Clinical Rehabilitation

Objective: We hypothesized that early ambulation with a gutter frame (GF) in elderly patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may reduce physical disability and allow earlier discharge.

Design: Blinded, randomized parallel groups trial.

Subjects: One hundred and ten consecutive AECOPD inpatients.

Interventions: Participants were recruited two days post admission and randomly allocated to four groups: GF with supplemental oxygen (GFSO), GF with supplemental air (GFSA), rollator with supplemental air (RSA) and rollator with supplemental oxygen (RSO) (air/oxygen was double-blinded to patients and investigators). Patients exercised three times daily (maximum of 15 minutes per session) with a physiotherapist or nurse.

Outcome measures: Physical disability measured by Barthel Index and perceived respiratory effort by Borg Scale.

Results: After intervention no significant difference was observed between the four groups in length of hospital stay (F = 0.78; p = 0.50), changes in mean Barthel score (F = 2.08; p = 0.11) and Borg score (F = 0.35; p = 0.79). However, improvement in Barthel score (mean 1.22 combined gutter frame group air/oxygen) was greater than the combined rollator group (mean 0.55; p = 0.003). Baseline Barthel score and nurses’ assessment of compliance were associated with improvement in Barthel score (p < 0.0001 and p < 0.002). Barthel score was predicted by use of gutter frame (F = 6.17; p = 0.01), not by use of rollator. Use of air/oxygen group was not related to improvement in Barthel score.

Conclusion: Short-term exercise therapy with gutter frame after AECOPD admission reduces physical disability in older patients but does not affect length of hospital stay. Use of supplemental oxygen during exercise has no additional benefits.

Objective: To evaluate the specific effects of balance and gait exercises among frail elderly individuals.

Design: A randomized three-group parallel controlled study.

Setting: Geriatric health services facility in Japan.

Subjects: Thirty-four frail elderly subjects attending the care facility were randomized into a control group, an exercise group with emphasis on balance or an exercise group with emphasis on gait re-education.

Interventions: The two exercise groups received balance or gait exercise for 40 minutes, 2–3 times weekly, for 12 weeks.

Main outcome measures: One Leg Standing Test, Functional Reach Test, Manual Perturbation Test, Functional Balance Scale, Performance-Oriented Mobility Assessment, Timed ‘Up and Go’ Test and Stair Climbing/Descending Test. These assessments were performed before and after 12-week intervention.

Results: Comparison of the performance before and after intervention demonstrated significant improvement in One Leg Standing Test, Functional Reach Test and Functional Balance Scale in the balance exercise group, and Functional Balance Scale, Timed ‘Up and Go’ Test and Stair Descending Test showed improvement in the gait exercise group. All test items showed no significant differences in the control groups. Among the three groups, the balance exercise group showed more significant improvement in Functional Balance Scale, and the gait exercise group showed more significant improvement in Performance-Oriented Mobility Assessment than the control group. The balance exercise group showed greater improvement in performance in Functional Reach Test than the gait exercise group.

Conclusions: Balance exercises led to improvements in static balance function, and gait exercises resulted in improvements to dynamic balance and gait functions in the very frail elderly.

Objective: To investigate whether sports injuries result in long-term disabilities and handicaps and to establish variables with a prognostic value for the occurrence of these long-term consequences.

Materials and methods: All patients older than 17 years of age and admitted to the University Hospital Groningen because of a sports injury were entered in the study. By filling in a questionnaire 1–4 years after the injury an inventory was made of the long-term consequences.

Main outcome measures: Absenteeism from work and sports, experienced disabilities or handicaps and the Sickness Impact Profile 68 (SIP68).

Results: Out of 306 patients 229 (75%) returned a completed questionnaire. Sixty-seven per cent of the working population had been unfit for work up to one year, whereas 4% still had not resumed work. Absenteeism from sports was also considerable; nearly half of the population did not participate in sports for more than a year. Furthermore, 32% of the patients still experienced disability or handicap following the injury. This finding is in agreement with the results of the SIP68 (odds ratio 6.8; confidence interval (95% CI): 3.51–13.08). Two prognostic variables could be distinguished: ‘gender’ and ‘type of sport’. Long-term consequences occur more often in women (p < 0.03) and with playing outdoor soccer, horse riding or skiing (p < 0.01).

