Ongoing Rehabilitation Research Articles

Construct validity of the Chelsea critical care physical assessment tool: an observational study of recovery from critical illness

IntroductionIntensive care unit-acquired weakness (ICU-AW) is common in survivors of critical illness, resulting in global weakness and functional deficit. Although ICU-AW is well described subjectively in the literature, the value of objective measures has yet to be established. This project aimed to evaluate the construct validity of the Chelsea Critical Care Physical Assessment tool (CPAx) by analyzing the association between CPAx scores and hospital-discharge location, as a measure of functional outcome.MethodsThe CPAx was integrated into practice as a service-improvement initiative in an 11-bed intensive care unit (ICU). For patients admitted for more than 48 hours, between 10 May 2010 and 13 November 2013, the last CPAx score within 24 hours of step down from the ICU or death was recorded (n = 499). At hospital discharge, patients were separated into seven categories, based on continued rehabilitation and care needs. Descriptive statistics were used to explore the association between ICU discharge CPAx score and hospital-discharge location.ResultsOf the 499 patients, 171 (34.3%) returned home with no ongoing rehabilitation or care input; 131 (26.2%) required community support; 28 (5.6%) went to inpatient rehabilitation for <6 weeks; and 25 (5.0%) went to inpatient rehabilitation for >6 weeks; 27 (5.4%) required nursing home level of care; 80 (16.0%) died in the ICU, and 37 (7.4%) died in hospital. A significant difference was found in the median CPAx score between groups (P < 0.0001). Four patients (0.8%) scored full marks (50) on the CPAx, all of whom went home with no ongoing needs; 16 patients (3.2%) scored 0 on the CPAx, all of whom died within 24 hours. A 0.8% ceiling effect and a 3.2% floor effect of the CPAx is found in the ICU. Compliance with completion of the CPAx stabilized at 78% of all ICU admissions.ConclusionThe CPAx score at ICU discharge has displayed construct validity by crudely discriminating between groups with different functional needs at hospital discharge. The CPAx has a limited floor and ceiling effect in survivors of critical illness. A significant proportion of patients had a requirement for postdischarge care and rehabilitation.

Cervical Spinal Cord Injury at the Victorian Spinal Cord Injury Service: Epidemiology of the Last Decade

Introduction Cervical spinal cord injury (CSCI) is a significant medical and socioeconomic problem. In Victoria, Australia, there has been limited research into the incidence of CSCI. The Austin Hospital's Victorian Spinal Cord Injury Service (VSCIS) is a tertiary referral hospital that accepts referrals for surgical management and ongoing neurological rehabilitation for south eastern Australia. The aim of this study was to characterise the epidemiology of CSCI managed operatively at the VSCIS over the last decade, in order to help fashion public health campaigns. Methods This was a retrospective review of medical records from January 2000 to December 2009 of all patients who underwent surgical management of acute CSCI in the VSCIS catchment region. Patients treated non-operatively were excluded. Outcome measures included: demographics, mechanism of injury and associated factors (like alcohol) and patient neurological status. Results Men were much more likely to have CSCI than women, with a 4:1 ratio, and the highest incidence of CSCI for men was in their 20s (39%). The most common cause of CSCI was transport related (52%), followed by falls (23%) and water-related incidents (16%). Falls were more prevalent among those &gt;50 years. Alcohol was associated in 22% of all CSCIs, including 42% of water-related injuries. Discussion Our retrospective epidemiological study identified at-risk groups presenting to our spinal injury service. Young males in their 20s were associated with an increased risk of transport-related accidents, water-related incidents in the summer months and accidents associated with alcohol. Another high risk group were men &gt;50 years who suffer falls, both from standing and from greater heights. Public awareness campaigns should target these groups to lower incidence of CSCI.

The Role the Frailty Syndrome Can Play in Advocacy and Resource Allocation for Our Ageing Population - Findings in a Dublin Day Hospital.

