Rehabilitation for a complex patient following cerebellar hemorrhage and obstructive hydrocephalus: A case report.

BACKGROUND AND PURPOSE: Inpatient rehabilitation facilities play an integral role in patient progress post-stroke. Cerebellar hemorrhages are an infrequent type of stroke and are therefore less discussed in the literature; however, inpatient rehabilitation continues to be an integral part of patient recovery. The purpose of this case report is to discuss the physical therapy interventions, challenges, and successes for a complex patient with a large cerebellar hemorrhage with obstructive hydrocephalus. Case Description: The patient is a 32-year-old male admitted to an inpatient rehabilitation facility. Prior to admission, the patient spent 1 month at a local hospital following a complicated recovery status post cerebellar hemorrhage with obstructive hydrocephalus. Interventions: The patient participated in at least 3 hours of combined therapy a day, split into 30- and 60-min sessions, and divided between physical, occupational, and speech therapy. Physical therapy interventions focused on various gait and coordination activities. Outcomes: The patient spent 47 days in an inpatient rehabilitation facility and demonstrated improvements in all aspects of the Functional Independence Measure®. The patient improved from an 18 to a 90 on the total FIM® score, allowing the patient to ultimately be discharged home with family able to provide 24/7 supervision.

Improvement During Inpatient Rehabilitation Among Older Adults With Guillain-Barré Syndrome, Multiple Sclerosis, Parkinson Disease, and Stroke.

OBJECTIVE: The aim of the study was to quantify the improvement in independence experienced by patients with the following diagnoses: Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke after inpatient rehabilitation. DESIGN: Subjects who were admitted to inpatient rehabilitation hospitals in 2012-2013 with an incident diagnosis of the following: Guillain-Barré syndrome (n = 1079), multiple sclerosis (n = 1438), Parkinson disease (n = 11,834), or stroke (n = 131,313), were included. The main outcome measure was improvement in Functional Independence Measure scores on self-care, mobility, and cognition during inpatient rehabilitation. We estimated percent improvement from a linear mixed-effects model adjusted for patients' age, sex, race/ethnicity, comorbidity count, diagnostic group (Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke), and admission score. RESULTS: All patient diagnostic groups receiving inpatient rehabilitation improved across all three domains. The largest adjusted percent improvements were observed in the mobility domain and the smallest in the cognition domain for all groups. Percent improvement in mobility ranged from 84.9% (multiple sclerosis) to 144.0% (Guillain-Barré syndrome), self-care from 49.5% (multiple sclerosis) to 84.1% (Guillain-Barré syndrome), and cognition from 34.0% (Parkinson disease) to 51.7% (Guillain-Barré syndrome). Patients with Guillain-Barré syndrome demonstrated the greatest percent improvement across all three domains. CONCLUSIONS: Patients with Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke should improve during inpatient rehabilitation but anticipated outcomes for patients with Guillain-Barré syndrome should be even higher.

Association of Rehabilitation Intensity for Stroke and Risk of Hospital Readmission.

BACKGROUND: Little is known about the use of rehabilitation in the acute care setting and its impact on hospital readmissions. OBJECTIVE: The objective of this study was to examine the association between the intensity of rehabilitation services received during the acute care stay for stroke and the risk of 30-day and 90-day hospital readmission. DESIGN: A retrospective cohort analysis of all acute care hospitals in Arkansas and Florida was conducted. METHODS: Patients (N=64,065) who were admitted for an incident stroke in 2009 or 2010 were included. Rehabilitation intensity was categorized as none, low, medium-low, medium-high, or high based on the sum and distribution of physical therapy, occupational therapy, and speech therapy charges within each hospital. Cox proportional hazards regression was used to estimate hazard ratios, controlling for demographic characteristics, illness severity, comorbidities, hospital variables, and state. RESULTS: Relative to participants who received the lowest intensity therapy, those who received higher-intensity therapy had a decreased risk of 30-day readmission. The risk was lowest for the highest-intensity group (hazard ratio=0.86; 95% confidence interval=0.79, 0.93). Individuals who received no therapy were at an increased risk of hospital readmission relative to those who received low-intensity therapy (hazard ratio=1.30; 95% confidence interval=1.22, 1.40). The findings were similar, but with smaller effects, for 90-day readmission. Furthermore, patients who received higher-intensity therapy had more comorbidities and greater illness severity relative to those who received lower-intensity therapy. LIMITATIONS: The results of the study are limited in scope and generalizability. Also, the study may not have adequately accounted for all potentially important covariates. CONCLUSIONS: Receipt of and intensity of rehabilitation therapy in the acute care of stroke is associated with a decreased risk of hospital readmission.

Minimal clinically important difference for comfortable speed as a measure of gait performance in patients undergoing inpatient rehabilitation after stroke.

[Purpose] The purpose of this retrospective study was to determine the minimal clinically important difference for comfortable gait speed for patients with stroke. [Subjects] Data were analyzed from 35 patients undergoing inpatient rehabilitation. [Methods] Two characteristics of gait were measured, assistance required and comfortable gait speed. Patients were grouped as either experiencing or not experiencing a decrease of 2 or more levels of assistance required over the course of rehabilitation. Receiver operating characteristic curve analysis was used to identify the change in gait speed that best differentiated between patients who did and did not experience the requisite decrease in assistance required for gait. [Results] Twenty-one patients decreased 2 or more levels of assistance whereas 14 did not. Walking speed increased significantly more in the group who experienced a decrease in assistance of at least 2 levels. The receiver operating characteristic curve analysis showed a change in walking speed of 0.13 m/s best distinguished between patients who did versus did not experience a reduction in assistance required. [Conclusion] An improvement in gait speed of 0.13 m/s or more is clinically important in patients with stroke.

