Poor Rehabilitation Outcome Research Articles

Patient Factors Affecting Surgeon Selection and the Decision to Delay Total Knee Arthroplasty

Background: Delaying total knee arthroplasty (TKA) carries an increased likelihood of poor rehabilitation outcomes. Reasons behind choosing to delay surgery are under investigated. This study explores potential factors related to the decision to delay a TKA procedure and preferences for post-surgical pain management.Methods: A cross-sectional online survey was conducted among TKA candidates in the US.Results: 6,298 persons received a screening questionnaire; 2,571 (41%) completed screening with 680 (26%) meeting survey eligibility criteria. 654 of 680 persons (96%) completed surveys. 154 (24%) respondents had delayed TKA. Interference with work and concerns about insufficient post-discharge pain management were found to be significant factors in this decision. A one unit increase in the ten point interference with work scale was associated with a 22% increase in the odds of delaying surgery (OR: 1.219; 95%CI: 1.095-1.356). Surgical candidates concerned about experiencing pain during the first several weeks following surgery had significantly higher odds of delaying surgery (OR: 1.64, 95% CI: 0.881-3.06). Ninety-two percent of respondents indicated they would seek surgeons who offered effective non-opiate pain management options during the first several weeks of the rehabilitation period; 66 percent indicated they would likely switch surgeons for access to a non-opioid pain management approach.Conclusions: Delaying a TKA is significantly influenced by concerns about interference with work and experiencing an extended period of post-surgical pain during a potentially prolonged recovery period. Access to postoperative pain management methods that reduce or eliminate opioid use during post-discharge rehabilitation and recovery is an important factor in the selection of a joint replacement surgeon.

Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity

BackgroundPeople with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.MethodsWe designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.ResultsOf the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.ConclusionsSince both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.Trial registrationThe study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.

Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study

Background: Physical activity plays an important role in the prevention and treatment of chronic musculoskeletal pain, but chronic pain may implicate a poor rehabilitation outcome. The concept of physical activity on prescription (PAP) is a therapeutic option for various diseases, but there is a lack of knowledge about how patients with chronic musculoskeletal pain experience receiving the prescription.Objectives: The objective of this study was to describe the experiences of and thoughts about receiving a prescription for physical activity of people with chronic musculoskeletal pain.Design: Interviews analysed using qualitative content analysis with an inductive approach.Setting: Three primary healthcare centres in a mixed rural and suburban area in the vicinity of a large city in western Sweden.Subjects: Fifteen individuals with chronic musculoskeletal pain.Results: Four categories were identified with the overarching theme “Physical activity in chronic pain requires extra support”. There were several barriers for increasing activity level and these patients suffered from the additional burden of pain. The categories were: “Important to identify needs”, “Barriers and facilitators for physical activity”, “Perceptions of PAP vary” and “Effects found of receiving PAP”.Conclusions: Despite the many positive experiences of receiving PAP, patients described confusion about the role and execution of PAP. Chronic pain is an additional barrier for increasing activity level, and it is crucial to consider these patients’ circumstances. This study suggests that patients with chronic musculoskeletal pain have a greater need for information and extra support to overcome existing barriers, before or when physical activity is prescribed.Key PointsPhysical activity is important for prevention and treatment of chronic pain and has earlier been shown to be increased by “physical activity on prescription”.Patients with chronic musculoskeletal pain required the prescriber to listen and take the patients’ circumstances, context, symptoms and current activity level into account to a greater extent.Patients with chronic musculoskeletal pain experienced more obstacles to increase their physical activity and, therefore, had a greater need for individually tailored information and support when prescribed physical activity.Patients with chronic musculoskeletal pain found it difficult to distinguish between physical activity on prescription and physiotherapy and perceived that also the physicians could not tell the difference.

Fear of Reinjury in Athletes.

