Neurological Rehabilitation Unit Research Articles

Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit

Objectives: The recent National Service Framework for Long Term Conditions recommends that patients participate more in decision making about their care. However, few protocols exist to support this. One potentially...

Incontinence after brain injury: prevalence, outcome and multidisciplinary management on a neurological rehabilitation unit

Objective: To investigate the prevalence, outcome and multidisciplinary management of incontinence in patients with acquired brain injury. Design: Retrospective case notes review. Setting: Regional neurological rehabilitation unit. Subjects: Two hundred and thirty-eight patients with acquired brain injury. Main measures: Bladder and bowel subscores of the Barthel Index and Functional Independence Measure; number of multidisciplinary goals addressing bladder and bowel function. Results: Fifty per cent of patients (n=112) had impaired bladder or bowel subscores on admission. Significant improvement was seen at discharge but 36% of patients (n=77) still had some degree of impairment. Over 90% of patients were set multidisciplinary goals addressing self-care (n=213) and mobility (n=205) but only 3.5% (n=8) were set multidisciplinary goals addressing bladder and bowel function. Conclusions: Incontinence was common in patients with brain injury on a neurological rehabilitation unit. Significant improvement was seen following rehabilitation. Bladder and bowel management was not well incorporated into the multidisciplinary management process.

PR_034: Specialized Rehabilitation for Complex Neurodisability: Do Longer Stay Programs Provide Value for Money?

Objectives: To examine the cost-benefits of longer stay inpatient rehabilitation for severely dependent patients: can continued rehabilitation beyond 4 months be justified by savings in the cost of ongoing care? Design: Longitudinal cohort analysis of serial change in fortnightly dependency ratings recorded during admission for rehabilitation. Setting: A specialist regional neurologic rehabilitation unit in the U.K. Participants: 51 of 410 consecutive admissions over 5 years met the inclusion criteria of high dependency (Northwick Park Dependency Scale and Care Needs Assessment [NPDS] score >25 points) on admission and length of stay (LOS) >125 days. Mean age ± SD of 39±17 years. Intervention: A postacute rehabilitation program for adults with complex neurologic disability of any cause. Main Outcome Measures: The NPDS, which provides a generic estimation of dependency, care hours, and weekly cost of continuing care in the community. Data were normally distributed (Kolmogorov-Smirnov, P>.05) so parametric statistics were applied. Results: The mean total LOS was 184±56 days (maximum, 312d) and mean cost of admission £52,443±£19,252 (US $91,775). The overall mean reduction in dependency from admission to discharge (NPDS score, 22±11 points) equated to weekly savings in care costs of £949±£62 (US $1660), which would have offset the cost of rehabilitation within 14 months. During the latter stages of admission (ie, between 4 months and discharge [mean, 58±56 days later]), smaller but significant changes were still demonstrated in dependency (t test, t=4.8, P<.000) and care costs (t test, t=2.0, P<.05). The mean additional cost of rehabilitation beyond 4 months (£16,766±£17,334) would be offset by savings in cost of care (mean, £114±£399 [US $200/wk]) within 36 months. Conclusions: The additional investment in longer-stay rehabilitation for this young and complex group of patients was offset by savings in the cost of care over a timeframe, which was short in comparison with their overall life expectancy.

Use of the Barthel Index and the Functional Independence Measure during early inpatient rehabilitation after single incident brain injury

Objective: To compare the appropriateness and responsiveness of the Barthel Index and the Functional Independence Measure (FIM) during early inpatient rehabilitation after single incident brain injury. Design: Cohort study. Setting: A regional neurological rehabilitation unit. Patients: Two hundred and fifty-nine consecutive patients undergoing inpatient comprehensive neurological rehabilitation following a vascular brain injury due to single cerebral infarction (n=75), spontaneous intracerebral haemorrhage (n=34) and subarachnoid haemorrhage (n=43), and 107 patients who had sustained traumatic brain injury. Measurements: Admission and discharge FIM total, physical and cognitive scores and the Barthel Index were recorded. Appropriateness and responsiveness in the study samples were determined by examining score distributions and floor and ceiling effects, and by an effect size calculation respectively. Non-parametric statistical analysis was used to calculate the significance of the change in scores. Results: In all patient groups there was a significant improvement (Wilcoxon's rank sum, P < 0.0001) in the Barthel Index (mean change score: vascular 3.9, traumatic 3.95) and FIM (mean change score: vascular 17.3, traumatic 17.4) scores during rehabilitation, and similar effect sizes were found for the Barthel Index (effect size: vascular 0.65, traumatic 0.55) and FIM total (effect size: vascular 0.59, traumatic 0.48) and physical scores in all patient groups. In each patient group the cognitive component of the FIM had the smallest effect size (0.35-0.43). Conclusions: All measures were appropriate for younger (less than 65 years of age) patients undergoing early inpatient rehabilitation after single incident vascular or traumatic brain injury. The Barthel Index and the total and physical FIM scores showed similar responsiveness, whilst the cognitive FIM score was least responsive. These findings suggest that none of the FIM scores have any advantage over the Barthel Index in evaluating change in these circumstances.

