Richard T. Connis

Stroke: a family dilemma

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.

Multidisciplinary rehabilitation versus medical care: A meta-analysis

Research studies in physical medicine have not demonstrated the effectiveness of inpatient rehabilitation services, primarily due to differences in methodological approaches which have led to inconsistent findings. Because of differing inclusion and outcome criteria, even meta-analyses have been inconclusive. To address this problem, research literature comparing the clinical effectiveness of rehabilitation programs with medical care was evaluated for three uniformly available outcome criteria: survival; functional ability; and discharge location. Published trials were obtained from citations in Index Medicus (Medicine) and Nursing and Allied Health Abstracts covering the recent 20 year period from 1974 to 1994. We used meta-analyses to test the hypotheses that specialized rehabilitative care (vs conventional medical care) improves health outcomes. Results of our meta-analyses indicated that rehabilitation services were significantly associated with better rates of survival and improved function during hospital stay (P < 0.01), but significance was not observed at follow-up. Also, rehabilitation patients returned to their homes and remained there more frequently than controls (P < 0.001). We concluded that patients who participate in inpatient rehabilitation programs function better at hospital discharge, have a better chance of short term survival, and return home more frequently than non-participants. However, long term survival and function were the same for experimental and control subjects. The sustaining benefit of returning home may suffice to justify the provision of inpatient rehabilitation. However, the lack of other long term benefits suggests that services may need to be continued at home or in subacute care settings to optimize their effectiveness.(ABSTRACT TRUNCATED AT 250 WORDS)

The Modification and Maintenance of Time Spent Attending Using Social Reinforcement, Token Reinforcement and Response Cost in an Applied Restaurant Setting

The purpose of this investigation was to evaluate a series of program variables used to modify the time a subject spent attending in an experimental restaurant setting. Selective behaviors of a mildly retarded, female young adult were evaluated, based on combinations of three treatment variables (social reinforcement, token reinforcement and response cost) in modifying the time spent attending to task. Further, the addition of an intermittent schedule of cost contingency, delayed token exchange, delayed performance feedback, and a final weekly pay check were evaluated, and resulting levels of response maintenance were investigated. Combinations of social reinforcement, tokens and response cost were found less effective in increasing percent of time spent attending to task than were simultaneous application of all treatment variables. Relationships were established between maintenance of appropriate attending behavior and the selective withdrawal of both token reinforcement and cost contingency. Data collected suggested that an intermittent schedule of response cost, weekly token exchanges, minimal feedback on performance earning and weekly checks, in that order, were effective in maintaining response gains. Follow-up measures indicated that treatment gains were maintained after all contingencies were removed. Limitations of the present investigation and future areas of research were outlined. Descriptors: Response cost, token economy, social reinforcement, response maintenance, mentally retarded, vocational training.

Changes in cognitive and social functioning of diabetic patients following initiation of insulin infusion therapy

Functional health outcomes resulting from intensive insulin regimens may differ depending upon the age of the diabetic patient. This study tested the hypothesis that health functioning is poorer for younger insulin-dependent diabetic (IDDM) patients following a change to the insulin infusion pump regimen, with progressive improvements occurring in functional health status at higher age levels. Thirty IDDM patients aged 10-47 years were administered health status instruments prior to changing to the new regimen, and again six months later. The instruments assessed physical, cognitive, psychological, and social health functioning. When compared at six months to an age-matched control group on conventional insulin therapy, declines in social activities were found for younger insulin pump patients, with improvements occurring linearly as age increased. Lower performance levels were also found for the younger patients in Conceptual Quotient (CQ), an indicator of cognitive functional status, with progressive improvements with age through the early 30s. However, corresponding declines in function occurred at the oldest age levels. Adaptation to an intensive diabetes regimen appears to be more difficult at younger and older age levels.

