1999 ACRM 76th Annual Meeting Abstracts

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1999 ACRM 76th Annual Meeting Abstracts Published here are the abstracts of papers and posters to be presented at the 76th Annual Meeting of the American Congress of Rehabilitation Medicine (ACRM), which will take place October 14-17, 1999, in Orlando, FL. Papers and posters were selected by ACRM's 1999 Program Committee after all submitted abstracts were reviewed and rated by members of the committee. They are grouped here into subject areas. The abstracts have not been subjected to the customary peer review by the Archives of Physical Medicine and Rehabilitation Editorial Board.

Papers The following are abstracts" of papers that will be offered concurrently on Friday, October 15, 1999, 11:15 am-12:15 pro.

Brain Injury "Time Trends in Brain Injury: Primary Rehabilitation Outcomes from 1994 through 1997o" Richard T. Linn, PhD (SUNY at Buffalo, Buffalo, NY); Carl V. Granger, MD; Sam Markello, PhD. The Uniform Data System for Medical Rehabilitation (UDSMR) has processed and reported on national rehabilitation outcomes data for more than 10 years. In the current study, we present trending data derived from UDSMR across a 4-year span (1994-1997) for individuals with brain injury in their first rehabilitation admission, including those with traumatic and nontraumatic brain injury. Primary outcomes analyzed for trends include time from illness onset to rehabilitation admission, length of rehabilitation stay (LOS), functional gain, functional gain per day of rehabilitation, and discharge placement. Results are reported on sample sizes of n = 9,825 (1994), n = 9,631 (1995), n = 14,606 (1996), and n = 16,409 (1997). Trend analyses were performed separately for individuals with traumatic brain injury, anoxia, and encephalitis. In general, time since onset to rehabilitation has diminished, LOS has shortened, functional gain has remained stable, functional gain per day of rehabilitation has increased, and numbers of individuals discharged to the community has remained stable. These results are discussed in terms of general trends in rehabilitation practices and outcomes, while highlighting differences among impairment groups.

"Development of the Community Balance and Mobility Scale for Clients With Traumatic Brain Injury." E. Inness, PT (University of Toronto, Toronto); J. Howe, PT; M.C. Verrier, DipP, OT; J.I. Williams, PhD. Present measures of balance are inadequate to assess the wide range of motor behaviors necessary for individuals integrating into the community after sustaining a mild to moderate TBI. The research goal is to develop a performance-based balance and mobility measure to evaluate these complex higher level skills. The Community Balance and Mobility Scale (CB&M) consists of 13 items each rated with a 6-point scale. Testing the metric properties of the CB&M involved 37 patients and 13 physical therapists (PTs) from eight facilities along the continuum of care. The total mean scores of the patients in the range of care settings were significantly different, indicating the test discriminates among patients at various stages in their rehabilitation. Initial test-retest reliability indicates a high agreement between tests with an intraclass correlation coefficient of .975 (95% confidence interval .810, .991). Internal consistency among the items is very high (Cronbach's alpha .96) and, with the exception of one item, the product moment Arch Phys Med Rehabil Vol 80, August 1999

correlation matrix demonstrates that the items reflect one underlying dimension. The ratings of the relevance of the items in measuring balance, as evaluated by the PTs, indicates good acceptance, particularly for those items that are closely related to functional tasks. In the first phase of testing, the CB&M is demonstrating the necessary properties required for a clinical measure.

"Incidence and Severity of Postconcussive Symptoms During Acute Inpatient Brain Injury Rehabilitation." Kathleen Kalmar, PhD (JFK Johnson Rehabilitation Institute, Edison, N J); Joseph T. Giacino, PhD; Keith D. Cicerone, PhD, ABPP. Little research is currently available concerning the subjective complaints of patients undergoing inpatient rehabilitation during the acute phase of recovery following brain injury. Prior studies have focused largely on postacute complaints in this population. We compared the frequency and severity of neurocognitive complaints in patients (n = 18) undergoing acute inpatient brain injury rehabilitation (IBI) with a sample of patients (n = 50) diagnosed with persistent postconcussive complaints (MTBI) and a third group (n = 57) of normal controls (NC). We hypothesized that the IBI group would report more frequent and more severe symptoms relative to the nonhospitalized MTBI and NC groups. Statistical analyses revealed significant differences (p < .025) among the three groups on both incidence and severity on all of but one symptom (change in appetite). Although this difference was primarily accounted for by the heightened complaints in the MTBI group (p < .012), there was no difference in the incidence or severity of complaints between the IBI and NC groups despite neuropsychometric evidence of neurocognitive impairment in the fBI group. It is not clear if the apparent underreporting of symptoms in the IBI group reflects neurologic or psychological factors, but represents a likely confound to the rehabilitation process.

