Microprocessor Controlled Knee Ankle Foot Orthosis (KAFO) vs Stance Control vs Locked KAFO: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the potential of a microprocessor swing and stance controlled knee-ankle-foot orthosis (MPO) to improve balance, functional mobility, and quality of life in individuals with lower-extremity impairments as compared to a stance-control-orthosis (SCO) and conventional knee-ankle-foot orthosis (KAFO) over a use-period of a month. DESIGN: Randomized crossover study. SETTING: Ambulatory research laboratory and home and community for community-dwelling adults. PARTICIPANTS: Persons (N=18) who actively used a unilateral KAFO or SCO for impairments due to neurologic or neuromuscular disease, orthopedic disease, or trauma. INTERVENTION: Participants were trained to acclimate and use SCO and MPO. MAIN OUTCOME MEASURES: The 6-minute walk test (6MWT), 10-m walk test, Berg Balance Scale (BBS), functional gait assessment (FGA), hill assessment index, stair assessment index (SAI), Five Times Sit to Stand Test, crosswalk test, Modified Falls Efficacy Scale, Orthotic and Prosthetic User's Survey (OPUS), and World Health Organization Quality of Life (WHQOL)-BREF Scale. RESULTS: Significant changes were observed in participants' self-selected gait speed (P=.023), BBS (P=.01), FGA (P=.002), and SAI (P<.001) between baseline and post-MPO assessment. Similar significant differences were seen when comparing post-MPO with post-SCO data. During the 6MWT, persons using the MPO walked significantly longer (P=.013) than when using their baseline device. Participants reported higher quality of life scores in the OPUS (P=.02) and physical health domain of the WHOQOL-BREF (P=.037) after using the MPO. Participants reported fewer falls when wearing the MPO (5) versus an SCO (38) or locked KAFO (15). CONCLUSIONS: The MPO may contribute to improved quality of life and health status of persons with lower-extremity impairments by providing the ability to have better walking speed, endurance, and functional balance.

Brain Injury Functional Outcome Measure (BI-FOM): A Single Instrument Capturing the Range of Recovery in Moderate-Severe Traumatic Brain Injury.

OBJECTIVE: To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM. DESIGN: Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range. SETTING: Six TBI Model System rehabilitation hospitals. PARTICIPANTS: Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up. INTERVENTIONS: Participants were administered the 49 assessment items in person or via telephone. MAIN OUTCOME MEASURES: Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance. RESULTS: After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM. CONCLUSIONS: The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages.

Rasch Analysis of Social Attitude Barriers and Facilitators to Participation for Individuals with Disabilities.

OBJECTIVES: To develop item banks of social attitude barriers and facilitators to participation and validate them with established instruments. DESIGN: We used the Rasch model to identify misfitting items and rating scale problems, calibrate items, and develop KeyForms and short forms. Correlations between the Social Attitude Barriers and Facilitators item banks with the Patient-Reported Outcomes Measurement Information System (PROMIS) Social Health domain and National Institutes of Health Toolbox Emotional Battery Social Relationships domain were computed to evaluate convergent and divergent validity. SETTING: Community-dwelling individuals traveled to 3 academic medical centers for testing. PARTICIPANTS: Participants (N=558) who had a primary impairment of stroke, spinal cord injury, or traumatic brain injury (mean age, 47.0±16.0y) completed 31 social attitude facilitator and 51 barrier items using a 5-point rating scale. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item banks to measure social attitude barriers and facilitators for individuals with disabilities. RESULTS: After combining the "never" and "rarely" rating scale categories, 30 Facilitator items fit the Rasch model and demonstrated person reliability of 0.93. After collapsing the "never" and "rarely" rating scale categories, 45 Barrier items fit the Rasch model and demonstrated person reliability of 0.95. Ceiling and floor effects were negligible for both item banks. Facilitators and Barriers item banks were negatively correlated, and these banks were moderately correlated with PROMIS and Toolbox measures, providing evidence of convergent and divergent validity. CONCLUSIONS: Findings support the reliability and validity of the Social Attitude Facilitators and Barriers item banks. These item banks allow investigators and clinicians to measure perceptions of social attitudes, providing information that can guide individual interventions to reduce barriers and promote facilitators. Moderate correlations between the Social Attitude banks and PROMIS and Toolbox variables provide support for the measurement and theory of environmental influences on social health and participation.

