Rehabilitation Consultation Research Articles

Human gait simulation with a neuromusculoskeletal model and evolutionary computation

AbstractThis paper describes a human gait animation system with a precise neuromusculoskeletal model and evolutionary computation. The neuromusculoskeletal model incorporates 14 rigid bodies, 19 degrees of freedom, 60 muscular models, 16 pairs of the neural oscillators, and other neuronal systems. By changing the search parameters and the evaluative criteria of the evolutionary search process, we demonstrate various locomotive patterns, such as normal gait, pathological gait, running and ape‐like walking. The proposed simulation system takes not only kinematic data but also in vivo dynamic data such as energy consumption information into consideration, so that the resultant locomotion patterns are natural and valid from a biomechanical point of view. Hence the simulation system can also be used for finding a biologically appropriate physical model to realize a desired gait by simultaneously modifying the body dynamics parameters with the neuronal parameters. This capability creates a novel application of human gait simulation systems, such as rehabilitation tool design and consultation for physically handicapped people. Copyright © 2003 John Wiley & Sons, Ltd.

Comprehensive trauma patient care by nonphysician providers.

Nonphysician providers are being increasingly used to care for trauma patients. As these complex patients recover, they require meticulous medical management and time-consuming psychosocial care. A retrospective evaluation of a unique patient care service staffed by nonphysician providers is presented. The Intermediate Care Service is designed to facilitate the management and long-term placement of trauma patients who no longer require intensive care while recovering from their injuries. The new diagnoses, physician order changes, and disposition of 93 patients cared for during a 6-month period are described. Most patients were admitted with neurologic injury. The most common new diagnosis was constipation; the most frequent new orders related to medications, including bowel management, and rehabilitation consultations. All patients were discharged from the hospital. The Intermediate Care Service represents a unique and valuable model for the collaborative management of complex trauma patients.

Containment of heart failure hospitalizations and cost by angiotensin-converting enzyme inhibitor dosage optimization

Using our model relating angiotensin-converting enzyme (ACE) inhibitor dosing and outcomes in heart failure (HF), we designed a prospective intervention trial for patients with systolic dysfunction. A clinical pharmacist initiated or titrated ACE inhibitor therapy or adjusted other medications within an HF management program based on Agency for Healthcare Policy and Research guidelines. Entry into the protocol required the approval of the attending physician. All patients received dietary, nursing, rehabilitation, social service, and clinical pharmacy consultations. Treatment conformed to Agency for Healthcare Policy and Research guidelines in 25% of patients (group A). Suboptimal therapy (75% of patients) was usually due to failure to administer an ACE inhibitor (48%) or inadequate dosing of an ACE inhibitor (46%). In 62% of suboptimal cases, the attending physician agreed to follow the clinical pharmacist’s recommendations (group B). Patients of physicians who declined pharmacist intervention served as a negative control (group C). On admission, mean enalapril-equivalent daily doses in groups A, B, and C were 30, 4, and 6 mg, respectively, and at discharge, 36, 18, and 6 mg, respectively. At 180 days, rehospitalization frequency and total charges were lower in groups A (31% and $5,600) and B (35% and $3,800) than in group C (63% [p <0.004] and $9,800 [p <0.04]). Thus, optimization of ACE inhibitor doses by a clinical pharmacist can greatly improve rehospitalization rates and significantly lower cost of care in an HF management program.

Rural health professionals' satisfaction with a rehabilitation mobile outreach program

Objective: To assess the extent to which rural physicians and allied health professionals are satisfied with consultation services provided by an interdisciplinary rehabilitation outreach team. Design: Descriptive survey. Setting: A rehabilitation outreach team that travels to 14 rural communities in eastern and northern Ontario, Canada. Subjects: Thirty-six rural physicians (response rate, 53.7%) and 62 allied health professionals (response rate, 92.5%) involved in the care of patients referred to the program. Main Outcome Measure: Consumer satisfaction questionnaire. Results: Most respondents (94.7%) indicated that they were satisfied with the interdisciplinary consultation, with comparable rates of satisfaction reported by physicians and allied health professionals. The highest satisfaction ratings were given to items addressing the clarity of recommendations provided by team members and the quality of the team's interaction with patients. The lowest ratings were associated with the waiting time between visits. Of all the individual disciplines on the team, physiatry was rated as most important for rural consultations. However, in open-ended comments, respondents indicated that the interdisciplinary aspect of the service was its most valued characteristic, whereas infrequent visits were the greatest drawback. Conclusion: The interdisciplinary outreach approach to rehabilitation consultation receives high satisfaction ratings from rural health professionals who refer patients to the outreach team, which supports this model as a way to enhance rehabilitation services in rural communities.