Conclusions: Sports injuries can lead to long-term disabilities and handicaps. The variables ‘gender’ and ‘type of sport’ were of prognostic significance.

Objective: To evaluate the use of an air flotation mattress overlay in patients with chronic pain.

Design: Four-week prospective AB design.

Setting: The mattress overlay was used in a community setting.

Subjects: Adult patients attending an outpatients clinic in a department of rheumatology, with chronic pain plus sleep problems, or pain sufficient to disturb sleep.

Interventions: An inexpensive low-pressure inflatable mattress overlay (Repose^TM), which is readily portable and has no electrical supply, was introduced to the patients. They were encouraged to use the support surface every night.

Main outcome measures: The primary outcome was measured by self-reported changes in sleep quantity and frequency of sleep disturbance. Secondary outcomes were self-reported changes in pain and use of analgesia, verified by medical notes.

Results: Nineteen female patients (mean age 61 years) completed the study. At baseline, mean length of sleep time was 3.8 h, with mean of 4.9 interruptions of mean 25.3 min: week 4, mean sleep time = 6.4 h, with a mean of 2.3 interruptions for mean 14.2 min (all measures p < 0.001). At baseline, median pain during the day was 6 and at night-time was 7; by week 4 a reduction in pain was reported both for the day (median = 5) and the night (median = 5) (both p < 0.001). Thirteen patients reported a reduction in the use of analgesia during the study.

Conclusions: In this pilot study of a new mattress overlay, statistically significant improvements in sleep and pain were noted over a four-week period.

Objective: Can psychological tests predict whether, on admission to a rehabilitation ward post amputation, a lower limb amputee will learn to use a prosthesis during the ensuing inpatient rehabilitation programme?

Design: A one-sample design in which psychological variables, and transfemoral/transtibial amputation site were tested as predictors of outcome.

Setting: An inpatient rehabilitation unit in the UK offering prosthetic provision.

Subjects: Forty-three consecutive patients with peripheral vascular disease (mean age 66.35 years, standard deviation 14.99) who had received an amputation on average 19 days previously on a surgical ward and were transferred to the unit for rehabilitation including assessment for prosthetic provision.

Main outcome measure: Whether the patient learnt to use a prosthesis independently during the stay on the rehabilitation unit.

Results: During their stay in the rehabilitation unit (mean length of stay = 42 days), 31 patients learnt to use a prosthesis and 12 did not. A forward stepwise logistic regression revealed that the Kendrick Object Learning Test score on admission correctly predicted outcome in 70% of cases. The predictive power rose to 81% correct when the amputation site (transfemoral or transtibial) was included amongst the predictors. Anxiety, depression and recovery locus of control scores were not significant predictors of functional prosthetic use in this study.

Conclusion: A simple test of learning ability and the amputation site can help to predict the patient's ability to learn to use a prosthesis following amputation and is recommended as part of the assessment process.

Objective: To examine variability in ‘uptime’ (the amount of time spent in the upright position).

Design: An observational study. Setting: The community (i.e., homes and schools in the Melbourne metropolitan area).

Subjects: Normal children between 8 and 15 years of age (18 girls and 8 boys).

Equipment: An ‘uptimer’, a lightweight, battery-operated remote monitor, was used to record uptime.

Procedure: Each child in the study wore the uptimer continuously over a 24-hour period, which included a typical day at school, on four separate occasions, one week apart.

Results: The variability in repeated measures of uptime in the same child (standard deviation 0.8 hours in 24 hours) was lower than the variability between the children (standard deviation 1.1 hours in 24 hours). We estimate that a single uptime measurement has reliability given by an ICC of 0.65 (95% confidence interval 0.49–0.82), which is calculated by dividing the between-child variability by the total variability (within-child and between-child variability). There were no systematic differences in mean uptime between occasions of measurement.