Using the ICF's environmental factors framework to develop an item bank measuring built and natural environmental features affecting persons with disabilities.

OBJECTIVES: To develop a measure of natural environment and human-made change features (Chapter 2 of the international classification of functioning, disability, and health) and evaluate the influence of perceived barriers on health-related quality of life. METHODS: A sample of 570 adults with stroke, spinal cord injury, and traumatic brain injury residing in community settings reported their functioning in home, outdoor, and community settings (mean age = 47.0 years, SD = 16.1). They rated 18 items with a 5-point rating scale to describe the influence of barriers to moving around, seeing objects, hearing sounds, hearing conversations, feeling safe, and regulating temperature and indicated whether any difficulties were due to environmental features. We used Rasch analysis to identify misfitting items and evaluate differential item functioning (DIF) across impairment groups. We computed correlations between barriers and patient-reported outcomes measurement information system (PROMIS) social domain measures and community participation indicators (CPI) measures. RESULTS: The 18 items demonstrated person reliability of .70, discriminating nearly three levels of barriers. All items fit the Rasch model; impairment-related DIF was negligible. Ceiling effects were negligible, but 25 % of the respondents were at the floor, indicating that they did not experience barriers that they attributed to the built and natural environment. As anticipated, barriers correlated moderately with PROMIS and CPI variables, suggesting that although this new item bank measures a construct that is related to participation and health-related quality of life, it also captures something unique. Known-groups validity was supported by wheelchair users reporting a higher level of barriers than did ambulatory respondents. CONCLUSIONS: Preliminary evidence supports the reliability and validity of this new measure of barriers to the built and natural environment. This measure allows investigators and clinicians to measure perceptions of the natural environment and human-made changes, providing information that can guide interventions to reduce barriers. Moderate relationships between barriers and PROMIS and CPI variables provide support for the measurement and theory of environmental influences on social health and participation.

Measuring Access to Information and Technology: Environmental Factors Affecting Persons With Neurologic Disorders.

OBJECTIVE: To develop and validate a patient-reported measure of access to information and technology (AIT) for persons with spinal cord injury, stroke, or traumatic brain injury. DESIGN: A mixed-methods approach was used to develop items, refine them through cognitive interviews, and evaluate their psychometric properties. Item responses were evaluated with the Rasch rating scale model. Correlational and analysis-of-variance methods were used to evaluate construct validity. SETTING: Community-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place. PARTICIPANTS: Individuals with a diagnosis of spinal cord injury, stroke, or traumatic brain injury (aged ≥18y, English speaking) participated in cognitive interviews (n=12 persons), field testing of the items (n=305 persons), and validation testing of the final set of items (n=604 persons). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A set of items to measure AIT for people with disabilities. RESULTS: A user-friendly multimedia touchscreen was used for self-administration of the items. A 23-item AIT measure demonstrated good evidence of internal consistency reliability, and content and construct validity. CONCLUSIONS: This new AIT measure will enable researchers and clinicians to determine to what extent environmental factors influence health outcomes and social participation in people with disabilities. The AIT measure could also provide disability advocates with more specific and detailed information about environmental factors to lobby for elimination of barriers.

Measuring Environmental Factors: Unique and Overlapping International Classification of Functioning, Disability and Health Coverage of 5 Instruments.

