DeLateur Bj

Return to work following injury: the role of economic, social, and job-related factors.

OBJECTIVES This study examined factors influencing return to work (RTW) following severe fracture to a lower extremity. METHODS This prospective cohort study followed 312 individuals treated for a lower extremity fracture at 3 level-1 trauma centers. Kaplan-Meier estimates of the proportion of RTW were computed, and a Cox proportional hazards model was used to examine the contribution of multiple risk factors on RTW. RESULTS Cumulative proportions of RTW at 3, 6, 9, and 12 months post-injury were 0.26, 0.49, 0.60, and 0.72. After accounting for the extent of impairment, characteristics of the patient that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW. CONCLUSIONS Despite relatively high rates of recovery, one quarter of persons with lower extremity fractures did not return to work by the end of 1 year. The analysis points to subgroups of individuals who are at high risk of delayed RTW, with implications for interventions at the patient, employer, and policy levels.

Continuous-scale physical functional performance in healthy older adults: A validation study

OBJECTIVE The continuous-scale physical functional performance test (CS-PFP) is an original instrument designed to provide a comprehensive, in-depth measure of physical function that reflects abilities in several separate physical domains. It is based on a concept of physical function as the integration of physiological capacity, physical performance, and psychosocial factors. SETTING The test was administered under standard conditions in a hospital facility with a neighborhood setting. The CS-PFP consists of a battery of 15 everyday tasks, ranging from easy to demanding, that sample the physical domains of upper and lower body strength, upper body flexibility, balance and coordination, and endurance. Participants are told to work safely but at maximal effort, and physical functional performance was measured as weight, time, or distance. Scores were standardized and scaled 0 to 12. The test yields a total score and separate physical domain scores. DESIGN The CS-PFP was evaluated using 148 older adults-78 community dwellers, 31 long-term care facility residents living independently, and 39 residents with some dependence. MAIN OUTCOME MEASURES Maximal physical performance assessment included measures of maximal oxygen consumption (VO2max), isokinetic strength, range of motion, gait, and balance. Psychosocial factors were measured as self-defined health status using the Sickness Impact Profile (SIP), self-perceived function using the Health Survey (SF36), and Instrumental Activities of Daily Living (IADL). RESULTS IADL scores were not significantly different among the groups. Test-retest correlations ranged from .84 to .97 and inter-rater reliability from .92 to .99 for the CS-PFP total and 5 domains. Internal consistency was high (Cronbachs alpha, .74 to .97). Both total and individual domain CS-PFP scores were significantly different for the three groups of study participants, increasing with higher levels of independence, supporting construct validity. CS-PFP domain scores were significantly correlated with measures of maximal physical performance (VO2max, strength, etc) and with physical but not emotional aspects of self-perceived function. CONCLUSION The CS-PFP is a valid, reliable measure of physical function, applicable to a wide range of functional levels, and having minimal floor and ceiling effect. The total and physical domains may be used to evaluate, discriminate, and predict physical functional performance for both research and clinical purposes.

Physical impairment and functional outcomes six months after severe lower extremity fractures

To determine functional outcomes after lower extremity fracture (LEF), a prospective follow-up study of patients admitted to three level I trauma centers for treatment of unilateral LEFs was conducted. In this paper we describe outcomes at 6 months after discharge from the initial hospitalization and examine the relationship between impairment and disability. A total of 444 patients met the entry criteria for the study. Of these 376 (85%) were successfully located and interviewed at 6 months; 302 (68%) returned to the trauma center at 6 months for a clinical assessment by a physical therapist. Study patients were predominantly young (mean age = 32.4), white (72%) men (70%) who were working before the injury (77%). The fractures resulted primarily from motor vehicle crashes (71%); mean hospital LOS was 12 days. Disability was measured using the Sickness Impact Profile (SIP), a well validated patient assessment of health status. The overall SIP score averaged for all patients was 10.2, denoting a moderate level of dysfunction or disability. Analysis of the 12 subscores that constitute the SIP indicate particularly high scores for ambulation (16.7 postdischarge vs. 1.2 preinjury), sleep and rest (14.0 vs. 5.1), emotional behavior (10.5 vs. 2.2), home management (15.1 vs. 2.6), recreation and pastimes (19.0 vs. 4.4), and most notably, work (33.2 vs. 8.3). Further analysis of the subgroup of patients working before the injury shows that 48% had returned to work at 6 months. Correlations between lower extremity impairment (range of motion, muscle strength, and pain) and the ambulation subscore of the SIP were high. However, correlations between impairment and more global areas of activity such as home management, work, and recreation were considerably lower. These results suggest that other factors, over and above the extent of physical impairment, significantly influence broader disability outcomes such as return to work. Further research is needed to define these factors so that effective interventions after acute care can be identified and appropriately targeted.