Medico-legal and ethical aspects in the management of wandering patients following brain injury: Questionnaire survey

Background. Different methods are often used to deter head injury patients, who have a tendency to wander, from leaving the rehabilitation wards. The extent to which these patients could be restrained is controversial. Despite the fact that the majority of these patients lack mental capacity, Mental Health Act sections are rarely invoked. Under common law, informal patients should have the right to refuse treatment and to leave the hospital whenever they like.Objective. To examine the current practice in the management of wandering patients following brain injury in rehabilitation units in the UK and to formulate practical guidelines based on this common practice.Methods. A postal survey in the form of a structured questionnaire was sent to 58 consultants in Rehabilitation Medicine and Neuropsychologists based at different neurological rehabilitation units in the UK.Results. A total of 30 clinicians (52%) completed the questionnaire. One-to-one supervision was the method most commonly used to manage wandering patients (83%) followed by implementation of a structured daily routine (73%) and the use of different medications (70%). Only 17% would lock the door without giving the patient lock combination/key and another 17% would physically restrain the patient without invoking mental health act (MHA) section; 60% would consider MHA section with great variability in the mental health team response time and the place where patient is managed once under MHA section.Conclusions. The questionnaire showed great variations in the methods and the medico-legal framework used in the management of wandering patients. There was, however, a tendency to avoid physical restraint which may reflect the recognition of the unlawfulness of detaining informal patients.

Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: How guidelines change management

Purpose. To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).Method. A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.Results. Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.Conclusions. Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.

Opsoclonus myoclonus following allogeneic haematopoietic stem cell transplantation

A 30-year-old woman with relapsed acute myeloid leukaemia (AML) underwent allogeneic haematopoietic stem cell transplantation (HSCT) in second complete remission, from a male matched unrelated donor in August 2004. There was a single mismatch at the DQB1 allele. The patient was conditioned with total body irradiation 14.4 Gy in six fractions, cyclophosphamide 120 mg/kg and CAMPATH 1H, with short-course methotrexate and cyclosporin A for graft-versus-host disease prophylaxis. She was readmitted at day 60 post transplant complaining of a week history of vague abdominal pain and diarrhoea, as well as feeling 'shaky'. On examination, she had a coarse jerking tremor, ataxia, dysdiadochokinesis and a marked inability to follow movement with her eyes. Abdominal examination was normal. The cyclosporin level was acceptable at 122 nmol/l, and brief discontinuation made no improvement in her symptoms. CT and MRI brain were normal, as was CSF taken at lumbar puncture. There was marked further deterioration in both speech and tremor, and the empirical use of foscarnet to cover the possibility of HHV 6 infection was also of no benefit. Bone marrow examination showed her to still be in morphological remission, although chimerism was 83% donor. A neurology opinion was sought, and a clinical diagnosis of opsoclonus myoclonus (OM) was made. Anti-Hu antibody was tested and was negative. A slow spontaneous recovery in symptoms occurred over the next 4 weeks and the patient was transferred to a neurological rehabilitation unit. Unfortunately, she suffered a frank haematological relapse of her AML a month later and ultimately died of her disease.

Structural quality of neurologic rehabilitation clinics

In 2003, criteria for assessing the structural quality of rehabilitation units for inpatient treatment were developed in cooperation with the German statutory pension insurance and health insurance. The aim of this study was to assess this quality using predefined valuation criteria and to test their applicability. In the context of the Quality Assurance Programme for Rehabilitation provided by the German statutory health insurance, the structural quality of 18 neurological rehabilitation units was assessed applying the criteria for the first time. On average, the 18 rehabilitation units fulfilled 93.9% of the basic criteria. Despite this high proportion, variability in the degree of realisation in the individual rehabilitation units could be demonstrated. The basic criteria are realistic in respect to the structural requirements, without leveling out the differences between the centres. Assessing the structural quality of rehabilitation units on the basis of defined standards allows for a benchmark between units as well as for improvements within the individual units.

