Timothy A. Reistetter

Spasticity: The misunderstood part of the upper motor neuron syndrome

Ivanhoe CB, Reistetter TA: Spasticity: The misunderstood part of the upper motor neuron syndrome. Am J Phys Med Rehabil 2004;83(suppl):S3–S9. Spasticity is a sensorimotor phenomenon related to the integration of the nervous system motor responses to sensory input. Although most commonly considered a velocity-dependent increase to tonic stretch, it is related to hypersensitivity of the reflex arc and changes that occur within the central nervous system, most notably, the spinal cord. Injury to the central nervous system results in loss of descending inhibition, allowing for the clinical manifestation of abnormal impulses. Muscle activity becomes overactive. This is mediated at several areas of the stretch-reflex pathway. Although spasticity is part of the upper motor neuron syndrome, it is frequently tied to the other presentations of the said syndrome. Contracture, hypertonia, weakness, and movement disorders can all coexist as a result of the upper motor neuron syndrome. Although basic science descriptions of spasticity are being elucidated, clinically, confusion exists.

Thirty-Day Hospital Readmission Following Discharge From Postacute Rehabilitation in Fee-for-Service Medicare Patients

IMPORTANCE The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. OBJECTIVE To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of records for 736,536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white. MAIN OUTCOMES AND MEASURES Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. RESULTS Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. CONCLUSIONS AND RELEVANCE Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

Normalized Movement Quality Measures for Therapeutic Robots Strongly Correlate With Clinical Motor Impairment Measures

In this paper, we analyze the correlations between four clinical measures (Fugl-Meyer upper extremity scale, Motor Activity Log, Action Research Arm Test, and Jebsen-Taylor Hand Function Test) and four robotic measures (smoothness of movement, trajectory error, average number of target hits per minute, and mean tangential speed), used to assess motor recovery. Data were gathered as part of a hybrid robotic and traditional upper extremity rehabilitation program for nine stroke patients. Smoothness of movement and trajectory error, temporally and spatially normalized measures of movement quality defined for point-to-point movements, were found to have significant moderate to strong correlations with all four of the clinical measures. The strong correlations suggest that smoothness of movement and trajectory error may be used to compare outcomes of different rehabilitation protocols and devices effectively, provide improved resolution for tracking patient progress compared to only pre- and post-treatment measurements, enable accurate adaptation of therapy based on patient progress, and deliver immediate and useful feedback to the patient and therapist.

The Uniform Data System for Medical Rehabilitation Report of Patients with Traumatic Brain Injury Discharged from Rehabilitation Programs in 2000 – 2007

Granger CV, Markello SJ, Graham JE, Deutsch A, Reistetter TA, Ottenbacher KJ: The Uniform Data System for Medical Rehabilitation: Report of patients with traumatic brain injury discharged from rehabilitation programs in 2000–2007. Objective:To provide benchmarking information for a large national sample of patients receiving inpatient rehabilitation after traumatic brain injury. Design:Secondary data analysis from 893 medical rehabilitation facilities located in the United States that contributed information to the Uniform Data System for Medical Rehabilitation from January 2000 through December 2007. Variables analyzed included demographic information (age, sex, marital status, race or ethnicity, prehospital living setting, and discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, Internation Classification of Diseases–9th revision codes for admitting diagnosis, and co-morbidities), and functional status information (FIM instrument [FIM] ratings at admission and discharge, FIM efficiency, FIM gain). Results:Descriptive statistics from 101,188 patients showed length of stay decreasing from a mean of 22.7 (±20.5) days to 16.6 (±14.8) days during the 8-yr study period. FIM total admission and discharge ratings also decreased. Mean admission ratings decreased from 58.6 (±24.7) to 54.8 (±21.2). Mean discharge ratings decreased from 92.4 (±24.2) to 85.0 (±24.0). Accordingly, mean functional independence measure change decreased from 33.8 (±20.5) to 30.2 (±18.4). The percentage of patients discharged to the community settings ranged from 81.3% in 2000 to 74.1% in 2007. All results are likely influenced by various policy changes affecting classification or documentation processes or both. Conclusions:National rehabilitation data from persons with traumatic brain injury in 2000–2007 indicate that patients are spending less time in an inpatient care setting than in the previous years and are experiencing improvements in functional independence during their stay. In addition, a majority of patients are discharged to community settings after inpatient rehabilitation.