Patient-oriented functional outcome after unilateral lower extremity fracture

Summary: To determine patient-perceived functional outcome after lower extremity fracture (LEF), a prospective, follow-up study of patients managed at three level I trauma centers was conducted. Patients with unilateral LEF involving the acetabulum and distally were eligible for the study. A total of 444 patients were enrolled. Of these, 363 (82%) were interviewed at 6 months postdischarge. Study patients were predominantly young (mean age 34 years), white (72%) men (71%) who had been working preinjury (78%). Their injuries resulted primarily from motor vehicle crashes (73%); 30% had more than one fracture to the same extremity. Functional status was measured using the Sickness Impact Profile (SIP), a well-validated, general health status instrument. Mean 6-month SIP scores were significantly worse (higher) than those based on preinjury activities (9.8 vs. 2.5) (p < 0.01). Overall disability levels were moderate compared with other health conditions. Analysis of the 12 subscores comprising the SIP indicated particularly high scores in ambulation (16.2 postdischarge vs. 1.1 preinjury), sleep/rest (13.1 vs. 5.1), household management (14.5 vs. 2.6), recreation (17.6 vs. 4.2), emotional well-being (9.9 vs. 2.1), and most significantly work (33.2 vs. 8.8). Of those working preinjury, only 49% had returned by 6 months. SIP scores were highest for persons with three or more fractures to the same extremity and for fracture patterns typical of high-energy forces.

The National Institute on Disability and Rehabilitation Research Burn Model System Database: A Tool for the Multicenter Study of the Outcome of Burn Injury

Advances in critical care and surgical management have significantly improved survival after burn injury over the past several decades. However, today, survival alone is an insufficient outcome. In 1994, the National Institute on Disability and Rehabilitation Research (NIDRR) created a burn model system program to evaluate the long-term sequelae of burn injuries. As part of this multicenter program, a comprehensive demographic and outcome database was developed to facilitate the study of a number of functional and psychosocial outcomes after burns. The purpose of this study is to review the database design and structure as well as the data obtained during the last 10 years. This is a descriptive study of the NIDRR database structure as well as the patient data obtained from the four participating burn centers from 1994 to 2004. Data obtained during hospitalization and at 6, 12, and 24 months after discharge were reviewed and descriptive statistics were calculated for select database fields. The database is divided into several subsections, including demographics, injury complications, patient disposition, and functional and psychological surveys. A total of 4600 patients have been entered into the NIDRR database. To date, 3449 (75%) patients were alive at discharged and consented to follow-up data collection. The NIDRR database provides an expansive repository of patient, injury, and outcome data that can be used to analyze the impact of burn injury on physical and psychosocial function and for the design of interventions to enhance the quality of life of burn survivors.

Community integration after burn injuries.