Stroke "Predicting Discharge Motor FIM from Admission Data: Comparison of Regression Analysis, Classification and Regression Trees and Artificial Neural Network Models." Deborah K.W. Waiters (SUNY at Buffalo, Buffalo, NY); Richard T. Linn, PhD; Margaret Kulas; Elizabeth Cuddihy, AMS; Carl Granger, MD. One objective of this research was to predict the discharge level of motor function of stroke patients based upon data collected at their admission to a rehabilitation facility. Another objective was to compare the performance and cost of three different modeling techniques for this

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prediction: regression analysis (RA), classification and regression trees (CART), and artificial neural networks (ANN). Data records were obtained from Uniform Data System for Medical Rehabilitation (UDSMR) for over 65,000 first-admission stroke patients who were discharged from rehabilitation facilities in 1995. Each of the three modeling techniques was applied to the data to predict the Motor FIM score of the patient upon discharge. It was found that only three of the admission variables were relevant in predicting the discharge Motor FIM: admission Motor FIM score, age, and admission Cognitive FIM score. Although the models had high R 2 values, the overall prediction accuracy of the models was less than 50% for predicting discharge FIM scores within +_5 points. The RA model was least costly, but least effective. The A N N model was most costly, but most effective. The CART model was significantly less costly than the ANN model and was almost as effective.

"Improving Outcomes in Stroke Rehabilitation." Bill Shuart, PhD (Madonna Rehabilitation Hospital, Lincoln, NE); Paul A. Dongilli Jr., PhD; Mark Hakel, PhD. Improvement of rehabilitation services is directly dependent on identification and use of outcome measures that are both reliable and valid. We have been interested in our facility in establishing an empirically validated system for measuring and improving our outcomes. This presentation will provide an overview of studies recently conducted in our hospital that focus on improving the rate of discharge home for stroke patients. Using retrospective review and correlational techniques, we subjected random samples of discharged stroke patients' medical records to thorough analysis. Findings with respect to the association of Functional Independence Measure (FIM) data with community discharge data confirm that the FIM is indeed a reliable and valid measure for this population. We then turned to identification of treatment variables most likely associated with producing the functional outcomes reflected in the FIM scores. We found, using independent samples and correlational analysis, that the amount or intensity of treatment provided (controlling for length of stay) was directly and positively related to the likelihood of community discharge. These findings are important in the context of today's health care climate, which is increasingly driven by empirical evidence of treatment efficacy. In conclusion, further key areas requiring research are discussed.

"Effects of Stroke on the Family and Evidence for Family Interventions Post Stroke." Nicol Korner-Bitensky, PhD (Jewish Rehabilitation Hospital, Laval, Quebec). Rapid discharge of clients with stroke means that they often return home with disabilities that impact negatively on family life. Indeed, there is evidence that those with stroke frequently fail to remain in the community, ending up in long term care facilities. This presentation will include a comprehensive review of (1) evidence regarding the mental and physical health impact of stroke on family members and factors that reduce the impact, and (2) what is known regarding provision of evidence based interventions to the family. Finally, specific measurement tools and actions clinicians can take will be discussed.

