Walking tolerance of patients recovering from hip fracture: a phase I trial.

PURPOSE: To find out how much physical activity in the form of walking can be tolerated by adults admitted for inpatient rehabilitation after hip fracture. METHOD: Using a phase I dose-response design, in addition to usual scheduled rehabilitation care participants without cognitive impairment were supervised to walk for a prescribed length of time on 5 consecutive days. Doses started at 3 min and were escalated when three participants successfully completed a dose. Secondary outcomes included physical activity and the Ambulatory Self-Confidence Questionnaire (ASCQ). RESULTS: The maximum tolerated dose of walking for the 13 participants (4 men and 9 women; mean age 81 years, SD 10) was 6 min. At 10 min only 1 of 5 participants was able to complete the dose. The main reason for not tolerating the prescribed dose was fatigue. Participants had relatively low levels of daily physical activity (mean 507 steps/day), and lacked confidence in their walking (ASCQ mean 4.6). CONCLUSION: Physical activity guidelines for older people are not appropriate for patients in active inpatient rehabilitation recovering from hip fracture where other factors such as fatigue may limit physical activity levels. These results can be taken into account when designing rehabilitation programmes after hip fracture. Implications for Rehabilitation Hip fracture is a common and serious fracture with ongoing disability for which people require inpatient rehabilitation to prepare for return to independent living in the community. The maximum tolerated dose of walking of 6 minutes suggests physical activity guidelines for older people are not applicable for those receiving active inpatient rehabilitation after hip fracture. The maximum tolerated dose of walking of 6 minutes during inpatient rehabilitation suggests rehabilitation programmes be structured to allow adequate time for recovery.

Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.

OBJECTIVES: To explore the key factors involved in decision making when selecting patients for rehabilitation after stroke and to examine the level of agreement among physician assessors regarding admission to rehabilitation. DESIGN: Questionnaire. SETTING: Health services with rehabilitation units in Victoria, Australia. PARTICIPANTS: Rehabilitation unit physicians. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Questionnaire with 2 components: the clinical and nonclinical factors that influence decision making and clinical case scenarios. RESULTS: Responses were received from 17 physicians from 12 of the 18 health services in Victoria. The most influential clinical factors listed by the respondents were prognosis, social supports, anticipated discharge destination, age, and anticipated length of stay. Key nonclinical factors were prioritization of internal health service referrals, patient's residence, and workforce capacity. Analysis of the clinical scenarios of patients with severe stroke showed that there was variability in the responses, with high levels of agreement for some cases and low levels for others. Almost all respondents agreed that prognosis was a key factor, yet, within the case scenarios, the reasons given for accepting or not accepting the patient demonstrated different opinions on the prognosis of the case presented. CONCLUSIONS: The decision-making processes in selection for rehabilitation and the factors that influence that decision require further investigation to optimize the use and outcomes from rehabilitation resources.

A study protocol of a randomised controlled trial incorporating a health economic analysis to investigate if additional allied health services for rehabilitation reduce length of stay without compromising patient outcomes.

BACKGROUND: Reducing patient length of stay is a high priority for health service providers. Preliminary information suggests additional Saturday rehabilitation services could reduce the time a patient stays in hospital by three days. This large trial will examine if providing additional physiotherapy and occupational therapy services on a Saturday reduces health care costs, and improves the health of hospital inpatients receiving rehabilitation compared to the usual Monday to Friday service. We will also investigate the cost effectiveness and patient outcomes of such a service. METHODS/DESIGN: A randomised controlled trial will evaluate the effect of providing additional physiotherapy and occupational therapy for rehabilitation. Seven hundred and twelve patients receiving inpatient rehabilitation at two metropolitan sites will be randomly allocated to the intervention group or control group. The control group will receive usual care physiotherapy and occupational therapy from Monday to Friday while the intervention group will receive the same amount of rehabilitation as the control group Monday to Friday plus a full physiotherapy and occupational therapy service on Saturday. The primary outcomes will be patient length of stay, quality of life (EuroQol questionnaire), the Functional Independence Measure (FIM), and health utilization and cost data. Secondary outcomes will assess clinical outcomes relevant to the goals of therapy: the 10 metre walk test, the timed up and go test, the Personal Care Participation Assessment and Resource Tool (PC PART), and the modified motor assessment scale. Blinded assessors will assess outcomes at admission and discharge, and follow up data on quality of life, function and health care costs will be collected at 6 and 12 months after discharge. Between group differences will be analysed with analysis of covariance using baseline measures as the covariate. A health economic analysis will be carried out alongside the randomised controlled trial. DISCUSSION: This paper outlines the study protocol for the first fully powered randomised controlled trial incorporating a health economic analysis to establish if additional Saturday allied health services for rehabilitation inpatients reduces length of stay without compromising discharge outcomes. If successful, this trial will have substantial health benefits for the patients and for organizations delivering rehabilitation services. CLINICAL TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry ACTRN12609000973213.