Diabetes Comorbidity and Age Influence Rehabilitation Outcomes After Hip Fracture

OBJECTIVE To examine the influence of diabetes on length of stay (LOS), functional status, and discharge setting in individuals with hip fracture. RESEARCH DESIGN AND METHODS This work included secondary analyses of 79,526 individuals from 915 rehabilitation facilities in the U.S. Patients were classified into three groups using the Centers for Medicare and Medicaid Services comorbidity structure: individuals without diabetes (77.0%), individuals with non-tier diabetes (18.3%), and individuals with tier diabetes (4.7%). RESULTS Mean age was 79.4 years (SD 9.6), and mean LOS was 13.3 days (SD 5.3). Tier diabetes was associated with longer LOS, lower functional status ratings, and reduced odds of discharge home when compared with individuals with no diabetes and non-tier diabetes. Statistically significant interactions (P < 0.05) were found between age and diabetes classification for LOS, functional status, and discharge setting. CONCLUSIONS The impact of diabetes on recovery after hip fracture is moderated by age.

Utility of Functional Status for Classifying Community Versus Institutional Discharges After Inpatient Rehabilitation for Stroke

OBJECTIVE To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke. DESIGN Retrospective cross-sectional design. SETTING Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Discharge FIM rating and discharge setting (community vs institutional). RESULTS Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77). CONCLUSIONS Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings.

Hospital Readmission in Persons With Stroke Following Postacute Inpatient Rehabilitation

BACKGROUND Readmission is an important quality indicator following acute care hospitalization. We examined factors associated with hospital readmission in persons with stroke following postacute inpatient rehabilitation. METHODS Prospective cohort study including 674 persons with stroke who received rehabilitation at 11 facilities located in eight states and the District of Columbia. Measures included hospital readmission within 3 months of discharge, sociodemographic characteristics, length of stay, primary payment source, comorbidities, stroke type, standardized assessments of motor and cognitive function, depressive symptoms, and social support. RESULTS Mean age was 71.5 years (SD = 10.5). Twenty-five percent of patients reported high depressive symptoms. Overall, 18% (n = 122) of the sample was rehospitalized. Univariate analyses showed that people who were rehospitalized were more likely (p < .05) to be non-Hispanic white, married, demonstrate less functional independence at discharge, experience longer lengths of stay in rehabilitation, and report more depressive symptoms and lower social support. In the fully adjusted multivariable hierarchical generalized linear model, motor functional status (OR = 0.98, 95% CI 0.96-0.99), depressive symptoms (OR = 1.80, 95% CI 1.06-3.05), and social support (OR = 2.28, 95% CI 1.29-4.03) remained statistically significant. In addition, a minority-by-depressive symptoms interaction term also reached statistical significance. CONCLUSION Functional status, depressive symptoms, and social support were important predictors of hospital readmission. These variables are not included in most administrative data sets. Future research to develop useful risk-adjustment models for rehospitalization following postacute inpatient rehabilitation services should include large diverse samples and explore practical sources for additional meaningful information.

Frailty as a predictor of falls in older Mexican Americans

Objective: Examine the relationship between frailty and falls. Method: A total of 847 Mexican Americans from the Hispanic Established Population for the Epidemiological Study of the Elderly were evaluated. The outcome variable was fall occurrence. Some predictor variables included were frailty, sociodemographic variables, functional and health status, and prior falls. Results: Those who fell were more likely to be women, not married, had prior falls, more functional problems and poorer health. The incidence rate ratio (IRR) for falls was 1.9 for nonfrail individuals and 3.2 for frail individuals. Prefrail individuals had 1.36 higher odds of falls (95% CI [1.11, 1.67]), individuals with prior falls had 1.26 higher odds of falls (95% CI [1.15, 1.37]), and those with poor balance had 1.49 higher odds of falls (95% CI [1.15, 1.95]) over the 2 years (p < .01). Discussion: Frailty increases the odds of falls in older Mexican Americans. Interventions tailored to reduce fall incidence and improve health care quality for older Mexican Americans are needed.