Outcome measures in neurological physical therapy practice: part II. A patient-centered process.

Physical therapists working in neurological practice must make choices about which standardized outcome measures are most appropriate for each patient. Significant time constraints in the clinic limit the number of measures that one can reasonably administer. Therapists must choose measures that will provide results that guide the selection of appropriate interventions and are likely to show clinically meaningful change. Therefore, therapists must be able to compare the merits of available measures to identify those that are most relevant for each patient and setting. This article describes a process for selecting outcome measures and illustrates the use of that process with a patient who has had a stroke. The link between selecting objective outcome measures and tracking patient progress is emphasized. Comparisons are made between 2 motor function measures (the Fugl-Meyer Assessment [FMA] of Physical Performance vs the Stroke Rehabilitation Assessment of Movement), and 2 balance measures (Berg Balance Scale vs the Activities-specific Balance Confidence Scale). The use of objective outcome measures allows therapists to quantify information that previously had been described in subjective terms. This allows the tracking of progress, and the comparison of effectiveness and costs across interventions, settings, providers, and patient characteristics.

Update on distance and velocity requirements for community ambulation.

PURPOSE: The purposes of this study were to provide an update to the ambulatory distance requirements for community ambulation and to update gait speed performance and requirements at intersections. METHODS: Distances were measured at 9 types of sites using a rolling measuring device in accordance with the protocol set forth by Lerner-Frankiel and associates. The 9 types of sites were supermarkets, drug stores, banks, department stores, post offices, medical offices, superstores, club warehouses, and hardware stores. Gait speed allotted by crosswalk signals as well as the gait speeds of individuals through crosswalks were recorded. Qualitative observations of the pedestrians' age (older - 65 years; younger < 65 years) and sex were also noted. RESULTS: Distances were measured at 141 different establishments. The shortest mean distance requirement was found in the medical offices at 65.82 (32.28) m. Club warehouses had the longest mean distance requirement at 676.82 (159.36) m. The mean gait speed used by the pedestrians (N = 139) was 1.32 (0.31) m/s while the mean speed necessary as set by the crosswalk signals was 0.49 (0.20) m/s. All of the individuals observed were able to cross the street within the allotted time and with adequate speed. The gait speeds met the normative data established for age and sex as well as data reported for slower older adults and some with incomplete spinal cord injury. CONCLUSIONS: Distance requirements for full community ambulation may need to be increased to 600 m or more. Gait speed requirements at crosswalks in the communities measured are set to accommodate the gait speed capabilities of older pedestrians who attempt crossing at controlled intersections.

Tests and measures used by specialist physical therapists when examining patients with stroke.

BACKGROUND AND PURPOSE: Examination procedures preferred by physical therapists have not been documented either specifically or comprehensively. The purpose of this study was to determine which tests and measures are used most frequently by specialists in the examination of adults with stroke. SUBJECTS: Physical therapy specialists were identified as having geriatric or neurologic certification through the American Board of Physical Therapy Specialties. A request to participate in a Web-based survey was sent to 471 individuals in the American Physical Therapy Association's Directory of Certified Specialists. METHODS: A comprehensive list of tests and measures was first derived from the Interactive Guide to Physical Therapist Practice. The list was finalized based on several exclusion criteria and the results of a pilot study. Subjects rated the frequency of use of 294 tests and measures with patients post-stroke on a Likert scale. RESULTS: The survey response rate was 31.7% (n = 128). The 50 most frequently used tests and measures were identified. DISCUSSION AND CONCLUSION: The results of this study do not identify the tests and measures that clinicians should use, only those that the specialists use. Nevertheless, clinicians may want to consider tests and measurements frequently used by specialists when examining adults with stroke.

Short-term recovery of limb muscle strength after acute stroke.

OBJECTIVES: To document, by using norm-referenced strength measures, the recovery of limb muscle strength of patients undergoing stroke rehabilitation and to examine the relation between comorbidities and the recovery of strength after stroke. DESIGN: Retrospective analysis of data from a consecutive convenience sample of patients examined clinically between 1994 and 1997. SETTING: Acute inpatient rehabilitation unit. PARTICIPANTS: Fifty patients with stroke who were able to follow commands and were examined during acute rehabilitation by a single examiner (AWA). INTERVENTIONS: Stroke rehabilitation emphasizing early movement, exercise with resistance, and daily functional activities. MAIN OUTCOME MEASURE: The strength at discharge of 7 muscle actions (shoulder abduction, elbow flexion, elbow extension, wrist extension, hip flexion, knee extension, ankle dorsiflexion) measured bilaterally with a hand-held dynamometer and compared with norm-referenced values. RESULTS: Differences in strength between admission and discharge were significant for all muscle actions on the weaker side and for 4 of the 7 muscle actions on the stronger side. At discharge, the bilateral strength of all muscle actions was weaker than predicted by data from healthy individuals of comparable age, sex, and weight (F>17.000, P<.001). Strength did not differ between subjects who did and did not have a previous stroke or comorbidities. CONCLUSIONS: Subjects undergoing inpatient rehabilitation soon after stroke experienced an increase in limb muscle strength bilaterally. This increase was not influenced by previous stroke or comorbidities.