Servicios monográficos de rehabilitación del daño cerebral en el marco sanitario / Specialized brain injury rehabilitation services in the healthcare setting

El presente artículo describe las condiciones que propiciaron el surgimiento de los Servicios de rehabilitación para personas con daño cerebral en España en la década de 1990. Se muestra la evolución epidemiológica de los TCE y de los ictus en los últimos 30 años, con reducción de los primeros e incremento de los segundos. Se repasan las características que definen a los Servicios de rehabilitación hospitalaria: su carácter monográfico o especializado, la composición multidisciplinar de los equipos y la elevada intensidad de los tratamientos. Se reflexiona acerca de los procesos que componen el proceso rehabilitador y de los modos de funcionamiento óptimo de estas Unidades. Por último, se hace un reconocimiento explícito de los espacios asistenciales limítrofes, Unidades de convalecencia y residencias de personas mayores, así como de la conveniencia de estratificar a los pacientes en base a su potencial rehabilitador y a la necesidad de cuidados a largo plazo (AU)

This paper describes the social conditions that allowed the dreation and development of Brain Injury Rehabilitation centers in Spain in the last decade of XXth century. The epidemiological changes of traumatic brain injury and of stroke in the last 30 years has implied a gradual decline of the incidence of the former and an advance of the latter. A review of the defining features of these services is undertaken: specialized or monographic, multidiciplinary teams, high intensity treatment. A reflection on the key processes of the rehabilitation offered and on the optimal functioning of theses Units is tackled. Lastly, boundary services are analysed, that is, alternative services such as Convalecence Units or Psychogeriatric Services that offer some kind of rehabilitation for peaple with stroke. There is a clear need to categorize patients with acquired brain injury according to their potential for rehabilitation and their needs of specialized long term care, in order to allocate them in the adequate treatment programme (AU)

Impact of the COVID-19 pandemic on rehabilitation setting. Part 1: professionals' views on the changes in routine care provided by a rehabilitation centre for patients with muscle diseases.

The outbreak of COVID-19 has forced the health care system to undergo profound rearrangements in services and facilities, especially during the periods of lockdown. In this context, inpatient and outpatient services had to rethink and reorganize their activities to meet the needs of severely disabled patients, as those affected by Muscular Dystrophies (MDs). We present the preliminary results of a survey aiming to explore the staff views on the changes in the care provided by the Gaetano Torre Rehabilitation Centre, and, the impact of these changes on professionals, patients and their families. The survey was carried out using an open-ended questionnaire including six-items, on the practical and psychological aspects emerged during the pandemic in relation to the healthcare services provided by the Centre and to the patients/caregivers conditions. The participants, most of them physiotherapists, highlighted 169 aspects emerging in the pandemic, 48.5% referring to the resources used to cope with critical issues and 51.5% concerning the difficulties encountered. Emotional aspects prevailed on practical aspects both in resources (52.4 vs 47.6%) and in difficulties (57.5 vs 42.5%) categories. In particular, with regard to patients' resources, psychological benefits, despite the burden, were greater than practical ones (87 vs 13%), in the form of improved intra-family relationships, feeling more cared for, and satisfaction for the received care. As for the patients' relatives, the staff indicated more resources than difficulties (72.8 vs 17.2%). Among the former, 75% concerned the emotional sphere, such as the perception of having a point of reference even in such a difficult time.

Rehabilitative management of post-acute COVID-19: clinical pictures and outcomes.