The impact of inpatient neurorehabilitation on psychological well–being on discharge and at 3 month follow–up

Neurological rehabilitation aims to improve quality of life of patients with acute and chronic neurological conditions. Much of the existing research focuses on the impact of rehabilitation on physical functioning, with less emphasis on emotional wellbeing. This study assessed changes in psychological functioning in patients on discharge from rehabilitation and three months after discharge. Patients admitted over a six-month period to a neurological rehabilitation unit were recruited prospectively to this study. Psychological functioning was measured by the self-report General Health Questionnaire and the Hospital Anxiety and Depression Scale. In addition, physical functioning was measured by the Barthel index and Functional Independence Measure. Psychological functioning was found to be significantly improved with rehabilitation. However, after three months, patients' scores returned to pre-treatment values. Anxiety was consistently elevated on admission, discharge and follow-up. In contrast, physical functioning improved from admission to discharge and was maintained at follow-up assessment. Rehabilitation services need to focus more on psychological functioning after discharge and identify effective strategies to maintain wellbeing.

Incidence, circonstances et conséquences des chutes chez les patients en rééducation après un premier accident vasculaire cérébral

Objectives. – To describe the incidence, circumstances, and consequences of falls in patients admitted in a rehabilitation ward after a stroke. Methods. – Prospective monitoring of falls over four years in a neurological rehabilitation unit. Use of fall registry. Inclusion criteria: age < 75 years, admission < 45 days after stroke onset, single stroke of 1 cerebral hemisphere (nonlacunar) or of the brain stem. Only falls due to loss of balance were considered; falls caused by a seizure or syncope were not considered. Results. – Of 217 consecutive patients with the inclusion criteria, 34 had fallen at least once (15.7%) and 10 twice (4.1%). Fall incidence, defined as the number of falls per patient per day was 2.2 per thousand. Half of the patients fell the first three weeks after admission. Most falls involved getting to or from the wheelchair or the bed; 1 patient had recovered minimal postural abilities at the gym but was not independent. Traumatic lesions were noted in 13 patients: they were minor in nine and severe in four, including three fractures. Conclusion. – Falls due to loss of balance are a major problem in patients undergoing rehabilitation after a stroke. Getting to and from wheelchairs in the bedroom and bathroom by patients who are not allowed to do so play a key role in many falls. Prevention programs should consider this information.

Prevention of falls in hospital inpatients

The recommendations of Dr Vassallo and his colleagues (June 2004 JRSM1) for prevention of falls in patients with unsafe gait, by simple risk stratification and targeting, seem a notably practical option. They identify confusion and previous falls as the main predictors. It is important to highlight that most of the patients in the study were elderly (mean age 82 years). Falls are also very troublesome in post-acute rehabilitation in younger patients. The Alderbourne Neuro-rehabilitation Unit treats a younger age group of patients with traumatic brain injury, multiple sclerosis, strokes, and non-traumatic spinal cord injury. The average age in May 2004 was 56. We audit all the incident forms pertaining to falls on the unit and a pattern similar to that observed by Vassallo et al. is emerging. During the eighteen months January 2003 to June 2004 there were 34 falls recorded among inpatients admitted for rehabilitation. 19 (55%) were isolated incidents but the other 15 were recurrent falls (6 patients with an average of 2.5 falls each). All of these fallers had cognitive impairment. Whilst most of these falls only resulted in minor injury, 2 resulted in trauma sufficient to affect the ability to participate in rehabilitation and increased the length of stay. Whilst a history of previous falls is a predictor of potential risk of future falls, cognitive impairment is the other predictor that requires highlighting. Low scores on three items of the admission Functional Independence Measure (a standardized outcome measure regularly used on neurological rehabilitation units)—namely, comprehension, memory and safety awareness—coupled with a history of falls, should assist in the risk assessment process for these patients. Having identified patients at high risk of falls the interventions to prevent further falls that have been reviewed include alert bracelets,2 attention to flooring,3 and corridor lighting, additional exercises as well as a multidisciplinary multiple intervention programme including the use of hip protectors. Vassallo et al. state that the 'arguments for a multifactorial intervention remain weak'. However in a randomized controlled trial Haines et al.4 showed a 30% reduction in falls using a targeted multiple interventions falls prevention programme. Chang et al.5 likewise concluded that such programmes are effective.