Evaluation of community integration is a meaningful outcome criterion after major burn injury. The Community Integration Questionnaire (CIQ) was administered to 463 individuals with major burn injuries. The CIQ results in Total, Home Integration, Social Integration, and Productivity scores. The purposes of this study were to determine change in CIQ scores over time and what burn injury and demographic factors predict CIQ scores. The CIQ scores did not change significantly from 6 to 12 to 24 months postburn injury. Home integration scores were best predicted by sex and living situation; Social Integration scores by marital status; and Productivity scores by functional outcome, burn severity, age, and preburn work factors. The data demonstrate that individuals with burn injuries have significant difficulties with community integration due to burn and nonburn related factors. CIQ scores did not improve over time but improvement may have occurred before the initial 6-month postburn injury follow-up in this study.

Evaluation of a Therapeutic Direct-Contact 915-MHz Microwave Applicator for Effective Deep-Tissue Heating in Humans

A 13-cm square direct-contact microwave applicator which operates at 915 MHz was evaluated in tissue models and human volunteers to determine its therapeutic effectiveness. It was found that the applicator with radome- and forced-air cooling selectively elevates temperatures in muscles (1-2 cm) to 43-45/spl deg/C. At this higher range of temperature, certain physiologic responses such as an increase in blood flow are produced. The applicator may also be used to heat malignant tumors of muscle.

Optimal Resistance Training: Comparison of DeLorme with Oxford Techniques

Fish DE, Krabak BJ, Johnson-Greene D, deLateur BJ: Optimal resistance training: Comparison of DeLorme with Oxford techniques. Am J Phys Med Rehabil 2003;82:903–909. ObjectiveProgressive resistive exercises, such as the DeLorme or Oxford techniques, improve strength by adding weights to arrive at the ten-repetition maximum (10RM; DeLorme) or by starting at the 10RM and removing weight (Oxford). The goal of this study was to examine the efficacy of each training method. DesignIn this randomized, prospective, group design, evaluator-blind clinical trial, 50 subjects performed either the Oxford or DeLorme weight-training techniques. Three times a week for 9 wks, subjects completed three sets of ten-repetition knee extensions based on the 10RM measured weekly. Incremental or decremental changes in training weight were utilized in training sessions based on the protocol randomly assigned to each subject. ResultsThe mean 10RM increase was 71.9 kg for the DeLorme group and 67.5 kg for the Oxford group, which was not significantly different. Examination with repeated measures multivariate analysis of variance revealed no significant difference between the two groups for 10RM increase, and no significant sex differences were found. Percentage change scores were not significantly different for 1RM and 10RM for both protocols and sexes. ConclusionBoth protocol groups were able to complete their lifting assignments and progressed similarly in weekly 10RM weight lifted. It can be concluded that both the DeLorme and Oxford protocols improve strength with equivalent efficacy. Further studies involving a larger sample size are needed to address potential sex-specific changes in strength improvement in response to the protocols.

Restoration of function

Restoration of function is crucial to the performance of activities of daily living, vocational and recreational activities, as well as to community integration and psychosocial aptitude. Strategies to optimize restoration of function include both physical considerations as well as metabolic considerations that can significantly impact physical capacity. Given the breadth of this topic, Drs. Herndon and deLateur focused on two of the most critical facets of restoration of function: metabolic support of the burn patient and exercise/fitness.

Patient self-reports three months after sustaining a major burn.

As survival rates of patients with major burns increase, it is becoming more important to study the course and quality of their recovery. Few studies of the recovery of these patients exist that use a prospective design and standardized measures. This paper describes a preliminary study of the self-reported health of patients three months after sustaining a major burn. An initial analysis was conducted on selected data gathered from 29 patients as part of a more comprehensive, prospective study of burn rehabilitation outcome. Measurements analyzed included the Sickness Impact Profile (SIP), the Health-Specific Locus of Control Scale (HLC), and the total body surface area burned (TBSA). Findings showed that TBSA was related to the degree to which patients perceived they had control over their health, but few correlations were found between TBSA, and HLC scale, and the SIP scale. On the SIP, most patients reported few or no problems, but a significant minority reported major problems in one or more areas of their lives. The problems that were reported tended to cluster in the areas of vocation and emotional adjustment. These results suggest that patients with major burns should not be considered a homogeneous group with respect to rehabilitation outcome.