Multidomain Geriatric Screen and Physical Fitness Assessment Identify Prefrailty/Frailty and Potentially Modifiable Risk Factors in Community-Dwelling Older Adults

INTRODUCTION@#Frailty begins in middle life and manifests as a decline in functional fitness. We described a model for community frailty screening and factors associated with prefrailty and frailty and fitness measures to distinguish prefrail/frail from robust older adults. We also compared the Fatigue, Resistance, Ambulation, Illnesses and Loss of weight (FRAIL) scale against Fried frailty phenotype and Frailty Index (FI).@*MATERIALS AND METHODS@#Community-dwelling adults ≥55 years old were designated robust, prefrail or frail using FRAIL. The multidomain geriatric screen included social profiling and cognitive, psychological and nutritional assessments. Physical fitness assessments included flexibility, grip strength, upper limb dexterity, lower body strength and power, tandem and dynamic balance and cardiorespiratory endurance.@*RESULTS@#In 135 subjects, 99 (73.3%) were robust, 34 (25.2%) were prefrail and 2 (1.5%) were frail. After adjusting for age and sex, depression (odds ratio [OR], 2.90; 95% confidence interval [CI], 1.05-7.90; = 0.040) and malnutrition (OR, 6.07; 95% CI, 2.52-14.64; <0.001) were independently associated with prefrailty/frailty. Prefrail/frail participants had significantly poorer performance in upper limb dexterity ( = 0.030), lower limb power ( = 0.003), tandem and dynamic balance ( = 0.031) and endurance ( = 0.006). Except for balance and flexibility, all fitness measures differentiated prefrail/frail from robust women. In men, only lower body strength was significantly associated with frailty. Area under receiver operating characteristic curves for FRAIL against FI and Fried were 0.808 (0.688-0.927, <0.001) and 0.645 (0.546-0.744, = 0.005), respectively.@*CONCLUSION@#Mood and nutrition are targets in frailty prevention. Physical fitness declines early in frailty and manifests differentially in both genders.

Combining levodopa and virtual reality-based therapy for rehabilitation of the upper limb after acute stroke: pilot study Part II

<p><b>INTRODUCTION</b>This study aimed to evaluate the safety and efficacy of a combination of levodopa and virtual reality (VR)-based therapy for the enhancement of upper limb recovery following acute stroke.</p><p><b>METHODS</b>This was a pilot single-blinded case series of acute stroke patients with upper extremity hemiparesis. Patients were randomised to standard care with concomitant administration of either levodopa alone (control group) or combination therapy consisting of VR-based motivational visuomotor feedback training with levodopa neuromodulation (VR group). Main clinical outcome measures were the Fugl-Meyer Upper Extremity (FM-UE) assessment and Action Research Arm Test (ARAT). Kinematic measurements of affected upper limb movement were evaluated as a secondary measure of improvement.</p><p><b>RESULTS</b>Of 42 patients screened, four patients were enrolled in each of the two groups. Two patients dropped out from the control group during the trial. Patients receiving combination therapy had clinically significant improvements in FM-UE assessment scores of 16.5 points compared to a 3.0-point improvement among control patients. Similarly, ARAT scores of VR group patients improved by 15.3 points compared to a 10.0-point improvement in the control group. Corresponding improvements were noted in kinematic measures, including hand-path ratio, demonstrating that the quality of upper limb movement improved in the VR group.</p><p><b>CONCLUSION</b>Our results suggest that VR-based therapy and pharmacotherapy may be combined for acute stroke rehabilitation. Bedside acquisition of kinematic measurements allows accurate assessment of the quality of limb movement, offering a sensitive clinical tool for quantifying motor recovery during the rehabilitation process after acute stroke.</p>

Predictors of Acute, Rehabilitation and Total Length of Stay in Acute Stroke: A Prospective Cohort Study

