Patients In Rehabilitation Settings Research Articles

Should we add antiplatelet agents to current deep venous thrombosis treatments? A Cochrane Review summary with commentary.

Venous thromboembolism (VTE) is an important complication in rehabilitation practice despite preventive measures. The management can be complicated because patients may have co-existing cardiovascular comorbidities. To assess the effects of antiplatelet agents in addition to current best medical practice (BMP) compared to current BMP (with or without placebo) for the treatment of deep venous thrombosis (DVT). A summary of the Cochrane Review by Flumignan et al. (2022), with comments from a rehabilitation perspective. The review included six studies with 1625 eligible participants, with data up to 37.2 months of follow-up. When used after standard initial treatment with anticoagulants, antiplatelet agents such as aspirin in addition to BMP, may reduce recurrence of DVT or pulmonary embolism, when compared to BMP plus placebo in a chronic DVT setting and there may be a lower risk for post-thrombotic syndrome in patients with acute DVT. There is no clear difference in side effects, major bleeding, or pulmonary embolism (PE) with the use of antiplatelet agents. Adding antiplatelet agents to standard anticoagulation treatment in patients with VTE could provide benefit without increasing risks in selected patient groups. However, high quality studies with a long-term follow up are needed, including patients in rehabilitation settings.

Implementing Remote Patient Monitoring of Physical Activity in Clinical Practice.

Remote patient monitoring (RPM) is a tool for patients to share data collected outside of office visits. RPM uses technology and the digital transmission of data to inform clinician decision-making in patient care. Using RPM to track routine physical activity is feasible to operationalize, given contemporary consumer-grade devices that can sync to the electronic health record. Objective monitoring through RPM can be more reliable than patient self-reporting for physical activity. This article reports on four pilot studies that highlight the utility and practicality of RPM for physical activity monitoring in outpatient clinical care. Settings include endocrinology, cardiology, neurology, and pulmonology settings. The four pilot use cases discussed demonstrate how RPM is utilized to monitor physical activity, a shift that has broad implications for prediction, prevention, diagnosis, and management of chronic disease and rehabilitation progress. If RPM for physical activity is to be expanded, it will be important to consider that certain populations may face challenges when accessing digital health services. RPM technology provides an opportunity for clinicians to obtain objective feedback for monitoring progress of patients in rehabilitation settings. Nurses working in rehabilitation settings may need to provide additional patient education and support to improve uptake.

Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel.

There is increased involvement of speech and language therapists (SLTs) in critical care and long-term units supporting patients with ventilatory needs and complex dysphagia. SLTs have a range of specialist knowledge in the function of the pharynx and larynx to enable them to support therapeutic interventions and contribute to the management of those patients. In Israel, there are currently no designated courses or training programmes for SLTs to establish advanced clinical skills in tracheostomy and ventilator management. There are currently standards of care for SLT working in designated wards for ventilated patients, however not in acute wards, critical care, and internal medicine wards where ventilated patients can be hospitalized. To identify the skills and expertise of the Israeli SLT workforce working with tracheostomy patients. Specifically, to identify their level of training, access to training, client population, work settings, and level of work confidence. The study involved electronic distribution of a 55-item online survey to SLTs in Israel. The questions included demographic information, training, confidence, and clinical support. Responses were received from 47 SLTs. The majority (40.4%) spent between 1% and 9% of their clinical time with ventilated patients. Almost 80% work with seniors (≥65 years) and almost 70% work with adults (18-65 years) half the time or more. In inpatient rehabilitation, 46.8% reported that they manage patients with tracheostomy half the time or more. In outpatient rehabilitation settings, 21.3% reported that they manage patients with tracheostomy half the time or more. Prior to managing complex airway patients independently, 55.3% received less than 5 h formal tracheostomy training whilst 68.1% received less than 5 h training on ventilated patients. Multidisciplinary teams (MDTs) existed for tracheostomy patients (85.1%) and ventilated patients (70.2%) and high levels of confidence were reported for managing patients with tracheostomies (mode of 4 in a scale of 0-5, where 5 means fully confident) and ventilated patients (mode of 3 in a scale of 0-5). A significant relationship was found between level of confidence and presence of an MDT. Limited training access was found for SLTs working with this complex population. A competency framework needs to be established with access to training and supervision. MDT existence contributes to confidence. Most respondents worked in rehabilitation settings, and very few worked in acute care, critical care, and internal medicine wards. It seems reasonable that in order to change this, minimal standards of care should be established on these wards. What is already known on the subject Speech and language therapists (SLTs) have an important role in critical care and long-term units supporting patients with complex dysphagia and undergo formal training and supervision in UK and Australia. What this paper adds to existing knowledge In Israel, most SLTs work with tracheostomy and ventilated adult patients in rehabilitation settings, whilst few work in acute, critical care, and internal medicine wards. There are limited opportunities for formal training and supervision, although MDT support enhances clinical confidence. What are the potential or actual clinical implications of this work? SLTs in Israel would benefit from establishing a competency framework for tracheostomy and ventilator patient management to support training, standards of care, and increase clinical involvement in acute settings. This will enhance clinical outcomes for their large population of complex airway patients.

