Patrick Semik

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.

Functional outcome following rehabilitation of the cancer patient

OBJECTIVE To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE Functional status as measured by the motor score of the Functional Independence Measure. RESULTS Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.

Relative Importance of Rehabilitation Therapy Characteristics on Functional Outcomes for Persons With Stroke

Background and Purpose— The purpose of this study was to evaluate the relative importance of therapy focus, intensity, and length of stay on greater than expected functional gain, controlling for stroke severity. Methods— This observational study included 198 first-stroke patients who were recruited from 8 in-patient rehabilitation facilities and 5 subacute programs. Stroke severity (motor, sensory and cognitive impairment) at admission was measured using an instrument combining all 3 aspects; self-care, mobility, and cognitive status at admission and discharge were measured with the Functional Independence Measure. Time spent by physical, occupational, and speech-language therapists on function- and impairment-focused activities were used to compute therapy intensity by discipline and type of activity. Residual change scores, estimated by regressing discharge on admission functional status, were modeled using patient and therapy characteristics. Results— Controlling for the stroke severity, greater than expected gains in self-care were predicted by longer lengths of stay and more intensive function-focused occupational therapy, and greater than expected cognitive gains were predicted by longer stays alone. Predictors of residual change in mobility, however, differed by gender: greater than expected gains in mobility for men were predicted by longer lengths of stay and more intense function-focused physical therapy whereas, for women, they were predicted by stroke severity alone. Conclusions— Unlike previous studies using raw functional gains, therapies accounted for a significant proportion of the variance in residual functional change. The results support studies suggesting that both content and amount of therapy are important aspects.

Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury

OBJECTIVE The increasing use of disability measures requires that the validity of these instruments be adequately demonstrated. This study sought to evaluate the concurrent validity of one disability measure, the Functional Independence Measure (FIMSM) using minutes of care reported by nursing staff. STUDY DESIGN Correlational, cohort design. SETTING Eight inpatient medical rehabilitation hospitals that subscribe to the Uniform Data System for Medical Rehabilitation. PATIENTS OR OTHER PARTICIPANTS 129 patients with traumatic brain injury (TBI) and 53 patients with traumatic spinal cord injury (SCI). INTERVENTIONS Routine rehabilitation care. MAIN OUTCOME MEASURES Patient-nurse contact times were recorded with a stop watch for a 24-hour period during the first and last weeks of inpatient rehabilitation. The FIM was also completed during the first and last weeks of rehabilitation. RESULTS Contact times declined from the first to last weeks of rehabilitation, concurrent with improving scores on motor and cognitive measures derived from the FIM. Statistically significant correlations between contact times and FIM measures were observed for medication dispensing, treatment provision, and teaching/activities of daily living at admission and discharge. Smaller and usually nonsignificant correlations were observed in activities that did not involve direct patient contact. Contact times increased exponentially as disability increased. CONCLUSIONS These results support the construct validity of the FIM by demonstrating strong relationships (r values in the range of .40 to .60) between burden of care and a measure of disability.

The national jockey injury study: an analysis of injuries to professional horse-racing jockeys.

While there have been numerous reports in the literature of accidents in equestrian sports, no comprehensive study has been conducted to ascertain the nature and incidence of injuries incurred by professional horse-racing jockeys. A survey was conducted to determine the types of injuries to jockeys and racing-related health concerns, including weight reduction methods. The questionnaire was completed by 706 professional jockeys actively competing at United States racetracks between July and October 1990 about injuries they had sustained in their careers. More than 1,700 injuries were reported. Fractures (n = 1,113) accounted for 64% of the total. The most common cause of injury was becoming unseated, followed by the horse falling. Relationships between characteristics of jockeys and injuries were evaluated. There were significant numbers of serious injuries with prolonged periods of not riding. Recommendations for improving jockey safety are made.

Measurement Properties of the Galveston Orientation and Amnesia Test (goat) and Improvement Patterns During Inpatient Rehabilitation

Objectives: To determine the measurement properties of the Galveston Orientation and Amnesia Test (GOAT) using the Rasch model and rating scale analysis (RSA). Design: Calibration of data collected weekly during rehabilitation. Setting: Six inpatient rehabilitation facilities. Participants: 77 patients admitted for their first rehabilitation after traumatic brain injury. Results: Rescoring the items as dichotomies, three strata of posttraumatic amnesia (PTA) were identified. All items cohered to define a single construct and the item hierarchy confirmed their hypothesized ordering. Conclusions: Equal-interval measures of PTA were developed that exhibited good reliability and validity. A self-scoring key was developed to more efficiently assess PTA.