Context:A sports injury has both physical and psychological consequences for the athlete. A common postinjury psychological response is elevated fear of reinjury.Objective:To provide an overview of the implications of fear of reinjury on the rehabilitation of athletes, including clinical methods to measure fear of reinjury; the impact of fear of reinjury on rehabilitation outcomes, including physical impairments, function, and return to sports rate; and potential interventions to address fear of reinjury during rehabilitation.Evidence Acquisition:PubMed was searched for articles published in the past 16 years (1990-2016) relating to fear of reinjury in athletes. The reference lists of the retrieved articles were searched for additionally relevant articles.Study Design:Clinical review.Level of Evidence:Level 3.Results:Fear of reinjury after a sports injury can negatively affect the recovery of physical impairments, reduce self-report function, and prevent a successful return to sport. Athletes with high fear of reinjury might benefit from a psychologically informed practice approach to improve rehabilitation outcomes. The application of psychologically informed practice would be to measure fear of reinjury in the injured athletes and provide interventions to reduce fear of reinjury to optimize rehabilitation outcomes.Conclusion:Fear of reinjury after a sports injury can lead to poor rehabilitation outcomes. Incorporating principles of psychologically informed practice into sports injury rehabilitation could improve rehabilitation outcomes for athletes with high fear of reinjury.

Predictors for rehabilitation outcome in Asian geriatric hip fracture patients.

To identify predictors for rehabilitation outcome in Asian geriatric hip fracture patients. Records of 153 consecutive Asian patients aged 61 to 99 years who underwent surgery for hip fracture and were followed up for at least one year were reviewed. They were stratified into 4 agegroups: 60-69 years (n=27), 70-79 years (n=70), 80-89 years (n=50), and ≥90 years (n=6). Any comorbidity, regardless of severity, was recorded. Pre-injury and postoperative functional status was evaluated using the 36-item Short Form Health Survey. Relative functional gain (RFG) is equal to absolute functional gain (physical component summary [PCS] score at one year minus PCS score at 6 weeks) divided by the maximum potential gain (maximum PCS score minus PCS score at 6 weeks). RFG of <0.5 and ≥0.5 is defined as poor and good rehabilitation outcome, respectively. In univariate analysis, age 80-89 years (p=0.026), arthritis (p=0.082), and hypercholesterolaemia (p=0.014) were predictors for RFG. In multivariate analysis, age 80-89 years (p=0.016) remained a predictor for poor RFG, and hypercholesterolaemia remained a predictor for good RFG. Poor rehabilitation outcome was associated with patient age of 80-89 years; an orthogeriatric approach may be beneficial in optimising rehabilitation outcome in elderly hip fracture patients.

Association Between Protein Intake, Occlusal Force, and Walking Speed in Older Adults

In a recent study published in the Journal of the American Geriatrics Society, Okada and colleagues reported that lower protein intake mediates the association between walking speed and occlusal force in older Japanese adults.1 This is an important finding because people with poor chewing ability due to loss of teeth have low nutrient and protein intake, causing skeletal muscle loss, but we have several concerns about this study. First, the amount of protein intake studied in this analysis should have been adjusted for the total energy intake using the residual method,2 but it was calculated using the density method, which does not measure protein intake independent of total energy intake. The residual method has no such limitation and has been used in important epidemiological studies (e.g., Health, Aging, and Body Composition (Health ABC)3 and a nationwide Japanese study4) focused on protein intake assessed using validated questionnaire tools. It would have been possible to perform the analysis using the residual method because protein intake was evaluated based on results of a brief self-administered diet history questionnaire. Otherwise, the authors should have described total energy intake when they used the density method to analyze the relationship between occlusal force, protein intake, and walking speed. The density method alone, which calculates energy from protein per total energy intake (% energy), cannot calculate the adequacy of protein intake independent of total energy intake. This was shown in the results of Health ABC.3 In addition, the unit for protein intake in Table 1 in reference1 (g/kcal) might be unnecessary, and the unit for protein intake percentile in Table 2 in reference1 (g/kcal) might be incorrect. Second, protein intake seemed to be sufficient in this study. In the Dietary Reference Intakes for Japanese 2015,5 the tentative dietary goals for preventing lifestyle-related disease (DG) include proteins as a desirable percentage of energy (% energy). For individuals aged 70 and older, the DG for protein was determined to be 13% to 20% (median 16.5%). Table 1 in reference1 shows that median protein intake (percentage of energy) was 15.6% for a walking speed of 0.8 m/s of less and 16.2% for a walking speed of greater than 0.8 m/s. These results were not lower than the DG mentioned in the Dietary Reference Intakes for Japanese 2015. To compare the differences in lower protein intake, energy-adjusted protein intake (g/d) should be reported. Third, the prevalence of chronic kidney disease (CKD) was not reported in the study. Older adults are more likely to develop CKD. Is it usually recommended that individuals with severe CKD not undergoing dialysis have low protein intake. Therefore, CKD may affect the relationship between occlusal force, walking speed, and protein intake. Fourth, sarcopenia and malnutrition, which are associated with occlusal force, walking speed, and protein intake, were not included in the structural equation modeling analysis. Chewing ability and sarcopenia, and sarcopenia and age have equal odds ratios.6 Walking speed is included as a diagnostic criterion for sarcopenia in the consensus reports of the European Working Group on Sarcopenia in Older People7 and the Asian Working Group for Sarcopenia.8 Dietary protein intake is associated with sarcopenia,3 and sarcopenia and malnutrition are associated with poor rehabilitation outcomes and physical functions.9 Therefore, body mass index (BMI) can be associated with occlusal force, walking speed, and protein intake, but only walking speed was adjusted for BMI. Occlusal force and protein intake should have also been adjusted for BMI. Structural equation modeling analysis should also include sarcopenia and malnutrition as latent variables. A clarification from the authors about these concerns would be welcome. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Saino, Wakabayashi, Maeda: drafting and critical revision of manuscript for important intellectual content, approved final version of manuscript. Sponsor's Role: None.