This study aimed to detect patients' characteristics who suffered severe and critical COVID-19 pneumonia admitted to the post-acute COVID-19 rehabilitation clinic in Ankara City Hospital, Physical Medicine and Rehabilitation Hospital and to share our experiences and outcomes of rehabilitation programmes applied. This study was designed as a single-centre, retrospective, observational study. Severe and critical COVID-19 patients, admitted to the post-acute COVID-19 rehabilitation clinic, were included in patient-based rehabilitation programmes, targeting neuromuscular and respiratory recovery. Functional status, oxygen (O2) requirement and daily living activities were assessed before and after rehabilitation. Eighty-five patients, of which 74% were male, were analysed, with the mean age of 58.27 ± 11.13 and mean body mass index of 25.29 ± 4.81 kg/m2. The most prevalent comorbidities were hypertension (49.4%) and diabetes mellitus (34.1%). Of the 85 patients, 84 received antiviral drugs, 81 low-molecular-weight heparin, 71 corticosteroids, 11 anakinra, 4 tocilizumab, 16 intravenous immunoglobulin and 6 plasmapheresis. 78.8% of the patients were admitted to the intensive care unit, with a mean length of stay of 19.41 ± 18.99 days, while those who needed O2 support with mechanic ventilation was 36.1%. Neurological complications, including Guillain-Barré syndrome, critical illness-related myopathy/neuropathy, cerebrovascular disease and steroid myopathy, were observed in 39 patients. On initial functional statuses, 55.3% were bedridden, 22.4% in wheelchair level and 20% mobilised with O2 support. After rehabilitation, these ratios were 2.4%, 4.7% and 8.2%, respectively. During admission, 71 (83.5%) patients required O2 support, but decreased to 7 (8.2%) post-rehabilitation. Barthel Index improved statistically from 44.82 ± 27.31 to 88.47 ± 17.56. Patient-based modulated rehabilitation programmes are highly effective in severe and critical COVID-19 complications, providing satisfactory well-being in daily living activities.

Safety, Feasibility, and Outcomes of Frequent, Long-Duration Rehabilitation in an Inpatient Rehabilitation Facility After Prolonged Hospitalization for Severe COVID-19: An Observational Study.

OBJECTIVE: he objective of this study was to evaluate safety, feasibility, and outcomes of 30 patients within an inpatient rehabilitation facility following hospitalization for severe Coronavirus Disease 19 (COVID-19) infection. METHODS: This was an observational study of 30 patients (ages 26-80 years) within a large, metropolitan, academic hospital following hospitalization for complications from severe COVID-19. Ninety percent of the participants required critical care, and 83% required mechanical ventilation during their hospitalization. Within an inpatient rehabilitation facility and model of care, frequent, long-duration rehabilitation was provided by occupational therapists, physical therapists, and speech language pathologists. RESULTS: The average inpatient rehabilitation facility length of stay was 11 days (ranging from 4-22 days). Patients averaged 165 min/d (ranging from 140-205 minutes) total of physical therapy, occupational therapy, and speech therapy. Twenty-eight of the 30 patients (93%) were discharged to the community. One patient required readmission from an inpatient rehabilitation facility to an acute hospital. All 30 patients improved their functional status with inpatient rehabilitation. CONCLUSION: In this cohort of 30 patients, inpatient rehabilitation after severe COVID-19 was safe and feasible. Patients were able to participate in frequent, long-duration rehabilitation with nearly all patients discharging to the community. Clinically, inpatient rehabilitation should be considered for patients with functional limitations following severe COVID-19. Given 90% of our cohort required critical care, future studies should investigate the efficacy and effectiveness of inpatient rehabilitation following hospitalization for critical illness. Frequent, long-duration rehabilitation shows promising potential to address functional impairments following hospitalization for severe COVID-19. IMPACT: Inpatient rehabilitation facilities should be considered as a discharge location for hospitalized survivors of COVID-19, especially severe COVID-19, with functional limitations precluding community discharge. Clinicians and administrators should consider inpatient rehabilitation and inpatient rehabilitation facilities to address the rehabilitation needs of COVID-19 and critical illness survivors.

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants' demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group's time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6-20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury.

Linking AM-PAC Cognition to PROMIS Cognitive Function.

