Richard T. Linn

Admission balance and outcomes of patients admitted for acute inpatient rehabilitation.

The objective of the study contained herein was to evaluate the clinical use of the Berg Balance Scale in a heterogeneous acute inpatient rehabilitation population and to assess the relationship between balance scores at admission and rehabilitation outcomes, including functional gain and length of stay. This was a prospective study of 45 patients with diagnoses including stroke (n = 15), traumatic brain injury (n = 19), and other impairments (n = 11) who were admitted for acute inpatient rehabilitation. Functional ability was evaluated with the Functional Independence Measure (FIM) instrument, and balance was measured using the 14-item Berg Balance Scale. These measures were assessed both at admission to and discharge from inpatient rehabilitation. Correlation and multiple regression analyses were used to determine the relationship between balance and functional ability scores at admission and rehabilitation outcomes at discharge, including length of stay, functional gain, and efficiency. Analyses of variance comparing impairment groups indicated that patients with traumatic brain injury were younger than the stroke and other groups, but there were no group differences on FIM or balance scores at admission or discharge. There were no significant group differences for any of the outcome measures. When the impairment groups were collapsed into a single heterogeneous group, multiple regression analyses demonstrated that the sitting unsupported item score at admission accounted for 27% of the variation in length of stay, once demographic influences were controlled. The FIM efficiency score was predicted best by the total Berg Balance Scale score, with 22% of the variance accounted for. In contrast, balance scores did not provide predictive information about the FIM gain score beyond that already provided by the FIM-Total score at admission, which accounted for 10% of the variance once demographics were controlled. Balance scores collected at admission to inpatient rehabilitation, in whole and in part, were shown to account for moderate amounts of variation in length of stay and the FIM efficiency score. For several of the rehabilitation outcomes, balance scores at admission accounted for more variation than scores on the FIM instrument. These findings suggest that routine assessment of balance at admission to inpatient rehabilitation may enhance the ability to predict rehabilitation outcomes beyond that provided by assessment of functional status alone.

Affective symptoms in the chronic stage of traumatic brain injury: A study of married couples

A convenient sample of 60 brain-injured subjects and their spouses was evaluated cross-sectionally in the chronic stage of recovery on self-rated measures of sensory, motor, cognitive and behavioural disability and on the SCL-90-R depression and anxiety subscales. A majority of the brain-injured subjects, who were on average almost 6 years post-injury, demonstrated elevations on the affective symptom scales, with almost 70% showing depression and 50% showing anxiety. The spouses of the brain-injured individuals also demonstrated significantly elevated affective symptom scales, with 73% acknowledging symptoms of depression and 55% demonstrating symptoms of anxiety. For the individuals with brain injury, those with higher self-ratings of cognitive disability and social aggression had higher self-ratings of depression and anxiety. In contrast, spouse gender appeared to have the greatest association with the presence of elevation affective responses, with female spouses having higher levels of depression and anxiety than male spouses. These findings are discussed in terms of the reactionary nature of affective disturbances in the chronic stage of recovery.

The effects of parental traumatic brain injury on the behaviour of parents and children.

Little is known about the effects of a parents brain injury and subsequent disabilities on the children in the family. This study examines 24 families in which one parent is brain injured. In each family the children were born before the parents injury and still lived at home at the time of interview. Reports of the uninjured parent indicate that most of the children experienced some degree of negative behavioural change after the parents injury. In 10 of the families, significant and problematic changes occurred. Types of problems included poor relationship with the injured parent, acting-out behaviour and emotional problems. Correlates of poor outcomes for the children were: (1) injured parents gender, (2) compromised parenting performance of the injured parent, (3) compromised parenting performance of the uninjured parent and (4) depression in the uninjured parent. This study points to the importance of recognizing traumatic brain injury as a major family stressor.

Comparison of logistic regression and neural networks to predict rehospitalization in patients with stroke