Musculoskeletal "Patient Education for Total Knee Arthroplasty: A Comparison of Four Education Methods." Deanna Melnyk, PT (Mount Sinai Hospital, Toronto); David Backstein; Gilbert Yee, MD; Carol Hutchison, MD. Introduction: Patients are often unaware of what is expected of them postoperatively. A high level of anxiety, fear, pain, and medication

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makes it difficult to learn postoperative exercises for the first time. It is important that effective and cost efficient methods are used. Methods: Eighty patients undergoing total knee arthroplasty (TKA) were randomized into 4 groups. Each group either viewed a videotape, received group teaching by a physiotherapist, individualized teaching, or was seen postoperatively. All groups were presented with an instructional booklet. Results: Patients who received personal contact with a physiotherapist in the preadmission clinic felt more adequately prepared for an independent recovery, had greater confidence, and had less fear about their ability to perform the exercises. Those who had individualized teaching also felt they had a greater understanding of what was expected of them postoperatively. Patient satisfaction was no different between group and individualized teaching. There was no difference between groups in the amount of physiotherapy treatment time. Conclusion: Physiotherapy group teaching in the preadmission clinic has a positive impact on patient recovery after TKA and is more cost effective than individualized teaching. Written material and videotape are not as effective as direct contact with a physiotherapist.

"Analgesia Following Total Knee Arthroplastyo" Deanna Melnyk, BSc (PT) (Mount Sinai Hospital, Toronto); Cristina Zanchetta, BSc (Phm); Kenny Tam, BN. Introduction: Analgesia is important in the acute stage of recovery from a total knee arthroplasty (TKA). The lumbar plexus block (LPB) is an alternative method of pain control that attempts to lessen unfavorable side effects by minimizing opioid use. However, the use of the LPB as a superior and exclusive method of analgesia following TKA needs to be justified. Methods: A retrospective chart review of 46 patients was undertaken to compare opioid use among patients with and without a LPB in the first 72 hours following TKA. The amount of range of motion (ROM) achieved among the two groups was also compared. Results: We found no statistically significant difference in total opioid use between patients who received a LPB and those who did not, regardless of concomitant nonsteroidal anti-inflammatory drug (NSAID) use. In terms of the rate of progression with ROM, there was no statistically significant difference in the degree of knee flexion reached in either group of patients in the early stages of recovery or at follow up. Conclusion: Our data suggests that the aim of the LPB in reducing opioid use is not met during the 72 hours of the acute rehabilitation phase of recovery.

"Painful Neck Movement in Spondylosis Versus Myofascial Pain Syndrome, An Additional Differentiating Sign." Tarek S. Shafshak, MD (Alexandria University Faculty of Medicine, Alexandria, Egypt); Wahid L. Ali, MD. Cervical spondylosis (CS) and myofascial pain syndrome (MPS) are common causes of neck pain in adults, but are managed differently. This study assessed painful neck movement (PNM) in CS versus MPS. A group of 50 patients with PNM due to MPS, and a second group of 60 patients with PNM attributed to CS were included. Pain severity was assessed using a numerical rating scale in a double-blind way during neck flexion, extension, rotation and lateral flexion to both sides. Also, the most painful movement (MPM) was determined subjectively. Flexion and extension scores, but not rotation and lateral flexion scores were significantly different between groups. Flexion scores were higher in the MPS group, while extension scores were higher in the CS group (p < .001). Neck extension was the MPM in 42 (70%) CS patients. However, neck flexion was the MPM in 33 (66%) MPS patients. Neck extension was more painful than flexion in 54 (90%) patients with CS, but neck flexion was more painful than extension in 43 (86%) patients with MPS (p < .01). It was concluded that the relative pain severity during neck flexion versus extension could be an additional differentiating criterion between CS and MPS.

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The following are abstracts of papers that will be offered concurrently on Saturday, October 16, 1999, 1:30-2:30pm.

Measures "Measurement Properties of Visual Analog Scales." Richard M. Smith, PhD (Rehabilitation Foundation, Inc., Wheaton, IL); Karon E Cook, PhD. The frequency of use of visual analog scales (VAS) to gather self-reported data on functional status and quality of life is increasing steadily. The exact measurement properties of these scales, ordinal, interval or ratio, have been called into question. Many authors treat VAS data as interval. However, recent Rasch analysis of VAS data suggest that these data may be ordinal at best. The determination of the appropriateness of the Rasch model to determine if VAS data are interval has not been established. The purpose of this paper is to evaluate the appropriateness of the Rasch model to evaluate the interval nature of VAS data. This was accomplished through the use of simulated and real data (Shoulder Pain and Disability Index). The data simulations used a construct of a variety of person distributions ranging from normal, skewed, and rectangular. The data were then collapsed into 10 category rating scales and analyzed with the Rasch rating scale model. These results suggest that the determination of the interval nature of the data through the use of step thresholds may be inappropriately influenced by the distribution of the person parameter. The analysis of the real VAS indicates that, although the person distributions fall within the range of those that simulations suggested were appropriate for analysis, the person use of the scales resulted in non-interval data.

