Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation.

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Chronic Stroke Sensorimotor Impairment Is Related to Smaller Hippocampal Volumes: An ENIGMA Analysis.

Background Persistent sensorimotor impairments after stroke can negatively impact quality of life. The hippocampus is vulnerable to poststroke secondary degeneration and is involved in sensorimotor behavior but has not been widely studied within the context of poststroke upper-limb sensorimotor impairment. We investigated associations between non-lesioned hippocampal volume and upper limb sensorimotor impairment in people with chronic stroke, hypothesizing that smaller ipsilesional hippocampal volumes would be associated with greater sensorimotor impairment. Methods and Results Cross-sectional T1-weighted magnetic resonance images of the brain were pooled from 357 participants with chronic stroke from 18 research cohorts of the ENIGMA (Enhancing NeuoImaging Genetics through Meta-Analysis) Stroke Recovery Working Group. Sensorimotor impairment was estimated from the FMA-UE (Fugl-Meyer Assessment of Upper Extremity). Robust mixed-effects linear models were used to test associations between poststroke sensorimotor impairment and hippocampal volumes (ipsilesional and contralesional separately; Bonferroni-corrected, P<0.025), controlling for age, sex, lesion volume, and lesioned hemisphere. In exploratory analyses, we tested for a sensorimotor impairment and sex interaction and relationships between lesion volume, sensorimotor damage, and hippocampal volume. Greater sensorimotor impairment was significantly associated with ipsilesional (P=0.005; ß=0.16) but not contralesional (P=0.96; ß=0.003) hippocampal volume, independent of lesion volume and other covariates (P=0.001; ß=0.26). Women showed progressively worsening sensorimotor impairment with smaller ipsilesional (P=0.008; ß=-0.26) and contralesional (P=0.006; ß=-0.27) hippocampal volumes compared with men. Hippocampal volume was associated with lesion size (P<0.001; ß=-0.21) and extent of sensorimotor damage (P=0.003; ß=-0.15). Conclusions The present study identifies novel associations between chronic poststroke sensorimotor impairment and ipsilesional hippocampal volume that are not caused by lesion size and may be stronger in women.

Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains.

PURPOSE: The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF). MATERIALS AND METHODS: The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data. RESULTS: There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model. CONCLUSIONS: The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.

Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery.

OBJECTIVE: To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature. DATA SOURCES: Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA. STUDY SELECTION: Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded. DATA EXTRACTION: Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer. DATA SYNTHESIS: Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms. CONCLUSIONS: Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.

Measuring Frailty in Inpatient Rehabilitation.

BACKGROUND: In response to the global aging population, there has been increasing research on frailty. How frailty is conceptualized is shifting with the development of frailty models, especially in the acute care arena. OBJECTIVE: To explore frailty/vulnerability risk factors available at admission that were associated with salient patient outcomes within the context of inpatient rehabilitation. DESIGN: Methodologies in acute care are not easily adapted for a typical admission evaluation or a rehabilitation patient. In this study, the concept of frailty among patients admitted to rehabilitation was developed from risk factors available at admission that were associated with two patient outcomes, adverse hospital outcomes and 30-day hospital readmissions. SETTING: Inpatient rehabilitation. PATIENTS: Data were included on all patients (n = 768) discharged from an inpatient rehabilitation unit of an academic medical center from 1 January 2012 through 31 December 2012. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Adverse events within the inpatient rehabilitation stay and 30-day hospital readmissions. RESULTS: Significant independent factors associated with adverse events in the rehabilitation unit included African American (1.77 OR; 95% CI 1.06-2.96), Hispanic (3.17 OR; 95% CI 1.13-8.94), having >9 total comorbid conditions (1.44 OR; 95% CI 1.244-1.66), and sphincter control domain (including bladder and bowel management) ≤ 9 FIM (0.92 OR; 95% CI 0.86-0.98). For 30-day readmission three variables were found to be significant: onset ≥7 days (2.31 OR; 95% CI 1.28-4.22), requiring a tube for feeding (3.45 OR; 95% CI 1.433-11.12), and being obese (4.72 OR; 95% CI 1.433-15.58). CONCLUSIONS: The findings highlight the need for early admission screening and identification of risk factors which can provide the time in the rehabilitation setting for the clinical team to treat and prevent the potential for poor outcomes.