OBJECTIVE: To link the Activity Measure for Post-Acute Care (AM-PAC) Applied Cognition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function, allowing for a common metric across scales. DESIGN: Cross-sectional survey study. SETTING: Outpatient rehabilitation clinics. PARTICIPANTS: Consecutive sample of 500 participants (N=500) aged ≥18 years presenting for outpatient therapy (physical, occupation, speech). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: AM-PAC Medicare and Generic Cognition short forms and PROMIS Cognitive Function items representing the PROMIS Cognitive Function item bank. RESULTS: The calibration of 25 AM-PAC cognition items with 11 fixed PROMIS cognitive function item parameters using item-response theory indicated that items were measuring the same underlying construct (cognition). Both scales measured a wide range of functioning. The AM-PAC Generic Cognitive assessment showed more reliability with lower levels of cognition, whereas the PROMIS Cognitive Function full-item bank was more reliable across a larger distribution of scores. Data were appropriate for a fixed-anchor item response theory-based crosswalk and AM-PAC Cognition raw scores were mapped onto the PROMIS metric. CONCLUSIONS: The crosswalk developed in this study allows for converting scores from the AM-PAC Applied Cognition to the PROMIS Cognitive Function scale.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities.

OBJECTIVE: To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES: Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN: We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS: We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS: In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS: Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

Barriers and facilitators for implementation of a patient prioritization tool in two specialized rehabilitation programs.

INTRODUCTION AND AIMS: Prioritization tools aim to manage access to care by ranking patients equitably in waiting lists based on determined criteria. Patient prioritization has been studied in a wide variety of clinical health services, including rehabilitation contexts. We created a web-based patient prioritization tool (PPT) with the participation of stakeholders in two rehabilitation programs, which we aim to implement into clinical practice. Successful implementation of such innovation can be influenced by a variety of determinants. The goal of this study was to explore facilitators and barriers to the implementation of a PPT in rehabilitation programs. METHODS: We used two questionnaires and conducted two focus groups among service providers from two rehabilitation programs. We used descriptive statistics to report results of the questionnaires and qualitative content analysis based on the Consolidated Framework for Implementation Research. RESULTS: Key facilitators are the flexibility and relative advantage of the tool to improve clinical practices and produce beneficial outcomes for patients. Main barriers are the lack of training, financial support and human resources to sustain the implementation process. CONCLUSION: This is the first study that highlights organizational, individual and innovation levels facilitators and barriers for the implementation of a prioritization tool from service providers' perspective.

The Important Impact of COVID-19 Pandemic on the Reorganization of a Rehabilitation Unit in a National Healthcare System Hospital in Italy: Lessons From Our Experience.

ABSTRACT: Since March 2020, when COVID-19 pandemic broke out, the world's healthcare systems' main concern has been fighting the pandemic. However, patients with other diseases, also requiring rehabilitation evaluations and treatments, continued to need care. Our rehabilitation unit managed to maintain contact with patients through alternative communication methods even during the lockdown period and in a situation of staff shortage. If face-to-face evaluations and treatments were necessary, preventive measures were followed to avoid hospital-associated contagion. Rehabilitation beds were cleared to leave them to the acute wards, and consultations for the acute care patients were carried out using personal protective equipment. In the future, the lessons from our experience could contribute toward drawing a plan of measures applicable in similar situations and some of these actions could become part of the rehabilitative practice.

Musculoskeletal injury outcomes: 2-year retrospective service evaluation of a UK defence primary care rehabilitation facility (PCRF).

INTRODUCTION: Musculoskeletal injury represents the leading cause of medical discharge from the UK Armed Forces. This study evaluates effectiveness of care provision within a large primary care rehabilitation facility (PCRF) against directed defence best practice guidelines (BPGs) METHODS: All new patient electronic records from January to July 16 were interrogated to identify demographics, causation, injury pathology, timelines and outcomes. RESULTS: 393 eligible records (81.9% male) were identified. 17.6% were officers, 32.8% were seniors and 49.6% were juniors. The average age was 35.1 years (mode 30). The average wait to treatment was 8.3 days with 75.6% key performance indicator compliance. 47.3% were repeat injuries. The average care timeline was 117.1 days with 8.7 average treatment sessions needed. 30 remained under care at 2 years. 17.8% accessed hydrotherapy and 44% underwent exercise remedial instructors care. 14.2% of individuals required concurrent DCMH care (15.9% male and 26.8% female). 28.5% required multidisciplinary injury assessment clinic intervention with 74.1% compliance against BPGs. 2.9% used the Defence Medical Rehabilitation Centre. Common pathologies were low back pain (LBP) (n=67), upper limb (UL) soft tissue (n=40) and knee trauma (n=38). LBP had the highest recurrence rates (71.6%). Anterior knee pain took the longest (173.1 days) but had the best outcome on discharge. Ankles and lower limb muscle injuries had the best outcomes. Patella tendinopathy and knee trauma had the poorest outcome on discharge. LBP and patellar tendinopathy had the lowest fully fit rates at 2 years (56.7% and 53.8%, respectively). At 2 years, 58.2% of individuals achieved full fitness (60.7% men and 46.4% women), rising to 64% and 55%, respectively, when including those retained with limitations. CONCLUSIONS: The PCRF was generally compliant with BPGs, achieving good functional outcomes on discharge. Women were disproportionally represented, had higher concurrent DCMH attendance and poorer overall long-term outcomes. Repeat injury rates were significantly high.