OBJECTIVES: To describe the unique and overlapping content of the newly developed Environmental Factors Item Banks (EFIB) and 7 legacy environmental factor instruments, and to evaluate the EFIB's construct validity by examining associations with legacy instruments. DESIGN: Cross-sectional, observational cohort. SETTING: Community. PARTICIPANTS: A sample of community-dwelling adults with stroke, spinal cord injury, and traumatic brain injury (N=568). INTERVENTIONS: None. MAIN OUTCOME MEASURES: EFIB covering domains of the built and natural environment; systems, services, and policies; social environment; and access to information and technology; the Craig Hospital Inventory of Environmental Factors (CHIEF) short form; the Facilitators and Barriers Survey/Mobility (FABS/M) short form; the Home and Community Environment Instrument (HACE); the Measure of the Quality of the Environment (MQE) short form; and 3 of the Patient Reported Outcomes Measurement Information System's (PROMIS) Quality of Social Support measures. RESULTS: The EFIB and legacy instruments assess most of the International Classification of Functioning, Disability and Health (ICF) environmental factors chapters, including chapter 1 (products and technology; 75 items corresponding to 11 codes), chapter 2 (natural environment and human-made changes; 31 items corresponding to 7 codes), chapter 3 (support and relationships; 74 items corresponding to 7 codes), chapter 4 (attitudes; 83 items corresponding to 8 codes), and chapter 5 (services, systems, and policies; 72 items corresponding to 16 codes). Construct validity is provided by moderate correlations between EFIB measures and the CHIEF, MQE barriers, HACE technology mobility, FABS/M community built features, and PROMIS item banks and by small correlations with other legacy instruments. Only 5 of the 66 legacy instrument correlation coefficients are moderate, suggesting they measure unique aspects of the environment, whereas all intra-EFIB correlations were at least moderate. CONCLUSIONS: The EFIB measures provide a brief and focused assessment of ICF environmental factor chapters. The pattern of correlations with legacy instruments provides initial evidence of construct validity.

Development of self-report measures of social attitudes that act as environmental barriers and facilitators for people with disabilities.

OBJECTIVE: To describe the development of new self-report measures of social attitudes that act as environmental facilitators or barriers to the participation of people with disabilities in society. DESIGN: A mixed-methods approach included a literature review; item classification, selection, and writing; cognitive interviews and field testing of participants with spinal cord injury (SCI), traumatic brain injury (TBI), or stroke; and rating scale analysis to evaluate initial psychometric properties. SETTING: General community. PARTICIPANTS: Individuals with SCI, TBI, or stroke participated in cognitive interviews (n=9); community residents with those same conditions participated in field testing (n=305). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Self-report item pool of social attitudes that act as facilitators or barriers to people with disabilities participating in society. RESULTS: An interdisciplinary team of experts classified 710 existing social environment items into content areas and wrote 32 new items. Additional qualitative item review included item refinement and winnowing of the pool prior to cognitive interviews and field testing of 82 items. Field test data indicated that the pool satisfies a 1-parameter item response theory measurement model and would be appropriate for development into a calibrated item bank. CONCLUSIONS: Our qualitative item review process supported a social environment conceptual framework that includes both social support and social attitudes. We developed a new social attitudes self-report item pool. Calibration testing of that pool is underway with a larger sample to develop a social attitudes item bank for persons with disabilities.