Frailty in a Post-Acute Care Population: A Scoping Review.

Frailty is a complex and growing phenomenon facing health care providers throughout the continuum of care. Frailty is not well understood in post-acute care (PAC) settings. The purpose of this scoping review was to summarize current evidence of frailty impact on outcomes and frailty mitigation initiatives in PAC. Three major publication databases were searched from January 2000 to June 2017 that identified 18 articles specifically addressing frailty in PAC. Three themes were identified: scales used to measure frailty, factors that led to an adverse outcome or diagnosis of frailty, and interventions to address frailty in PAC. Scales used to measure frailty were dominated by physical factors and scarce on nutrition and social support. Functional decline, grip strength, gait speed, polypharmacy, and nutrition were identified in the studies as factors that identify frailty and are associated with poor outcomes. All these frailty characteristics compromise patients' ability to benefit from rehabilitation, which further establishes the importance of PAC providers to identify, prevent, and treat frailty. Intervention studies had mixed outcomes, suggesting a need for further development in this area. The findings of this scoping review highlight the need for a comprehensive multidimensional assessment of frailty risks in PAC. LEVEL OF EVIDENCE: IV.

A conceptual model for vision rehabilitation.

Vision impairments are highly prevalent after acquired brain injury (ABI). Conceptual models that focus on constructing intellectual frameworks greatly facilitate comprehension and implementation of practice guidelines in an interprofessional setting. The purpose of this article is to provide a review of the vision literature in ABI, describe a conceptual model for vision rehabilitation, explain its potential clinical inferences, and discuss its translation into rehabilitation across multiple practice settings and disciplines.

Using Functional Status in the Acute Hospital to Predict Discharge Destination for Stroke Patients.

OBJECTIVE: The aim of this study was to determine whether functional status, as measured by the AcuteFIM instrument, can be used to predict discharge destination of stroke patients from the acute hospital setting. DESIGN: A retrospective cohort study was carried out in an urban academic medical center. Data were collected on 481 new-onset stroke patients 18 yrs or older in an acute hospital between January 1 and September 30, 2013. Functional Independence Measure (FIM) instrument data were linked to a subset of 54 patients who received additional services at an inpatient rehabilitation facility. A receiver operator characteristic curve was constructed to validate the predictive ability of the AcuteFIM instrument and to determine the optimal cutoff score associated with discharge to a community setting. RESULTS: All AcuteFIM items in stroke patients at admission demonstrated strong interitem correlation coefficients (all above 0.6) and high internal consistency (Cronbach α = 0.94). The AcuteFIM total score was positively associated with discharge to the community from the acute hospital (odds ratio, 1.06; 95% confidence interval, 1.05-1.07). Receiver operator characteristic curve analysis generated a c statistic of 0.89 (95% confidence interval, 0.87-0.92), indicating that the AcuteFIM instrument is predictive of patient discharge to the community setting. CONCLUSION: This study suggests that the AcuteFIM instrument is a reliable tool that can be used to predict discharge destination from the acute hospital among stroke patients.

The impact of inpatient rehabilitation on function and survival of newly diagnosed patients with glioblastoma.