Delayed Emergency Analgesia for Patients With Dementia and Hip Fracture.

Dementia is a risk factor for hip fracture and is associated with poorer rehabilitation outcome and decreased survival. There is evidence to suggest that pain in patients with dementia and hip fractures may be undertreated in prehospital, emergency department (ED), and postoperative settings. We studied consecutive new patients with hip fracture who presented to an ED with a census of 55 322 attendances per year in a regional Orthopaedic Centre in Ireland between January 01, 2013, and March 31, 2014, identified using a registry for the Irish National Hip Fracture Database. Patients were considered to have dementia when the diagnosis was documented in their medical notes, either prior to or during the index admission. The outcome measure used was time in minutes from ED arrival to the first dose of analgesic. Time-to-event analysis of the primary outcome was by the Kaplan-Meier method, stratified by cognitive status. We identified 133 consecutive patients who presented to ED de novo over 15 months with hip fractures. Of these 38 (29%) had documented dementia. The median Mini-Mental State Examination score of patients with dementia was 17, interquartile range (IQR) 10 to 19. The median age of patients with known dementia was 84 (IQR 79-87). The interval between ED arrival and first dose of analgesia was significantly longer for patients with dementia than for the cognitively intact, p 1⁄4 .027 (log rank; Figure 1). Median time to analgesia for patients with dementia was 164 minutes versus 90 minutes for the cognitively intact. These findings suggest that timely pain relief for patients with dementia and hip fracture is problematic. Many factors, including clinician awareness, difficulty in detecting pain and assessing response to pain relief in patients with dementia, the potential for undertriage, and delayed diagnosis of fractures, may be involved. Recent studies in other health-care jurisdictions (United Kingdom and Australia) also reported dementia as a barrier to analgesia for hip fractures in the ED. Taken together with these, our study suggests that more active assessment and management of pain are required in this increasingly prevalent and vulnerable condition. Acknowledgment

Poor oral status is associated with rehabilitation outcome in older people.

Poor oral status is associated with increased physical dependency and cognitive decline. Malnutrition, a potential result of poor oral status, is associated with poorer rehabilitation outcome and physical function. However, the association between oral status and rehabilitation outcome is not fully understood. The present study investigated the association of poor oral status with rehabilitation outcome in older patients. A retrospective cohort study was carried out of 108 consecutive patients (mean age 80.5 ± 6.8 years; 50.9% men) who were admitted to convalescent rehabilitation wards. The Revised Oral Assessment Guide was used to evaluate oral status. Rehabilitation outcome was evaluated by the Functional Independence Measure (FIM) on discharge. Multivariate analyses were applied to examine the associations between poor oral status and motor-FIM on discharge. According to the Revised Oral Assessment Guide score, 14.8% of participants had normal oral status, 52.8% had slight to moderate oral problems and 32.4% had severe oral problems. The median scores of motor-FIM on admission and on discharge were 52 (interquartile range 25-70) and 75 (interquartile range 51-89), respectively. Multivariate analysis showed that the Revised Oral Assessment Guide score and the motor-/cognitive-FIM scores on admission were significant independent factors for motor-FIM on discharge, after adjusted for sex, age, length of stay, nutritional status, handgrip and causative diseases (P < 0.001). Poor oral status is associated with rehabilitation outcome in older people. Geriatr Gerontol Int 2017; 17: 598-604.