Feasibility of computerized adaptive testing for collection of patient-reported outcomes after inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility of computer adaptive testing (CAT) using an Internet or telephone interface to collect patient-reported outcomes after inpatient rehabilitation and to examine patient characteristics associated with completion of the CAT-administered measure and mode of administration. DESIGN: Prospective cohort study of patients contacted approximately 4 weeks after discharge from inpatient rehabilitation. Patients selected an Internet or telephone interface. SETTING: Rehabilitation hospital. PARTICIPANTS: Patients (N=674) with diagnoses of neurologic, orthopedic, or medically complex conditions. INTERVENTIONS: None. MAIN OUTCOME MEASURE: CAT version of the Community Participation Indicators (CAT-CPI). RESULTS: From an eligible pool of 3221 patients, 674 (21%) agreed to complete the CAT-CPI. Patients who agreed to complete the CAT-CPI were younger and reported slightly higher satisfaction with overall care than those who did not participate. Among these patients, 231 (34%) actually completed the CAT-CPI; 141 (61%) selected telephone administration, and 90 (39%) selected Internet administration. Decreased odds of completing the CAT-CPI were associated with black and other race; stroke, brain injury, or orthopedic and other impairments; and being a Medicaid beneficiary, whereas increased odds of completing the CAT-CPI were associated with longer length of stay and higher discharge FIM cognition measure. Decreased odds of choosing Internet administration were associated with younger age, retirement status, and being a woman, whereas increased odds of choosing Internet administration were associated with higher discharge FIM motor measure. CONCLUSIONS: CAT administration by Internet and telephone has limited feasibility for collecting postrehabilitation outcomes for most rehabilitation patients, but it is feasible for a subset of patients. Providing alternative ways of answering questions helps assure that a larger proportion of patients will respond.

Development of a measure of skin care belief scales for persons with spinal cord injury.

OBJECTIVES: To develop and validate a measure of skin care beliefs and to describe the skin care behaviors of persons with spinal cord injury (SCI). DESIGN: A mixed-methods design was used to develop the Skin Care Beliefs Scales (SCBS). The health belief model framed the hypotheses. Phase 1 included item development, content validity testing, and pilot testing. Phase 2 included testing the scale structure (principal components analysis), internal consistency reliability, test-retest reliability, and relationships between the belief scales and care behaviors. SETTING: Two acute rehabilitation hospitals and Internet websites. PARTICIPANTS: Patients with SCI (N=462; qualitative/pilot n=56; psychometric study n=406) participated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The pilot and phase 2 studies, respectively, used 146-item and 114-item versions of the SCBS. A skin care activity log was used to record skin care behaviors. RESULTS: Content validity indicated that the items were relevant and clear. The analysis resulted in 11 independent scales reflecting 3 general beliefs (susceptibility, severity, self-efficacy) and barrier and benefit behavior-specific scales for skin checks, wheelchair pressure reliefs, and turning and sitting times. With the exception of skin check barriers (α=.65), Cronbach alphas of the scale ranged from .74 to .94. Test-retest intraclass correlations were fair to excellent (range, .42-.75). Construct validity was supported. Hierarchical linear regression indicated that turning benefits, barriers, susceptibility, and self-efficacy were significant predictors of turning time. Benefits or barriers were correlated significantly with skin check and pressure relief adherence (ρ range, -.17 to -.33). Self-efficacy was correlated with wheelchair pressure relief (ρ=.18). Skin care behavior adherence varied widely (eg, 0%-100%). CONCLUSIONS: The scales showed acceptable reliability and validity. Further testing with larger samples is desirable.

Psychometric properties of the communication Confidence Rating Scale for Aphasia (CCRSA): phase 1.

Confidence is a construct that has not been explored previously in aphasia research. We developed the Communication Confidence Rating Scale for Aphasia (CCRSA) to assess confidence in communicating in a variety of activities and evaluated its psychometric properties using rating scale (Rasch) analysis. The CCRSA was administered to 21 individuals with aphasia before and after participation in a computer-based language therapy study. Person reliability of the 8-item CCRSA was .77. The 5-category rating scale demonstrated monotonic increases in average measures from low to high ratings. However, one item ("I follow news, sports, stories on TV/movies") misfit the construct defined by the other items (mean square infit = 1.69, item-measure correlation = .41). Deleting this item improved reliability to .79; the 7 remaining items demonstrated excellent fit to the underlying construct, although there was a modest ceiling effect in this sample. Pre- to posttreatment changes on the 7-item CCRSA measure were statistically significant using a paired samples t test. Findings support the reliability and sensitivity of the CCRSA in assessing participants' self-report of communication confidence. Further evaluation of communication confidence is required with larger and more diverse samples.