OBJECTIVE: To examine the impact of an inpatient rehabilitation program on functional improvement and survival among patients with newly diagnosed glioblastoma multiforme (GBM) who underwent surgical resection of the brain tumor. DESIGN: A retrospective cohort study of newly diagnosed patients with GBM between 2003 and 2010, with survival data updated through January 23, 2013. SETTING: An urban academic nonprofit medical center that included acute medical and inpatient rehabilitation. PARTICIPANTS: Data for newly diagnosed patients with GBM were examined; of these patients, 100 underwent inpatient rehabilitation after resection, and 312 did not undergo inpatient rehabilitation. MAIN OUTCOME MEASUREMENTS: Overall functional improvement and survival time for patients who participated in the inpatient rehabilitation program. RESULTS: A total of 89 patients (93.7%) who underwent inpatient rehabilitation improved in functional status from admission to discharge, with the highest gain observed in mobility (96.8%), followed by self-care (88.4%), communication/social cognition (75.8%), and sphincter control (50.5%). The median overall survival among inpatient rehabilitation patients was 14.3 versus 17.9 months for patients who did not undergo inpatient rehabilitation (P = .03). However, after we adjusted for age, extent of resection, and Karnofsky Performance Status Scale scores, we found no statistical difference in the survival rate between patients who did and did not undergo inpatient rehabilitation (hazard ratio [HR], 0.84; P = .16). Among the patients who underwent inpatient rehabilitation, older age (HR, 2.24; P = .0006), a low degree of resection (HR, 1.67; P = .02), and lack of a Stupp regimen (HR, 1.71; P = .05) were associated with greater hazard of mortality. CONCLUSIONS: Patients who undergo inpatient rehabilitation demonstrate significant functional improvements, primarily in the mobility domain. Confounder adjusted multivariate analysis showed no survival difference between patients who did and did not undergo inpatient rehabilitation; this finding suggests that a structured inpatient rehabilitation program may level the survival field in lower-functioning patients who otherwise may be faced with a dismal prognosis.

Transferring inpatient rehabilitation facility cancer patients back to acute care (TRIPBAC).

OBJECTIVE: To determine predictive factors for TRansferring Inpatient rehabilitation facility (IRF) cancer Patients Back to Acute Care (TRIPBAC). DESIGN: A retrospective chart review of patients with cancer admitted to an IRF from 2009 to 2010 because of a functional impairment that developed as a direct consequence of their cancer or its treatment. SETTING: IRF of a community-based, academic, tertiary care facility. METHODS: The characterization of patients with cancer in the IRF was primarily based on analysis of the IRF Patient Assessment Instrument and other internal IRF data logs. MAIN OUTCOME MEASUREMENT: Frequency and reasons for TRIPBAC. RESULTS: The TRIPBAC rate in our IRF was 17.4%. The most common reasons for TRIPBAC were postneurosurgical complications (31%). Factors associated with TRIPBAC were a motor Functional Independence Measure score of 35 points or lower on admission (odds ratio 4.01, 95% confidence interval 1.79-8.98; P = .001) and the presence of a feeding tube or a modified diet (odds ratio 3.18, 95% confidence interval 1.44-7.04; P = .004). CONCLUSIONS: Motor Functional Independence Measure score on admission is the best predictor for TRIPBAC in patients with cancer admitted to our IRF, followed by the presence of a feeding tube or a modified diet.

Perceptions of inpatient rehabilitation changes after the Centers for Medicare and Medicaid Service 2010 regulatory updates contrasted with actual performance.

OBJECTIVES: To compare and contrast subjective perceptions with objective compliance of the impact of the 2010 Centers for Medicare and Medicaid Service updates of the Medicare Benefit Policy Manual. DESIGN OR SETTING: Cross-sectional survey. PARTICIPANTS AND METHODS: An electronic survey was sent by the Uniform Data System for Medical Rehabilitation to all enrolled inpatient rehabilitation facility subscribers (n = 817). The survey was sent April 15, 2011, and responses were tabulated if they were received by May 15, 2011. MAIN OUTCOME MEASUREMENTS: Comparing and contrasting of the subjective perception to objective evaluation and/or compliance with the Medicare Benefit Policy Manual on case mix index, length of stay, admissions by diagnostic category as well as perception of preadmission screening, postadmission evaluation, plan of care, and interdisciplinary conferencing. RESULTS: Twenty-five percent of the 817 facilities responded, for a total of 209 responses. Complete data were present in 148 of the respondents. For most diagnostic categories, perception of change did not mirror reality of change; neither did the perception between change in case mix index and length of stay. Perception did match reality in stroke and multiple trauma cases; respondents perceived an increase in admissions for the 2 impairments, and there was an overall increase in reality. CONCLUSION: Comparison with actual data identified that gaps exist between diagnostic category perceptions and actual diagnostic category admission performance. Regulations such as the 75%-60% rule and audit focus on non-neurologic conditions as well as actual inpatient rehabilitation facility program payment reports may have influenced respondents perceptions to change associated with the Medicare Benefit Policy Manual modifications. This disparity between perception and actual data may have implications for programmatic planning, forecasting, and resource allocation.

