Clinical Rehabilitation

Objective: To determine the effect of exercise interventions for acutely hospitalized older medical patients on functional status and hospital outcomes.

Data sources: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PEDro, Current Contents and Sports Discus were searched until February 2006. Additional studies were identified through reference and citation tracking and contacting authors of eligible trials.

Review methods: Eligible studies were prospective randomized or pseudor and omized controlled trials comparing exercise for medical inpatients to alternate or no treatment controls. Of 3138 potentially relevant articles screened by two independent reviewers, seven randomized controlled trials and two pseudorandomized controlled trials were included. Two independent reviewers extracted data relating to patient and hospital outcomes and assessed the method quality.

Results: Pooled analysis of multidisciplinary interventions that included exercise indicated a significant increase in the proportion of patients discharged to home at hospital discharge (relative risk 1.08; 95% confidence interval (CI) 1.03 –1.14) and a small but important reduction in acute hospital length of stay (weighted mean difference – / 1.08 days; 95% CI – / 1.93 to – / 0.22) and total hospital costs (weighted mean difference – / US$280; 95% CI – / $493 to – / $65) compared with usual care. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay. The effect of exercise on functional outcome measures is unclear. There was no influence of exercise intervention on adverse events.

Conclusions: Multidisciplinary intervention that includes exercise improves patient and hospital outcomes for acutely hospitalized older medical patients.

Objective: To evaluate the effect of repetitive locomotor training on an electromechanical gait trainer plus physiotherapy in subacute stroke patients.

Design: Randomized controlled trial.

Setting: Four German neurological rehabilitation centres. Subjects: One hundred and fifty-five non-ambulatory patients (first-time stroke <60 days).

Intervention: Group A received 20 min locomotor training and 25 min physiotherapy; group B had 45 min physiotherapy every week day for four weeks.

Main outcome measures: Primary variables were gait ability (Functional Ambulation Category, 0-5) and the Barthel Index (0-100), blindly assessed at study onset, end, and six months later for follow-up. Responders to the therapy had to become ambulatory (Functional Ambulation Category 4 or 5) or reach a Barthel Index of ≥ 75. Secondary variables were walking velocity, endurance, mobility and leg power.

Results: The intention-to-treat analysis revealed that significantly greater number of patients in group A could walk independently: 41 of 77 versus 17 of 78 in group B (P B < 0.0001) at treatment end. Also, significantly more group A patients had reached a Barthel Index ≥ 75: 44 of 77 versus 21 of 78 (P B < 0.0001). At six-month follow-up, the superior gait ability in group A persisted (54 of 77 versus 28 of 78, P B < 0.0001), while the Barthel Index responder rate did not differ. For all secondary variables, group A patients had improved significantly more (P B < 0.0001) during the treatment period, but not during follow-up.

Conclusions: Intensive locomotor training plus physiotherapy resulted in a significantly better gait ability and daily living competence in subacute stroke patients compared with physiotherapy alone.

Objectives: To assess the effects of botulinum toxin A (BT-A) on hemiplegic shoulder pain associated with spasticity.

Design: Randomized, double-blind, placebo-controlled study.

Setting: Outpatient clinic of a rehabilitation department. Participants: Patients, more than three months post stroke, with hemiplegic shoulder pain associated with shoulder adductor and elbow flexor spasticity, randomly assigned to BT-A or placebo.

Intervention: One-time injection of BT-A (500 units) into the pectoralis major and biceps brachii on the hemiplegic side.

Main measures: Visual analogue scale of shoulder pain (0 –10), shoulder adductor and elbow flexor tone using the Ashworth Scale and passive range of shoulder abduction. These were assessed at baseline, four weeks, eight weeks and 12 weeks post injection.

Results: Seventeen patients were enrolled, eight in the BT-A group and nine in the placebo group. At baseline, the median visual analogue scale score for shoulder pain was 6, the median Ashworth Scale shoulder adductor and elbow flexor spasticity score was 2 and the median range of shoulder abduction 76 degrees. Subjects who received BT-A showed significantly greater improvements in median shoulder adductor and elbow flexor Ashworth Scale scores than placebo at week 4 (P B / 0.01) but not at week 8 and 12. For shoulder pain and passive shoulder abduction range, all subjects showed postinjection improvements and no difference could be demonstrated between the two groups.

Discussion: Possible reasons for the negative finding in this study include the small sample size and the presence of causes of shoulder pain not related to spasticity which could have confounded outcome.

Objective: To study the impact of assertive conservative therapy on walking in frail elderly patients with intracapsular fracture of the proximal femaur.

Design: Prospective non-randomized controlled trial.

Setting: Two private geriatric rehabilitation hospitals.

Subjects: From October 1997 to December 2004, 20 patients, not indicated for surgery, were treated with conservative therapy. There were 18 women and 2 men, and their ages were 87.1±4.2 (mean ±SD) years. All of them could walk before hip fracture.