<p><b>INTRODUCTION</b>The poststroke acute and rehabilitation length of stay (LOS) are key markers of stroke care efficiency. This study aimed to describe the characteristics and identify the predictors of poststroke acute, rehabilitation and total LOS. This study also defined a subgroup of patients as "short" LOS and compared its complication rates and functional outcomes in rehabilitation with a "long" acute LOS group.</p><p><b>MATERIALS AND METHODS</b>A prospective cohort study (n = 1277) was conducted in a dedicated rehabilitation unit within a tertiary academic acute hospital over a 5-year period between 2004 and 2009. The functional independence measure (FIM) was the primary functional outcome measure in the rehabilitation phase. A group with an acute LOS of less than 7 days was defined as "short" acute LOS.</p><p><b>RESULTS</b>Ischaemic strokes comprised 1019 (80%) of the cohort while the rest were haemorrhagic strokes. The mean acute and rehabilitation LOS were 9 ± 7 days and 18 ± 10 days, respectively. Haemorrhagic strokes and anterior circulation infarcts had significantly longer acute, rehabilitation and total LOS compared to posterior circulation and lacunar infarcts. The acute, rehabilitation and total LOS were significantly shorter for stroke admissions after 2007. There was poor correlation (r = 0.12) between the acute and rehabilitation LOS. In multivariate analyses, stroke type was strongly associated with acute LOS, while rehabilitation admission FIM scores were significantly associated with rehabilitation LOS. Patients in the short acute LOS group had fewer medical complications and similar FIM efficacies compared to the longer acute LOS group.</p><p><b>CONCLUSION</b>Consideration for stroke type and initial functional status will facilitate programme planning that has a better estimation of the LOS duration, allowing for more equitable resource distribution across the inpatient stroke continuum. We advocate earlier transfers of appropriate patients to rehabilitation units as this ensures rehabilitation efficacy is maintained while the development of medical complications is potentially minimised.</p>

The use of virtual reality-based therapy to augment poststroke upper limb recovery

Stroke remains one of the major causes of disability worldwide. This case report illustrates the complementary use of biomechanical and kinematic in-game markers, in addition to standard clinical outcomes, to comprehensively assess and track a patient's disabilities. A 65-year-old patient was admitted for right-sided weakness and clinically diagnosed with acute ischaemic stroke. She participated in a short trial of standard stroke occupational therapy and physiotherapy with additional daily virtual reality (VR)-based therapy. Outcomes were tracked using kinematic data and conventional clinical assessments. Her Functional Independence Measure score improved from 87 to 113 and Fugl-Meyer motor score improved from 56 to 62, denoting clinically significant improvement. Corresponding kinematic analysis revealed improved hand path ratios and a decrease in velocity peaks. Further research is being undertaken to elucidate the optimal type, timing, setting and duration of VR-based therapy, as well as the use of neuropharmacological adjuncts.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.

Functional outcomes of cancer patients in an inpatient rehabilitation setting

<p><b>INTRODUCTION</b>Cancer is the leading cause of death and the second most common cause of hospitalisation in Singapore. Significant functional gains are achievable with cancer rehabilitation yet there are no formal cancer rehabilitation programmes in Singapore. This study aims to describe the demographics, clinical characteristics, complications and functional outcomes of cancer patients undergoing comprehensive inpatient rehabilitation at our unit and compare these with non-cancer patients. It also seeks to compare these data within sub-groups of the cancer cohort.</p><p><b>MATERIALS AND METHODS</b>This is a prospective cohort study. The Department of Rehabilitation Medicine database was reviewed for the period between 1 July 2002 and 31 December 2006. One thousand seven hundred and fifty patients had complete records, of which 58 are cancer patients. The primary outcome measures were the discharge total Functional Independence Measure (FIM), FIM gain and FIM efficiency. Other outcome measures included the length of rehabilitation stay, discharge destination, complication rates, rate of transfer back to the referring unit, the length of survival of the cancer patients upon discharge and the durability of the functional improvement made.</p><p><b>RESULTS</b>The mean age of the cancer patients was 57.4 +/- 16.1 years and 62% were male. The mean admission total FIM was 70.9 +/- 18.0 and the total discharge FIM was 86.2 +/- 18.3. The average FIM gain was 15.3 +/- 11.6 and the mean efficiency was 0.867 +/- 0.806. This improvement is highly significant, and there is no statistical difference in FIM gain or efficiency between the cancer and non-cancer cohort, or between the cancer subgroups. The length of stay was similar in cancer and non-cancer cohorts but cancer patients with spinal metastasis and those who underwent concomitant radiotherapy stayed longer. There were good rates of discharge home, transfer back, survivorship and durability in functional gains.</p><p><b>CONCLUSION</b>Cancer patients benefit as much as non-cancer patients in undergoing a rehabilitation programme. More patients should be admitted to such programmes and these programmes should be better structured and refined.</p>

