Steven Faux

Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice

OBJECTIVE To study the correlation between adherence to recommended management and good recovery outcomes in an Australian cohort of inpatients receiving rehabilitation. DESIGN Processes of care were audited and included those recommended in the Australian Clinical Guidelines for Stroke Rehabilitation and Recovery. SETTING National audit data from 68 rehabilitation units were used, with each hospital contributing up to 40 consecutive cases. PARTICIPANTS Not applicable. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Discharged home or an increase of greater than or equal to 22 in FIM scores between admission and discharge. Multivariable logistic regression models controlling for patient clustering were used to assess the associations between adherence to recommended management and recovery outcomes (dependent variables). RESULTS Hospitals contributed 2119 patients (median age 75y, 53% men). We found that rehabilitation units providing evidence-based management (eg, treatment for sensorimotor impairment 38%, hypertonicity 56%, mobility 94%, and home assessments 71%) were more likely to provide better recovery outcomes for people with stroke. A discharge FIM score of 100 was clinically relevant and was strongly correlated with whether or not a patient was discharged home. We found very good correlation between admission and discharge FIM scores in stroke rehabilitation. CONCLUSIONS This is one of the first study comparing adherence to recommended management in Australian rehabilitation units and stroke recovery outcomes based on national audit data. Novel findings include the significance of an FIM score between 80 and 100 and the clinical significance of various management processes.

Emergency Department Assessment of Mild Traumatic Brain Injury and Prediction of Post-Concussion Symptoms at One Month Post Injury

Mild traumatic brain injury (mTBI) is a common injury and a significant proportion of those affected report chronic symptoms. This study investigated prediction of post-concussion symptoms using an Emergency Department (ED) assessment that examined neuropsychological and balance deficits and pain severity of 29 concussed individuals. Thirty participants with minor orthopedic injuries and 30 ED visitors were recruited as control subjects. Concussed and orthopedically injured participants were followed up by telephone at one month to assess symptom severity. In the ED, concussed subjects performed worse on some neuropsychological tests and had impaired balance compared to controls. They also reported significantly more post-concussive symptoms at follow-up. Neurocognitive impairment, pain and balance deficits were all significantly correlated with severity of post-concussion symptoms. The findings suggest that a combination of variables assessable in the ED may be useful in predicting which individuals will suffer persistent post-concussion problems. Thanks to Karleigh Kwapil and Veronica DeMonte from the Cognitive Psychophysiology Laboratory of the University of Queensland for training in the Rapid Screen of Concussion protocol and for advice over the duration of the project.

Protocol and pilot data for establishing the Australian Stroke Clinical Registry

Background Disease registries assist with clinical practice improvement. The Australian Stroke Clinical Registry aims to provide national, prospective, systematic data on processes and outcomes for stroke. We describe the methods of establishment and initial experience of operation. Methods Australian Stroke Clinical Registry conforms to new national operating principles and technical standards for clinical quality registers. Features include: online data capture from acute public and private hospital sites; opt-out consent; expert consensus agreed core minimum dataset with standard definitions; outcomes assessed at 3 months post-stroke; formal governance oversight; and formative evaluations for improvements. Results Qualitative feedback from sites indicates that the web-tool is simple to use and the user manuals, data dictionary, and training are appropriate. However, sites desire automated data-entry methods for routine demography variables and the opt-out consent protocol has sometimes been problematic. Data from 204 patients (median age 71 years, 54% males, 60% Australian) were collected from four pilot hospitals from June to October 2009 (mean, 50 cases per month) including ischaemic stroke (in 72%), intracerebral haemorrhage (16%), transient ischaemic attack (9%), and undetermined (3%), with only one case opting out. Conclusion Australian Stroke Clinical Registry has been well established, but further refinements and broad roll-out are required before realising its potential of improving patient care through clinician feedback and allowance of local, national, and international comparative data.

Emergency department assessment of mild traumatic brain injury and the prediction of postconcussive symptoms: a 3-month prospective study.