Reassessment of Poststroke Dysphagia in Rehabilitation Facility Results in Reduction in Diet Restrictions

Background: Dysphagia assessment in postacute stroke patients can decrease the incidence of complications like malnutrition, dehydration, and aspiration pneumonia. It also helps to avoid unnecessary diet restrictions. The aim of this study is to verify if regular reassessment of dysphagia would change the diet management of postacute stroke patients in rehabilitation settings. Methods: This single-center retrospective study included 63 patients referred to an inpatient neurological rehabilitation center between 2018–2019. A standardized clinical swallowing evaluation and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) were performed. Diet level according to Functional Oral Intake Scale (FOIS) was evaluated. As the primary endpoint, the FOIS values based on diagnostic procedures were assessed at hospital discharge, rehabilitation admission, and after FEES. Results: 19 women (30%) and 44 men (70%), with a mean age of 75 y (SD ± 10.08), were enrolled. The intergroup ANOVA revealed significant differences (p < 0.001) between dietary prescriptions in an acute care setting and following clinical and endoscopic reassessment in the rehabilitation center. Diet recommendations changed in 41 of 63 (65%) enrolled patients (p < 0.001). Conclusion: Instrumental diagnostic by FEES during the early convalescence period of stroke patients leads to clinically relevant changes to diet restrictions and lower rates of pneumonia. Our findings underline the need for regular and qualitative dysphagia diagnostics in stroke patients participating in neurological rehabilitation.

Prevalence of sarcopenia and its association with activities of daily living and dysphagia in convalescent rehabilitation ward inpatients

The purpose of this study was to investigate the prevalence of sarcopenia following stroke, musculoskeletal disease, or hospital-associated deconditioning in convalescent rehabilitation ward inpatients. The association between the activities of daily living (ADLs), dysphagia, and sarcopenia was also assessed. A cross-sectional study was performed in consecutive patients admitted to convalescent rehabilitation wards. Sarcopenia was defined as a loss of skeletal muscle mass and decreased muscle strength. The primary outcome was the Functional Independence Measure (FIM) score. Body mass index, Mini Nutritional Assessment-Short Form score, Food Intake Level Scale (FILS) score, Charlson Comorbidity Index, premorbid modified Rankin scale, time from onset, reason for admission, bioelectrical impedance analysis for skeletal muscle mass and fat mass, and handgrip strength were also assessed. Univariate and multivariate analyses were used to determine whether ADLs and dysphagia were associated with sarcopenia. The study included 637 patients (mean age: 74 years; 271 men and 366 women). Sarcopenia was diagnosed in 343 (53.0%) patients (141 men and 202 women). Sarcopenia was identified in 53.6% (125/233) of stroke patients (59.8%, 50.0%, and 34.6% of patients with brain infarctions, brain hemorrhages, and subarachnoid hemorrhages, respectively). Sarcopenia was found in 51.3% (154/300) of patients with musculoskeletal diseases (59.5%, 53.6%, and 36.5% of patients with hip fractures, vertebral compression fractures, and total knee arthroplasty, respectively). Of patients with hospital-associated deconditioning, 61.5% (64/104) had sarcopenia (95.1% and 39.7% of patients with pneumonia and other acute diseases, respectively). Multivariate analysis showed that FIM motor domain and FILS scores were independently associated with skeletal muscle mass loss and decreased muscle strength. The prevalence of sarcopenia in convalescent rehabilitation ward inpatients was 53.0%. ADLs and dysphagia were independently associated with sarcopenia in this study population. Sarcopenia with disabilities should be assessed for all patients in rehabilitation settings.