Conclusion: As an estimate of the time that a child spends in the upright position, a single 24-hour period of measurement of uptime may vary considerably from one occasion to the next. However, this within-child variability is less than the variability between children. In large-scale field studies a one-off measurement of uptime may be acceptable, but in small rehabilitation studies uptime should be measured on at least three occasions.

Background: Pressure mapping systems offer a new technology to assist with pressure care assessment. Data output from such systems can be presented in three forms: numerical data, a three-dimensional grid and a colour-coded pressure map.

Objectives: To (1) investigate whether sole use of the pressure map was a reliable method of interpreting interface pressures when compared with use of the numerical data; (2) establish the inter and intra-rater reliability of using pressure maps to assess pressure and determine whether reliability depended upon system operator experience; and (3) examine whether reliability extended to the range of seating surfaces being tested.

Design: A reliability study assessing the ranking of pressure maps recorded by the Force Sensing Array pressure mapping system.

Setting: A university occupational therapy department and a community NHS trust.

Subjects: Fifteen occupational therapists with experience in pressure mapping and 50 occupational therapy students with no practical experience of pressure mapping.

Interventions: Two sets of pressure maps were pre-recorded with an able-bodied adult seated on a variety of surfaces, with maps on each individual surface recorded over a 20-minute period at 2-minute intervals. Subjects ranked both sets of maps in terms of ‘best to poorest’ distribution of pressure.

Main outcome measures: Rank orders of (1) pressure maps; (2) average interface pressures (mmHg); (3) maximum interface pressures (mmHg). Results: The use of pressure maps to interpret interface pressures was a reliable method. Significant agreement existed within (p < 0.001) and between groups of operators and reliability extended over the range of seating surfaces tested.

Conclusions: The practice of using pressure maps to interpret interface pressures in seating as opposed to using the associated numerical data can be supported. This was shown to be a reliable method of assessment by both experienced and less experienced operators across a range of seating surfaces.

Objective: To identify evidence-based prognostic factors in the subacute phase after a stroke for future residence at six months to one year post stroke.

Design: Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, PsycLIT and Sociological Abstracts. (2) Reference lists, personal archives and consultation of experts in the field. (3) Guidelines.

Methods: Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for future residence; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration.

Results: From 1027 potentially relevant studies 10 studies involving a total of 3564 patients met the inclusion criteria. No prognostic factor was identified in at least two level A (i.e., a good level of scientific evidence according to the methodological score) studies, our standard for scientific proof. The following factors were found in at least one level A study: low initial ADL functioning, high age, cognitive disturbance, paresis of arm and leg, not alert as initial level of consciousness, old hemiplegia, homonymous hemianopia, visual extinction, constructional apraxia, no transfer to the stroke unit, nonlacunar stroke type, visuospatial construction problems, urinary incontinence and female gender.

Conclusions: At present there is insufficient evidence concerning possible predictors in the subacute stage of stroke to make an evidence-based prediction of the future residence. In the scientific research until now social factors and their contribution to the possibility of living independently have not been investigated, or at least less well. None of the studies in this review described a conceptual framework as basis for the choice of the examined prognostic factors.

Objective: To identify the life goals of people with long-term neurological disabilities and to correlate them with measures of disability.

Design: Cross-sectional descriptive study.

Setting: Centre for continuing disability management

Subjects: Patients with static or progressive neurological disorders.

Interventions: Survey using questionnaires and disability scales.

Measures: Life goals were identified with a life goals questionnaire. Subjects were also assessed using the Barthel Index, Rivermead Extended Activities of Daily Living Index, Rivermead Mobility Index, Short Orientation Memory Concentration test and Hospital Anxiety and Depression Scale.

