Rehabilitation Medicine Service Research Articles

Measurement properties of the neurobehavioral cognitive status examination (Cognistat) in traumatic brain injury rehabilitation.

Objective: Evaluate measurement properties of the Neurobehavioral Cognitive Status Examination (Cognistat) using Rasch analysis. Design: Calibration of item responses from 120 individuals admitted to a rehabilitation medicine service for traumatic brain injury (TBI) and 296 community-dwelling adults with TBI. Results: Three strata of performance were differentiated despite a skewed distribution toward high performance among the community sample. Elimination of easier items created a better targeted instrument (i.e., generated more spread among individuals) without a significant increase in error. Memory and verbal reasoning were the most difficult domains for each sample; however, analyses indicated significant measurement error. Conclusions: As a screening instrument, the Cognistat reliably classifies multiple levels of cognitive status in both acute and postacute TBI settings; however, this measure is unsuitable for generating a profile of neurocognitive strengths and weaknesses.

Secondary Mania in Older Adults

Although mania is commonly associated with bipolar disorder, it can have many etiologies (1). Thus, “primary mania” results from bipolar disorder, whereas “secondary mania” results from pharmacological, metabolic, or neurologic causes (1, 2). Older adults are at risk for secondary mania because of increased medical comorbidities and neurological changes. In one retrospective study of 50 patients with mania who were older than 65 years, it was the first manic episode for 28% of the patients and 71% had a comorbid neurological disorder (3). The etiology of mania is important because although acute symptomatic treatment of both primary and secondary mania may be similar, appropriate treatment of secondary mania includes addressing the cause (1). We present here two case histories of secondary mania in older adults, discuss their presentations and differential diagnosis in turn, and discuss treatment.

Poster 46: Pediatric Risk of Mortality Assessment in Critical Care and Correlation With Functional Outcomes

Objectives: To evaluate how well assessments of injury severity and mortality risk done in the critical care setting predict functional outcome on discharge for survivors of central nervous system (CNS) injury in the pediatric population and to test the hypothesis that Pediatric Risk of Mortality (PRISM) scores obtained in the critical care setting will predict functional outcome (Functional Rehabilitation Evaluation of Sensori-Neurologic Outcomes [FRESNO] scores) on discharge from the hospital. Design: Retrospective study. Setting: Regional tertiary care pediatric hospital with a large inpatient rehabilitation medicine service. Participants: Patients with CNS injury of varied etiology admitted to the pediatric intensive care unit (ICU) and subsequently treated by the inpatient rehabilitation medicine (neurotrauma) service. Interventions: Not applicable. Main Outcome Measures: PRISM and FRESNO assessment tool. Results: The study identified 63 patients ranging in age from 0.7 to 18.3 years which were evaluated using both outcome measures. Identified patients sustained CNS injuries of varying etiology including traumatic brain injury, nonaccidental trauma, anoxic injury, vascular accidents, and others. Analysis of the data revealed no statistically significant correlation between PRISM score on ICU admission and FRESNO score on discharge from the neurotrauma unit. Conclusions: Although PRISM assessment has been demonstrated to adequately predict mortality risk and give some indication of injury severity it does not predict functional level at discharge for survivors. These results point to the need to develop assessment protocols (vs individual tools) that provide accurate information about prognosis from a functional point of view. In addition, approaches should be multidisciplinary and consider both acute and long term outcomes.

Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: A randomized controlled pilot study

da Cunha IT Jr, Lim PA, Qureshy H, Henson H, Monga T, Protas EJ. Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: a randomized controlled pilot study. Arch Phys Med Rehabil 2002;83:1258-65. Objective: To investigate gait outcomes with supported treadmill ambulation training (STAT) associated with regular rehabilitation in acute stroke survivors. Design: Randomized controlled trial, pilot study. Setting: Rehabilitation medicine service at a Veterans Affairs medical center. Participants: Seven acute stroke survivors assigned to regular intervention group and 6 patients assigned to STAT intervention. Interventions: Regular intervention consisted of 3 hours daily of physical therapy, kinesiotherapy, and occupational therapy. STAT group received regular rehabilitation with STAT substituted for usual gait training. Participants were tested at baseline, treated for an average of 3 weeks, and retested on discharge. The analysis of covariance procedure was used to test for differences between the 2 approaches. Main Outcome Measures: Functional Ambulation Category Scale, gait speed, walking distance, gait energy expenditure, and gait energy cost. Results: The small sample size did not generate enough power to detect significant differences in any variable. However, medium to large effect sizes of 0.7 and 1.16 standard deviation units were observed for gait energy cost and walk distance, respectively. Conclusions: This pilot study indicated that STAT is a safe, feasible, and promising intervention for acute stroke survivors. A larger trial is warranted for statistical relevance. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