New Device Makes Tracheostomy Dressing Changes Easier and More Comfortable.

PURPOSE: This study compared the use of the tracheostomy dressing applicator (TDA) to the standard procedure for tracheostomy dressing changes. DESIGN: A prospective quasi-experimental study was performed. METHODS: Nineteen patients and 117 nurses answered a survey after changing the tracheostomy dressing with the TDA and using standard procedure. FINDINGS: Nurses rated the TDA easier to use in patients with average-sized necks and more favorably on observed discomfort in patients with average-sized and larger necks. Patients rated less discomfort with the TDA compared with the standard method of dressing change. CONCLUSION: The TDA is an effective device to facilitate tracheostomy dressing changes, possibly improving compliance and decreasing skin complications. CLINICAL RELEVANCE: The TDA is a useful device that can improve efficiency of dressing changes with the potential to save time and improve outcomes.

Effects of gender on inpatient rehabilitation outcomes in the elderly with incomplete paraplegia from nontraumatic spinal cord injury.

OBJECTIVE: To examine gender differences in rehabilitation outcomes for patients with nontraumatic spinal cord injury. RESEARCH DESIGN: Secondary analysis was conducted on Medicare beneficiary data from 65 to 74 year olds with incomplete paraplegia discharged from inpatient rehabilitation facilities in 2002 through 2005. MAIN OUTCOME MEASURES: Length of stay, Functional Independence Measure instrument motor item and subscale scores on discharge, and discharge destination. RESULTS: Among patients with degenerative spinal disease, men had significantly longer rehabilitation stays than women (P < 0.001). Men with degenerative spinal disease had significantly lower discharge Functional Independence Measure scores than women, indicating more dependence in self-care (P < 0.001) and mobility (P < 0.001). Among patients with degenerative spinal disease, men were less likely to walk (odds ratio = 0.58; 95% CI = 0.38-0.87) and less likely to be independent with bladder management (odds ratio = 0.44; 95% CI = 0.31-0.62). Among patients with vascular ischemia, men were more independent (B = 2.59; 99% CI = 0.42-4.76) in mobility than women. There were no gender differences in the malignant spinal tumors group. There were no gender differences in being discharged to a community-based residence. CONCLUSIONS: Gender distributions varied by etiology. Gender differences were found in demographics, length of stay, and functional outcomes but not discharge destination. Men were more dependent than women at discharge in the etiology group with the least overall disability (degenerative spinal disease) and more independent in mobility than women at discharge in the etiology group with the most overall disability (vascular ischemia).

Effects of an Implementation Intervention to Promote Use of Patient-Reported Outcome Measures on Clinicians' Perceptions of Evidence-Based Practice, Implementation Leadership, and Team Functioning.

INTRODUCTION: Patient-reported outcome measures (PROMs) are administered rarely during rehabilitation hospitalizations because clinicians are unfamiliar with their use and the technology to integrate PROMs into electronic medical records is nascent. This study evaluated an implementation intervention that targeted teams' perceptions of evidence-based practice (EBP), implementation leadership, and team functioning that might facilitate PROM use. METHODS: We compared clinicians' perceptions on three inpatient rehabilitation units, with sequential implementation across units. Clinicians completed the EBP Attitudes Scale, Implementation Leadership Scale, and the Team Functioning Survey before, shortly after, and 1 month after training. RESULTS: Forty-seven clinicians participated, including nurses (27.7%), occupational (21.3%) and physical therapists (21.3%), and two physicians. They worked on spinal cord injury (46.8%), neurologic (40.4%), or pediatric (12.8%) units. EBP Attitude Scale scores improved from preintervention to postintervention and remained above baseline levels at follow-up. The interaction between time and unit was statistically significant for the Divergence subscale such that Pediatric Unit scores increased from preintervention to postintervention and follow-up, while on the spinal cord injury, unit scores increased from preintervention to postintervention, and on the Neurologic Unit scores declined from preintervention to postintervention and follow-up. The EBP Attitudes Requirements score increased at postintervention and follow-up. The Implementation Leadership Scale Proactive score and team functioning survey scores decreased slightly. DISCUSSION: Implementing PROMs had varied effects on EBP attitudes and perceptions of leadership and team functioning. Perceptions across units were distinctive on the Evidence-Based Practice Attitudes Scale Divergence subscale. Introduction of PROMs should consider clinician attitudes regarding EBP as well as implementation leadership and team functioning.