Low-bandwidth telemedicine for remote orthotic assessment.

A model for performing remote orthotic assessments using low-bandwidth computer communication technology (video conferencing) was developed, tested, and evaluated. System evaluation involved comparing a series of remote assessments with on-site assessments. While most on-site and on-line results were similar, discrepancies which occurred were attributed to between-clinician differences, measurement technique differences, technical and learning obstacles at the start of the project, and within subject variations during the day. On-line assessment efficiency improved with each on-line session and corresponded with increased confidence in the system, easier system use, and better overall satisfaction. An on-line debriefing session was held with all project clinicians. These clinicians supported continued use of the communication system for rehabilitation consultation and education. Clinically. preliminary face-to-face meetings and a regular practice schedule were recommended. Technically, the system was considered good; however, suggested improvements included using a high quality speaker-phone system, streamlining the video capture process, and providing more reliable telecommunication connections.

A CLINICAL REHABILITATION COURSE FOR COLLEGE UNDERGRADUATES PROVIDES AN INTRODUCTION TO BIOPSYCHOSOCIAL INTERVENTIONS THAT MINIMIZE DISABLEMENT1

A two-credits per semester clinical medicine course was established in the Department of Physical Medicine and Rehabilitation (PM&R) in cooperation with the Johns Hopkins University undergraduate Human Biology faculty to present the variety of inpatient consultation personnel, units, patient diagnostic groups, and functional problems. College students spend 4 hr weekly on the PM&R consultation service as team members under resident supervision. The curriculum emphasizes student understanding of the roles of rehabilitation team members. Objectives include demonstration of working knowledge of the Biopsychosocial Model, the World Health Organization Model of disablement and interdisciplinary rehabilitation intervention. The course includes simulations of physical impairments, demonstrations of adaptive equipment, interactive chart reviews, readings, and audio lectures. A retrospective sequential review was made of the last 100 physical medicine and rehabilitation consultations with student attendance. The results confirm student exposure to many ward settings (surgery, 30%; neurology/neurosurgery, 28%; medicine, 24%; intensive care, 15%; oncology, 2%; and psychiatry, 1%), patient complexity (averaging 10 problems), and multiple ICD-9 diagnosis categories (circulatory, 36%; neurologic, 22%; musculoskeletal, 17%; neoplasms, 10%; injury, 5%; endocrine, 4%; infections, 3%; and others, 3%). The rehabilitation consultation service is particularly effective as an introduction to hospital-based medical practice due to the diagnostic variety of the patients, the functional approach of rehabilitation, and student exposure to multiple hospital settings. The Biopsychosocial Model of medical practice is demonstrated through multiple interdisciplinary perspectives of needs and interventions for patients with obvious functional deficits. This process develops a rudimentary understanding of the effect of illness on the person and the variety of medically effective therapeutic modalities.

Measuring quality and cost of care: evaluation of an amputation clinical pathway

This study was based on nursing literature supporting the use of clinical pathways in case management systems to improve quality, reduce cost, and increase efficiency. Its purpose was to provide a descriptive analysis of outcomes in lower-extremity amputation caused by arterial occlusive disease. Patients were admitted between Jan. 1, 1989, and Sept. 1, 1995, with arterial occlusive disease for an above- or below-knee amputation and were cared for in three consecutive phases of nursing case management: (1) without a clinical pathway (group I), (2) with a consultation to rehabilitation services in the postoperative stay (group II), and (3) with a rehabilitation-focused clinical pathway (group III). The results of the study indicated more patients were able to return home from acute care and rehabilitation (52%) in group III than in group I and group II (40% and 44%, respectively). In addition, the hospital length of stay was reduced from 11 days to 8 days (geometric mean) once a rehabilitation consultation was included in the plan of care (group II). Although hospital charges rose initially with rehabilitation consultation ($18,627), they were reduced significantly when the pathway was used ($12,629; adjusted for rate increases). When patients were separated by level of amputation, those with below-knee amputations in group III had a significantly shorter length of stay and lower hospital charges than those in the other two groups, but comorbidity remained high. Nurse case managers can use this clinical pathway as a model for care as the findings support its cost effectiveness. They also demonstrate its effectiveness in enhancing the of quality care through a rehabilitation-focused, goal-oriented plan to return patients home.