Psychometric properties of the communication confidence rating scale for aphasia (CCRSA): Phase 1

Abstract Confidence is a construct that has not been explored previously in aphasia research. We developed the Communication Confidence Rating Scale for Aphasia (CCRSA) to assess confidence in communicating in a variety of activities and evaluated its psychometric properties using rating scale (Rasch) analysis. The CCRSA was administered to 21 individuals with aphasia before and after participation in a computer-based language therapy study. Person reliability of the 8-item CCRSA was .77. The 5-category rating scale demonstrated monotonic increases in average measures from low to high ratings. However, one item (“I follow news, sports, stories on TV/movies”) misfit the construct defined by the other items (mean square infit = 1.69, item-measure correlation = .41). Deleting this item improved reliability to .79; the 7 remaining items demonstrated excellent fit to the underlying construct, although there was a modest ceiling effect in this sample. Pre- to posttreatment changes on the 7-item CCRSA measure were statistically significant using a paired samples t test. Findings support the reliability and sensitivity of the CCRSA in assessing participants’ self-report of communication confidence. Further evaluation of communication confidence is required with larger and more diverse samples.

Development of Self-Report Measures of Social Attitudes That Act As Environmental Barriers and Facilitators for People With Disabilities

OBJECTIVE To describe the development of new self-report measures of social attitudes that act as environmental facilitators or barriers to the participation of people with disabilities in society. DESIGN A mixed-methods approach included a literature review; item classification, selection, and writing; cognitive interviews and field testing of participants with spinal cord injury (SCI), traumatic brain injury (TBI), or stroke; and rating scale analysis to evaluate initial psychometric properties. SETTING General community. PARTICIPANTS Individuals with SCI, TBI, or stroke participated in cognitive interviews (n=9); community residents with those same conditions participated in field testing (n=305). INTERVENTIONS None. MAIN OUTCOME MEASURE Self-report item pool of social attitudes that act as facilitators or barriers to people with disabilities participating in society. RESULTS An interdisciplinary team of experts classified 710 existing social environment items into content areas and wrote 32 new items. Additional qualitative item review included item refinement and winnowing of the pool prior to cognitive interviews and field testing of 82 items. Field test data indicated that the pool satisfies a 1-parameter item response theory measurement model and would be appropriate for development into a calibrated item bank. CONCLUSIONS Our qualitative item review process supported a social environment conceptual framework that includes both social support and social attitudes. We developed a new social attitudes self-report item pool. Calibration testing of that pool is underway with a larger sample to develop a social attitudes item bank for persons with disabilities.

Effects of Gender on Inpatient Rehabilitation Outcomes in the Elderly With Incomplete Paraplegia From Nontraumatic Spinal Cord Injury

Abstract Objective: To examine gender differences in rehabilitation outcomes for patients with nontraumatic spinal cord injury. Research Design: Secondary analysis was conducted on Medicare beneficiary data from 65 to 74 year olds with incomplete paraplegia discharged from inpatient rehabilitation facilities in 2002 through 2005. Main Outcome Measures: Length of stay, Functional Independence Measure instrument motor item and subscale scores on discharge, and discharge destination. Results: Among patients with degenerative spinal disease, men had significantly longer rehabilitation stays than women (P < 0.001). Men with degenerative spinal disease had significantly lower discharge Functional Independence Measure scores than women, indicating more dependence in self-care (P < 0.001) and mobility (P < 0.001). Among patients with degenerative spinal disease, men were less likely to walk (odds ratio = 0.58; 95% Cl = 0.38−0.87) and less likely to be independent with bladder management (odds ratio = 0.44; 95% Cl = 0.31−0.62). Among patients with vascular ischemia, men were more independent (B = 2.59; 99% Cl= 0.42−4.76) in mobility than women. There were no gender differences in the malignant spinal tumors group. There were no gender differences in being discharged to a community-based residence. Conclusions: Gender distributions varied by etiology. Gender differences were found in demographics, length of stay, and functional outcomes but not discharge destination. Men were more dependent than women at discharge in the etiology group with the least overall disability (degenerative spinal disease) and more independent in mobility than women at discharge in the etiology group with the most overall disability (vascular ischemia).

Cancer Rehabilitation: Do Functional Gains Relate to 60 Percent Rule Classification or to the Presence of Metastasis?

Literature supporting the benefits of inpatient rehabilitation for cancer patients is increasing. Many cancer patients, however, do not qualify for inclusion in the Centers for Medicare and Medicaid 60% rule and consequently may not receive services. The benefit of inpatient rehabilitation in this specific cancer group has not been investigated and is the focus of this study.