Psychological Factors Affecting Rehabilitation and Outcomes Following Elective Orthopaedic Surgery.

Orthopaedic surgery often requires many months of rehabilitation to achieve a successful outcome, regardless of subspecialty. Several important psychological factors strongly influence pain perceptions, rehabilitation compliance, and patient outcomes after common orthopaedic surgeries that require extensive rehabilitation, including total joint arthroplasty, anterior cruciate ligament reconstruction, and spine surgery for degenerative disease. Early recognition of patients exhibiting psychological distress, fear-avoidance behavior, or poor perceived self-efficacy or pessimistic personality traits can be used to improve preoperative risk stratification for poor rehabilitation or surgical outcomes. Several intervention strategies exist to address these psychological factors when they appear to contribute suboptimal postoperative rehabilitation or recovery.

Clinical and cost effectiveness of enhanced oral healthcare in stroke care settings (SOCLE II): a pilot, stepped wedge, cluster randomized, controlled trial protocol.

Stroke-associated pneumonia, a leading cause of hospital-acquired infection after stroke, affects a fifth of stroke survivors annually. Associated with increased risk of death and poorer rehabilitation outcomes, research suggests a possible relationship between stroke-associated pneumonia and patients' oral health. The aim of this study is to evaluate the feasibility of a randomized controlled trial of the clinical and cost effectiveness of enhanced oral healthcare vs. usual oral healthcare for people in stroke care settings. Our pilot, multicentered, pragmatic, stepped wedge, cluster randomized controlled trial oral healthcare [Stroke Oral healthCare pLan Evaluation (SOCLE II)] will compare enhanced oral healthcare intervention and usual oral healthcare. Over 13 months, across 4 wards, we seek to recruit 400 patients (estimating an average of 23 beds per site and a 50% recruitment rate) and 60 nursing staff (estimating an average of 20 members of staff per site and a 75% recruitment rate). Initially, control data (usual oral healthcare) will be collected from all sites. In a randomized, stepped manner, wards will convert to deliver the enhanced oral healthcare intervention. Outcomes will be captured across dimensions of care (as recommended for evaluations of complex interventions) at baseline and weekly thereafter. Primary outcomes are pneumonia (patients), knowledge and attitudes (staff), and specialist dental referrals (service). Secondary outcomes include oral health quality of life, plaque, antibiotics, length of stay, death (patients), use of oral healthcare equipment and products, completed assessments, and documented oral healthcare plans (staff). As one of the first stepped wedge, cluster randomized, controlled trials in stroke care mapping of the complex intervention, our choice of primary and secondary outcomes and choice of trial design are described.

Rehabilitation nutrition for sarcopenia with disability: a combination of both rehabilitation and nutrition care management.

Malnutrition and sarcopenia often occur in rehabilitation settings. The prevalence of malnutrition and sarcopenia in older patients undergoing rehabilitation is 49–67 % and 40–46.5 %, respectively. Malnutrition and sarcopenia are associated with poorer rehabilitation outcome and physical function. Therefore, a combination of both rehabilitation and nutrition care management may improve outcome in disabled elderly with malnutrition and sarcopenia. The concept of rehabilitation nutrition as a combination of both rehabilitation and nutrition care management and the International Classification of Functioning, Disability and Health guidelines are used to evaluate nutrition status and to maximize functionality in the elderly and other people with disability. Assessment of the multifactorial causes of primary and secondary sarcopenia is important because rehabilitation nutrition for sarcopenia differs depending on its etiology. Treatment of age-related sarcopenia should include resistance training and dietary supplements of amino acids. Therapy for activity-related sarcopenia includes reduced bed rest time and early mobilization and physical activity. Treatment for disease-related sarcopenia requires therapies for advanced organ failure, inflammatory disease, malignancy, or endocrine disease, while therapy for nutrition-related sarcopenia involves appropriate nutrition management to increase muscle mass. Because primary and secondary sarcopenia often coexist in people with disability, the concept of rehabilitation nutrition is useful for their treatment. Stroke, hip fracture, and hospital-associated deconditioning are major causes of disability, and inpatients of rehabilitation facilities often have malnutrition and sarcopenia. We review the concept of rehabilitation nutrition, the rehabilitation nutrition options for stroke, hip fracture, hospital-associated deconditioning, sarcopenic dysphagia, and then evaluate the amount of research interest in rehabilitation nutrition.