Frail individuals are at higher risk of adverse outcomes, and need identification and priority access to Comprehensive Geriatric Assessment (CGA). We prospectively collected data on new referrals to our day hospital. Levels of frailty were measured with the SHARE Frailty Instrument for Primary Care (SHARE-FI). Of 257 patients assessed (90 men, 167 women), 110 (43%) were non-frail, 66 (26%) pre-frail and 81 (32%) frail. Mean age was 82 years for the non-frail, 83 for the pre-frail and 84 for the frail. Forty-one percent of the frail reported two or more falls in the preceding year, compared to 38% of the pre-frail and 21% of the non-frail (P for trend = 0.003). Of 27 patients who were referred for ongoing multidisciplinary assessment and rehabilitation, 16 (59%) were frail. The frailty syndrome has the potential to become an advocacy tool for older people and help target effective, but finite, CGA resources.

Factors Affecting Quality of Life of the Homebound Elderly Hemiparetic Stroke Patients

[Purpose] This study examined the quality of life (QOL) of homebound elderly hemiparetic stroke patients and factors that affect it. [Subjects] The subjects of the study were 21 homebound elderly hemiparetic stroke patients who were 65 years old or over and required care for daily living (12 males and 9 females, average age: 79.3 ± 8.4 years old). Their physical and psychological conditions, QOL, and other characteristics were researched. [Methods] The Functional Independence Measure (FIM) was used for the activities of daily living (ADL) assessment, and the MOS 36-Item Short-Form Health Survey (SF-36, Japanese version 1.2) was used for the QOL assessment. [Results] No correlations were observed between the QOL of homebound elderly hemiparetic stroke patients and their age and gender. However, the results showed that their QOL was affected by their independence in ADL, bedridden degree, and care-need level. [Conclusion] These results suggest that in order to improve the QOL of homebound elderly hemiparetic stroke patients, ongoing rehabilitation to improve independence in ADL and lower the bedridden degree and care-need level is required.

Efficacy of leisure intervention groups in rehabilitation of people with an acquired brain injury

Purpose: To determine whether participation in a week-long residential leisure intervention program targeting individuals with an acquired brain injury (ABI) improved the leisure satisfaction, self-esteem and quality of life (QOL) of participants. The program included leisure awareness, leisure resources, social interaction skills and leisure activity skills. Method: Using a pre- and post-intervention design leisure satisfaction, self-esteem and QOL were assessed prior to, immediately following and at three months post program. Data were analyzed using Wilcoxon signed-rank tests. Results: Participants were eight men and four women aged between 19 and 49 years who were recent clients of a rural Brain Injury Rehabilitation Service. The majority (7/12) had acquired their ABI more than two years previously, and for most (10/12) the cause was trauma. Program participants showed clinically important and statistically significant improvements in leisure satisfaction (p = 0.002), self-esteem (p = 0.03) and QOL (p = 0.02 to 0.008 for four domains of the World Health Organisation Quality of Life – Bref scale) three months post program. Conclusion: Adults with an ABI participating in leisure education programs can experience improvements in leisure satisfaction, self-esteem and QOL following the program. The findings suggest that active leisure intervention programs should be included in the ongoing rehabilitative care of adults with an ABI.Implications for RehabilitationLeisure participation, leisure satisfaction and social integration can be seriously compromised following an acquired brain injury (ABI).Engagement in leisure activities has positive effects on physical and mental health and is increasingly recognised as an important determinant of quality of life (QOL) for people with ABI.Participation in a short-term intensive leisure intervention program can improve leisure satisfaction, self-esteem and QOL.Active leisure intervention programs should be included in the ongoing rehabilitation and reintegration of adults with ABI.