Functional Outcomes of an Interdisciplinary Outpatient Rehabilitation Program for Patients with Malignant Brain Tumors.

BACKGROUND: Malignant brain tumors cause significant impairments in function because of the nature of the disease. Nevertheless, patients with malignant brain tumors can make functional gains equivalent to those with stroke and traumatic brain injury in the inpatient rehabilitation setting. However, the efficacy of outpatient rehabilitation in this population has received little study. OBJECTIVE: To determine if an interdisciplinary outpatient rehabilitation program will improve functional outcomes in patients with malignant brain tumors. DESIGN: Nonrandomized prospective longitudinal study. SETTING: Six affiliated outpatient sites of one institution. PATIENTS: Forty-nine adults with malignant brain tumors were enrolled. METHODS: Patients received interdisciplinary therapy services, with duration determined by the therapist evaluations. The therapists scored the Day Rehabilitation Outcome Scale (DayROS) and Disability Rating Scale (DRS) on admission and discharge. The caregivers filled out the DRS at discharge, 1 month, and 3 months after discharge. MAIN OUTCOME MEASUREMENTS: The primary study outcome measure was the DayROS, which is a functional measure similar to the Functional Independence Measure. DRS was another functional outcome measure assessing basic self-care, dependence on others, and psychosocial adaptability. RESULTS: Forty-six of 49 enrolled patients (94%) completed the day rehabilitation program. The average length of stay was 76.9 days. There was a significant improvement in total DayROS (P < .001), mobility (P < .001), Activities of Daily Living ( P < .001), and communication (P < .001) DayROS subscores from admission to discharge. There were no significant changes over time in the DRS scores. Women had higher DayROS gains (P = .003) and better therapist DRS scores from admission to discharge than men (P = .010). CONCLUSIONS: Patients with malignant brain tumors can make functional gains in an interdisciplinary outpatient rehabilitation program. This level of care should be considered in this patient population. LEVEL OF EVIDENCE: II.

Enhancing quality of prosthetic services with process and outcome information.

BACKGROUND: Prosthetic clinics in the United States must attain accreditation in order to receive reimbursement from Medicare. The accreditation process requires clinics to establish and implement performance management plans and quality improvement activities. This report describes the experience of seven prosthetic clinics in collecting patient-reported outcome data and using it to improve quality of services. OBJECTIVES: To describe the experience of prosthetic clinics implementing outcome monitoring and quality improvement activities as part of routine patient care. STUDY DESIGN: Qualitative, ethnographic design. METHODS: Clinics incorporated the Orthotics Prosthetics Users' Survey into routine care for patients aged 18 years and older who received a new lower limb prosthesis or socket. Orthotics Prosthetics Users' Survey measures lower extremity functional status, quality of life, and satisfaction with device and services. Clinics selected Orthotics Prosthetics Users' Survey-derived indicators on which to implement quality improvement action plans. RESULTS: Seven clinics participated, but only three were able to sustain data collection. Two clinics initiated quality improvement activities focused on improving declining satisfaction or functional scores. CONCLUSIONS: Quality improvement activities based on patient-reported outcomes require a high degree of organizational commitment and support. External facilitation can support clinics' quality improvement activities. Clinical relevance This project illustrates the challenges of sustaining quality improvement activities using patient-reported outcome data in prosthetic clinics.