Motor imagery ability in stroke patients: the relationship between implicit and explicit motor imagery measures

There is little consensus on how motor imagery ability should be measured in stroke patients. In particular it is unclear how two methods tapping different aspects of the motor imagery process relate to each other. The aim of this study was to investigate the relationship between implicit and explicit motor imagery ability by comparing performance of stroke patients and controls on a motor imagery questionnaire and a hand laterality judgment task (HLJT). Sixteen ischemic stroke patients (36 ± 13 weeks post-stroke) and 16 controls, matched by age (51 ± 10 years), gender (7 females) and handedness (3 left-handed), performed a HLJT and completed a motor imagery questionnaire. Our study shows that neither in the healthy controls nor in patients, a correlation is found between the HLJT and the motor imagery questionnaire. Although the patient group scored significantly lower than the control group on the visual motor imagery component (U = 60; p = 0.010) and the kinesthetic motor imagery component (U = 63.5; p = 0.015) of the questionnaire, there were no significant differences between patients and controls on accuracy scores of the HLJT. Analyses of the reaction time profiles of patients and controls showed that patient were still able to use an implicit motor imagery strategy in the HLJT task. Our results show that after stroke performance on tests that measure two different aspects of motor imagery ability, e.g., implicit and explicit motor imagery, can be differently affected. These results articulate the complex relation phenomenological experience and the different components of motor imagery have and caution the use of one tool as an instrument for use in screening, selecting and monitoring stroke patients in rehabilitation settings.

Patients undergoing subacute rehabilitation have accurate expectations of their health-related quality of life at discharge

BackgroundExpectations held by patients and health professionals may affect treatment choices and participation (by both patients and health professionals) in therapeutic interventions in contemporary patient-centered healthcare environments. If patients in rehabilitation settings overestimate their discharge health-related quality of life, they may become despondent as their progress falls short of their expectations. On the other hand, underestimating their discharge health-related quality of life may lead to a lack of motivation to participate in therapies if they do not perceive likely benefit. There is a scarcity of empirical evidence evaluating whether patients’ expectations of future health states are accurate. The purpose of this study is to evaluate the accuracy with which older patients admitted for subacute in-hospital rehabilitation can anticipate their discharge health-related quality of life.MethodsA prospective longitudinal cohort investigation of agreement between patients’ anticipated discharge health-related quality of life (as reported on the EQ-5D instrument at admission to a rehabilitation unit) and their actual self-reported health-related quality of life at the time of discharge from this unit was undertaken. The mini-mental state examination was used as an indicator of patients’ cognitive ability.ResultsOverall, 232(85%) patients had all assessment data completed and were included in analysis. Kappa scores ranged from 0.42-0.68 across the five EQ-5D domains and two patient cognition groups. The percentage of exact correct matches within each domain ranged from 69% to 85% across domains and cognition groups. Overall 40% of participants in each cognition group correctly anticipated all of their self-reported discharge EQ-5D domain responses.ConclusionsPatients admitted for subacute in-hospital rehabilitation were able to anticipate their discharge health-related quality of life on the EQ-5D instrument with a moderate level of accuracy. This finding adds to the foundational empirical work supporting joint treatment decision making and patient-centered models of care during rehabilitation following acute illness or injury. Accurate patient expectations of the impact of treatment (or disease progression) on future health-related related quality of life is likely to allow patients and health professionals to successfully target interventions to priority areas where meaningful gains can be achieved.

Underlying Pathology and Associated Factors of Hemiplegic Shoulder Pain

The prevalence of hemiplegic shoulder pain is approximately 22%-23% in the general population of stroke survivors and approximately 54%-55% among stroke patients in rehabilitation settings. Hemiplegic shoulder pain causes a reduced quality-of-life, poor functional recovery, depression, disturbed sleep, and prolonged hospitalization. Herein, we attempted to understand, based on a literature review and experts' opinion, the pathologic processes underlying hemiplegic shoulder pain and the major associated factors contributing to its development. The systematization of underlying pathologies was proposed, which might eventually enable a more constructive clinical approach in evaluating and treating patients with hemiplegic shoulder pain.

Assessments of the reliability of the Iranian version of the Berg Balance Scale in patients with multiple sclerosis.

Because of the balance limitations in many patients, balance assessment is necessary for multiple sclerosis patients in rehabilitation settings. The aim of this study was to investigate the Interrater reliability and the internal consistency of the Iranian version of the Berg Balance Scale (BBS) when applied to patients with multiple sclerosis (MS) in Tehran. Fifty MS patients (with mean age of 36.6±9.5 years) from Hospitals of the Iran University of Medical Sciences and MS Society of Iran were included. Interrater reliability was measured with the Kappa statistics and Intraclass Correlation Coefficients (ICCs). The mean values of the BBS scored by the 2 evaluators were 37.7 ±12.9 and 38.l ± 12.3, respectively. Kappa scores for BBS varied from 0.7 to 1.0 Intraclass correlation coefficient for the BBS's sum score was excellent (ICC=0.99 with 95% confidence interval, 0.98-0.99). An excellent internal consistency was found within the BBS's sum score (Cronbach Alpha =0.9). The item -to -total correlations for all items were higher than 0.6. The Iranian version of the BBS has excellent interrater reliability and internal consistency for the assessment of MS patients when applied in clinics.