ObjectiveTo investigate the utility of a brief emergency department (ED) bedside screen for the prediction of postconcussive symptoms at 3 months following mild traumatic brain injury (MTBI). ParticipantsOne hundred patients with MTBI (78% men; mean age = 33.6 years); 2 control groups (each n = 100), a “minor nonhead injury” group (77% men; mean age = 32.2 years) and an “uninjured ED visitor” group (78% men; mean age = 33.6 years). Main MeasuresBrief measures of neuropsychological functioning, acute pain, and postural stability were collected in the ED; telephone follow-up at 3 months using the Rivermead Post-Concussion Symptoms Questionnaire was undertaken. ResultsNeuropsychological deficits, acute pain, and postural instability in the ED were significantly associated with postconcussive symptoms at 3-month follow-up. A regression formula using 3 easily obtainable measures obtained during acute stage of injury—immediate and delayed memory for 5 words and a visual analog scale score of acute headache—provided 80% sensitivity and 76% specificity for the prediction of clinically significant symptoms at 3 months postinjury. ConclusionA small combination of variables assessable in the ED may predict MTBI patients likely to experience persistent postconcussive symptoms.

Emergency department prediction of post-concussive syndrome following mild traumatic brain injury—an international cross-validation study

Background: Between 20–50% of those suffering a mild traumatic brain injury (MTBI) will suffer symptoms beyond 3 months or post-concussive disorder (PCD). Researchers in Sydney conducted a prospective controlled study which identified that bedside recordings of memory impairment together with recordings of moderate or severe pain could predict those who would suffer PCS with 80% sensitivity and specificity of 76%. Primary objective: This study is a cross-validation study of the Sydney predictive model conducted at Montreal General Hospital, Montreal, Canada. Methods: One hundred and seven patients were assessed in the Emergency Department following a MTBI and followed up by phone at 3 months. The Rivermead Post-Concussive Questionnaire was the main outcome measure. Results: Regression analysis showed that immediate verbal recall and quantitative recording of headache was able to predict PCD with a sensitivity of 71.4% and a specificity of 63.3%. In the combined MTBI groups from Sydney and Montreal the sensitivity was 70.2% and the specificity was 64.2%. Conclusion: This is the first study to compare populations from different countries with diverse language groups using a predictive model for identifying PCD following MTBI. The model may be able to identify an ‘at risk’ population to whom pre-emptive treatment can be offered.

Perceptions and attitudes of rehabilitation medicine physicians on complementary and alternative medicine in Australia

Background:  The growing demand for complementary and alternative medicine (CAM) is undeniable. We report a first study about the attitudes and behaviour of Australian rehabilitation physicians to CAM.

Inter-observer reliability of clinical outcome measures in a lower limb amputee population

Purpose : In an attempt to find a more clinically useful functional outcome measure specifically tailored for lower limb amputees undergoing inpatient prosthetic rehabilitation, a 6-month prospective assessment of inter-rater reliability for Harold Wood - Stanmore Mobility Scale Data, including two handicap scales, was undertaken. An analysis of the data is presented in this paper. Methods : An inter-rater reliability study was undertaken using four observers to complete admission and discharge scores for the three disability/handicap scales on 14 consecutive patients over 6 months. Results : The disability mobility scale demonstrated perfect observer agreement on admission and at discharge the inter-rater reliability for this measure was high (0.83). By contrast, reliability between observers for admission scores on the handicap mobility scale was poor at 0.49 but reasonably high on discharge (0.83). On admission, inter-rater reliability for handicap physical independence was very low (0.15). At discharge, reliability improved to 0.69 being more consistent with results achieved for the other axes. Conclusions : This study confirms the good inter-rater reliability demonstrated previously in the literature but reveals poor inter-rater reliability for the two handicap scales. The latter will require modification before they can be used with confidence in conjunction with the disability scale.

