Linda Lovell

Incidence of and Risk Factors for Medical Complications During Stroke Rehabilitation

Background and Purpose — The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility. Methods — A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation. Results — Seventy-five percent of patients experienced ≥1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67). Conclusions — Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.

SPINAL CORD INJURY REHABILITATION OUTCOME: THE IMPACT OF AGE

The effect of age on self-care and mobility skill performance after spinal cord injury was studied using a 15-task modified Barthel Index (MBI) to score functional abilities for 708 patients aged 6 through 88 years. Analysis of covariance showed no relationship between age and discharge MBI score; however, patients with paraplegia, incomplete lesions, and greater admission functional ratings had greater discharge functional scores than did those with quadriplegia, complete lesions, and lower admission scores, respectively. Advancing age was associated with increased dependence in only seven functional skills (bathing, upper and lower body dressing, stair climbing, and transfers to chair, toilet and bath) and only for patients with complete paraplegia. Other MBI component tasks and patients with complete quadriplegia, incomplete paraplegia and incomplete quadriplegia demonstrated no relationship between age and skill performance. Results of this study support the practice of providing comprehensive rehabilitation services to all patients following spinal cord injury regardless of age.

Stroke Rehabilitation: Clinical Predictors of Resource Utilization

OBJECTIVE To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission. DESIGN Statistical analysis of data prospectively collected from stroke rehabilitation patients. SETTING Large, urban, academic freestanding rehabilitation facility. PARTICIPANTS A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation. MAIN OUTCOME MEASURES Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD). METHODS Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis. RESULTS Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001). CONCLUSION Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.

The older adult with a spinal cord injury

Sixty-two consecutive acute spinal cord injury (SCI) patients who were aged 55 years or older were studied and compared to 296 SCI patients of age less than 55 years. Compared to younger patients, the older group had significantly more females (29%), preexisting medical conditions (87%), associated injuries (55%), incomplete quadriplegic patients (63%), and persons whose injuries resulted from falls (53%). There were no differences between groups in frequency of ventilator use, occurrence of medical complications, or acute length of stay, but older patients tended to have fewer surgical spinal fusions (40%), shorter rehabilitation stays (66.5 days), more indwelling urethral cathteters (31%), and more nursing home discharges (19%). With other factors being controlled, advancing age was predictive only of nursing home discharge, and not of acute or rehabilitation lengths of stay. Among older SCI patients, those with complete injuries were nearly 3 times as likely to have been discharged to nursing homes in our series compared to older patients with incomplete lesions. Although many aspects of the presentation, course, and care of older SCI individuals are similar to those of younger patients, there are several unique features of older adults with a SCI.

Stroke Rehabilitation Indwelling Urinary Catheters, Enteral Feeding Tubes, and Tracheostomies Are Associated With Resource Use and Functional Outcomes

Background and Purpose— The aim of this study was to investigate the associations between tracheostomies, enteral feeding tubes, and indwelling urinary catheters and functional outcome measures, incidence of medical complications, and resource use in an inpatient stroke rehabilitation program. Methods— A cohort of 1553 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke characteristics, impairment (National Institutes of Health Stroke Scale) and disability level (Functional Independence Measure [FIM]), preexisting medical conditions, and the presence of tracheostomies, enteral feeding tubes, and indwelling urinary catheters were recorded at admission. The occurrence of medical complications during rehabilitation, discharge disability level, length of rehabilitation stay, and rehabilitation hospital charges were recorded at discharge. Results— Compared with patients with no medical tubes, patients with 3 medical tubes had significantly higher National Institutes of Health Stroke Scale scores, lower admission and discharge FIM scores, reduced FIM efficiency scores (average FIM score change per day), and twice the number of medical complications. Patients with 3 medical tubes stayed 28 days longer in acute hospitalization and 20 days longer in rehabilitation compared with patients with no medical tubes. The presence of even a single medical tube was associated with longer length of stay, more medical complications during rehabilitation, and greater disability level at discharge. Conclusions— The presence of ≥1 medical tubes is associated with more severe and disabling strokes, an increased number of medical complications, longer acute and rehabilitation hospitalizations, and greater resource use.

Rehabilitation outcomes in complete C5 quadriplegia

Establishment of rehabilitation goals for spinal cord injury patients generally has been based on the degree of residual motor function. Despite extensive clinical experience with spinal cord injury rehabilitation, there have been no reports of the ability of C5 quadriplegic patients to perform self-care and mobility skills before and after rehabilitation. This study was designed to examine the rehabilitation outcomes of 63 patients with C5 complete quadriplegia, who completed an interdisciplinary inpatient rehabilitation program, using the 100-point modified Barthel Index as a means of rating functional status. There were statistically significant increases in the mean modified Barthel index scores from 7.1 on admission to 28.9 on discharge for the entire group of patients. The self-care subscore increased significantly from 6.5 on admission to 20.0 on discharge and the mobility subscore increased significantly from 0.5 on admission to 8.9 on discharge. Ability to perform self-care and mobility subscore tasks is described. This study documented significant improvements in function during comprehensive rehabilitation among patients with C5 spinal cord injury

Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: A case-control study

Marciniak C, Korutz AW, Lin E, Roth E, Welty L, Lovell L: Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: a case-control study. Objective:To assess the association of selected clinical factors and specific medication use (proton pump inhibitors, H2 receptor antagonists [H2 blockers], and angiotensin-converting enzyme inhibitors) with presence of pneumonia in patients with stroke undergoing acute inpatient rehabilitation. Design:Matched case-control study in a freestanding urban academic inpatient acute rehabilitation hospital. Participants were 72 stroke survivors, consisting of 36 patients who developed pneumonia during rehabilitation hospitalization individually matched in order of decreasing priority on age, sex, stroke side, depth, and severity with 36 patients with stroke not developing pneumonia. Potential risk factors, including severe dysphagia, dietary interventions, presence of tracheostomy or feeding tube, and specific medications, were assessed for association with pneumonia during rehabilitation using separate univariate and multivariate analyses. Functional change was assessed using the functional independence measure. Results:Although pneumonia was associated with proton pump inhibitors or H2 blockers (odds ratio, 3.3; 95% confidence interval, 1.0–13.7), any feeding tube (odds ratio: 5.0; 95% confidence interval, 1.4–27.0), severe dysphagia (odds ratio: 15.0; 95% confidence interval, 2.3–631), and tracheostomy (odds ratio: 10; 95% confidence interval, 1.4–434.0) on univariate evaluation, none of these individual factors was significantly associated with pneumonia in a multivariate model. Risk factors were found to be highly related to each other. Odds of pneumonia did not significantly decrease with angiotensin-converting enzyme inhibitors (odds ratio: 0.9; 95% confidence interval, 0.2–3.0). Patients with pneumonia had a significantly lower functional independence measure score at discharge. Conclusions:A reduction in pneumonia was not found with the use of angiotensin-converting enzyme inhibitors. Although tracheostomies, feeding tubes, proton pump inhibitor or H2 blocker use, and the presence of dysphagia were identified as risk factors for pneumonia on univariate analyses, none of these factors demonstrated an independent association with pneumonia on multivariate analyses. It may be more that the underlying impairment, rather than the assessed interventions, may confer greater risk of pneumonia in the poststroke patient.

Rehabilitation outcomes in patients with complete thoracic spinal cord injury

This paper describes the functional outcomes and lengths of stay of 184 patients discharged from comprehensive rehabilitation with complete thoracic traumatic spinal cord injuries. The 100-point modified Barthel Index (MBI) was used to assess functional abilities. There were statistically significant improvements in the mean total MBI score for the entire sample from 35.2 at rehabilitation admission to 71.0 at discharge. The mean lengths of stay were 46 days in acute care and 84 days in the rehabilitation facility. There were 79 patients with lesions between Tl and T6 (“high paraplegics”) and 105 patients with lesions between T7 and T12 (“low paraplegics”). There were no significant differences in the mean MBI scores, self-care subscores, mobility subscores, acute lengths of stay or rehabilitation lengths of stay between high and low paraplegic patients. However, low paraplegic patients were more likely to walk than were the high paraplegic patients. Surgical stabilization was performed on 36% of the sample; total MBI scores were similar for surgically stabilized and nonsurgically stabilized patients. High and low thoracic paraplegic patients achieved significant functional gains during rehabilitation. These functional gains occurred in a setting which provided for the vocational, psychosocial and recreational needs of the individual, and which fostered independence, community participation and a return to a healthy and active lifestyle.

Community Skill Performance and Its Association with the Ability to Perform Everyday Tasks by Stroke Survivors One Year Following Rehabilitation Discharge

Abstract Background: Stroke survivors experience functional loss in basic activities of daily living (ADLs) and in everyday community activities or instrumental activities of daily living (IADLs). Historically there has been a greater focus by rehabilitation professionals on basic ADLs than on IADLs. Purpose: The purpose of this study was to describe the relationship between the ability to perform ADLs and community activities in a large group of stroke patients measured 1 year following rehabilitation discharge. Method: A structured survey was administered by telephone. Outcome measures were the Frenchay Activities Index (FAI), a measure of IADL, and the FIMTM, a measure of disability. Results: Visual inspection of the relationship between FAI scores and FIMTM scores revealed that the data largely followed a curvilinear pattern. Curve estimation regression models were used to determine the line of best fit. A cubic function was found to give a good fit with an R2 of 0.644. The three activities in which stroke patients most frequently engaged were social outings, walking outside for more than 15 minutes, and local shopping. The three activities in which stroke patients engaged the least were gainful work, gardening outside, and household/car maintenance. Conclusion: A score of approximately 80 or greater on the FIMTM was associated with a substantially increased level of participation in home and community activities.

Spinal Cord Injury Care System: Fifteen­ year Experience at the Rehabilitation Institute of Chicago

A statistical study of I5 years of the spinal cord injury care system of the Rehabilitation Institute of Chicago is reported. The Rehabilitation Institute of Chicago (RIC) is the rehabilitation component of the Midwest Regional Spinal Cord Injury Care System, a collaborative programme with Northwestern Memorial Hospital and Northwestern University. Data are reported on 1382 patients, a representative sample of the over 2000 patients treated since the inception of the centre. The sample was predominately male (83%, N =1147) and Caucasian (64%, N=888). The most common aetiology was motor vehicle accidents (36%, N=505). During the 15-year period there were significant decreases in both acute and rehabilitation lengths of stay. Ninety three per cent of the patients were discharged home. Rehabilitation benefits were demonstrated by improvements in the Modified Barthel Index. The research, educational and clinical programmes are described.