The effect of an integrated multidisciplinary rehabilitation programme for patients with chronic low back pain: Long-term follow up of a randomised controlled trial.

OBJECTIVE: To compare the long-term effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme, in terms of back-specific disability, in patients with chronic low back pain. DESIGN: A single-centre, pragmatic, two-arm parallel, randomised controlled trial. SETTING: A rheumatology rehabilitation centre in Denmark. SUBJECTS: A total of 165 adults (aged ⩾ 18 years) with chronic low back pain. INTERVENTIONS: An integrated programme (a pre-admission day, two weeks at home, two weeks inpatient followed by home-based activities, plus two 2-day inpatient booster sessions, and six-month follow-up visit) was compared with an existing programme (four-week inpatient, and six-month follow-up visit). MAIN MEASURE: The primary outcome was disability measured using the Oswestry Disability Index after one year. Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). Analysis was by intention-to-treat, using linear mixed models. RESULTS: 303 patients were assessed for eligibility of whom 165 patients (mean age 50 years (SD 13) with a mean Oswestry Disability Index score of 42 (SD 11)) were randomly allocated (1:1 ratio) to the integrated programme (n = 82) or the existing programme (n = 83). The mean difference (integrated programme minus existing programme) in disability was -0.53 (95% CI -4.08 to 3.02); p = 0.770). No statistically significant differences were found in the secondary outcomes. CONCLUSION: The integrated programme was not more effective in reducing long-term disability in patients with chronic low back pain than the existing programme.

Development of a Multidimensional, Multigroup Measure of Self-Care for Inpatient Rehabilitation.

OBJECTIVE: To develop and evaluate a measure of clinician-observed and patient-performed self-care function for use during inpatient rehabilitation. DESIGN: Retrospective analysis of self-care assessments collected by therapists using confirmatory factor analysis (CFA) followed by multidimensional item response theory (MIRT). SETTING: Freestanding inpatient rehabilitation hospital in the Midwestern United States. PARTICIPANTS: Inpatients (N=7719) with stroke, traumatic brain injury, spinal cord injury, neurologic disorders, and musculoskeletal conditions. INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: A total of 19 clinician-selected self-care measures including the FIM and patient-performed, clinician-rated measures of balance, upper extremity function, strength, changing body position, and swallowing. Clinicians completed assessments on admission and at least 1 interim assessment. RESULTS: CFA was completed for 3 patient groups defined by their highest level of balance (sitting, standing, walking). We reduced the number of items by 47.5% while maintaining acceptable internal consistency; unidimensionality within each item set required development of testlets. A recursive analysis defined a self-care measure with sensitivity (Cohen dmax-min =1.13; Cohen dlast-first.=0.91) greater than the FIM self-care items (dmax-min.=0.94; dlast-first .=0.83). The CFA models provided good to acceptable fit (root mean square error of approximations 0.03-0.06). Most patients with admission FIM self-care ratings of total assistance (88%, 297 of 338) made improvements on the MIRT self-care measure that were undetected by the FIM; the FIM detected no change for 26% of these patients (78 of 297). The remaining 74% (219 of 297) improved on the MIRT-based measure an average of 14 days earlier than was detected by the FIM. CONCLUSIONS: This MIRT self-care measure possesses measurement properties that are superior to the FIM, particularly for patients near its floor or ceiling. Methods assure accommodation for multidimensionality and high levels of sensitivity. This self-care measure has the potential to improve monitoring of self-care and manage therapy effectively during inpatient rehabilitation.