Patient dissatisfaction: insights into the rehabilitation process.

Most patients admitted for inpatient rehabilitation find it beneficial even when there is little change in physical disability. The aim of this study was to determine the characteristics of patients who felt that they had not benefited from inpatient rehabilitation and to delineate the underlying reasons for this perception. From a database of 331 patients admitted to a neurological rehabilitation unit over a three-year period, we ascertained those with a low score (< 5) on a self-rated visual analogue scale (VAS) regarding their perception of the benefit of rehabilitation. We investigated their disability outcomes, aspects of the rehabilitation process through analysis of integrated care pathways, and from inspection of the multidisciplinary record identified specific adverse factors which might contribute to dissatisfaction. Low VAS scores were detected in 6% of patients (n = 19). These did not correlate with baseline demographic factors or disability levels, but were associated with unresolved external problems regarding community care and accommodation, and conflicts between patients and therapists. We conclude that from the patients' perspective, successful inpatient rehabilitation depends on adequate attention given to community-based issues and health care professionals recognising patients' needs. When these two conditions are not fulfilled, patients are more likely to express a lack of satisfaction with their rehabilitation.

Rehabilitation outcomes after brain injury: disability measures or goal achievement?

The outcome of rehabilitation interventions following brain injury is commonly rated by disability scales. Goal-setting and achievement are important in inpatient rehabilitation, but seldom assessed as outcomes. To compare the information acquired from using disability ratings and goal attainment/variances as outcome measures in brain injury rehabilitation. An inpatient regional neurological rehabilitation unit. One hundred and seventy-seven patients admitted after single incident brain injury over a three-year period. (1) Disability outcomes by the Barthel Index and the Functional Independence Measure, (2) goal achievement and variance distribution, and (3) the influence of diagnosis and demographics on these measures. Patients improved significantly on all disability scales employed (p < 0.0001), with the baseline admission scores being inversely correlated with changes in dependency by discharge (rho approximately -0.4). The median attainment rate of long-term goals was 75% per patient. Nonachievement was most frequently due to cognitive problems (38%), followed by behavioural difficulties and physical limitations (18% each). Goal achievement correlated poorly with disability outcome at discharge (rho < 0.3). Patients who accomplished all their goals tended to be less disabled at admission. Diagnostic groups and demographic factors had little influence on either disability or goal achievement outcomes. The use of a simple goal achievement and variance coding scheme has been relatively straightforward to incorporate into the daily practice of the unit. It provides useful information on rehabilitation process and outcome after brain injury that is complementary to the utilization of disability measures.

Integrated care pathways: disease-specific or process-specific?

conventional teaching on integrated care pathways (ICP) suggests that they have to be specific both to a particular setting and to a specific diagnosis. We wished to explore the potential for a generic process-based care pathway. we evaluated three different, disease-specific ICPs in use on a neurological rehabilitation unit to identify prompts common to and differing between them. Variance types and goal outcomes in all three diagnostic groups were compared. 93% of prompts on the care pathway were common to all three diagnostic groups. The prompts that differed were unique to each diagnostic group and provided important guidelines about management. in neurorehabilitation, where the process of multidisciplinary care is well defined, it is possible to develop a process-based ICP. Process-based ICPs may not be unique to rehabilitation but may also be relevant to other settings in which patients with differing diagnoses share similar needs.

A review of the management of Guillain-Barr?? syndrome in a regional neurological rehabilitation unit

A database search was performed to identify all patients presenting to a Rehabilitation Centre over a five-year period with a confirmed diagnosis of Guillain-Barré syndrome. Retrospective analysis of acute and rehabilitation hospital notes was performed and information on demographics, management and outcome obtained. There were equal numbers of males and females with an average age of 36 years. 75% had a prodromal illness and 62.5% presented with distal paraesthesia. 75% exhibited cranial nerve signs and 62.5% required artificial ventilation for a prolonged period. The investigations performed and treatment given varied and did not always coincide with current evidence. An aetiological agent was identified in 50%. There were a wide variety of complications in the acute hospital and the inpatient stay was prolonged in all but 1. There was one complication after transfer to the rehabilitation unit and statistical analysis of the admission and discharge FIM scores revealed a statistically significant improvement in outcome (p = 0.013). There is currently no consensus on the management of patients with GBS in the acute setting despite a wide evidence base. Many patients are being discharged without access to rehabilitation services. Our results suggest that rehabilitation makes a measurable and significant difference and should be available to all patients with GBS.