Abstract T P245: Time to Percutaneous Endoscopic Gastrostomy (PEG) Placement and National Institutes of Health Stroke Scale (NIHSS) Correlations in Acute Ischemic Stroke (AIS)

Purpose: American Heart Association 2013 guidelines for AIS management emphasize the use of PEG feeding for patients who cannot take solids/liquids orally and a 2-3 week preference for NG after stroke onset. Recent studies suggest 14-28 days before a PEG is placed. Concerns about shortened time-intervals between AIS and PEG placement have arisen, possibly averting rehabilitation of a patient capacity to swallow. High NIHSS scores may be predictive of a patient need for PEG placement. The pilot study was to investigate PEG placement timing and correlation of the NIHSS in patients admitted with AIS in a 5-campus hospital system. Methods: Adult patients (18-99yrs) with AIS ICD-9 primary discharge codes, correlated with PEG placement procedural codes, and NIHSS scores Sept 2012 to Jun 2013. All patients were determined unable to safely swallow, requiring enteral feeding prior to discharge. Patients with chronic dysphagia, previous PEG, traumatic brain injury, intracranial/subarachnoid hemorrhage were excluded. Retrospective chart audit of 56 cases initially identified, 22 final AIS patients had PEG placement for dysphagia prior to hospital discharge with NIHSS documentation. Results: Final cohort statistics: 7 females (32%) and 15 males (68%); mean patient age 78.9 years, median of 78.5 years. Mean number of days between acute onset/admission and PEG placement 12.1 days, median of 7.0 days. Mean admission NIHSS scale was 16.6 points, median 17.5 points. Mean NIHSS score at PEG placement was 19.5 points, median 21 points. 16 patients (72.7%) with NIHSS of 14 points or greater, a score previously correlated with poor long-term rehabilitation outcomes. Comparison of admission NIHSS to NIHSS at the time of PEG placement, 13 patients (59%) had an equal or increased score. Conclusions: Significantly shorter PEG interval times than currently recommended were noted, with high NIHSS. Current rationales are not well understood. Further research is needed to insure ‘allow for swallow’ recovery in the dysphagic AIS patient while mitigating risk of malnutrition and aspiration.

Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning a prospective cohort study

To investigate the association between nutritional status and rehabilitation outcome in elderly inpatients with hospital-associated deconditioning. A prospective cohort study. One hundred sixty-nine consecutive elderly inpatients diagnosed with hospital-associated deconditioning. Nutritional status at referral was assessed by the Mini Nutritional Assessment Short Form at the University Medical Center. Body mass index, haemoglobin, albumin, total lymphocyte count, C-reactive protein, cause of malnutrition, and feeding route were also investigated. Primary outcome was Barthel Index score at discharge. A total of 148 patients (87.6%) were malnourished, and 21 were at risk for malnutrition. There were no patients with normal nutritional status. Malnourished patients had a lower Barthel Index score at discharge than those at risk for malnutrition. Chronic disease-related malnutrition, oral intake, and parenteral nutrition were associated with the Barthel Index score at discharge. There were significant correlations between the Barthel Index score at discharge and nutritional score, albumin, and total lymphocyte count. In multiple regression analysis, Mini Nutritional Assessment Short Form, albumin, and chronic disease-related malnutrition were significantly associated with the Barthel Index score at discharge. Most elderly inpatients with hospital-associated deconditioning are malnourished. Nutritional status, albumin, and chronic disease-related malnutrition are associated with poor rehabilitation outcome in hospital-associated deconditioning.