A taxonomy for classification of stroke rehabilitation services

Hoenig H, Sloane R, Horner RD, Zolkewitz M, Duncan PW, Hamilton BB. A taxonomy for classification of stroke rehabilitation services. Arch Phys Med Rehabil 2000;81:853-62. Objective: To develop a taxonomy for use in measuring stroke rehabilitation services. Design: A cross-sectional study using facility-level survey data and extant data files. Setting: Veterans Administration medical centers (VAMCs). Variables: (1) A list of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (2) a classification or typology of VAMCs according to the type of postacute stroke care on-site. Main Outcome Measures: Data sources included extant Veterans Administration (VA) computerized databases, VA central office administrative files, and 2 mailed surveys to VA rehabilitation medicine services and stroke acute care services. The rehabilitation taxonomy was derived using 2 methods that assess face and construct validity, respectively: (1) an expert panel rating, using a modified Delphi process, of the clinical importance of each of the rehabilitation characteristics; and (2) a comparison of rehabilitation characteristics across the different types of VAMCs. Variables were included in the final taxonomy if the expert panel reached consensus that the variable was clinically important, or if there were statistically significant differences in these characteristics across the different types of medical centers. Results: Of 67 possible rehabilitation characteristics, a multidisciplinary expert panel reached consensus about the likely clinical importance of 21 rehabilitation characteristics, 11 of which showed statistically significant differences across different types of VAMCs. An additional 9 variables that lacked expert panel consensus differed significantly among the different medical centers. These 30 variables represent a preliminary taxonomy of key rehabilitation characteristics. Among the 20 variables that varied significantly across the different types of medical centers, 18 showed a pattern with the greatest amount of resources and organizational sophistication being found in VAMCs with rehabilitation units, followed by medical centers with geriatric units, and the least amount of resources and organizational sophistication was seen in medical centers whose postacute care services were limited to nursing home or intermediate care. Conclusion: Thirty rehabilitation characteristics had face validity and/or construct validity, and can be considered to represent a preliminary taxonomy for measuring stroke rehabilitation services. This study also shows that there are significant differences among hospitals in resources and organization of care deemed to be important for stroke patients. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Stroke patients: Do they have a predilection for extrapyramidal side effects from amiodarone?

This report describes two patients with recent stroke who, upon transfer to the rehabilitation medicine service, were noted to have extrapyramidal features. Both patients were receiving amiodarone for management of atrial fibrillation. When this medication was discontinued, there was slow resolution of extrapyramidal features and an improvement in function. Physicians managing acute stroke patients should be alert for features of amiodarone neurotoxicity, because these side effects may occur more readily in patients with recent neurologic impairment and may impede their progress in rehabilitation.

Central pontine myelinolysis after liver transplantation: a case report

Abstract A patient development deteriorating mental status, quadriparesis, and severe pseudobulbar palsy with the inability to speak or swallow following orthotopic liver transplantation (OLT). Subsequently, abnormalities were found in the pons on MRI that were consistent with central pontine myelinolysis (CPM). Marked recovery occurred following transfer to the rehabilitation medicine service. Seven months following development of CPM, a mild dysarthria has persisted, but full ambulation has returned. Although no significant fluctuations in serum sodium were seen perioperatively, multiple risk factors associated with the development of CPM were present, including end-stage liver disease, a history of

Assessment of Independent Living Skills for Psychotic Patients

It is well known that psychotic patients have severe social and life-skill deficits. Psychiatric rehabilitation programs are designed to teach these skills to patients. Before implementing such a program, patient deficits should be evaluated with reliable measures. The present study assessed the psychometric properties of the French version of the "Independent Living Skills Survey" (ILSS) developed by Wallace, Kochanowicz and Wallace (Wallace C J, Kochanowicz N, Wallace J [1985] Independent living skills survey. Unpublished manuscript, Mental Health Clinical Research Center for the Study of Schizophrenia, West Los Angeles Veterans Administration Medical Center, Rehabilitation Medicine Service [Brentwood Division], Los Angeles, CA). Although widely used, the patient version of this scale has unknown psychometric properties. The ILSS was composed of 75 items, rated as present or absent and distributed in 10 scales. The French version was administered to 145 patients with a psychotic diagnosis who were living in the community. All scales had very good psychometric qualities with the exception of the job-maintenance scale. The test-retest reliability varied from .48 to .85, and alpha coefficients were good for seven of the nine scales. Various aspects of construct validity were explored. The scales discriminated between patients as a function of their subgroups, sex, and diagnosis. Concurrent validity confirmed the specificity of the ILSS dimensions. Factor analysis revealed two factors, one for basic skills and one representing higher order skills. Recommendations for future development of the ILSS are proposed.