Implementing the National Service Framework for long-term (neurological) conditions: service user and service provider experiences

Purpose: This research explored the experiences of service users and providers during the implementation of the National Service Framework (NSF) for Long-Term (Neurological) Conditions (LTNCs). Method: A participatory qualitative research design was employed. Data were collected using 50 semi-structured interviews with service users, 25 of whom were re-interviewed on three occasions. Forty-five semi-structured interviews were also conducted with service providers who worked with individuals with LTNCs. Interviews focused on health, well-being and quality of life in relation to service provision, access and delivery. Data were thematically analysed individually and collaboratively during two data analysis workshops. Results: Three major themes were identified that related to the implementation of the NSF: “Diagnosis and treatment”, “Better connected services” and “On-going rehabilitation”. Service users reported that effective care was provided when in hospital settings but such treatments often terminated on return to their communities despite on-going need. In hospital and community settings, service providers indicated that they lacked the support and resources to provide continuous care, with patients reaching a crisis point before referral to specialist care. Conclusion: This research highlighted a range of issues concerning the recent UK-drive towards patient-centred approaches within healthcare, as service users were disempowered within the LTNC care pathway. Moreover, service providers indicated that resource constraints limited their ability to provide long-term, intensive and integrated service provision.Implications for RehabilitationOur research suggests that many service users with long-term neurological conditions experienced disconnections between services within their National Service Framework care pathway.For health and social care practitioners, a lack of continuity within a care pathway was suggested to be most pertinent following immediate care and moving to rehabilitative care.Our findings also indicate that service providers lack the necessary financial resources and staffing capacity to provide on-going and comprehensive rehabilitation.This article aims to help practitioners better understand particular issues during the implementation of the National Service Framework for long-term neurological conditions from the perspectives of service users and service providers.

Disorders of Consciousness and Disordered Care: Families, Caregivers, and Narratives of Necessity

By their nature, care decisions for patients with severe disorders of consciousness must involve surrogates. Patients, so impaired, have lost their decision-making capacity and the ability to direct their own care. Surrogates—family members, friends, or other intimates—must step in and make decisions about ongoing care or its withdrawal. This article shares the narrative experiences of these surrogate decision makers as they encounter the American health care system and accompany patients from injury through rehabilitation. Through their perspectives, the article considers challenges to ongoing care and rehabilitation that are a function of a prevailing medical infrastructure and reimbursement framework better suited to patients with acute care needs. Specific attention is paid to the ethical challenges posed by reimbursement strategies such as “medical necessity” as well as those proposed for the Affordable Care Act. The argument concludes that when it comes to care for a disorder related to consciousness, its provision is not discretionary, and its receipt is not an entitlement but a civil right.

Developing stroke-specific vocational rehabilitation: a soft systems analysis of current service provision

Purpose: This study aimed to clarify the existing service provision of stroke-specific vocational rehabilitation (VR) in one English county, in order to facilitate future service development. Method: Using soft systems methodology, services in Health, Social Care, Department of Work and Pensions, the voluntary and private sectors, which were identified as supporting return to work after stroke, were mapped using a mixed-methodology approach. Results: A lack of a sanctioned VR pathway meant access to support relied on brokered provision and tacit knowledge. The timing of an intervention was complex and there was a substantial degree of unmet need for mild stroke patients. VR was seen as “non-essential” due to competing commissioning priorities. Service providers from all sectors lacked training and cross-sector partnerships were tenuous and provider roles unclear. Conclusions: Stroke-specific VR should be delivered by an integrated, cross-sector multi-disciplinary team and integrated commissioning between health and other sectors is necessary. Although early intervention is important, support later on in the recovery process is also necessary. Service providers need adequate training to meet the needs of stroke survivors wishing to return to work and better awareness of best practice guidelines. Business cases which demonstrate the efficacy and cost-effectiveness of VR are vital.Implications for RehabilitationThe timeliness of a vocational rehabilitation (VR) intervention is complex; services need to be responsive to the changing needs of the stroke survivor throughout their recovery process and have better mechanisms to ensure re-entry into the stroke pathway is possible.Return to work is a recognised health outcome; health services need to develop better mechanisms for interagency/cross sector working and liaison with employers and not assume that VR is beyond their remit. Therapists and non-health service providers should receive sufficient training to meet the needs of stroke survivors wishing to return to work. Rehabilitation teams must decide how to implement national guidance within existing resources and what training is needed to deploy SSVR.The lack of a sanctioned pathway results in disorganised and patchy provision of VR for stroke survivors; mild stroke patients can fall through the net and receive little or no support. The journey back to work commences at the point of stroke. Mechanisms for identifying acute stroke survivors who were working at onset and for assessing the impact of the stroke on their work need to be put in place. The entire MDT has a role to play. In the absence of a VR specialist, even patients without obvious disability should be referred for ongoing rehabilitation with detailed work assessment and signposted to employment specialists e.g. disability employment advisors EARLY after stroke.Health-based VR interventions can influence work return and job retention. However, therapists must routinely measure work outcomes to inform their business case and be encouraged to demonstrate these outcomes to local commissioners. Commissioners should consider emerging evidence of early VR interventions on reduced length of stay, health and social care resource use and the wider health benefits of maintaining employment.