Impact of a Sleep Enhancement Protocol on Nighttime Room Entries in an Inpatient Rehabilitation Facility.

PURPOSE: This study examined whether a sleep enhancement protocol (SEP) could reduce nighttime room entries (NREs) for patients with orthopedic injury (OI) or acquired brain injury (ABI) in an inpatient rehabilitation facility. DESIGN: A two-wave prospective study assessing standard of care (SOC) versus SEP. METHODS: Sixty-five participants completed baseline and follow-up questionnaires and wore an actigraph for approximately 7 days. In the SEP, nighttime care was "bundled." FINDINGS: In SOC, NREs were associated with less efficient sleep and greater daytime fatigue. Nighttime room entries were approximately 50% lower in the SEP than SOC. Participants in the OI SOC had more room entries than any other group. There were no significant changes in room entries in the ABI SEP group. CONCLUSIONS: There was a relationship between NREs and sleep. The SEP was effective at reducing NREs for patients with OI, but not ABI. CLINICAL RELEVANCE: Sleep enhancement protocols in inpatient rehabilitation facilities may be effective at improving sleep. Future research may focus on developing individualized protocols to improve sleep across patients with a variety of presenting diagnoses.

Clostridium difficile Infection Reservoirs Within an Acute Rehabilitation Environment.

OBJECTIVE: Clostridium difficile infection is a common hospital-associated infection spread via patient contact or contaminated environments. The risk for spread of C difficile may be greater in inpatient rehabilitation units than in some hospital units as patients are not confined to their rooms and often share equipment. Environmental disinfection is challenging in shared medical equipment, especially in equipment with complex designs. The study aimed to examine the presence of C difficile spores within an acute rehabilitation environment and to evaluate disinfection effectiveness. DESIGN: Cultures were performed on 28 rehabilitation rooms, 28 rehabilitation floor surfaces, and 80 shared devices and equipment. Two disinfection interventions were implemented, and environmental cultures then were repeated postintervention. RESULTS: Environmental cultures positive for CD spores were rehabilitation rooms (1/28), rehabilitation floors (13/28), and wheelchairs (3/20). After the implementation of new disinfection methods, repeat cultures were obtained and produced negative results. CONCLUSIONS: Nonsporicidal disinfectant was not effective on hospital floors. Sporicidal disinfection of the floor is important when rates of C difficile infection are increased. Wheelchairs are complex devices and difficult to properly clean. The hospital purchased an ultraviolent device for wheelchair cleaning with a subsequent reduction in spores on repeat cultures. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the impact of Clostridium difficile infections on the healthcare system; (2) Describe potential reservoirs of Clostridium difficile in the inpatient rehabilitation environment; and (3) Discuss interventions that may be implemented to reduce the reservoirs of Clostridium difficile on the rehabilitation unit. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

[Post-COVID-19 rehabilitation; a matter of customisation]. / Nazorg voor covid-19-patiënten.

In the early phase of the COVID-19 pandemic, knowledge about the natural course of recovery of COVID-19 is limited. We therefore describe - based on generic knowledge of post IC syndrome (PICS) and (pulmonary) rehabilitation - the possibilities to organize personalized rehabilitation programs in several care settings. To illustrate variety in need for rehabilitation, we described three cases of critical COVID-19 disease survivors after treatment in the intensive care unit. Some patients require immediate rehabilitation following hospitalization, but rehabilitation may also be initiated in the home environment. For the latter population monitoring of progress and recovery should be organized to assess whether a more intensified multidisciplinary rehabilitation program is needed. This may be initiated in one of the medical rehabilitation centers or in pulmonary rehabilitation centers. Post-COVID-19 rehabilitation, regardless of the specific form, should be patient-centered and multidisciplinary organized.