Results: Ninety-three subjects participated in the study. The frequency with which goals were chosen as extremely important was: family 64; personal care 59; residential arrangements 58; partner 53; social contacts 30; financial status 29; leisure 26; religion 22; and work 19. Positive correlation was noted between stated importance of: personal care and independence in ADL; work and independence; partner and cognitive ability; religion and age; and financial status and anxiety. There was negative correlation between grades of personal care and depression, work and age, residential arrangements and RMI, and social contact and anxiety and depression. Depressed patients rated fewer goals as being of extreme importance.

Conclusions: People with disabilities attach great significance to relationships and personal care. Grades of life goals correlated with measures of disability, cognition and emotion.

Objective: To investigate the effect of increasing effort on energy cost as measured by oxygen consumption (V.O2) during cycling exercise in individuals early after acquired brain injury (ABI).

Design: An experimental correlation design.

Setting: Specialist neurorehabilitation centre.

Participants: Thirty-eight individuals were recruited early after acquired brain injury. Nine individuals had spasticity; Ashworth Scale >1 in either upper or lower limbs.

Intervention: The V.O2 was measured in relation to workload during a graded exercise test.

Results: The V.O2 increased in a linear fashion with increases in workload in 34 individuals. Only one individual with spasticity demonstrated a nonlinear relationship.

Conclusion: Increasing the workload during cycling exercise does not disproportionately increase energy cost in most individuals with spasticity early after ABI.

Objective: To examine the effect of additional cognitive demand on cycling performance in individuals with acquired brain injury (ABI).

Design: Prospective observational study.

Setting: Rivermead Rehabilitation Centre.

Participants: Ten individuals with ABI (7 men, 3 women) (traumatic brain injury 7, tumour 1, stroke 2) and 10 healthy controls (6 men, 4 women).

Intervention: Individuals were asked to maintain a set cadence during a three-stage incremental cycling test in both single-task (no additional task) and dual-task (whilst performing an additional cognitive task) conditions.

Results: The ABI group showed a slight slowing in cadence in stages 1 and 3 of the graded exercise test from the single-to the dual-task condition, although this was not significant (p £ 0.05). The control group showed no slowing of cadence at any incremental stage. When directly comparing the ABI with the control group, the change in cadence observed in dual-task conditions was only significantly different in stage 3 (p £ 0.05).

Conclusions: Clinicians should be aware of the possibility that giving additional cognitive tasks (such as monitoring exercise intensity) while individuals with acquired brain injury are performing exercises may detrimentally affect performance. The effect may be more marked when the individuals are performing exercise at higher intensities.

Objective: To investigate stroke patients’ and carers’ perceptions of the family support organizer (FSO) service in order to highlight its value for potential purchasers and to help shed light on findings from randomized controlled trials.

Design and subjects: Twenty semi-structured interviews were undertaken with a sub sample of stroke patients and their primary informal carers after completion of nine-month outcome assessments as part of a randomized controlled trial.

Setting: Community stroke services in North Nottinghamshire, UK.

Results: Interviewees who received the service reported that the presence of an FSO was valuable in many respects, including helping to claim benefits, as a source of information on stroke, and providing continuity between stroke services. Emotional support was only described by a few. Interviewees who did not receive the service described feelings of isolation and being let down by other stroke services after discharge. They also reported problems accessing information. Help needed to address the practical problems after stroke was commonly reported. For those who did not receive the FSO service, access to support appeared to be found through other channels.

Conclusion: The FSO service appeared to be an information service. In order to evaluate community stroke services, a mixture of qualitative and quantitative outcome measures are necessary.

Objective: To assess inter-rater reliability of the Frenchay Activities Index (FAI) when used by occupational therapists in stroke patients.

Design: Independent administration of the FAI by occupational therapists in 45 stroke outpatients.

Setting: Outpatient departments of two Dutch rehabilitation centres.

Statistics: Agreement between pairs of raters was assessed at item level using weighted Kappa and the percentage absolute agreement and for the total score using intra-class correlations (ICC), Bland–Altman plots and computation of the smallest real difference (SMR).