Perceived injustice contributes to poor rehabilitation outcomes in individuals who have sustained workplace injuries

The experience of unnecessary suffering as a result of another's actions or the experience of irreparable losses are likely to give rise to perceptions of injustice. Until recently, little systematic research had been conducted on the effects of perceptions of injustice on recovery outcomes following injury. It is now becoming clear that justice-related appraisals can have a dramatic impact on the physical and emotional consequences of injury. High levels of perceived injustice have been associated with more severe pain, more severe emotional distress, and more pronounced disability. Research has also pointed to multiple sources of a client's perceptions of injustice including, the person responsible for the accident, the insurance representative, as well as the health care provider. This presentation will summarize what is currently known about the relation between perceived injustice and recovery outcomes. The presentation will also address the processes by which perceptions of injustice might contribute to adverse health and mental health outcomes consequent to injury. Implications for prevention and intervention will be discussed.

In-patient Rehabilitation Outcomes Following Lower Extremity Fracture in Patients with Pneumonia

Pneumonia is a common comorbidity among hospitalized older adults and may impede functional restoration and increase medical cost. Medicare reimbursement rates for patients receiving in-patient medical rehabilitation services are higher for individuals who have comorbid pneumonia. We examined the impact of comorbid pneumonia on outcomes for patients with lower extremity fracture receiving in-patient medical rehabilitation services. Secondary data analysis of medical records obtained from 919 in-patient rehabilitation facilities in the United States. The sample included 153,241 subjects who received in-patient rehabilitation services following lower extremity fracture in 2005-2007. We used multivariable linear regression to evaluate the independent effects of pneumonia on stay and discharge functional status (Functional Independence Measure instrument), and logistic regression models to explore discharge to home versus not home. Pneumonia was a comorbidity for 4,265 (2.8%) of the subjects with lower extremity fracture. The multivariable models indicated that subjects with no payment-eligible comorbidity experienced shorter stay (regression coefficient -0.44, 95% CI -0.60 to -0.28 d), higher discharge functional status ratings (regression coefficient 1.84, 95% CI 1.42-2.25 points), and higher odds of home discharge (odds ratio 1.19, 95% CI 1.09-1.29), compared to subjects with pneumonia. Our findings suggest that comorbid pneumonia is associated with poorer rehabilitation outcomes (stay, discharge functional status, and discharge setting) among subjects receiving in-patient rehabilitation services for lower extremity fracture.

Abstract TP322: Towards better screening for Post Stroke Depression

Post stroke depression (PSD), occurring in 33% of stroke survivors, is considered the most critical obstacle to rehabilitation after stroke. PSD is consistently linked with increased length of hospital stay, motivation to undergo rehabilitation, poorer rehabilitation outcomes, decreased engagement in recreational and social pursuits, decreased quality of life, and mortality. Although addressing PSD should be considered a critical factor in stroke recovery, the condition remains largely under-diagnosed. A challenge to diagnosis of PSD is a lack of appropriate screening tools. Existing screening tools were not designed for stroke populations or are too time consuming and complex to be utilized routinely. The goal of the present study was to identify a quick, two item screening tool for PSD that requires no training or scoring. Specifically, we examined what brief combination of dichotomized self-report questions can be used as indicators for a DSM-IV-TR classification of depression in stroke survivors In this prospective natural history study, a consecutive sample of 121 stroke survivors completed comprehensive interviews at 10 days post stroke. Contender questions assessing mood, cognition, physical functioning, social support, and relationship profiles were selected based on previous findings. At 10 days, 7 of 121 participants were classified as depressed in accordance with the SCID-I, the gold standard diagnostic tool for clinical depression. Results of logistic regression indicated that patients who met threshold on two MHI item, are you a happy person and have you been so down in the dumps, were 25 times more likely to be depressed than patients who did not (C Statistic &gt; 0.90). As well, these brief questions better predicted PSD at 10 days than did the total MHI score. In the present paper, screening models are considered with regard to practical and theoretical issues in the assessment of PSD. The present study indicates that quick and simple screening tools designed for PSD can be used to select patients for diagnostic assessments and facilitate timely diagnoses of PSD. The present study contributes to our understanding of the clinical presentation of depression in the context of stroke and to our goal of facilitating recovery from stroke.