Influence of Sex and Age on Inpatient Rehabilitation Outcomes Among Older Adults With Traumatic Brain Injury

UNLABELLED Graham JE, Radice-Neumann DM, Reistetter TA, Hammond FM, Dijkers M, Granger CV. Influence of sex and age on inpatient rehabilitation outcomes among older adults with traumatic brain injury. OBJECTIVE To assess the influence of sex and age on inpatient rehabilitation outcomes in a large national sample of older adults with traumatic brain injury (TBI). DESIGN Prospective case series. SETTING Eight hundred forty-eight inpatient rehabilitation facilities that subscribe to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS Patients (n=18,413) age 65 years and older admitted for inpatient rehabilitation after TBI from 2005 through 2007. INTERVENTIONS None. MAIN OUTCOME MEASURES Rehabilitation length of stay, discharge FIM motor and cognitive ratings, discharge setting, and scheduled home health services at discharge. RESULTS Mean age +/- SD of the sample was 79+/-7 years, and 47% were women. In multivariable models, higher age was associated with shorter lengths of stay (P<.001), lower discharge FIM motor and cognitive ratings (P<.001), and greater odds of home health services at discharge (P<.001). Women demonstrated shorter lengths of stay (P=.006) and greater odds of being scheduled for home health services at discharge (P<.001) than men. The sex-by-age interaction term was not significant in any outcome model. Sex differences and trends were consistent across the entire age range of the sample. CONCLUSIONS Sex and age patterns in rehabilitation outcomes among older adults with TBI varied by outcome. The current findings related to rehabilitation length of stay may be helpful for facility-level resource planning. Additional studies are warranted to identify the factors associated with returning to home and to assess the long-term benefits of combined inpatient rehabilitation and home health services for older adults with TBI.

The Uniform Data System for Medical Rehabilitation: report of patients with hip fracture discharged from comprehensive medical programs in 2000-2007.

Objective: The aim of this study was to provide benchmarking information for a large national sample of patients receiving inpatient rehabilitation because of a hip fracture. Design: A secondary data analysis of records from 893 medical rehabilitation facilities located in the United States that contributed information to the Uniform Data System for Medical Rehabilitation from January 2000 through December 2007 was performed. Variables analyzed included demographic information (age, sex, marital status, race/ethnicity, prehospital living setting, and discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, International Classification of Diseases, Ninth Revision, codes for admitting diagnosis, comorbidities), and Functional Status Information (FIM instrument ratings at admission and discharge, FIM efficiency, and FIM gain). Results: Descriptive statistics from 303,594 patients showed length of stay decreasing from a mean (SD) of 14.5 (7.9) days to 13.3 (5.5) days over the 8-yr study period. FIM total admission and discharge ratings also decreased. Mean admission ratings decreased from 72.5 (14.5) to 59.9 (15.7). Mean discharge ratings decreased from 95.8 (18.1) to 86.0 (19.8). FIM change per day remained relatively stable; mean for the entire sample was 2.1 (1.6). The percentage of persons discharged to the community also decreased across the study period, ranging from 77.8% in 2000 to 70.0% in 2007. All results are likely influenced by various policy changes affecting classification and/or documentation processes. Conclusions: National rehabilitation data from persons with hip fracture in 2000-2007 indicate that patients are spending less time in inpatient rehabilitation care than in previous years and are experiencing improvements in functional independence during their stay. In addition, most patients are discharged to the community after inpatient rehabilitation.