A qualitative study exploring patients’ and carers’ experiences of Early Supported Discharge services after stroke

Objective: To investigate patients’ and carers’ experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision. Design and subjects: Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services. Setting: Community stroke services in Nottinghamshire, UK. Results: A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation; speed of response; intensity and duration of therapy; respite time for the carer; rehabilitation exercises and provision of technical equipment; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain; lack of education and training of carers; inadequate provision and delivery of stroke-related information; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Conclusions: Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.

Effects of Community-Based Cardiac Rehabilitation on Body Composition and Physical Function in Individuals with Stable Coronary Artery Disease: 1.6-Year Followup

Objective. To examine long-term changes in physical function and body composition in coronary artery disease (CAD) patients participating in ongoing community-based cardiac rehabilitation (CR). Design. Thirty-four individuals (69.7 ± 8.2 years; 79% men) participated in this longitudinal observational study. Baseline and follow-up assessments included incremental shuttle walk, short physical performance battery, handgrip strength, chair stands, body composition, last year physical activity, and CR attendance. Results. Participants attended 38.5 ± 30.3% sessions during 1.6 ± 0.2 year followup. A significant increase in 30-second chair stands (17.0 ± 4.7 to 19.6 ± 6.4, P < 0.001), body weight (75.8 ± 11.1 to 77.2 ± 12.1 kg, P = 0.001), and body fat (27.0 ± 9.5 to 29.1 ± 9.6%, P < 0.001) and a decline in handgrip strength (36.4 ± 9.4 to 33.0 ± 10.6 kg·f, P < 0.001) and muscle mass (40.8 ± 5.6 to 39.3 ± 5.8%, P < 0.001) were observed during followup. There was no significant change in shuttle walk duration. CR attendance was not correlated to observed changes. Conclusions. Elderly CAD patients participating in a maintenance CR program improve lower-body muscle strength but experience a decline in handgrip strength and unfavourable changes in body composition, irrespective of CR attendance.

Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial

BackgroundIn New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent.Methods/designThis study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study.DiscussionThe lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home.Trial registrationACTRN12612000464864

Finding a new normal: a grounded theory study of rehabilitation after treatment for upper gastrointestinal or gynaecological cancers - the patient's perspective

This paper reports on a study of perspectives of rehabilitation needs by 33 people treated for upper gastrointestinal and gynaecological cancers. This study used focus groups informed by grounded theory and involved adult participants who had completed radical treatment at a UK cancer centre. Patients were involved in the design. Findings indicate that these patients are likely to have ongoing rehabilitation needs and that there was poor awareness of possible treatment of symptoms and of rehabilitation services. Novel findings include distinct perspectives of adults who have completed treatment for upper gastrointestinal and gynaecological cancers regarding their rehabilitation needs. Patients on surgical pathways, or who had longer hospital stays, had a better understanding of the rehabilitation services available to them and they accessed them more easily to ameliorate their post-treatment symptoms. Furthermore rehabilitation services are not equally accessed by patients on different treatment pathways. A grounded theory of cancer rehabilitation was developed with core categories of: impacts on the person, adjustment after treatment, individualised tailored support and information sources. The overarching theme is 'seeking a new normal'. Individualised tailored support is integral to seeking and establishing a new normal. Routine assessment and referral for rehabilitation treatment warrants further evaluation in these groups.