Activity recognition from a wearable camera

This paper proposes a novel activity recognition approach from video data obtained with a wearable camera. The objective is to recognise the users activities from a tiny front-facing camera embedded in his/her glasses. Our system allows carers to remotely access the current status of a specified person, which can be broadly applied to those living with disabilities including the elderly who require cognitive assistance or guidance for daily activities. We collected, trained and tested our system on videos collected from different environmental settings. Sequences of four basic activities (drinking, walking, going upstairs and downstairs) are tested and evaluated in challenging real-world scenarios. An optical flow procedure is used as our primary feature extraction method, from which we downsize, reformat and classify sequence of activities using k-Nearest Neighbour algorithm (k-NN), LogitBoost (on Decision Stumps) and Support Vector Machine (SVM). We suggest the optimal settings of these classifiers through cross-validations and achieve an accuracy of 54.2% to 71.9%. Further smoothing using Hidden Markov Model (HMM) improves the result to 68.5%-82.1%.

The efficacy of Wii-based Movement Therapy for upper limb rehabilitation in the chronic poststroke period: a randomized controlled trial.

Background More effective and efficient rehabilitation is urgently needed to address the prevalence of unmet rehabilitation needs after stroke. This study compared the efficacy of two poststroke upper limb therapy protocols. Aims and/or hypothesis We tested the hypothesis that Wii-based movement therapy would be as effective as modified constraint-induced movement therapy for post-stroke upper-limb motor rehabilitation. Methods Forty-one patients, 2–46 months poststroke, completed a 14-day program of Wii-based Movement Therapy or modified Constraint-induced Movement Therapy in a dose-matched, assessor-blinded randomized controlled trial, conducted in a research institute or patients homes. Primary outcome measures were the Wolf Motor Function Test timed-tasks and Motor Activity Log Quality of Movement scale. Patients were assessed at prebaseline (14 days pretherapy), baseline, post-therapy, and six-month follow-up. Data were analyzed using linear mixed models and repeated measures analysis of variance. Results There were no differences between groups for either primary outcome at any time point. Motor function was stable between prebaseline and baseline (P > 0·05), improved with therapy (P < 0·001); and improvements were maintained at six-months (P > 0·05). Wolf Motor Function Test timed-tasks log times improved from 2·1 ± 0·22 to 1·7 ± 0·22 s after Wii-based Movement Therapy, and 2·6 ± 0·23 to 2·3 ± 0·24 s after modified Constraint-induced Movement Therapy. Motor Activity Log Quality of Movement scale scores improved from 67·7 ± 6·07 to 102·4 ± 6·48 after Wii-based Movement Therapy and 64·1 ± 7·30 to 93·0 ± 5·95 after modified Constraint-induced Movement Therapy (mean ± standard error of the mean). Patient preference, acceptance, and continued engagement were higher for Wii-based Movement Therapy than modified Constraint-induced Movement Therapy. Conclusions This study demonstrates that Wii-based Movement Therapy is an effective upper limb rehabilitation poststroke with high patient compliance. It is as effective as modified Constraint-induced Movement Therapy for improving more affected upper limb movement and increased independence in activities of daily living.

Telephone follow-up was more expensive but more efficient than postal in a national stroke registry

OBJECTIVE To compare the efficiency and differential costs of telephone- vs. mail-based assessments of outcome in patients registered in a national clinical quality of care registry, the Australian Stroke Clinical Registry (AuSCR). STUDY DESIGN AND SETTING The participants admitted to hospital with stroke or transient ischemic attack were randomly assigned to complete a health questionnaire by mail or telephone interview at 3-6 months postevent. Response rate, researcher burden, and costs of each method were compared. RESULTS Compared with the participants in the mail questionnaire arm (n=277; 50% female; mean age: 70 years), those in the telephone arm (n=282; 45% female; mean age: 68 years) required a shorter time to complete the follow-up (mean difference: 24.2 days; 95% confidence interval [CI]: 15.0, 33.5 days). However, the average cost of completing a telephone follow-up was greater (US