A review of the management of Guillain-Barré syndrome in a regional neurological rehabilitation unit

A review of the management of Guillain-Barré syndrome in a regional neurological rehabilitation unit

Does neurorehabilitation have a role in relapsing-remitting multiple sclerosis?

Patients with relapsing-remitting multiple sclerosis (RR MS) often make incomplete recovery from disabling exacerbations, despite corticosteroid treatment. Inpatient rehabilitation has been shown to be valuable in progressive MS, but its role in RR MS is less clear. We evaluated the effect of rehabilitation in consecutive patients with RR MS admitted to a neurological rehabilitation unit. Outcome measures applied on admission and discharge included the Expanded Disability Status Scale (EDSS), the Barthel Index (BI) and the Functional Independence Measure (FIM), as well as a visual analogue scale (VAS) of the patients' perception of rehabilitation impact. Confounding factors including the timing of steroid therapy and re-admissions were also examined. RR patients showed considerable improvement following rehabilitation, with a median change of -0.5 on EDSS, +4 on BI and +12 on FIM (mean change of -0.8 EDSS, +4.5 BI and +15.6 FIM points; effect sizes of -1.01, 0.97 and 0.86, respectively), which was significantly greater than other MS subtypes. RR patients rated their admissions highly (median VAS 8.9, interquartile range 7.5-9.9), and the VAS scores correlated modestly with disability measures (Spearman's rho = -0.42, 0.31 and 0.24 versus EDSS, BI and FIM, respectively; p = 0.007-0.040). Repeat admissions and the timing of steroid treatment did not have a significant effect on outcome. This suggests that inpatient rehabilitation is useful in RR MS, particularly in patients with incomplete recovery from relapses who have accumulated moderate to severe disability.

Behavioral assessment of unilateral neglect: Study of the psychometric properties of the Catherine Bergego Scale

Azouvi P, Olivier S, de Montety G, Samuel C, Louis-Dreyfus A, Tesio L. Behavioral assessment of unilateral neglect: study of the psychometric properties of the Catherine Bergego Scale. Arch Phys Med Rehabil 2003;84:51-7. Objective: To assess the psychometric properties of a scale for spatial neglect in everyday life. Design: Validation study. Setting: A neurologic rehabilitation unit in a university hospital. Participants: Eighty-three consecutive right-hemisphere stroke patients. Interventions: Not applicable. Main Outcome Measures: The Catherine Bergego Scale (CBS) was used to assess neglect behavior and anosognosia. Its sensitivity was compared with that of 3 conventional tests. The inner structure of the scale was studied by principal component analysis. In addition, linearity, unidimensionality, and reliability of the scale were tested through Rasch analysis. Results: Behavioral assessment correlated significantly to, but was more sensitive than, conventional tests. Anosognosia correlated significantly with neglect severity, although individual dissociations occurred. Factorial analysis disclosed a single underlying factor, explaining 65.8% of total variance. Rasch analysis also revealed that the 10 items defined a common, single ability continuum with widespread measurement range and quite regular item distribution, and showed a satisfactory reliability. Conclusion: Behavioral assessment proved to be more sensitive than conventional paper and pencil tasks. Both conventional statistics and Rasch analysis suggest that the CBS is reliable and valid, and that the 10 items define a homogeneous construct. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

The five item Barthel index

OBJECTIVESRoutine data collection is now considered mandatory. Therefore, staff rated clinical scales that consist of multiple items should have the minimum number of items necessary for rigorous measurement. This study...

Asymptomatic carriage of Klebsiella pneumoniae producingextended-spectrum b-lactamase by patientsin a neurological early rehabilitation unit: Management of an outbreak

During 11 months 58 extended-spectrum b-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) isolates were grown from 10 patients on a neurological early rehabilitation unit. The patients had no signs of infection but were colonized in the nose and trachea, and unusually only one had colonization in the gut.A single clone of ESBL-Kp was identified by pulse field gel electrophoresis. Strong hygienic precautions similar to those for Methicillin-resistantStaphylococcus aureus patients prevented spread of the bacteria to other wards. However, rehabilitation for patients with severe neurological failures made it very difficult to follow hygienic requirements. Disinfection of mucous membranes was difficult. Eventually the application of a nasal spray containing povidone–iodine proved to be successful.