Interventions: Thirteen patients accepted our assertive therapy, which consisted of standing on the fractured limb and walking in parallel bars as soon as possible. Seven patients refused our methods and were conventionally treated; the injured limb was immobilized under skin traction, and then they gradually tried to use a wheelchair for pain reduction.

Main measures: We used the following measures before therapy and six months after: Merle d'Aubigné & Postel's Hip Score, Functional Independence Measure (FIM) and face pain scale.

Results: The two groups were similar demographically. All patients except one (n = 12) responded to our method and could walk. However, the patients treated with the conventional method (n = 7) did not recover the ability to walk. The mean FIM (transfer and locomotion, five items) was 18.2 ±7.9 points in the former and 9.4 ± 4.3 points in the latter.

Conclusion: Assertive rehabilitation was more effective at restoring the ambulatory ability of frail elderly patients with intracapsular fracture of the hip than the conventional method.

Objective: To evaluate the effect of pre-emptive swallowing stimulation on the recovery of swallowing function in long-term intubated patients.

Design and subjects: Patients in the intensive care unit intubated for at least 48 hours due to respiratory distress from March to August 2004 were randomly divided into two groups. Fifteen patients of mean age 55.39±17.9 years were stimulated (experimental group) and 18 patients of mean age 61.39±13.5 years were not stimulated (control group). The duration of intubation was 15.59±6.7 days in the experimental group and 15.79±6.5 days in the control group. Duration of stimulation in the experimental group was 7.39±3.6 days. After extubation, we compared the severity of dysphagia via video-fluoroscopic swallow study.

Results: There were no statistically significant differences in the percentage of aspiration and the swallowed volume between the two groups. However, oral transit time in the experimental group (0.379±0.07 seconds) was significantly shorter than that of the control group (0.839±0.10 seconds), and the oropharyngeal swallowing efficiency of the experimental group (73.39±17.4%/s) was significantly higher than that of the control group (50.19±13.0%/s).

Conclusion: Pre-emptive swallowing stimulation during intubation assists in the recovery of swallowing function in long-term intubated patients.

Background: Goal-directed training is an activity-based approach to therapy. Meaningful, client-selected goals are used to provide opportunities for problem solving and to indirectly drive the movements required to successfully meet the task demands. This is in contrast to interventions that focus on changing body functions. Here, the principles of goal-directed training will be studied through two case studies with the aim of linking theories of treatment to clinical practice.

Principles illustrated: The approach is based on the dynamic systems motor control theory and occupation-based therapy models, which suggest that movement patterns emerge from the interaction between the person's abilities, environment and the goal. Motor learning principles are applied to structure and schedule practice.

Theory in practice: Four components provide the basis for goal-directed training: (1) selection of a meaningful goal; (2) analysis of baseline performance; (3) intervention/ practice regime; and (4) evaluation of outcome. Two individuals with acquired brain injury practised self-care tasks: eating and tying hair into a ponytail. Intensive training was undertaken over four weeks and the intervention outcome measured using the Goal Attainment Scale.

Conclusions: The positive achievements in the self-care tasks illustrated that theories of motor control and motor learning can be applied to goal-directed training. The examples demonstrated that the approach could be applied to individuals with a range of abilities.

Objective: To describe the development of the Adelaide Driving Self-Efficacy Scale (ADSES) and to report on its reliability and validity.

Methods: A set of 12 driving behaviours, developed through literature review, clinical experience and expert review, were rated for self-efficacy using a Likert scale. Internal consistency was investigated using a Cronbach's alpha coefficient and construct validity by comparing ADSES scores of stroke and non-stroke drivers. Criterion-related validity was examined by comparing ADSES scores with the result on a standardized on-road assessment.

Setting: A rehabilitation hospital in Adelaide, South Australia.

Participants: Staff from the hospital and stroke patients from the rehabilitation unit. Data from a non-stroke sample (n -/ 79) and stroke patients (n -/ 81) were used to test internal consistency and construct validity. A separate group of 45 people recommended for a driving assessment, of whom 34 were stroke patients, were used to test criterion validity.

Results: Cronbach's alpha coefficient was 0.98, indicating high internal consistency. The non-stroke and stroke groups showed significant differences in ADSES scores (t(158)-/ 5.5, P B < 0.05), demonstrating construct validity. Differences in ADSES scores for those participants who passed or failed the on-road assessment were significant for both the entire driving assessment group (t(43)-/ 3.2, P B < 0.05) and the stroke subgroup (t(43)-/ 3.2, P B < 0.05), indicating criterion validity.

Conclusion: The ADSES has demonstrated internal consistency and construct validity with the stroke and non-stroke population. The scale demonstrated criterion validity in its relationship with outcome of an on-road driving assessment. It appears to be a reliable and valid measure of driving self-efficacy.

Objective: In the present study we aim to assess the reliability and validity of the 20-item version of the Dutch Measure of Processes of Care (MPOC).

Design: The reliability, concurrent validity, predictive validity and construct validity of the Dutch MPOC-20 were determined. A subset of MPOC-20 data was extracted from a large Dutch MPOC (56-item version) database.