Is achievement of short-term goals a valid measure of patient progress in inpatient neurological rehabilitation?

OBJECTIVE: To determine whether the use of short-term goal setting is effective in monitoring patient progress, with regard to achievement of rehabilitation goals for discharge and predicted length of hospital stay. DESIGN: A prospective observational cohort study. SETTING: An inpatient rehabilitation unit co-located with a large tertiary teaching hospital. SUBJECTS: Consecutive cases admitted to rehabilitation with a neurological condition and a planned length of stay of three weeks or longer. PROCEDURE: Discharge and short-term goals and predicted length were set in the initial team meeting. Goals were set, and achievement scored, in the domains of health, social functioning, communication and cognition, mobility and activities of daily living (ADLs) and a composite goal of global function. Actual length of stay and discharge destination were recorded. RESULTS: Data from 53 consecutive cases were examined, with 45 cases returning home. The median length of stay was 49 days (interquartile (IQ) 30-74). Significant correlations (P<0.05) were demonstrated between short-term goal achievement and discharge goals for continence (rho = 0.62), transfers (rho = 0.53), personal activities of daily living (rho = 0.47) and global function (rho = 0.62). For those that returned home, there were significant correlations (P<0.05) between adherence to predicted length of stay and achieving their initial goals in transfers (rho = 0.44), walking (rho = 0.51) and global function (rho = 0.55). CONCLUSION: Short-term goal setting is a valid measure of patient progress in inpatient neurological rehabilitation and can be used to identify patients who are not progressing as anticipated, facilitating review of the rehabilitation plan.

Goal achievement in the six months after inpatient rehabilitation for stroke.

PURPOSE: The purpose of the project was to identify characteristics associated with successful re-integration into the community post-inpatient rehabilitation after stroke. A key issue was determining re-integration from the person's perspective, taking into account the person's preferred lifestyle choices. RESEARCH DESIGN: A prospective exploratory follow up study. PARTICIPANTS: A consecutive sample of 45 participants discharged from IP rehabilitation following stroke and 23 carers associated with the participants. MEASURES: Goal attainment scaling was utilised to determine successful community integration. Factors that may have contributed to goal achievement were measured prior to discharge and at 6 months post-discharge. Scales used include the Functional Independence Measure, Mini Mental test, the CES-D depression scale and a self-efficacy scale, Strategies Used by People to Promote Health. London Handicap Scale scores and Carer Strain Index were collected at 6 months. RESULTS: Twenty percent of participants achieved all their goals. Significant correlations were observed between goal achievement score and concurrent measures of physical function, depression and self efficacy at 6 months post-discharge. CONCLUSIONS: Stroke survivors who achieved their goals were less likely to be depressed, showed stronger self efficacy beliefs and more positive perceptions of their participation in everyday and community life.

Comparison of disability and quality of life measures in patients with long-term psychotic disorders and patients with multiple sclerosis: an application of the WHO Disability Assessment Schedule II and WHO Quality of Life-BREF.

The aim of this article is to compare the applications of the WHO Disability Assessment Schedule II (WHODAS II) and WHO Quality of Life-BREF (WHOQOL-BREF) in the assessment of patients with psychotic disorders and multiple sclerosis, and to assess the feasibility and usefulness of such universal measures in the psychiatric as well as physical rehabilitation setting. Twenty patients with psychotic disorders from St Vincent's Mental Health Service and 20 patients from the Medical Rehabilitation Ward of St Vincent's Hospital were assessed. The WHODAS II and WHOQOL-BREF were administered to each patient to obtain their perception of the impact of their disability and their health-related quality of life (HRQoL). The WHODAS II and WHOQOL-BREF interviews were meaningful as they highlighted aspects of patients' disabilities as well as issues that led to impairment in HRQoL. The WHODAS II and WHOQOL-BREF total scores were higher overall for patients with multiple sclerosis, reflecting, in particular, the physical impact of this condition. Patients with psychotic disorders generally did not report difficulty in self-care. Both patients with multiple sclerosis and patients with psychotic disorders reported similar levels of difficulty in the domain of participation in society. Universal measures of disability and HRQoL are feasible for use in patients with long-term physical and psychiatric illnesses. Similarities in the disability profiles of patients in the two groups reflect the consequences of the long-term conditions under investigation. Both groups of patients reported similar levels of social disability, confirming that barriers to participation in society affect all patients with disabling conditions.