Religiousness affects mental health, pain and quality of life in older people in an outpatient rehabilitation setting

To evaluate the relationship between religiousness and mental health, hospitalization, pain, disability and quality of life in older adults from an outpatient rehabilitation setting in Sao Paulo, Brazil. Cross-sectional study. A total of 110 patients aged 60 years or older were interviewed during attendance at an outpatient rehabilitation service. Researchers administered a standardized questionnaire that assessed socio-demographic data, religiousness, self-reported quality of life, anxiety, physical activity limitation, depression, pain and cognition. Predictors were included in each model analysis, and a backward conditional method was used for variable selection using logistic regression (categorical outcomes) or linear regression (continuous outcomes). Thirty-one patients (28.2%) fulfilled criteria for significant depressive symptoms, 27 (24.5%) for anxiety, and 10 (9.6%) for cognitive impairment. Pain was present in 89 (80.7%) patients. Limited depressive symptoms (as assessed by the Geriatric Depression Scale), and greater self-reported quality of life were related to greater self-reported religiousness, as were scores on the Mini-Mental State Examination (less cognitive impairment), and lower ratings of pain. Religiousness is related to significantly less depressive symptoms, better quality of life, less cognitive impairment, and less perceived pain. Clinicians should consider taking a spiritual history and ensuring that spiritual needs are addressed among older patients in rehabilitation settings.

Interpreting Laboratory Values in the Rehabilitation Setting

Treating patients in rehabilitation settings is becoming increasingly complex for a variety of reasons, such as the presence of several comorbid conditions, increased age, and earlier discharge from acute care facilities. As a result, careful monitoring and assessment by nurses is essential. Laboratory testing can improve the assessment when nurses are able to recognize when and what should be reported and what types of treatments may be needed. Understanding what laboratory findings should be monitored and what added assessment criteria are necessary can be daunting. Therefore, this article reviews critical laboratory and other assessment findings in light of common health problems faced by patients in rehabilitation settings. A case study is used to highlight the importance of laboratory testing.

Behavioral Intentions and Action Plans Promote Physical Exercise: A Longitudinal Study with Orthopedic Rehabilitation Patients

Patients in rehabilitation settings often face difficulties in complying with physical exercise regimens. To examine social-cognitive determinants in the adoption and maintenance of exercise, a study with four points in time was launched, scrutinizing beliefs and behaviors of 509 orthopedic patients. Although exercise levels increased over time, a sizable number of patients remained inactive. Perceived self-efficacy and outcome expectancies predicted levels of intention and action plans. The latter two in turn were proximal predictors of subsequent exercise. In light of the findings, it is argued that planning helps to bridge the intention-behavior gap. Planning is an alterable variable and is therefore suitable for effective intervention.

Brain Injury Rehabilitation Settings: A Gold Mine for Student and Staff Learning

This article explores cognitive, psychomotor, and affective learning relative to the professional development of senior nursing students and staff in a long-term brain injury rehabilitation setting. Valuable opportunities for learning exist in this environment. Nursing students acquire a much different perspective toward caring for patients in rehabilitation settings than in acute care; they also gain tremendous opportunities to strengthen the clinical judgement and psychomotor skills applicable to most clinical work environments following graduation. In addition, they assume professional attitudes toward and interest in caring for long-term brain-injured patients as they work closely with expert rehabilitation nurses. When staff nurses interact with students, they receive reciprocal benefits. Staff nurses profit by refining and broadening the scope of their own practice; they also develop a positive self-image and a feeling of pride in their work. More importantly, staff nurses in a long-term brain injury rehabilitation setting regain the feeling that their daily efforts are really worthwhile.