Results: ICC of the total score was good (0.90; 95% confidence interval (95% CI): 0.82–0.94). The Bland–Altman plot did not reveal relationships between agreement and height of scores. Reliability at item level was good (kappa >0.60) in 11 out of 15 items. The item ‘gainful work’ showed high agreement but a low kappa due to an extremely skewed score distribution. Reliability was insufficient in three items: ‘local shopping’, ‘social occasions’ and ‘actively pursuing hobby’. Clarification of scoring instructions of these items might further improve the inter-rater reliability of the FAI.

Conclusion: The FAI is a reliable instrument to measure outcomes of outpatient rehabilitation in patients with stroke.

Objective: To examine the relative effects of footwear and an ankle-foot orthosis (AFO) on hemiplegic gait.

Design: A case series with three contrasting conditions: walking without footwear, with footwear alone, and with footwear and an AFO. Spatio-temporal parameters reflecting walking performance were analysed using an analysis of variance (ANOVA).

Patients: Five patients with hemiplegia and reduced mobility following stroke.

Setting: A specialist rehabilitation centre.

Intervention: Wearing either footwear alone, or footwear with an AFO.

Measures: Video recordings of gait were subjected to a kinematic analysis to determine spatio-temporal parameters.

Results: Stride length was increased by an average of 5 cm when wearing footwear. An additional 5-cm increase was also observed when wearing an AFO. Swing velocity was also affected by the manipulation.

Conclusions: The appropriate comparative baseline for assessing the efficacy of an AFO is subjects walking with existing footwear and not barefoot.

Objective: A new scale, the Mobility Scale for Acute Stroke Patients (MSAS), was developed to specifically discriminate between the lower levels of mobility found in acute stroke patients in the first two weeks post onset. The aim of this study was to investigate the concurrent validity of this new scale with other established scales.

Main outcome measures: Concurrent validity was assessed with respect to four other well-validated measures: Motor Assessment Scale (MAS), Functional Ambulation Classification system (FAC), Functional Independence Measure (FIM), and Barthel Index (BI). The measures selected for comparison contained items similar to those in the MSAS.

Subjects: From a total of 539 patients who were admitted over a two-year period with a primary diagnosis of stroke, 106 satisfied the criteria for inclusion in this study.

Results: The MSAS was found to have a high level of concurrent validity (r > 0.80) when the total score was correlated with the total scores of the MAS, FAC, FIM (mobility and ADL) and BI. A high level of association was found between the nonbed mobility items (sit to stand, stand and walk) of the MSAS and the mobility items (toileting, transfers, walk and stairs) of the FIM and BI. There was a weaker association between the MSAS items and the ADL items (activities of daily living) of the BI and FIM.

Conclusion: A new scale designed specifically for acute stroke patients was found to have a high degree of concurrent validity when compared with four other scales containing similar items.

Objective: To investigate which knee kinematic characteristics show the greatest differences between stroke patients with minimal residual disability and age-matched healthy volunteers as a first step towards the development of a sensitive, objective measure of performance of movement for use in the clinical setting.

Design: A comparative study.

Setting: A movement analysis laboratory.

Subjects: Ten patients between 6 and 12 months post stroke aged between 65 and 74 years and 10 age-matched healthy volunteers. All patients had made a good recovery and were able to complete all of the functional tasks.

Interventions: Each subject had re‘ective markers placed on anatomical landmarks and was filmed performing three movement tasks: sit-to-stand, walking, and step on block.

Main outcome measures: Knee kinematic characteristics involving timing, joint angle and angular velocity at key points during each task.

Results: Significant differences were found between patients and volunteers for only some of the timing and joint angle characteristics but for all angular velocity characteristics for which the mean differences ranged from 31.85 degrees/s for sit-to-stand (p = 0.013) to 82.5 degrees/s (p = 0.014) for the swing phase of gait.

Conclusions: These preliminary findings suggest that angular velocity of the knee during functional tasks might have potential as a sensitive, objective measure of performance of movement after stroke for patients with minimal residual disability.