Musculoskeletal Complications of Cancer

A variety of complications associated with cancer may adversely affect the spine and musculoskeletal system, resulting in physical impairment, pain, or both. Dysfunction may arise because of tissue injury at the primary site of disease; from metastatic lesions and paraneoplastic syndromes; or as the result of treatment and bed rest. This study evaluated 50 patients seen in consultation by the Rehabilitation Service at Memorial Sloan-Kettering Cancer Center (28 retrospective, 22 prospective). Patients were evaluated for functional problems resulting from their disease or therapy. Patients were noted to have an average of 1.74 physical impairments. Thirteen (26%) patients had only one identifiable problem adversely affecting function. Fifty-four percent of patients were found to have two physical impairments. Ten patients (20%) had three or more such abnormalities. The mean Karnofsky score, a measure commonly used in assessing cancer patient function, at initial evaluation was 46.6 (standard deviation (SD) 12.05). The most frequently encountered problem limiting function was deconditioning (56%); 36% of patients had central nervous system dysfunction; 28% had peripheral neurologic disease; 22% of patients were found to have bone metastasis. Additionally, pain was present in 44% of all patients. These results suggest that it is common for cancer patients who are referred for physiatric evaluation to have more than one functional problem, and that deconditioning, neurological, and skeletal abnormalities are common causes of impairment in cancer patients.Cancer is a significant cause of morbidity and mortality in the United States.1 It is a disease process which is inherently destructive, both at the primary site as well as areas to which it may spread. Additionally, remote effects of cancer, such as paraneoplastic syndromes, may result in further compromise of the patient. Antineoplastic therapies such as chemotherapy, radiotherapy, and surgery are also potentially injurious to native tissues and organ systems. The deleterious effects of these direct and indirect consequences of cancer, whether affecting the musculoskeletal, nervous, cardiovascular, or pulmonary systems, may result in functional impairment and disability. Therefore, it is not surprising to find a high prevalence of disabilities among cancer patients.2,3Significant functional impairment has been noted by previous authors.2,3 A variety of organ systems may be either primarily or secondarily involved, including the spine and musculoskeletal systems. These authors have demonstrated a high prevalence of functional deficits in cancer patients. Additionally, they noted that the majority of cancer patients with disabilities can be successfully treated by physical medicine intervention. The principal impediments preventing patients from obtaining optimal rehabilitation, as determined by these authors were: primary care physicians' inability to recognize functional impairment; and a lack of understanding by these same physicians in rehabilitation principles.2The scope of musculoskeletal and neurological impairments, as well as the number of functionally compromising problems faced by the individual patient is less well known. The object of this survey was to evaluate a series of cancer patients, seen in consultation by a rehabilitation medicine service, for musculoskeletal, neurologic, and other relevant impairments.

Medical Evaluations Get Failing Grades

For more information, contact: Wilbert E. Fordyce, PhD. Dept. of Rehabilitation Medicine and Pain Service. University of Washington. Seattle. Wash. 98195.

Vocational Rehabilitation Index assessment of rehabilitation medicine service patients

Only a minority of working-age patients referred to rehabilitation medicine services return to work, but could more be helped? A first step is identifying those potentially able to do so. This paper describes the retrospective application of the Vocational Rehabilitation Index (VRI) to 223 patients of working age and with various diagnoses referred to one rehabilitation medicine service. The VRI discriminates between patients who return to work and those who do not, as well as between groups with apparently differing degrees of need for vocational rehabilitation assistance. It also has good face validity. Results suggest that it is feasible to apply the VRI in rehabilitation medicine settings and that further prospective evaluation and practical applications should be undertaken.

Work of a rehabilitation medicine service.

The results of the work of the Edinburgh Rehabilitation Medicine Service in one year were evaluated. Over 1400 new patients were seen, of whom 525 were in hospital at the time. Patients most often referred were those who had had cardiovascular accidents, back pain, lower limb amputations, and head injuries and those convalescing after heart surgery. Most patients had several problems. Many were referred so that they could obtain wheelchairs or other appliances, or for assessment of their ability to drive. Only 3% of the referrals were considered inappropriate. Of the inpatients, 455 (87%) returned home after treatment, but 13 (2%) did not respond satisfactorily to rehabilitation. Twelve per cent (18% of the inpatients) were referred from other health boards, suggesting a need for similar facilities elsewhere.