Consumer satisfaction with a rehabilitation mobile outreach program

Accessibility to rehabilitation services is often difficult for people with disabilities who live in rural areas. This study examined consumer satisfaction with a rehabilitation outreach approach that utilizes a mobile clinic to provide consultation services. The descriptive survey took place in fifteen rural communities in eastern and northeastern Ontario, Canada. Valid postconsultation mail surveys were completed by 143 consecutive patients with mixed diagnoses (or proxy family members) who had been seen during mobile clinic visits to their home communities (85.1% of patients approached). There were 59 men and 84 women, with an average age of 58.7 years. The main outcome measure was a consumer satisfaction scale. A high level of global satisfaction was reported, with 97.2% of respondents reporting a preference for community outreach over the alternative of traveling to an urban rehabilitation center. Enhanced accessibility was considered to be the major advantage of the outreach program, but concerns about the continuity of care were also expressed. Providing interdisciplinary rehabilitation consultation services on an outreach basis is associated with a high level of consumer satisfaction. From a consumer perspective, the outreach approach seems to be a viable way of addressing some of the rehabilitation needs of rural people with disabilities.

Rehabilitation medicine consultation in persons hospitalized with AIDS. An analysis of thirty cases.

This retrospective study outlines interventions taken as a result of rehabilitation medicine consultation in persons hospitalized with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). The medical records of 30 persons with HIV infection consecutively referred for rehabilitation medicine consultation over a one-year period were reviewed. The sample was composed primarily of white, homosexual males with a mean age of 38.5 (SD, 8.5) years and a mean length of AIDS diagnosis of 14.6 (SD, 14.1) months. Rehabilitation medicine evaluation resulted in additional diagnoses in four cases (13.3%), prescriptions for new medications in 8 (26.7%), physical modalities/devices in 9 (30.0%) and referrals to occupational, physical and speech therapies in 26 (86.7%), 24 (80.0%) and 3 (10.0%) patients, respectively. Interventions were often directed toward deconditioning, painful peripheral neuropathy and fatigue. Mean survival after rehabilitation consultation was approximately 23 weeks. No intervention was novel or unusual suggesting that current knowledge is sufficient to manage much of the disability associated with HIV infection. This study concludes that rehabilitation medicine can contribute to the management of persons hospitalized with AIDS. Further research should address efficacy of intervention, fatigue as a source of disability and the value of early rehabilitation intervention.

Responsible and responsive rehabilitation consultation on the ADA: The importance of training for psychologists.

Responsible and responsive rehabilitation consultation on the ADA: The importance of training for psychologists.

Responsible and responsive rehabilitation consultation on the ADA: The importance of training for psychologists.

Responsible and responsive rehabilitation consultation on the ADA: The importance of training for psychologists.

Responsible and responsive rehabilitation consultation on the ADA: The importance of training for psychologists.

Responsible and responsive rehabilitation consultation on the ADA: The importance of training for psychologists.

A Consultative Rehabilitation Approach in Industry

In 1982, amendments to the Michigan Worker’s Disability Compensation Act mandated a substantial increase in the maximum weekly benefit rate to injured workers (from the 1981 maximum of $210 per week to $307 per week). This rate increase became a focus for cost containment by many state employers. One such employer, Motor Wheel Corporation-Lansing Plant, decided to utilize external rehabilitation consultants to facilitate a higher return to work rate of injured workers to lessen compensation expenditures. This article describes the development and preliminary evaluation of the rehabilitation process within Motor Wheel-Lansing Plant.