CONTEXT Rehospitalization following inpatient medical rehabilitation has important health and economic implications for patients who have experienced a stroke. OBJECTIVE Compare logistic regression and neural networks in predicting rehospitalization at 3-6-month follow-up for patients with stroke discharged from medical rehabilitation. DESIGN The study was retrospective using information from a national database representative of medical rehabilitation patients across the US. SETTING Information submitted to the Uniform Data System for Medical Rehabilitation from 1997 and 1998 by 167 hospital and rehabilitation facilities from 40 states was examined. PARTICIPANTS 9584 patient records were included in the sample. The mean age was 70.74 years (SD = 12.87). The sample included 51.6% females and was 77.6% non-Hispanic White with an average length of stay of 21.47 days (SD = 15.47). MAIN OUTCOME MEASURES Hospital readmission from 80 to 180 days following discharge. RESULTS Statistically significant variables (P <.05) in the logistic model included sphincter control, self-care ability, age, marital status, ethnicity and length of stay. Area under the ROC curves were 0.68 and 0.74 for logistic regression and neural network analysis, respectively. The Hosmer-Lemeshow goodness-of-fit chi-square was 11.32 (df = 8, P = 0.22) for neural network analysis and 16.33 (df = 8, P = 0.11) for logistic regression. Calibration curves indicated a slightly better fit for the neural network model. CONCLUSION There was no statistically significant or practical advantage in predicting hospital readmission using neural network analysis in comparison to logistic regression for persons who experienced a stroke and received medical rehabilitation during the period of the study.

A Review of the Postconcussion Syndrome

Objective: This review will focus on aspects of the postconcussion syndrome (PCS), including accompanying symptomatology, neuropsychological changes, brain imaging studies and treatment. Method: In each topic area, those research studies resulting in the most interpretable data are reported. Since there is little research in some aspects of the PCS, some studies of limited merit are described, with their limitations outlined, in lieu of not reporting any study. The section on psychopharmacology largely consists of opinions of recognized clinicians, since there is almost no research on the psychopharmacology of PCS. Results: Mild traumatic brain injury is a relatively frequent occurrence which often results in the postconcussion syndrome (PCS), consisting of complaints of irritability, fatigue, headache, difficulty concentrating, dizziness, and memory problems. Anxiety and depression are also frequently present, especially later in its course. Although the PCS has often been thought to reflect a psychological response to injury, there is considerable recent evidence to suggest that it is primarily a physiologic disturbance. For most individuals, treatment consists primarily of education of the patient and his/her family, along with supportive counseling regarding emerging problems at work or at home. A subgroup of patients, however, may require psychopharmacologic intervention. Conclusion: More research is needed in all aspects of PCS, especially its neurophysiology and pharmacologic treatment. Relationships between neurophysiological changes and behavioral and neuropsychological changes are unknown. New imaging techniques, such as single-photon emission tomography, and positron emission tomography will likely play an important role in understanding the physiology of this disorder.

Mapping the neural systems that mediate the Paced Auditory Serial Addition Task (PASAT).

The paced auditory serial addition task (PASAT), in which subjects hear a number-string and add the two most-recently heard numbers, is a neuropsychological test sensitive to cerebral dysfunction. We mapped the brain regions activated by the PASAT using positron emission tomography (PET) and 15O-water to measure cerebral blood flow. We parsed the PASAT by mapping sites activated by immediate repetition of numbers and by repetition of the prior number after the presentation of the next number in the series. The PASAT activated dispersed non-contiguous foci in the superior temporal gyri, bifrontal and biparietal sites, the anterior cingulate and bilateral cerebellar sites. These sites are consistent with the elements of the task that include auditory perception and processing, speech production, working memory, and attention. Sites mediating addition were not identified. The extent of the sites activated during the performance of the PASAT accounts for the sensitivity of this test and justifies its use in a variety of seemingly disparate conditions.

Disparity in health services and outcomes for persons with hip fracture and lower extremity joint replacement.

Objective. Examine disparity in health services and outcomes for adults with a hip fracture or lower extremity joint replacement. Materials and methods. This study examined 28,522 patient records including 12,328 (mean age 76.6 years) with hip fracture and 16,194 (mean age 71.8 years) with joint replacement. Results. Non-Hispanic white and black patients were significantly (P <0.05) more likely to be discharged home alone and responsible for their own care than were Asian or Hispanic patients. Sixty-four percent of Hispanic patients received inpatient rehabilitation after hip fracture and 36% after hip or knee arthroplasty. In contrast, 58% of non-Hispanic white persons, 67% of black persons, and 56% of Asian persons received inpatient medical rehabilitation after hip or knee joint replacement. Conclusion. Disparity in outcomes appeared to be related to family structure and social support.