"Rehabilitation at Risk: Can Practicing Therapists Develop Outcome Measures to Demonstrate the Effectiveness of Rehabilita. tion?" Catherine M. Pittman, PhD (Memorial Hospital, South Bend, IN); Margaret Sak, OTR. Introduction: Rehabilitation is under scrutiny and at risk. Practitioners are in an optimal position to identify functional outcomes and thereby provide the strongest evidence of the value of rehabilitation. We developed an interdisciplinary functional outcome assessment for an outpatient neurological rehabilitation program. We utilized input from patients to validate the relevance of the measures in daily life. We investigated whether length and type of treatment predicted outcome. Methods: Fifty-four individuals treated in the program during 1996 were assessed with a 13-item structured clinical interview at intake, at discharge, and at 90-day follow up. Change scores were calculated for each subject by subtracting summary scores for the intake assessment from the discharge summary scores, as well as from the follow-up summary scores. Results/Conclusions: MANOVA on the scores obtained at intake, discharge, and follow up revealed a significant effect for the within-subjects factor of time of assessment. Univariate ANOVAs showed scores increased from intake to discharge, and were maintained at follow up. Also, even when controlling for length of time, a greater number of occupational therapy visits was associated with greater discharge change scores, as well as greater follow-up change scores.

"Measuring Community Integration and Quality of Life of Adults With Spinal Cord Injury." Kathryn A. Boschen, Phi) (University of Toronto, Toronto); Mark Tonack, MA; Judy Gargaro, IVIEd. The purpose of this 2-year study was to examine various factors influencing community integration, independent living, and quality of life of people with spinal cord injury (SCI), and to identify consumergenerated proposals for change in rehabilitation service provision which may assist these individuals in attaining higher levels of re-integration, productivity, and life satisfaction. The research design contained 2 phases: a quantitative questionnaire data-collection phase (n = 100) and a subsequent qualitative consumer focus group session phase (n = 48). The sample consisted of community-residing male and female adults with SCI, of any age, who were 1 to 5 years post-

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rehabilitation discharge and not currently involved in active inpatient rehabilitation. Participants were randomly recruited from the research database of a large urban SCI rehabilitation center. The questionnaire included instruments measuring life activities, productivity, community integration, locus of control, environmental barriers/facilitators, and quality of life. Six small focus groups were used for consumers to interpret and draw recommendations from the questionnaire results. The results provided evidence that people with SCI who demonstrate greater capability in life activities, who have greater internal locus of control, and who live in more facilitating environmental circumstances have a higher degree of community re-integration and quality of life than those lacking these attributes.

Stroke "Using Visual-Perception Testing to Screen for Readiness to Drive After a Stroke: A Multicenter Study." Nicol A. Kormer-Bitensky, PhD (Jewish Rehabilitation Hospital, Lava/, Quebec); Barbara L. Mazer, MSc; Susan Sofer, BSc; Isabelle Grlinas, PhD; Mary Beth Meyer, OTR; Carol Morrison; Linda Tritch; Mary Ann Roelke; Marie White. Rationale: Increasingly, health professionals are called upon to make decisions regarding fitness to drive after a neurological event. It is not feasible to perform an extensive on-road assessment of each client. Rather, it behooves us to find a quick screening process for use in everyday practice. Objective: This validation study was designed to deterl~ne the ability of a widely used visual-perception assessment tool, the Motor Free Visual Perception Test (MVPT), to predict on-road driving outcome in subjects with stroke. Previous research in a single center suggested that of nine tools evaluated, this tool was the most predictive of on-road performance. Study Design: 269 individuals with stroke completed visual-perception testing and on-road evaluation in six evaluation sites in North America. Results: Using a dichotomized score on the MVPT to classify good versus poor visual-perception, the positive predictive value of the MVPT in identifying those who would fail the onroad test was 60.9% (n = 67/110). Conclusion: The predictive validity of the MVPT was not sufficiently high to recommend its use as the sole screening tool. Newly developed tools that demand more complex-visual perception and cognitive abilities are currently being tested and will be discussed.

