patients were less medically complex than SNF and IRF patients. IRF patients were more dependent in discharge self-care even after controlling for severity. For the full discharge mobility regression model, urinary incontinence was the only significant covariate. Conclusions For the patients in our U.S.-based study, direct discharge to home with home care was the optimal strategy for patients after total joint replacement surgery who were healthy and had social support. For sicker patients, availability of 24-hour medical and nursing care may be needed, but intensive therapy services did not seem to provide additional improvement in functional recovery in these patients.

The redevelopment and validation of the Rehabilitation Adherence Questionnaire for injured athletes

This study was designed to redevelop and examine the validity of the Rehabilitation Adherence Questionnaire (RAQ), which can be used in both research and medical rehabilitation settings. The participants in the study were composed of 240 injured athletes (first analysis 120, second analysis 120 athletes) who participated in a physical rehabilitation program. Scale development, descriptive analysis, and factor analysis (exploratory factor analysis, confirmatory factor analysis) developed 25 items of RAQ for injured athletes. RAQ had six subscales such as support from significant others (five items), pain tolerance (five items), scheduling (four items), self-motivation (five Items), perceived exertion (three items), and environmental conditions (three items). Criterion-related validity, differential validity, and test-retest reliability of RAQ indicated that RAQ can be used both in clinic-based study and rehabilitation settings. In summary, this study showed good psychometric properties of RAQ.

Eigenschaften und Nutzen des Rasch-Modells in der klinischen Diagnostik

In medical rehabilitation settings the use of appropriate assessment instruments is essential in many ways. A high quality of psychometric scales has to be ensured in order to allow for an appropriate interpretation of diagnostical data as well as for the evaluation of treatment outcomes and for quality assurance within rehabilitation clinics. Assessment scales developed by means of Rasch analysis possess desirable properties, especially because person parameters reach interval level by definition, and the assumption of only one latent dimension suffices to predict respondents behaviour sufficiently. Accordingly, Rasch scales are strictly one-dimensional and thus allow for unambiguous interpretation of diagnostic results. In this article it is shown which specific properties characterize Rasch scales and how Rasch analysis can be used in order to allow for a more differentiated and clinically meaningful data interpretation and to enhance analysis of clinical data.

Early Work-Related Interventions in a Medical Rehabilitation Setting

AbstractEarly work-related interventions are extremely difficult when an employee is on long-term absence and in medical rehabilitation because of a severe illness or injury. The role of the medical rehabilitation setting is often focused on care and cure; there is little focus on work and work resumption. In this respect health care can hinder employees in their work resumption and in their focus on work. In this study, an intervention was undertaken to increase the focus on return to work in the medical rehabilitation setting with the aim of an integrated approach to return to work. The intervention was carried out in eight rehabilitation settings. During implementation, four different organisational models related to the return-to-work activities were recognised, varying from an integration of return-to-work activities within medical rehabilitation to a complete separation of the medical rehabilitation and the return-to-work activities. Every centre reported an increase of work-related activities and an increase in the return-to-work rate of employees was found.

Prevalence of cognitive impairment in medical rehabilitation settings for older people

This paper considers findings with respect to the frequency with which cognitive impairment occurs in physician led community hospital rehabilitation service settings for older people. Particularly in light of the relevant National Service Framework this has implications for staffing, staff training and liaison psychiatry access with respect to these services.

Validating a self-medication risk assessment instrument

Summary Objectives The purpose of the study was to refine and validate the self-medication risk assessment instrument for use as a reliable screening method to identify people who may have difficulty managing their medication safely. Specific objectives of the study were to demonstrate the reliability of the instrument. Design The study, using a correlational design, was designed to test inter- and intra-rater reliability of the instrument using a sample of 45 patients and 45 pairs of assessors. Each pair of assessors assessed the same patient on the same day and one of the original assessors returned to reassess the patient approximately one week later. Setting The data collection took place in Acute medical and Community Rehabilitation settings and via Community Nursing, Pharmacy and Social Care staff in Hull and the East Riding of Yorkshire. Participants 45 patients and 45 pairs of assessors from Nursing, Pharmacy and Social Care backgrounds. Main Outcome measures Reliability of the instrument when used by different and same assessors and identification of key risk factors related to self-medication risk assessment. Results The instrument has demonstrated strong inter- and intra-rater reliability for both outcome of assessment findings and risk category. Three key elements of the assessment criteria, mental state, attitude and knowledge about medications and severe visual impairment demonstrated a high level of criterion validity. Conclusion The self-medication assessment instrument shows promise in terms of reliability but further testing is required to demonstrate its validity and the possible weighting of individual items in the instrument.

Cultural competence in the multidisciplinary rehabilitation setting: are we falling short of meeting needs?

Niemeier JP, Burnett DM, Whitaker DA. Cultural competence in the multidisciplinary rehabilitation setting: are we falling short of meeting needs? Arch Phys Med Rehabil 2003;84:1240–5. We present issues relevant to rehabilitation providers who wish to develop or improve their cultural competence in their medical setting and interdisciplinary team. Two case scenarios are presented that illustrate the complexities introduced into the medical rehabilitation setting by the increased numbers of minority patients in the United States in the last 20 years. Professional codes of conduct and practice are discussed for 3 rehabilitation disciplines: physiatry, rehabilitation psychology and neuropsychology, and nursing. The current status of and improvements in professional and continuing medical education are then outlined. Challenges faced by rehabilitation providers seeking to become more culturally competent in their practices are related in the following topic areas: (1) continuing education in language and cultural issues, (2) assessment instruments appropriate for diverse patient populations, (3) majority versus minority population values and beliefs, (4) impact of the immigration and acculturation experiences, (5) health care and insurance coverage issues, (6) attitudes and beliefs about disability, and (7) past experiences with medical professionals and systems. Suggestions for developing and applying enhanced cultural awareness in clinical rehabilitation practice are provided.

Relationship between illness, rehabilitation and work (ZERA)--an training program for medical-vocational rehabilitation of the mentally ill

A training programme for rehabilitation of people with mental illness is presented, designed particularly for schizophrenic patients who need occupational rehabilitation. The training goal is to connect aspects of the schizophrenic disorder with vocational issues. It is aimed at supporting the participants in developing a realistic and appropriate vocational perspective in line with their illness related restrictions and current vocational possibilities, seeking to find out the individual's optimal ability to take stress so as to avoid over- or understimulation in vocational respects. The ZERA training has been developed for implementation in different medical and vocational rehabilitation settings for persons with mental illness. An initial control-group study was carried out to evaluate the effectiveness of this group training approach, and preliminary results have revealed changes in the experimental group in accordance with the objectives of the training and encourage further research.