Evaluation of the Cost of Comprehensive Outpatient Therapies in Patients with Malignant Brain Tumors.

OBJECTIVE: The aim of this study was to compare the cost of comprehensive outpatient therapy (day rehabilitation) in individuals with malignant brain tumors to those with stroke and traumatic brain injury. DESIGN: This was a prospective, nonrandomized, longitudinal study of 49 consecutive adults with malignant brain tumors enrolled in the 6 day rehabilitation sites of 1 institution over 35 months. The control group was composed of 50 patients with brain injury and 50 patients with stroke, who were also enrolled in the day rehabilitation program during the same period. A comparison was made of the total Medicare cost and the cost per day of day rehabilitation in patients with malignant brain tumors compared with the control group. RESULTS: The patients with malignant brain tumors had lower total cost and cost per day than did the combined traumatic brain injury and stroke group during day rehabilitation (F2,143 = 3.056 [P = 0.05] and F2,142 = 5.046 [P = 0.008], respectively). CONCLUSIONS: The cost of comprehensive outpatient rehabilitation in patients with malignant brain tumors is less expensive than that of patients with traumatic brain injury or stroke, which are neurological diagnoses commonly seen in day rehabilitation. This study shows that cost should not be a barrier to providing outpatient therapies to this patient population.

Health-Related Quality of Life and Cancer-Related Symptoms During Interdisciplinary Outpatient Rehabilitation for Malignant Brain Tumor.

OBJECTIVE: The aim of the study was to determine the relationships between functional outcomes, clinical symptoms, and health-related quality of life among patients with malignant brain tumors receiving interdisciplinary outpatient rehabilitation. DESIGN: A prospective study of 49 adults with malignant brain tumors participating in outpatient therapies was performed. Outcome measures included the Functional Assessment of Cancer Therapy-Brain (FACT-Br) for health-related quality of life and the Patient-Reported Outcome Measures Instrument Survey (PROMIS) Depression and Pain Behavior scales measured at admission, discharge, 1 and 3 mos after discharge. Day Rehabilitation Outcome Scale (DayROS), a functional measure, was measured at admission and discharge. RESULTS: The FACT-Br scores, PROMIS pain, and PROMIS depression scores did not significantly change. There were many negative associations seen between FACT-Br and PROMIS depression (all P < .0001) and less associations with PROMIS pain. There was a positive correlation between Day Rehabilitation Outcome Scale and FACT-Br (P = .0058) and a negative association with PROMIS pain (P = .028), but not with PROMIS depression. There were no correlations between Day Rehabilitation Outcome Scale gains and change in PROMIS depression, FACT-Br total, or PROMIS pain. CONCLUSIONS: Health-related quality of life, pain, and depression did not worsen. Patients who reported less depression and pain had better reported health-related quality of life. Level of function was also associated with HRQOL and pain, but not depression.

Stroke caregiving: difficult times, resource use, and needs during the first 2 years.

Despite high levels of distress among stroke caregivers, research on resource use and unmet needs is limited. The major purposes of this study were to identify the most difficult times, unmet needs, and advice of caregivers during the first 2 years of caregiving; and to examine resource use and perceptions of resource importance. Qualitative and quantitative methods were used. The hospitalization period and first months at home were most difficult for 76% of caregivers. Unmet needs were related to caregiver preparation, promoting the survivor's function, and sustaining the self and family. Although 50% or more of caregivers rated most resources important, only home health care was used by 50% of caregivers. Findings can aid clinicians in educating and counseling caregivers to reduce distress.

Cancer Rehabilitation: Do Functional Gains Relate to 60 Percent Rule Classification or to the Presence of Metastasis?