The Ethics of Mechanical Restraints

Robert J. Moss is co-director, Section of Geriatric Medicine, and Clinical Ethics Scholar-in-Residence, Lutheran General Hospital. John La Pluma is director, Center for Clinical Ethics, Lutheran General Hospital, Park Ridge, Ill. As mechanical restraints have never been proven effective in clinical practice, they should not be used routinely. They should be considered a nonvalidated therapy requiring consent. Mechanical restraints are leather or cloth devices, bedrails, or geri-chairs, used to modify the behavior of an individual through the limitation of physical movement. They may be applied as many as 500,000 times a day in the United States in acute and long-term care settings, particularly in providing care for persons over the age of sixty.[1] When restraints are used to protect a patient from harm, their use is for therapeutic purposes. There is considerable uncertainty, however, about whether restraints are safe or effective and whether their benefits outweigh their risks in clinical care. Thus, as Rubenstein and colleagues have noted, the use of mechanical restraints appears to have emerged as a of care by consensus rather than by scientific data.[2] Given that available empirical data suggest that restraints can be inefficacious and dangerous, we contend that mechanical restraints should be considered an investigational or nonvalidated therapy. At the very least, this requires that patients or their reliable proxies give formal informed consent to use of restraints, following full disclosure of their likely risks and benefits. In this context, we Will briefly review current empirical data on restraint utilization and efficacy, and identify the ethical considerations posed for health care professionals when they consider using mechanical restraints in the care of elderly patients. Epidemiology: The incidence of mechanical restraints in the United States varies by setting: 7.4 percent to 22 percent of acute care patients, 3.6 to 5 percent of psychiatric patients, 33 percent of patients in rehabilitation settings, and from 25 percent to 41 percent of patients in long-term care settings may be restrained.[3] In the acute hospital setting, wrist and jacket or chest restraints are most commonly used, particularly on medical and surgical floors. In the hospital, moreover, often more than one restraint is applied simultaneously; up to 20 percent of patients may concurrently be taking major tranquilizers.[4] In extended care settings, lap belts are common, and 40 percent of physically restrained residents also receive psychotropic medications.[5] Depending on the setting, restraints may be used for different reasons. In the acute setting, the most commonly noted indication is perceived danger to self or others.[6] In one prospective study, nurses restrained patients to allow treatments to be implemented (34%), to prevent patients from wandering (23%), and from falling of bed (11%), to violent behavior (11%), to promote sitting balance (11%), and to protect themselves (11%).[7] On the rehabilitation unit, restraints are used to keep the patient in a bed or chair (presumably to prevent them from falling). On the psychiatric ward, the management of violent or out of control behavior is the most frequent reason for restraints; it may also be one of the more common reasons for their application in the nursing home. According to the National Nursing Home Survey, restraints are used in managing 33.4 percent of agitated residents, 36 percent of aggressive residents, and 34 percent of residents who wander or pace.[8] However, the motivation for restraining patients in both the acute and long-term care settings may not always be patient safety. Restraints are frequently applied to protect an institution from liability subsequent to a patient's fall.[9] Such institutions may breach the standard of care if physicians have failed to order restraint use and bedrail elevation, or have allowed a patient to ambulate prematurely. …

Carbamazepine replacement of phenytoin, phenobarbital and primidone in a rehabilitation setting: effects on seizure control

Most patients who receive anticonvulsants after traumatic brain injury are treated with the sedative anticonvulsants phenytoin and/or phenobarbital, or perhaps primidone. However, there is considerable evidence demonstrating that these medications have a deleterious effect on cognitive function. Thus, in a rehabilitation setting, alternatives should be sought. Carbamazepine has been found to be relatively free of such effects, and would be an optimum alternative if seizure control were comparable. We have studied the effects of withdrawing phenytoin, phenobarbital and primidone, and using carbamazepine as the primary anticonvulsant in 27 patients at the Greenery Rehabilitation and Skilled Nursing Center for whom ongoing anticonvulsant treatment was considered to be necessary due to previous seizures or a high risk of the occurrence of seizure. We compared a 3 month baseline period (just prior to carbamazepine introduction or sedative anticonvulsant tapering), to a 3 month post-withdrawal period immediately following sedative anticonvulsant withdrawal, when carbamazepine was the sole anticonvulsant. In 20 out of 21 patients in whom carbamazepine replaced sedative anticonvulsants seizure control was essentially similar or somewhat improved. In only one patient did the substitution with carbamazepine result in a loss of seizure control. Six patients were initially receiving carbamazepine in combination with phenytoin and/or phenobarbital. The removal of phenytoin and phenobarbital, leaving carbamazepine as sole therapy, resulted in improved seizure control in three patients and no change in the other three. In the light of carbamazepine's reportedly less detrimental effects on cognitive function and behaviour in other patient populations, it should perhaps be considered as a first line anticonvulsant, especially for patients in rehabilitation settings.