Gait Speed as a Measure in Geriatric Assessment in Clinical Settings: A Systematic Review

Gait speed is a quick, inexpensive, reliable measure of functional capacity with well-documented predictive value for major health-related outcomes. Numerous epidemiological studies have documented gait speed in healthy, community-dwelling older people. The purpose of this study is to undertake a systematic review and meta-analysis of gait speed in a specific group with mobility limitations-geriatric patients in clinical settings. Relevant databases were searched systematically for original research articles published in February 2011 measuring gait speed in persons aged 70 or older in hospital inpatient or outpatients settings. Meta-analysis determined gait speed data for each setting adjusting for covariates. The review included 48 studies providing data from 7,000 participants. Across the hospital settings, the gait speed estimate for usual pace was 0.58 m/s (95% confidence interval [CI]: 0.49-0.67) and for maximal pace was 0.89 m/s (95% CI: 0.75-1.02). These estimates were based on most recent year of publication (2011) and median percentage of female participants (63%). Gait speed at usual pace in acute care settings was 0.46 m/s (95% CI: 0.34-0.57), which was significantly slower than the gait speed of 0.74 m/s (95% CI: 0.65-0.83) recorded in outpatient settings. Gait speed is an important measure in comprehensive geriatric assessment. The consolidation of data from multiple studies reported in this meta-analysis highlights the mobility limitations experienced by older people in clinical settings and the need for ongoing rehabilitation to attain levels sufficient for reintegration in the community.

Evaluation of neuropsychological rehabilitation following severe traumatic brain injury: A case report

This case study presents the evaluation of traumatic brain injury rehabilitation for Jane, a 35-year-old woman who sustained a severe traumatic brain injury (TBI). On-going rehabilitation addressed difficulties within a structured neuro-rehabilitative therapeutic milieu and was holistically evaluated. Results showed improvement in mood and quality of life and at the compensatory level for cognition. At the impairment level, many of the affected areas of cognition remained at least below predicted pre-morbid levels. This supports the view that although TBI impairments may be permanent, structured neuro-rehabilitation can be effective through external and compensatory aids. Recording this holistically contributes to evidencing this.

Dam Removal in the Pacific Northwest: Lessons for the Nation

Over the past dozen years, a number of large dams in the Pacific Northwest have been removed in an effort to restore riverine ecosystems and dependent species like salmon. These dam removals provide perhaps the best example of large-scale environmental remediation in the 21st century. This restoration, however, has occurred on a case-by-case basis, without a comprehensive plan. Yet the result has been to put into motion ongoing rehabilitation efforts in four distinct river basins: the Elwah and White Salmon in Washington and the Sandy and Rogue in Oregon. In all, nine significant dams have been removed, and four more — in the contentious Klamath Basin of Oregon and California — are slated for removal in within the next decade. This article surveys both the successful and proposed removals in to draw lessons both within and beyond the Pacific Northwest. We identify a number of factors that determine both the speed and success of dam removal efforts, including the availability of the federal licensing process under the Federal Power Act, the existence and organization of local opposition, the amount and sources of funding, and the support of federal and state resource agencies and well-positioned members of Congress. These factors suggest that the promised removal of the Klamath Dams as well as calls for removing the federal dams on the Lower Snake face significant odds.