BACKGROUND: Literature supporting the benefits of inpatient rehabilitation for cancer patients is increasing. Many cancer patients, however, do not qualify for inclusion in the Centers for Medicare and Medicaid 60% rule and consequently may not receive services. The benefit of inpatient rehabilitation in this specific cancer group has not been investigated and is the focus of this study. OBJECTIVE: To investigate functional gains made during inpatient rehabilitation by patients impaired by cancer, and to compare the functional gains made during inpatient rehabilitation for patients impaired by cancer in relation to the presence or absence of metastatic disease and compliance or noncompliance with the Medicare 60% rule. SETTING: Freestanding university-affiliated rehabilitation hospital. PARTICIPANTS: A total of 176 adult patients admitted for inpatient rehabilitation due to cancer. METHODS: Retrospective chart review of patients admitted for inpatient rehabilitation with deficits identified related to cancer. MAIN OUTCOME MEASURES: Demographic data including cancer type, presence of metastasis, age, gender, marital status, ethnicity, length of stay (LOS), discharge destination, and transfer to acute care. Functional status including admission and discharge Functional Independence Measure Score (FIM), total, motor, and cognitive FIM gains, total, motor, and cognitive FIM efficiency for the study sample, for patients with and without a diagnosis compliant with the 60% rule and for patients with and without metastatic disease. RESULTS: In all, 176 cases met inclusion criteria. An admission coded diagnosis that was compliant with the 60% rule was present in 97 cases (55.1%). In 153 cases, the presence or absence of metastatic disease was known. Metastatic disease was present in 69 cases (45%). All groups (total sample, metastatic versus nonmetastatic, compliant versus noncompliant) made significant functional gains. Patients with a diagnosis noncompliant with the 60% rule had higher admission total FIM (P = .001), discharge total FIM (P = .014), admission motor FIM (P = .005), admission cognitive FIM (P = .008), and discharge cognitive FIM (P < .001) scores than those with a compliant diagnosis. Patients with metastatic disease had higher admission total FIM (P = .026) and admission (P = .001) and discharge (P = .02) cognitive FIM scores than patients with nonmetastatic disease. There were no significant differences between groups regarding total, motor, or cognitive FIM gains or total motor or cognitive FIM efficiencies. Differences in age, length of stay, and admission motor and discharge FIM scores between groups were related to cancer types and source of impairment. CONCLUSION: Patients with functional limitations resulting from cancer or its treatment made significant functional gains in inpatient rehabilitation. There were no significant differences in functional gains made by those with or without metastatic disease or those compliant versus noncompliant with the 60% rule. The presence of metastatic disease or a diagnosis not compliant with the 60% rule does not preclude cancer patients from making significant functional gains.

Relative importance of rehabilitation therapy characteristics on functional outcomes for persons with stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the relative importance of therapy focus, intensity, and length of stay on greater than expected functional gain, controlling for stroke severity. METHODS: This observational study included 198 first-stroke patients who were recruited from 8 in-patient rehabilitation facilities and 5 subacute programs. Stroke severity (motor, sensory and cognitive impairment) at admission was measured using an instrument combining all 3 aspects; self-care, mobility, and cognitive status at admission and discharge were measured with the Functional Independence Measure. Time spent by physical, occupational, and speech-language therapists on function- and impairment-focused activities were used to compute therapy intensity by discipline and type of activity. Residual change scores, estimated by regressing discharge on admission functional status, were modeled using patient and therapy characteristics. RESULTS: Controlling for the stroke severity, greater than expected gains in self-care were predicted by longer lengths of stay and more intensive function-focused occupational therapy, and greater than expected cognitive gains were predicted by longer stays alone. Predictors of residual change in mobility, however, differed by gender: greater than expected gains in mobility for men were predicted by longer lengths of stay and more intense function-focused physical therapy whereas, for women, they were predicted by stroke severity alone. CONCLUSIONS: Unlike previous studies using raw functional gains, therapies accounted for a significant proportion of the variance in residual functional change. The results support studies suggesting that both content and amount of therapy are important aspects.