Hospital-based rehabilitative care versus outpatient services: Effects on functioning and health status

PURPOSE The goal of this clinical trial was to examine the long-term impact of rehabilitative care on the health status of patients diagnosed with a disabling disorder. METHOD Study patients consisted of first-time hospitalizations from diagnostic groups commonly admitted for inpatient rehabilitation, including nervous, circulatory, and musculoskeletal disorders or injury. Patients were randomly assigned to inpatient rehabilitation (n = 43) or to outpatient follow-up (n = 42) in which the usual medical services were provided but no scheduled rehabilitative therapies were offered. Specific objectives of the study were to determine the effects of impatient rehabilitation on: (1) functional ability, (2) health and mental health status, (3) personal adjustment, and (4) family function. Cost and use of health-care resources were descriptively assessed. RESULTS Analysis of covariance found no significant treatment effects, either at 6 months or at 1 year, for any of the variables under study. In addition, there were no differences between groups in their use of nursing homes, length of hospital stay, mortality, or in the number of hospital readmissions or clinic visits during the first year after hospital discharge. Use of rehabilitation services and cost of care was significantly higher than outpatient services. The findings were consistent with previous studies for most outcomes, with the major exception being functional improvements. Contrary to earlier studies, rehabilitation was not found to effectively produce lasting functional outcomes. However, study conditions may not have fully corresponded to those of previous studies, and further research is needed. The patient sample was representative of a full inpatient service and therefore more heterogeneous than samples reported in prior studies, but the small sample size (due to reductions in the number of admitted patients to the rehabilitation unit during the course of the study) precluded subgroup analysis of diagnostic groupings. CONCLUSION The findings suggest that hospital-based rehabilitative care does not have lasting benefits, and that alternative care or supportive follow-up by a subacute-care facility may be needed to assist patients in maintaining functional gains and health benefits.

The relationship of family dynamics/social support to patient functioning in IDDM patients on intensive insulin therapy

A 6 month pilot study was conducted to examine the relationship between family dynamics/social support and patient functioning in diabetic patients on intensive insulin therapy. Intensified therapy was associated with improvements in the DUHP symptom score, MHI psychological well-being score, and in the DUHP social functioning score. In diabetic patients, regardless of therapy, extreme family dynamics were correlated with higher DUHP symptom scores and lower MHI psychological well-being scores at the initial measurement time. However, over the 6 month study period, extreme family dynamics were predictive of improvements in the DUHP symptoms score and in the quality of friendships in diabetic patients on intensive insuline therapy. In diabetic patients, regardless of therapy, higher levels of social support correlated with higher levels of psychological and social functioning at the initial measurement time, and with improvements in quality of family life over the 6 month measurement time. Higher social support was also associated with improvements in quantity of friends and the DUHP social functioning score in diabetic patients on intensive insulin therapy. The study also generated empiric support for co-evolutionary models of disease states/family dynamics/treatment systems by showing that 6 month changes in family dynamics were predicted by the initial FACES adaptability measure and the initial mean monthly glucose value. Intensified therapy predicted lower family cohesion and more family rigidity over the 6 month study period. These findings also suggest, when combined with the result that diabetic patients from more cohesive families experienced a rise in monthly mean glucose values, that some diabetic patients may become trapped in a vicious cycle which perpetuates poor glucose control and extreme family dynamics.

RISK SCREENING FOR ADVERSE OUTCOMES IN SUBACUTE CARE

Purpose of this study was to identify variables near hospital admission that could identify patients at risk for placement, death, or readmission. The goals were to assess sensitivity and specificity of screening strategies in predicting adverse outcomes that deter or affect home health care. We evaluated whether generic screens might efficiently identify type of outcome. Criteria reported in the literature were used to predict outcomes for 1,332 admissions. Factors that discriminated type of outcome included comorbidity, mental status, living arrangement, transfer to special care, prior admission, iatrogenic trauma, and pending litigation. We conclude risk scores can accurately predict outcome of hospital treatment, which may be useful in targeting patients for intervention. Using billing data, although rather insensitive, was the most cost-effective strategy.

Meta-Analysis with Longitudinal Studies: Controlling for Analytical Bias

A recent study published in an international medical Journal presented an opportunity to demonstrate the difficulties of interpreting meta-analysis results with longitudinal data. We conducted a new meta-analysis using identical data from the published study and showed contradictory results.

CAN META-ANALYSIS HELP DETERMINE WHETHER REHABILITATION MEDICINE IMPROVES OUTCOME? '

Critical assessment of current meta-analyses of research evaluating outcomes of programs in rehabilitation is presented as are recommendations for use of appropriate selection criteria and data in future meta-analyses.