Inpatient rehabilitation facilities under the prospective payment system: lessons learned.

For better or for worse, third-party payers are the major drivers of rehabilitation care, and the largest payer for inpatient rehabilitation care in the United States remains the Medicare program. Reimbursement for inpatient rehabilitation facilities (IRF) remained unchanged for many years after the establishment of the program. With the transition of the program to a Prospective Payment System (IRF-PPS), Medicare intermediaries have begun to strictly enforce the new regulations they developed. This paper chronicled and described IRF-PPS history and impact methodology on inpatient rehabilitation facilities. The IRF-PPS resulted in the decrease in Medicare costs and operating expenses. Lengths of rehabilitation stay significantly declined, but the case-mix index significantly increased. Many facilities have shifted to treating high-cost, complex patients. Because of the IRF-PPS, IRFs have learned to how to maximize their profits. However, they need to learn strategies that truly reflect the complexity of their patients. They need to identify and document appropriate rehabilitation diagnoses and comorbidities that will produce the greatest reimbursement. They need to document accurately the admission functional status based upon a 72-hour observation period. Most of all, research needs to demonstrate the types of patients who benefit from IRF admissions.

The stroke survivor.

PURPOSE: This article reviews the physiological basis of stroke rehabilitation and describes the theories and interventions involved in the rehabilitation of the stroke survivor. ISSUES: Stroke remains the third most common cause of death in the Western World, and is the leading cause of adult disability and placement into extended care facilities. Stroke is not a disease of the old, but affects many people under the age of 65. Comprehensive rehabilitation may improve the functional abilities of the stroke survivor, despite age and neurologic deficit, and decrease long-term patient care costs. Rehabilitation not only involves restoring independence in mobility and activities of daily living, but maximizing compensatory strategies in linguistic and cognitive function. Strategies to reintegrate the stroke survivor into the community are discussed. Secondary complications of stroke are described, and interventions are suggested to prevent and treat potential medical issues. CONCLUSION: Stroke rehabilitation may be a lifetime endeavour, and requires proper medical resources to successfully address physical, linguistic, cognitive and psychosocial issues. Good communication between the rehabilitation team, the patient and the family facilitates optimal care and provides the stroke survivor with the opportunity to reach his maximal functional potential.

Recovery patterns of shoulder subluxation after stroke: a six-month follow-up study.

PURPOSE: Poststroke shoulder subluxation is a common complication that is thought to be irreversible without intervention. This study explores the natural recovery patterns of shoulder subluxation 6 months after stroke onset. METHOD: Ten first-stroke survivors were evaluated in a free-standing rehabilitation hospital within 6 weeks of stroke onset and were reevaluated 6 months thereafter. Shoulder subluxation was measured in terms of glenohumeral asymmetries between affected and unaffected shoulders using anteroposterior radiographs before and after fitting of an appropriate support. Main outcome measures included shoulder subluxation asymmetries, range of motion, pain, and motor function as measured by the Fugl-Meyer Motor Function Assessment. RESULTS: Decreases in vertical asymmetry 6 months after initial evaluation were correlated with significant motor recovery (r =.7382, p =.018) and were associated with increases in the range of motion of shoulder abduction (r =.7167, p =.020). However, changes in vertical asymmetries were not correlated with changes in shoulder flexion (r =.3744, p =.286) or external rotation (r =.2155, p =.578) range of motion or with changes in shoulder pain (r = -.5189, p =.124). Six-month vertical asymmetries were correlated only with 6-month shoulder abduction range of motion (r =.6408, p =.046). CONCLUSION: Reductions in shoulder subluxation may occur spontaneously only when significant motor recovery of the affected upper limb occurs.

Returning to life. Stroke survivor community and Internet resources.

Returning to the community can be as traumatic an experience to the stroke survivor as experiencing the stroke itself. Smoothing the transition between the hospital and home can be accomplished through many support services and organizations offered through the community. This article explores the many resources readily available to the stroke survivor.

Role of flexible laryngoscopy in evaluating aspiration.

Flexible fiberoptic laryngoscopy is used to evaluate dysphagia, but its clinical utility has not been compared to that of the videofluorographic swallowing study (VFSS). This study correlates parameters of both procedures and identifies laryngoscopic predictors of aspiration in 105 patients. Presence of aspiration, pharyngeal residue, laryngeal sensation, vocal cord mobility, and glottic closure during flexible laryngoscopy (FL), and gag reflex were correlated with aspiration during the VFSS. An algorithm for laryngoscopically detecting aspiration was synthesized. Aspiration (p = .004) and pharyngeal residue (p < .00001) were highly correlated between the two studies. Aspiration during the VFSS was correlated with pharyngeal residue (p < .00001) and laryngeal sensation (p = .027) during FL, but not glottic closure (p = .169) nor vocal cord mobility (p = .056). Patients with a normal gag reflex and without aspiration or pharyngeal residue during FL had a 2.94% risk of aspiration during the VFSS. Flexible laryngoscopy can be used as a relatively safe, portable screening test for aspiration, but cannot always replace the VFSS to identify the presence or cause of aspiration.