Satisfaction With Medical Rehabilitation in Patients With Orthopedic Impairment

OBJECTIVE To examine patient satisfaction after orthopedic impairment at 80 to 180 days after inpatient rehabilitation. DESIGN Retrospective design examining records from facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDSmr). SETTING Information submitted to UDSmr from 1997 to 1998 by 177 hospital and rehabilitation facilities from 40 states. PARTICIPANTS The sample (N=7781) was 72.63% female and 88.60% non-Hispanic white, with a mean age +/- standard deviation of 73.07+/-11.81 years, and average length of stay (LOS) of 13.84+/-10.48 days. INTERVENTION Usual rehabilitation care. Main outcome measures Level of satisfaction 80 to 180 days after discharge as well as motor, cognitive, and subscale ratings for the FIM trade mark instrument. Predictor variables included gender, age, English language, marital status, discharge setting, LOS, rehospitalization, FIM gain, and primary payer. RESULTS A logistic regression model was used to predict patient satisfaction at follow-up. Five statistically significant (P<.05) variables were found and correctly classified 94.9% of the patients. Discharge motor FIM rating, rehospitalization, age, patients primary language, and discharge setting were associated with increased satisfaction. Discharge motor FIM ratings were significantly associated with increased satisfaction in patients with joint replacements and lower-extremity fractures. CONCLUSION unctional and demographic variables were identified as predictors of satisfaction in patients with orthopedic impairments.

Effect of functional gain on satisfaction with medical rehabilitation after stroke.

Tooth LR, Ottenbacher KJ, Smith PM, Illig SB, Linn RT, Gonzales VA, Granger CV: Effect of functional gain on satisfaction with medical rehabilitation after stroke. Am J Phys Med Rehabil 2003;82:692–699. Objective To examine the association between gain in motor and cognitive functional status with patient satisfaction 3–6 mo after rehabilitation discharge. Design Patient satisfaction and changes in functional status were examined in 18,375 patients with stroke who received inpatient medical rehabilitation. Information was obtained from 144 hospitals and rehabilitation facilities contributing records to the Uniform Data System for Medical Rehabilitation and the National Follow-up Services. Results Data analysis revealed significant (P < 0.05) differences in satisfaction responses based on whether information was collected from patient self-report or from a family member proxy, and the two subsets were analyzed separately. Logistic regression revealed the following significant predictors of satisfaction for data collected from stroke patients: cognitive and motor gain, rehospitalization, who the patient was living with at follow-up, age, and follow-up therapy. In the patient-reported data subset, compared with patients who showed improved cognitive or motor functional status, those with no change, respectively, had a 31% and 33% reduced risk of dissatisfaction. In addition, rehospitalized patients had a higher risk of dissatisfaction. For the proxy reported data subset, significant influences on satisfaction were health maintenance, rehospitalization, stroke type, ethnicity, cognitive FIM™ gain, length of stay, and follow-up therapy. Conclusions Ratings of satisfaction with rehabilitation services were affected by change in functional status and whether the information was collected from patient rating or proxy response.

Satisfaction With Medical Rehabilitation After Spinal Cord Injury

Study Design. Retrospective Objective. To predict satisfaction with medical rehabilitation. Summary of Background Data. While spinal cord injury (SCI) patient satisfaction with life and community services has been investigated, satisfaction with medical rehabilitation has not. Methods. Information submitted to the Uniform Data System for Medical Rehabilitation (1998–2001) by 134 hospitals/rehabilitation facilities in the United States (n = 6,205 patients with SCI) was examined. Predictors were sociodemographic variables, Case Mix Groupings (CMG) (401–505, 5001), length of stay, rehospitalization, follow-up therapy, and health maintenance. Satisfaction was assessed at a mean of 92.2 days (SD 11.9 days) postdischarge. Data were analyzed according to who reported the outcome (patient, n = 3,858 or family/other, n = 1,869). Statistical modeling was conducted using logistic regression. Results. High overall satisfaction was reported (94%). Significant predictors for the patient report data were CMG and rehospitalization. Compared with CMG 5001 (short stay, <3 days), patients in CMGs 401/2/3 and 501/2/3/4/5 had a 54% to 74% lower likelihood of being dissatisfied. Rehospitalized patients had a higher likelihood of dissatisfaction (odds ratio 2.3, 95% confidence interval 1.7 to 3.2). Significant predictors for the family/other report data were CMG (compared to CMG 5001, CMGs 401/2, 403, and 501/2 had a 70% lower likelihood of dissatisfaction), rehospitalization (odds ratio 1.7, 95% confidence interval 1.1–2.5), and marital status (married = 50% lower likelihood of dissatisfaction, 95% confidence interval 0.26–0.96). Conclusions. Satisfaction with medical rehabilitation services following SCI is related to functional abilities, rehospitalization, and marital status. Slightly different results were found for whether satisfaction was rated by the patient or family/other. The complex relationships among satisfaction, patient demographics, and functional status require continued examination.