"Recovery of Walking after Stroke." Sara J. Mulroy, Phi), PT (Rancho Los Amigos Medical Center, Downey, CA); JoAnne K. Gronley, DPT; Jacquelin Perry, MD; Walter B. Weiss, MPT; Craig J. Newsam, MPT. The purpose of this study was to document walking recovery following stroke. Forty-six patients were tested at admission to rehabilitation, discharge, and 6 months poststroke. Stride characteristics and lower extremity kinematics were recorded while patients walked l0 meters. Changes in patient performance were calculated. Kinematic parameters that best predicted stride characteristics were identified with stepwise regression. Velocity increased from 14.4m/min at admission to 22.5m/ min at discharge and 30.9m/rain (39% normal) at 6 months. Initially, most patients displayed either knee hyperextension with inadequate ankle dorsiflexion in stance (25%) or excessive flexion at both joints (47%). At discharge and 6 months fewer patients had inadequate dorsiflexion or excessive knee flexion. Thigh extension in terminal stance was decreased at admission and discharge (2.9 ° and 4.0 ° extension) but improved at 6 months (9 ° extension). Although average peak knee flexion in swing remained unchanged (40°), 6 patients displayed markedly decreased knee flexion (20.5 °) at 6 months. Terminal stance thigh extension was the strongest predictor of velocity at admission and discharge and of stride length at all three tests (r = -.58 to -.74). Peak swing knee flexion was the best predictor of velocity and cadence at 6 months (r = .71). Improved ankle and knee postures

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resulted in increased thigh extension which contributed to velocity and stride length gains. Late development of a stiff-legged gait impeded walking recovery in 22% of patients.

population. Further studies are necessary to clarify whether these differences in the SCI populations were due to lack of physical activity in these individuals.

"Trial of an Alternating Pressure Wheelchair Cushion for the Reduction of Seating Pressure." Lyn Weiss MD (Nassau County Medical Center, East Meadow, NY); Arthur Ezra PhD; Mehendra Shah, MS; Lee Jacknow, MS.

"Nutritional Status and Pressure Ulcer Prevalence in Persons with Chronic Spinal Cord Injury Living in the Community." Gladys P. Rodriguez, PhD (Baylor College of Medicine, Houston); Hector M. Garza, BS; Susan G. Eisele, BS.

The purpose of this study is to determine the effectiveness of a new technology that will reduce seating pressures and therefore, ultimately reduce the risk of decubiti. The new technology is an alternating pressure wheelchair cushion consisting of six slats that individually and progressively raise and lower in order to decrease capillary pressure under the slat. Methods: Fifteen able-bodied individuals were tested on four types of seating systems (RoHo cushion, IshDish cushion, Jay cushion and standard wheelchair without a cushion) as well as the alternating pressure wheelchair cushion. Pressure measurements were taken using a TekScan pressure sensing mat. Static and dynamic pressures were recorded. Results: The alternating pressure cushion was able to significantly lower the seating pressure under the ischial tuberosities more than the other wheelchair cushions. In most cases, the pressure reduction was close to 32mmHg, the standard capillary refilling pressure. Results with the other cushions varied between subjects, with some cushions offering more relief than others, depending on the particular subject. The average peak pressure using the RoHo cushion was 123.46mmHg, ll0.6mmHg for the Jay cushion, 120.27mmHg for the Ishdish, and 169.76mmHg for no cushion. Using the alternating pressure relief cushion, the average peak pressure with the slat down was 41.96mmHg. Four subjects had pressure readings below 32mmHg. The results of this trial encouraged the investigators to pursue further testing of disabled subjects and to develop an alternating pressure cushion that could be used in a standard wheelchair.

