The art of medicine: subjective measures as predictors of outcome in stroke and traumatic brain injury.

This study was designed to explore new ways of predicting the functional outcomes of stroke and brain injury patients. Upon admission and initial assessment of functional performance, we used an on-line computer program to indicate the most important and subjective judgment items to set rehabilitation goals for patients. The functional performance and discharge outcomes of patients from an inpatient program were measured by using five nonmedical functional items from the patient evaluation conference system (PECS). For stroke patients we most frequently selected motor loss, perceptual/cognitive deficit, spasticity, sensory deficit (PECS medical items), and comprehension (subjective cue). For traumatic brain injury patients, however, we selected motor loss, perceptual/cognitive deficit, spasticity (PECS medical items), communication, and comprehension (subjective cues). Data were statistically analyzed using the Fisher Exact Test. Of the medical function items, a level of independence in the sensory deficit function in stroke patients at admission was associated with a patient achieving independence in ambulation at discharge. Demonstrating a moderate or maximum level of attention, concentration, and realism was positively related to a patient achieving a level of independence in ambulation at discharge. Independence in the function items of behavior and interaction was associated with moderate or maximum levels of comprehension at admission. In traumatic brain injury patients, none of the subjective cues were associated with achieving independence at discharge in any of the functional levels. This paper demonstrates the value of developing a way to assess subjective measures that are based on their ability to predict outcomes. Using such a method, new predictive measures can be developed.

Agitation in closed head injury: haloperidol effects on rehabilitation outcome.

The role of agitation as a prognostic indicator of outcome in 26 patients with severe traumatic closed head injury was studied to explore haloperidol effects on the outcome of rehabilitation treatment. The incidence and degree of agitation and post-traumatic amnesia (PTA) in brain-injured patients undergoing comprehensive inpatient rehabilitation were also studied. Variables measured included length of coma, PTA, rehabilitation admission and discharge functional status, and CT scan results. Of the 26 patients, 25 were agitated after emerging from coma and 11 required intervention with haloperidol. Treated and nontreated patients were compared statistically. No differences were found between groups as to demographics, length of coma, and most importantly, in success of rehabilitation outcome. The duration of PTA was significantly longer in the treated group.

Computerized tomography head scans as predictors of rehabilitation outcome.

This study explored the relationship between rehabilitation functional outcome, demographic characteristics, and predicted goal achievement for 30 patients with closed head injury according to characteristics of their computerized tomography (CT) head scans performed within 10 days of injury. Goals and outcome were measured according to levels of independent/dependent function at discharge from an interdisciplinary inpatient rehabilitation program by means of the Patient Evaluation Conference System (PECS). Patients were classified into the three following major subgroups according to CT findings: (1) normal; (2) 1 hemisphere lesion; and (3) bilateral lesion. Marked differences in patient outcome and in the team's ability to accurately predict outcome were found to match the subgroups so classified. The need to incorporate CT scan data into early team planning and goal setting is stressed.

Patient profiles: utilization in functional performance assessment.

A computerized XY graphic plotted profile has been developed as a method of displaying patient progress and goals using the Patient Evaluation Conference System (PECS) as the data source. Each profile is a bar graph of functional status and goal scores for specific contact-evaluation points. Contacts are represented by different colors so that one color is superimposed on the other. Individual functional items are plotted on the X-axis at the appropriate level of independent or dependent function, as indicated by the 0 to 7 scale which appears on the Y-axis. The profile is used in goal-oriented team conferences, and provides a focus on particular problems of low status or discrepencies between status and goals. This visual aid can provide a display of rehabilitation progress useful to the patient, family, and staff.

Functional abilities and distress levels in brain injured patients at long-term follow-up.

An investigative long-term follow-up study of brain injured individuals who had been inpatients in an interdisciplinary rehabilitation program was conducted by means of a mailed questionnaire. Level of distress, gauged by the Brief Symptom Inventory (BSI), was compared to the level of functional abilities as determined by a shortened self-report version of the Patient Evaluation Conference System (PECS). Functional skills compared included self-care, mobility, living arrangements, communication, recreation/leisure, and education/employment. Significant negative relationships of distress levels to independence in self-care, mobility, living arrangements, and communication were found.

Cancer rehabilitation. An analysis of 36 program approaches.

Information about comprehensive rehabilitation for patients with cancer is limited. Only a few descriptions of existing models are found in the literature. A survey questionnaire concerning the description and operation of cancer rehabilitation programs was developed and mailed to identified programs in 95 facilities throughout the country. Thirty-six facilities responded with data appropriate for analysis of their method of organization, treatment approaches, team composition, program emphasis, evaluation procedures, and program results. A literature and survey analysis provide support for an interdisciplinary team approach for rehabilitation of cancer patients disabled by the disease or its treatment. In addition, the survey shows favorable acceptance and success of cancer rehabilitation programs, especially in community hospital settings.

Vocational/educational services in a medical rehabilitation facility: outcomes in spinal cord and brain injured patients.

Records of 86 patients were reviewed to study whether adding on-site professional vocational/educational staff to a multidisciplinary medical rehabilitation program made an impact on vocational/educational outcomes in patients with spinal cord and brain injuries. Differences in such outcomes between the 2 patient groups were also explored. Patients who participated in an inpatient program prior to the addition of on-site vocational/educational staff were compared to those who participated after professional staff were added. Vocational/educational placement rates increased from 19% or lower to as high as 78% in cases where vocational/educational services were appropriate.

Functional performance assessment: a program approach.

An interdisciplinary method of functional assessment is presented utilizing the Patient Evaluation Conference System, or PECS (Harvey and Jellinek, 1979), which has been successfully applied to a medical rehabilitation setting to guide treatment and to assess program effectiveness. Our method requires that functional performance items be evaluated in terms of progress using an 8-point, 0 to 7 scale, 0 representing unmeasured or unmeasurable function, and 7 representing fully independent or normal function. Rehabilitation outcomes of 4 or below present varying degrees of dependent function, and outcomes of 5 or more represent degrees of independent function. Data are presented which demonstrate level of gain, goal-setting effectiveness, and degree of independent function.