Risk factors for discharge to an acute care hospital from inpatient rehabilitation among stroke patients.

OBJECTIVE: To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PARTICIPANTS: A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings. METHODS OR INTERVENTIONS: Logistic regression analysis. MAIN OUTCOME MEASUREMENTS: Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit. RESULTS: No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance. CONCLUSION: Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting.

Joint replacement and hip fracture readmission rates: impact of discharge destination.

OBJECTIVE: To determine if discharge destination after hospitalization for hip replacement or repair influences the hospital readmission rate. DESIGN: A retrospective cohort study that included consecutive patients with a primary diagnosis of hip replacement or repair who were discharged from the acute hospital in a 3-year period. SETTING: Urban academic nonprofit hospital. PATIENTS: Data for 606 orthopedic patients discharged alive from the acute hospital between January 2004 and September 2006 were abstracted from the University Health-System Consortium (UHC) Clinical DataBase/Resource Manager clinical database for the study hospital. MAIN OUTCOME MEASURES: Unplanned readmission rate to the study-site hospital within 180 days after discharge after hip replacement or repair. RESULTS: Unplanned readmission within 180 days occurred at a rate of 8.3% and varied significantly by discharge destination: home 5.1%, home with home health care services 10.5%, skilled nursing facility 12.3%, inpatient rehabilitation 4.2%, and other 42.9%. Variables from the surgical admission that were significantly associated with higher risk of readmission included admission severity, burden of comorbidities, any days in the intensive care unit, long length of stay, and cost. When controlling for multiple independent risk factors, discharge to inpatient rehabilitation (P = .015) remained a significant independent predictor of lower risk of readmission within 180 days. CONCLUSION: Discharge to acute inpatient rehabilitation was associated with a lower risk of hospital readmission. Identification of patients with orthopedic procedures who may benefit from inpatient rehabilitation and further medical management before discharge from the acute hospital may be an important strategy in prevention of hospital readmission.

Client-centered occupational therapy using constraint-induced therapy.

Constraint-induced therapy (CIT) is a rehabilitation intervention designed to promote increased use of a weak or paralyzed arm, most commonly in patients who sustained a stroke. CIT involves constraining the unaffected arm in a sling or mitt, forcing the use of the weaker or paralyzed arm in daily activities. The aim of this study was to determine whether immobilizing the uninvolved arm of persons who experienced a stroke while participating in meaningful activities of daily living would increase their satisfaction and performance in life roles. Nine clients participated in a pilot study consisting of 2 weeks of individualized occupation-based CIT. This pilot study combined therapy in the clinic with therapy in the individual's home environment and incorporated meaningful daily activities chosen by the client into treatment. Results revealed a significant change in reported satisfaction and performance postintervention; however, a decline in satisfaction at follow-up despite continued motor improvement. Even though voluntary movements demonstrated improvement, participants were not satisfied with their performance in functional goal-related activities in their natural environment. Motor improvement can be repeated; however, at follow-up, participants were not satisfied with the improvement in meaningful activities that they identified. This may have to do with participants wanting or expecting their affected upper extremity to function better despite the deficits. It is also possible that participants expected their function to improve at the rate that it did during treatment. Further investigation using meaningful activity is needed to identify integration of the affected upper extremity into individuals' own environments and determine how it affects overall life roles and satisfaction over time.