Results from a prospective acute inpatient rehabilitation database: clinical characteristics and functional outcomes using the Functional Independence Measure

<p><b>INTRODUCTION</b>Rehabilitation improves functional outcomes, but there is little data on the profiles and outcomes of patients undergoing inpatient rehabilitation in Singapore. The aims of this paper were to document the clinical characteristics and functional outcomes, using the Functional Independence Measure (FIM), of all patients admitted to an inpatient rehabilitation unit in a tertiary teaching hospital, and to identify and analyse factors significantly associated with better discharge functional scores and higher functional gains.</p><p><b>MATERIALS AND METHODS</b>In this prospective cohort study over a 4-year period, clinical and functional data for 1502 patients admitted consecutively to the Singapore General Hospital inpatient rehabilitation unit were charted into a custom-designed rehabilitation database. The primary outcome measures were the discharge total FIM scores, FIM gain and FIM efficiency. Multiple linear regression analysis was used to identify independent variables associated with better discharge FIM scores and FIM gain.</p><p><b>RESULTS</b>The mean age was 61.3 +/- 15.0 years and 57.2% of the patients were male. Stroke (57.9%) followed by spinal cord injury (9.7%) were the most common diagnoses. The average rehabilitation length of stay was 21.5 +/- 19.0 days. The mean admission total FIM score was 70.3 +/- 23.2 and the mean discharge total FIM score was 87.3 +/- 23.0, with this gain being highly significant (P <0.001). The mean FIM gain was 17.0 +/- 13.4 and FIM efficiency was 0.95 +/- 0.90 points/day. Factors associated with better functional outcomes were higher admission motor and cognitive FIM scores, male gender, a longer rehabilitation length of stay and the use of acupuncture. Factors associated with poorer functional outcomes were older age, clinical deconditioning, ischaemic heart disease, depression, pressure sores and the presence of a domestic worker as a caregiver.</p><p><b>CONCLUSIONS</b>The FIM is an easy-to-use, standardised and robust general measure of functional disability. Multiple demographic, clinical and socio-cultural variables are associated with the primary functional outcomes and should be taken into account in rehabilitation and discharge planning. Nevertheless, rehabilitation improves functional outcomes across a wide range of diagnoses. Further research should be aimed at evaluating long-term disability postdischarge from inpatient rehabilitation and translating these findings into improving rehabilitation and healthcare resource utilisation.</p>

A brief review of traumatic brain injury rehabilitation

<p><b>INTRODUCTION</b>This article aims to provide an overview of the epidemiology, medical and rehabilitation issues, current evidence for traumatic brain injury (TBI) rehabilitation, recent advances and emerging practices. Special TBI population groups will also be addressed.</p><p><b>MATERIALS AND METHODS</b>We included publications indexed in Medline and the Cochrane Database of Systemic Reviews from 1974 to 2006, relevant chapters in major rehabilitation texts and Physical Medicine and Rehabilitation Clinics of North America and accessed Internet publications.</p><p><b>RESULTS</b>TBI has been implicated by the World Health Organisation to be a 21st century epidemic similar to malaria and HIV/AIDS, not restricted to the developed world. One third of patients may suffer severe TBI with long-term cognitive and behavioural disabilities. Injuries to the brain do not only damage the cerebrum but may give rise to a multisystem disorder due to associated injuries in 20% of cases, which can include complex neurological impairments, neuroendocrine and neuromedical complications. There is promising evidence of improved outcome and functional benefits with early induction into a transdisciplinary brain injury rehabilitation programme. However, TBI research is fraught with difficulties because of an intrinsically heterogeneous population due to age, injury severity and type, functional outcome measures and small samples. Recent advances in TBI rehabilitation include task-specific training of cognitive deficits, computer-aided cognitive remediation and visual-spatial and visual scanning techniques and body weight-supported treadmill training for motor deficits. In addition, special rehabilitation issues for mild TBI, TBI-related vegetative states, elderly and young TBI, ethical issues and local data will also be discussed.</p>