Functional outcome of hemorrhagic and nonhemorrhagic stroke patients after in-patient rehabilitation.

Differences in functional prognosis for patients with hemorrhagic and nonhemorrhagic strokes are unclear. The purpose of this study is to compare the functional outcome of hemorrhagic and nonhemorrhagic stroke patients after inpatient stroke rehabilitation. By retrospective review, 25 hemorrhagic stroke patients were matched with 25 nonhemorrhagic stroke patients on the basis of age and onset to admission interval. Discharge Functional Independence Measure (FIM), FIM gain, FIM efficiency, length of stay (LOS), and discharge disposition were compared. Admission FIM, gender, and comorbidities were similar between the two groups. There were no differences in discharge FIM, FIM gain, and discharge to home rates between groups. However, the hemorrhagic group had a significantly shorter LOS (31.7 v 37.6 days; P = 0.05) with higher FIM-total efficiency (0.84 v 0.60; P = 0.02). The FIM-motor scale accounted for most of the gains in efficiency (0.71 v 0.53; P = 0.05) with no significant difference in FIM-cognition efficiency between groups. Post hoc analysis revealed that onset to admission interval was a strong predictor of LOS (r = 0.62; P < 0.0001). Hemorrhagic stroke patients appear to exhibit functional gains somewhat faster than nonhemorrhagic counterparts. Confirmation of these preliminary findings must await future studies.

Shoulder pain and subluxation after stroke: correlation or coincidence?

OBJECTIVE: Few studies have concomitantly examined shoulder subluxation and other potential causes of shoulder pain in persons who have had a stroke. This study explores whether shoulder pain after stroke is related to shoulder subluxation, age, limitations in shoulder range of motion, and upper extremity motor impairment. METHOD: Shoulder pain was measured with a visual analog scale in 20 subjects admitted to a rehabilitation hospital within 6 weeks of onset of their first stroke. Degree of shoulder pain was correlated with vertical, horizontal, and total asymmetries of glenohumeral subluxation; age; shoulder flexion, abduction, and external rotation; and the upper extremity subscore of the Fugl-Meyer Motor Assessment. RESULTS: Shoulder pain after stroke was not correlated with age (rk = .019, p = .916); vertical (rk = .081, p = .324), horizontal (rk = .126, p = .241), or total asymmetry (rk = -.098, p = .288); shoulder flexion (rk = .049, p = .390) or abduction (rk = -.074, p = .337); or Fugl-Meyer scores (rk = -.123, p = .257). In contrast, shoulder pain was strongly correlated with degree of shoulder external rotation (rk = -.457, p = .006). CONCLUSION: These results do not support a strong relationship between shoulder subluxation and pain after stroke. Appropriate precautions should be taken to prevent range of motion limitations that may result in shoulder pain.

Shoulder subluxation after stroke: a comparison of four supports.

OBJECTIVE: Shoulder subluxation is a well-known sequela of stroke. This study quantitatively compares the reduction of shoulder subluxation using four supports: the single-strap hemisling, the Bobath roll, the Rolyan humeral cuff sling, and the Cavalier support. DESIGN/SETTING: Anteroposterior shoulder radiographs of 20 consecutive first-time stroke survivors in a freestanding rehabilitation hospital were taken within 6 weeks of stroke onset. Vertical, horizontal, and total asymmetries of glenohumeral subluxation compared with the unaffected shoulders were measured before and after fitting of each support. MAIN OUTCOME MEASURES: Group means were compared to find which supports altered subluxation asymmetries and approximated the unaffected shoulder. Individual data were tallied to detect how often each support best reduced subluxation asymmetries. RESULTS: The single-strap hemisling eliminated the vertical asymmetry of subluxation over the entire study group, but each support corrected the vertical asymmetry best in some subjects (55%, 20%, 40%, and 5%, respectively). The Bobath roll and the Cavalier support produced lateral displacements of the humeral head of the affected shoulder (p = 0.005, 0.004, respectively). The Rolyan humeral cuff sling significantly reduced total subluxation asymmetry (p = 0.008), whereas the single-strap hemisling, Bobath roll, and Cavalier support did not alter total asymmetry (p = 0.091, 0.283, 0.502, respectively). CONCLUSION: When treating shoulder subluxation, several different types of supports should be evaluated to optimize the function of the affected extremity and the reduction of the shoulder subluxation.