Outcome measurements in major trauma—Results of a consensus meeting

BackgroundThe NHS Outcomes Framework for England has identified recovery from major injury as an important clinical area. At present, there are no established outcome indicators. As more patients survive major trauma, outcomes will need to be measured in terms of morbidity and not mortality alone. ObjectiveTo make recommendations for a selection of outcome measures that could be integrated into National Clinical Audit data collection and form part of clinical governance requirements for Regional Trauma Networks (RTNs) and measures by which RTNs are held to account by government. Specific focus was given to acute care and rehabilitation for both adults and children. MethodA Multiprofessional, multidisciplinary expert group reviewed the current evidence on outcome measures for major trauma in the adult and children's populations, informed by a systematic review carried out jointly by the Trauma Audit and Research Network (TARN) and the Cochrane Injuries Group. A structured discussion covered functional and quality of life outcome measures as well as patient experience and indicators such as return to work, education and social dependency. ResultsFor the adult population the group agreed with the in-hospital performance and hospital discharge measures recommended in the TARN and Cochrane systematic review. Concerning longer-term outcome indicators, the group suggested the use of the Glasgow Outcome Scale – Extended (GOS-E) and European Quality of Life 5D (EQ-5D) with consideration to be given to the World Health Organisation Quality of Life survey (WHO-QoL). For patients who had ongoing inpatient rehabilitation needs the group thought the measurement of the Rehabilitation Complexity Scale (RCS) and Functional Independence Measure (FIM) were important in total brain injury and, the American Spinal Injury Association Impairment Scale (ASIA) and Spinal Cord Independence Measure (SCIM) in spinal cord injury. For children the group recommended the use of the King's Outcome Scale for Childhood Head Injury (KOSCHI) and Paediatric Quality of Life measure (Peds-QL) preferably at multiple intervals following injury to take into account effects on development. ConclusionSpecific recommendations were made for the use of outcome measures in adults and children with major trauma and those with complex rehabilitation needs following injury. More work on outcome measures in major trauma is needed especially for children. There are currently no robust measures of patient experience for use in major trauma. The importance of data linkage to allow measurement of non-clinical outcomes such as return to work, maintainence of education and societal dependency was emphasised by the group. A system for recording outcomes should be piloted post injury and at 6 and 12 months, with those still requiring inpatient rehabilitation after this time having longer follow up.

A multi-site study of the feasibility and clinical utility of Goal Attainment Scaling in geriatric day hospitals

Background: Goal Attainment Scaling (GAS) is an individualized goal-setting and measurement approach that is useful for patients with multiple, individualized health problems, such as those served by geriatric day hospitals (GDHs) and other specialized geriatric programmes. Purpose: To assess the feasibility and utility of GAS in a multi-site study of six GDH affiliated with the Regional Geriatric Programmes of Ontario. Method: Individualized GAS guides were developed for 15 consecutively admitted patients at each site [total n = 90; mean age: 76.2 SD 8.3; 58.9% female; mean attendances: 24.0 SD 10.3]. Staff members (n = 39) were surveyed on their experience with GAS. Results: Mean goals/patient ranged across sites from 2.1 to 4.3. Mean GAS discharge score was 52.3 SD 8.7, close to the theoretically expected values of 50 SD 10. Common goals included mobility, community reintegration, basic and instrumental activities of daily living, medical issues, cognition/communication, and home safety. Estimated mean time to develop a GAS guide ranged across sites from 15.3 to 43.8 min. Conclusion: Clients were often involved in goal setting; family involvement was less frequent. The staff survey identified challenges and benefits regarding the use of GAS. Study results are being used to inform a more consistent approach to the clinical and research use of GAS in GDH.Implications for RehabilitationThe geriatric day hospital (GDH) has had a long history as one element of a comprehensive system of specialized geriatric services with potential advantages including ongoing treatment and rehabilitation from an interdisciplinary team. Despite this history, the evidence for the effectiveness of GDHs in rehabilitation of older persons has been equivocal.We found that Goal Attainment Scaling (GAS) was able to detect clinically relevant change in this setting which can aid in demonstrating evidence for the utility and impact of GDHs.GAS was feasible in this setting and clinicians felt that GAS may have an effect on speeding up discharge, as a result of having a clearer focus on outcomes that are desired for each patient.Clinicians felt the involvement of clients and families in goals settings resulted in more meaningful outcomes for clients and GAS aided in identifying highly individual outcomes such as quality of life and community integration that are routinely difficult to measure with standardized tools.