Subjects: Participants were 405 mothers and 22 fathers of children aged 1-18 years recruited through nine paediatric rehabilitation centres in the Netherlands.

Main measures: The participants filled out the MPOC-20 items, the Client Satisfaction Questionnaire (CSQ), and two additional questions about satisfaction with services and the amount of stress they experienced.

Results: The internal consistency analyses (alphas 0.75-0.87) and the test-retest analyses (intraclass correlation coefficients (ICCs) 0.78-0.91) showed that the Dutch MPOC-20 is a reliable tool. The concurrent validity of the Dutch MPOC-20 was confirmed by positive correlations between MPOC-20 scale scores and the CSQ (r 0.39-0.69), and between MPOC-20 scale scores and an overall satisfaction variable (r 0.37-0.66). The predictive validity of the Dutch MPOC-20 was supported by moderately negative correlations between MPOC-20 scores and a stress variable (r -0.27 to -0.44). The construct validity of the Dutch MPOC-20 was confirmed by significant scale intercorrelations (r 0.41-0.84) and a factor analysis.

Conclusions: The 20-item version of the MPOC (Dutch MPOC-20) is a reliable and valid measure of the family-centredness of paediatric rehabilitation.

Objective: To assess the capacity of the Biodex Stability System using a one-leg stance protocol to differentiate between injured and non-injured limbs and between level of disabilities.

Design: Cross-sectional study.

Setting: Military and civilian clinic.

Subjects: Thirty-four individuals with a second-degree lateral ankle sprain and 36 healthy subjects.

Methods and measures: Subjects were tested on the Stability System 30 days after injury using a one-leg stance protocol in the dynamic limit-of-stability mode. All subjects also filled out a disability questionnaire (Lower Extremity Functional Scale). The groups were compared based on the overall dynamic limit-of-stability score and its relationship with the score on the disability questionnaire was also examined.

Results: The overall dynamic limit-of-stability scores (subjects with a lateral ankle sprain: 13.0% (5.5)-26.0% (9.2); healthy subjects: 16.9% (7.9)-27.9% (9.6)) clustered in the lower end of the theoretical range of 0–100%. Statistically significant differences in the overall dynamic limit-of-stability scores were found between the injured and non-injured limbs but group differences were small and clinically not relevant. No significant relationships were found between the overall dynamic limit-of-stability scores and the Lower Extremity Functional Scale scores (58.2 (11.8)) of the subjects with a lateral ankle sprain.

Conclusions: The one-leg stance protocol carried out in the dynamic limit-of-stability mode is very challenging and offers a very limited capacity to differentiate between injured and non-injured limbs. The main outcome of the Stability System does not appear to be a good indicator of the functional capacity of people with a lateral ankle sprain.

Objective: Difficult behaviours are significant contributors to the distress experienced by carers of people with a traumatic brain injury. This study investigated whether the beliefs carers hold about such behaviours also contribute to the distress.

Design: Questionnaire survey.

Participants: Forty family carers recruited from Headway, a traumatic brain injury support organization.

Main measures: Zung's Self-Rating Depression Scale, Perceived Stress Scale, Social Support Questionnaire, a measure of the severity of difficult behaviours shown by the person cared for and two measures of carer beliefs about the behaviour (including the Controlling Beliefs Scale).

Results: Higher depression and stress scores were associated with more severe behaviours and less social support. Carer belief in their own ability to control the behaviours was associated with less stress. Belief that the behaviour was under the control of the person with traumatic brain injury and/or was motivated by hostile intentions was associated with more depression but less stress. Taken together, severity of behaviour and social support accounted for about 19% of the variance in both depression and stress scores. Carer beliefs accounted for another 5% of the depression scores, and another 11% of the stress scores.

Conclusions: The results were consistent with the idea that carer beliefs about difficult behaviour contribute to carer distress, but longitudinal and treatment studies are needed to establish causality.

Objective: To assess and describe life satisfaction in individuals with spinal cord injury (SCI) with regard to pain.

Design: A cross-sectional descriptive study of self-reported life satisfaction in individuals with SCI, with and without pain.

Setting: Spinal outpatient clinic.

Subjects: Two hundred and thirty patients with SCI were mailed a questionnaire.

Interventions: Mailed survey.

Main measures: Ratings of pain intensity, pain unpleasantness, mood, and life satisfaction (LiSat-9).

Results: In total 191 (83%) of the questionnaires were returned and analysed. Patients with pain experienced lower life satisfaction compared with individuals who were pain free. Continuous pain interfered to a greater extent than did intermittent pain. In logistic regression analysis the univariate relationship between pain and low life satisfaction was removed. Predictive for lower scores of life satisfaction were higher ratings of mood disorders.

Conclusion: Life satisfaction is negatively affected in patients with SCI and pain compared to patients with SCI but without pain. Higher levels of anxiety and depression seem to be predictive for this decreased life satisfaction.