Interdisciplinary communication in inpatient rehabilitation facility: evidence of under-documentation of spatial neglect after stroke

Purpose: Spatial neglect commonly occurs after stroke and predicts poor rehabilitation outcomes. However, this disorder is under-recognized in clinical practices, which may result from the failure to document its presence. This study aimed to identify the predictors for documentation of spatial neglect in inpatient rehabilitation facilities. Method: We performed a comprehensive chart review to investigate whether the presence of spatial neglect was documented in 74 neglect patients’ clinical notes recorded by physicians, nurses, or occupational therapists (OTs), or in team conference notes. Independent variables included neglect severity, length of stay, Functional Independence Measure at admission and discharge. Results: Of the 74 neglect patients, 75.7% were documented by OTs, 63.5% by physicians, and 17.6% by nurses. Although 93.2% of neglect patients were recognized by at least one clinician group, only 31.1% were discussed in multidisciplinary team conferences. Neglect patients who were documented by physicians were more likely to be documented in team conferences. While no factors predicted whether a neglect patient would be documented by nurses or OTs, we found significant predictors for neglect documentation in physician and team conference notes. The odds of being documented by physicians were increasingly greater with poorer efficiency of cognitive rehabilitation (odds ratio = 0.70). The odds of being discussed in team conferences were increasingly greater with more severe neglect (odds ratio = 0.98), and with longer stay in hospitalization (odds ratio = 1.06). Conclusions: Multidisciplinary care may not involve as much interdisciplinary communication as needed to document important disease states. Stroke rehabilitation professionals should be able to recognize spatial neglect independently and document it consistently.Implications for RehabilitationOccupational therapists detected and documented more neglect cases than physicians or nurses. Nurses’ documentation rate of spatial neglect was much lower than physicians or occupational therapists.Spatial neglect was more likely to be documented by physicians if the patients had poor efficiency in cognitive outcome improvement.Stroke patients with more severe neglect or with longer stay were more likely to be documented in team conference notes.No neglect patient was coded with the ICD-9-CM code (781.8), suggesting that using such code for institutional or nation-wide prevalence research on spatial neglect is likely to be unfruitful.

Poster 82 Prism Treatment May Facilitate Stroke Survivors' Recovery to Independence

Spatial neglect post stroke is a strong, significant predictor of poor rehabilitation outcome. Previously, we reported that the prism treatment selectively improved motor bias in neglect patients. The present study evaluated whether neglect patients' motor functions improved with prism treatment.

Functional Assessment of Spatial Neglect: A Review of the Catherine Bergego Scale and an Introduction of the Kessler Foundation Neglect Assessment Process

Spatial neglect is a debilitating poststroke neurocognitive disorder associated with prolonged hospitalization and poor rehabilitation outcomes. The literature suggests a high prevalence of this disorder, but clinicians have difficulty reliably identifying affected survivors. This discrepancy may result from suboptimal use of validated neglect assessment procedures. In this article, we suggest use of a validated assessment tool that is sensitive to identification of neglect and its functional consequences – the Catherine Bergego Scale (CBS). We provide detailed item-by-item instructions for observation and scoring – the Kessler Foundation Neglect Assessment Process (KF-NAP). Rehabilitation researchers may be able to use the CBS via the KF-NAP to measure ecological outcomes and specific, separable perceptual-attentional and motor-exploratory spatial behaviors.

On Enhancing Competent Work with African American Clients: Challenging Persistent Racial Disparity Trends by Examining the Role of the Working Alliance

Trends of racial disparities continue to persist across a variety of rehabilitation domains (e.g., acceptance rates, types of services offered, rehabilitation outcomes). African Americans consistently have poorer rehabilitation outcomes when compared to their White counterparts. Scholars have identified issues of racial bias in clinical judgment within cross-racial client-counselor relationships as a likely central factor contributing to this trend. The strength of the working alliance between counselor and client has been shown to be predictive of positive client outcomes. Factors within the helping relationship, such as color-blind attitudes and racial microaggressions, which have been shown to erode the alliance with African American clients, are discussed, as well as the use of broaching strategies to directly address the issue of race with clients as a means of strengthening the working alliance.