Isokinetic knee extensor strength deficit following matrix-induced autologous chondrocyte implantation

BackgroundAutologous chondrocyte implantation has become an established technique for addressing knee cartilage defects. Despite reported improvement in pain and regeneration of hyaline-like repair tissue, little has been reported on the recovery of knee strength. MethodsKnee strength assessment was undertaken in 60 patients at 5years following autologous chondrocyte implantation. Using an isokinetic dynamometer, and during isokinetic knee extension and flexion angular velocities of 60°, 90° and 120°/s, the peak torque, torque at 45° of knee flexion and hamstrings/quadriceps ratio was obtained, in both the operated and non-operated limbs. Pain at the time of assessment was obtained. Independent sample t-tests were used to assess differences in the operated and non-operated sides. FindingsThere were no significant differences (p>0.05) between the operated and non-operated legs in the peak knee flexor torque or knee flexor torque at a knee flexion angle of 45°, at all angular velocities (60°, 90° and 120°/s). While the peak knee extensor torque was less in the operated leg at all angular velocities, these differences were not significant (p>0.05). However, a significantly reduced (p<0.05) knee extensor torque at a knee flexion angle of 45°, was observed at all speeds. InterpretationWhile patients had recovered their knee flexor strength, they still demonstrated a reduced knee extensor strength profile at 5years. This demonstrates that the early supervised rehabilitation phase following autologous chondrocyte implantation is not sufficient to restore long-term knee strength, and ongoing patient advice and rehabilitation is required extending beyond this early period. It is unknown how this prolonged reduction in strength may affect long-term graft outcome.

Redefining the golden hour for severe head injury in an urban setting: The effect of prehospital arrival times on patient outcomes

BackgroundIn patients with severe head injuries, transportation to a trauma centre within the “golden hour” are important markers of trauma system effectiveness but evidence regarding impacts on patient outcomes is limited. ObjectiveTo determine the effect of patient arrival within the golden hour on patient outcomes. MethodsA retrospective cohort of adult patients with severe head injuries (head AIS≥3) arriving within 24h of injury was identified using the trauma registry from 2000 to 2011. Survival analysis was used to determine the effect of patient arrival time on overall mortality. Study outcomes were in hospital mortality and survival to hospital discharge without requiring transfer for ongoing rehabilitation or nursing home care. ResultsThere was a significant association with mortality with each incremental minute of patient arrival (HR 1.002, 95%CI 1.001–1.004, p=0.001). There was however no survival benefit observed for patients arriving within 60min of injury time (HR 0.77, 95%CI 0.50–1.18, p=0.22) but an apparent benefit for those presenting within 2h of injury time (HR 0.31, 95%CI 0.15–0.66, p=0.002). Patient arrival within 60min of injury time was associated with increased odds of survival to hospital discharge without requiring ongoing rehabilitation (OR 1.78, 95%CI 1.14–2.79, p=0.01). ConclusionA survival benefit exists in patients arriving earlier to hospital after severe head injury but the benefit may extend beyond the golden hour. There was evidence of improved functional outcomes in patients arriving within 60min of injury time.

Tulsa Oklahoma Oktoberfest Tent Collapse Report

Background. On October 17, 2007, a severe weather event collapsed two large tents and several smaller tents causing 23 injuries requiring evacuation to emergency departments in Tulsa, OK. Methods. This paper is a retrospective analysis of the regional health system's response to this event. Data from the Tulsa Fire Department, The Emergency Medical Services Authority (EMSA), receiving hospitals and coordinating services were reviewed and analyzed. EMS patient care reports were reviewed and analyzed using triage designators assigned in the field, injury severity scores, and critical mortality. Results. EMT's and paramedics from Tulsa Fire Department and EMSA provided care at the scene under unified incident command. Of the 23 patients transported by EMS, four were hospitalized, one with critical spinal injury and one with critical head injury. One patient is still in ongoing rehabilitation. Discussion. Analysis of the 2007 Tulsa Oktoberfest mass casualty incident revealed rapid police/fire/EMS response despite challenges of operations at dark under severe weather conditions and the need to treat a significant number of injured victims. There were no fatalities. Of the patients transported by EMS, a minority sustained critical injuries, with most sustaining injuries amenable to discharge after emergency department care.