Jodie K. Haselkorn

Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke

BACKGROUND Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. METHODS In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. RESULTS At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. CONCLUSIONS In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

A Randomized Clinical Trial of an Activity and Exercise Adherence Intervention in Chronic Pulmonary Disease

OBJECTIVES To evaluate the effectiveness of an exercise adherence intervention to maintain daily activity, adherence to exercise, and exercise capacity over 1 year after completion of an outpatient pulmonary rehabilitation program. DESIGN A 2-group, experimental design was used with randomization into intervention and usual care groups. SETTING Outpatient pulmonary rehabilitation program in a university-affiliated medical center. PARTICIPANTS One hundred six subjects (98 men; 98 with chronic obstructive pulmonary disease) with a mean age of 67 years and chronic lung disease. INTERVENTION Twelve-week adherence intervention (weekly phone calls and home visit) including counseling on establishing, monitoring, and problem-solving in maintaining a home exercise program. MAIN OUTCOME MEASURES Primary outcomes included daily activity (accelerometer), exercise adherence (exercise diary), and exercise capacity (six-minute walk test). All measures were performed at baseline, after the pulmonary rehabilitation program (8 wk), after the adherence intervention (20 wk), and at 1 year. RESULTS A rank-based analysis of covariance showed less decline at 20 weeks in exercise adherence (intervention mean, +3 min; control mean, -13 min; P=.015) and exercise capacity (intervention mean, -10.7 m; control mean, -35.4 m; P=.023). There were no differences in daily activity at 20 weeks or any differences in any primary variable at 1 year. CONCLUSIONS The intervention enhanced exercise adherence and exercise capacity in the short term but produced no long-term benefit. These findings are in part attributed to the disappointing measurement characteristics of the accelerometer used to measure daily activity. The intervention was acceptable to participants. Further study is needed to fashion interventions that have more persistent benefit.

The effect of Medicare's payment system for rehabilitation hospitals on length of stay, charges, and total payments.

BACKGROUND Medicares system for the payment of rehabilitation hospitals is based on limits derived from a hospitals average allowable charges per patient discharged during a base year. Thereafter, payments are capped but hospitals receive incentive payments if charges per patient are reduced in succeeding years. We hypothesized that per-patient charges would increase during the base year and then decrease in subsequent years. Hospitals would thus have higher reimbursement limits and receive incentive payments for reducing their charges. METHODS We analyzed Medicare claims data for 190,921 discharges from 69 rehabilitation hospitals from 1987 through 1994. We compared total charges, length of stay, and interim payments before, during, and after each hospitals base year. RESULTS After we controlled for inflation and temporal and seasonal trends, mean charges per patient discharged increased from

The Gulf War era multiple sclerosis cohort: age and incidence rates by race, sex and service

25,131 for patients discharged before the base year to

Stroke: a family dilemma

32,167 for patients discharged in the base year (a 28 percent increase, P<0.001) and the mean length of stay increased from 22.1 to 26.7 days (a 21 percent increase, P<0.001). After the base year, mean charges decreased to

Multicenter Randomized Trial of Robot-Assisted Rehabilitation for Chronic Stroke: Methods and Entry Characteristics for VA ROBOTICS

29,307 (a 9 percent decrease) and the mean length of stay decreased to 24.0 days (a 10 percent decrease) (P<0.001 for both comparisons). Analysis of data on patients according to diagnosis -- for example, spinal cord injury, brain injury, stroke, amputations and deformities, hip fracture, and arthritis and joint disorders -- showed similar findings for each, with increases in charges and length of stay in the base year, followed by smaller reductions thereafter. For-profit hospitals had greater increases than nonprofit hospitals in their per-patient charges (mean increase,

Multidisciplinary rehabilitation versus medical care: A meta-analysis

7,434 vs.

Prevalence and correlates of depression among veterans with multiple sclerosis

2,929; P<0.001) and length of stay (mean increase, 4.6 vs. 2.3 days, P<0.001) during the base year. CONCLUSIONS Although Medicares reimbursement system for rehabilitation hospitals put an upper limit on total payments, its design was associated with substantial extra costs, including significantly increased payments to hospitals and doctors and increased numbers of hospital days for the average patient.

Exercise and Quality of Life Among People With Multiple Sclerosis: Looking Beyond Physical Functioning to Mental Health and Participation in Life

We characterize here a new nationwide incident cohort of multiple sclerosis from the US military-veteran population. This cohort provides an update to the only other US nationwide incidence study of multiple sclerosis performed during the 1970s. Medical records and data from the Department of Defense and Department of Veterans Affairs for cases of multiple sclerosis who served in the military between 1990, the start of the Gulf War era, and 2007 and who were service-connected for this disorder by the Department of Veterans Affairs from 1990 on, were reviewed. A total of 2691 patients were confirmed as having multiple sclerosis: 2288 definite, 190 possible, 207 clinically isolated syndrome and six neuromyelitis optica. Overall racial categories were White, Black and other, which included all Hispanics. There were 1278 White males and 556 females; 360 Black males and 296 females; and 200 others, 153 (77%) of whom were Hispanic. Mean age at onset of 30.7 years did not differ significantly by race or sex. Age at onset was 17-50 years in 99%, the same age range as 99% of the military. Average annual age specific (age 17-50 years) incidence rates per 100 000 for the entire series were 9.6 with 95% confidence interval of 9.3-10.0. Rates for Blacks were highest at 12.1 with confidence interval 11.2-13.1, Whites were 9.3 (interval 8.9-9.8) and others 6.9 (interval 6.0-7.9). For 83 Hispanics defined for 2000-07, the rate was 8.2 (interval 6.5-10.1). Much smaller numbers gave rates of 3.3 for Asian/Pacific Islanders and 3.1 for native Americans. Rates by sex for Whites were 7.3 and 25.8 male and female, respectively, for Blacks 8.4 and 26.3, and for Hispanics 6.6 and 17.0. Rates by service were high for Air Force (10.9) and Army (10.6), medium for Navy (9.1) and Coast Guard (7.9), and low for Marines (5.3). Relative risk of multiple sclerosis was 3.39 female:male and 1.27 Black:White. These new findings indicate that females of all races now have incidence rates for multiple sclerosis some three times those of their male counterparts and that among these groups, Blacks have the highest and others (probably including Hispanics) the lowest incidence rates regardless of sex or service. The low rate for Marines is unexplained. This Gulf War era multiple sclerosis cohort provides a unique resource for further study.

The prevalence of overweight and obesity in veterans with multiple sclerosis

Research studying the clinical effectiveness of stroke rehabilitation has focused on managing acute stages and on evaluating short-term treatment programmes. However, many studies suggest that stroke affects long-term quality of life and the well-being of the family. This article reviews the stroke literature relative to aging, disability, and rehabilitation. The social effects of stroke in terms of clinical problems which make rehabilitation a family dilemma are discussed. Issues identified include the need for family assessment, education, advocacy, and counselling to foster treatment compliance and social support.