Evoked potentials in Puerto Rican male adults: [formula omitted] and H.J. Flax (Rehabilitation Medicine Service, VAH, San Juan, Puerto Rico 00936, U.S.A.)

Evoked potentials in Puerto Rican male adults: [formula omitted] and H.J. Flax (Rehabilitation Medicine Service, VAH, San Juan, Puerto Rico 00936, U.S.A.)

The effects of introducing the Klein-Bell ADL Scale in a rehabilitation service.

This study investigated the impact of introducing the Klein-Bell ADL Scale into a rehabilitation medicine service. A pretest and a posttest questionnaire of rehabilitation team members and a pretest and a posttest audit of occupational therapy documentation were completed. Results of the questionnaire suggested that the ADL scale influenced rehabilitation team members' observations in the combined area of occupational therapy involvement in self-care, improvement in the identification of treatment goals and plans, and communication between team members. Results of the audit suggested that the thoroughness and quantification of occupational therapy documentation improved. The clinical implications of these findings recommend the use of the Klein-Bell ADL Scale in rehabilitation services for improving occupational therapy documentation and for enhancing rehabilitation team effectiveness.

Evaluation of family stroke education.

To increase families' involvement in rehabilitation, a series of informational sessions called the Family Stroke Education Class was implemented at a 305 bed medical center serving disabled veterans and their families. Questionnaires completed by family and patients at the meetings showed that anxiety level decreased significantly. More than 90% of participants felt more comfortable about approaching team members with questions in the future, and 77% felt more informed as a result of taking the class. Knowledge scores improved significantly and sustained over a 3 month time period. The educational format was a practical way of including the needs and soliciting participation of the family as well as a means for providing basic information on stroke rehabilitation.

Identifying social needs of patients with neuromuscular disorders.

Ron L. Evans, MSW, is a clinical assistant professor at the University of Washington School of Social Work and a social worker at the Rehabilitation Medicine Service, Veterans Administration Medical Center, Seattle, WA. Vicki Becker, MEd, OTR, is supervisor of occupational therapy at the Mason Clinic, Virginia Mason Medical Center, Seattle, WA. Bruce W. Stone, MSW, is a social worker at Harborview Medical Center, Seattle, WA.

Local twitch response evoked by palpation and needle penetration of a trigger point in human muscle

Rehabilitation Medicine Service, VA Medical Center, Long Beach, CA 90822, and Department of PM & R, University of California, IrvineU.S.A

Narcissism in the physical rehabilitation patient.

During my years as the psychologist on a rehabilitation medicine service, 1 have had a chance to observe narcissistic phenomena in some patients who were medically ill, chronically disabled, and brain injured. When we consider narcissistic phenomena, we are usually thinking about the problems that a physically healthy person is having with living and getting along with others. Of course, narcissistic people also become medically ill at times, and their various difficulties in living and being with others become as obvious in the sickroom or hospital as in their personal lives and their work. Illness can also make nonnarcissistic people narcissistic. Freud noted that the sick person withdraws libido from objects and becomes narcissistic. 1'p'83 This is the same mechanism that Freud describes as the basic dynamic of schizophrenic psychosis as well--a condition that is more generally recognized as narcissistic per se. Actually, narcissism is a collection of related phenomena that come and go throughout the life cycle and that have a different significance, depending on the circumstance. Narcissism during medical illness must be understood in the context of narcissism in general. Whenever a person's interests are being seriously threatened, attention, energy, and concern are withdrawn from their usual loci and directed back onto the self and its activities. For example, if a man's business is failing, we are not surprised to learn that he shows the following narcissistic phenomena: that he thinks of nothing else, neglects his family, loses his temper inappropriately, misinterprets the good wishes of others, and is often inconsiderate, demanding, even irrational. Similarly, during adolescence and young adulthood, when the individual has to make career and personal decisions that will affect the rest of his life, while becoming more independent and assuming more personal responsibility, the individual is often self-involved, inconsiderate, impulsive, overemotional, and hostile to those in authority. These breakdowns in control, insight, effective behavior, and relatedness are narcissistic phenomena. They are the consequences of moving libido,

Employing reality orientation in a short term treatment setting

This paper reports on the experience of a short stay rehabilitation medicine service with a reality orientation program. It describes techniques and programs, and reports results in terms of patient improvement.

The reliability of a scaling system for the psychological evaluation of admissions to a rehabilitation medicine service.

The reliability of a scaling system for the psychological evaluation of admissions to a rehabilitation medicine service.