Spinal Cord "Serum Cholesterol and Lipoproteins in Chronic and Acute Spinal Cord Injury Persons." Mahtash Moussavi, PhD (Baylor College of Medicine, Houston); Francisca Ribas-Cardus, MS; Gladys Rodriguez, PhD. We measured serum cholesterol, high density lipoproteins (HDL), low density lipoproteins (LDL), and triglycerides in chronic and acute spinal cord injury (SCI) population to determine if fat and cholesterol intake and duration of injury affects serum levels of these chemicals. Serum cholesterol, HDL, LDL and triglycerides were measured in 10 chronic (2.4 to 47.0 years postinjury) and 28 acute (0.5 to 1.2 years postinjury) men with SCI using standard laboratory techniques. The fat and cholesterol intake was determined from the written three-day food records using a computer program developed by the School of Public Health. Descriptive statistics was used to analyze the data. The results indicated that the serum cholesterol, HDL and triglyceride were significantly (.002 < p < 001), higher in chronic SCI compared to acute ones. In contrast, dietary intake of cholesterol, fat and saturated fat were significantly (p < .001), lower in chronic SCI than the acute ones. The serum cholesterol and lipoproteins were lower in both chronic and acute SCI compared to reference values for the able-bodied

A sample of 155 persons with SCI of more than two years duration was surveyed to ascertain their nutritional status. Thirty-three of the subjects had a pressure ulcer. The nutritional indices measured were body mass index (BMI), transferrin (TRAN), serum albumin (ALB), lymphocyte count (LYMPH) and creatinine height index (CHI). Mean values of TRAN were lower in persons with ulcers than in persons without ulcers. Only 10 of the subjects with ulcers had TRAN values above 200, the lower limit of normal in the able-bodied population. Nineteen of the subjects with ulcers had LYMPH of less than 1800, an indication of mild immune compromise. Only two of the subjects with ulcers had CHI values in the normal able-bodied range. There was no significant difference in the values of BMI and ALB of persons with ulcers compared to those without ulcers. Results of this survey could influence the way in which nutrition is monitored in persons with pressure ulcers, and affect the design of nutritional interventions. Duplicating this survey with a larger sample, to include more subjects with ulcers, would make it possible to analyze the interaction of ulcer stage and time since ulcer appearance with nutritional indices.

"A Simple Approach to Increasing Affected Muscle Size Within a Year of Clinically Complete Spinal Cord Injury." G. Dudley, PhD (University of Georgia, Athens, GA); M. Castro, PhD; S. Rogers, PT; D. Apple, Jr., MD. Three adult males with clinically complete spinal cord injury (SCI), who were part of a larger project (Castro and colleagues. J Appl Physiol 1999:86:350-8), participated in this pilot project. We tested the hypothesis that affected skeletal muscle within a year of injury would be responsive to intermittent high force loading by showing an increase in size. Surface electrical stimulation conditioning of the left m. quadriceps femoris started 11 months after SCI, was done 2 days per week at the subject's home and lasted 8 weeks. For each session, four sets of 10 contractions were evoked using 30Hz trains with a 5s/5s work/rest ratio and 3 minutes of rest between sets. Two subjects performed knee extensions with weight attached to the ankle. The other performed isometric actions. Stimulation current was increased over the course of conditioning to evoke greater isometric torque, 67Nm or more, or increase the load used for full knee extension, up to ll.5kg. Magnetic resonance imaging of the thighs was done 1.5, 6, 11, and 13 months after injury to assess muscle size. Average cross-sectional area of m. quadriceps femoris declined (p < .05) 16% --2 % (mean -+SE) from 1.5 to 6 months postinjury. It showed a further 3 % decrease by 11 months after SCI. Conditioning evoked a 20% _+ 1 % increase (p < .05) in size of m. quadriceps femoris. The results suggest that affected skeletal muscle is extremely responsive to intermittent high force loading within a year of SCI. Such conditioning was sufficient to reverse the atrophy evident from 1.5 to 13 months after SCI.

The following are abstracts of papers that will be offered concurrently on Sunday, October 17, 1999, 10:15-11:15 am.

Brain Injury "Effect of Increased Intervention on Community Integration at Discharge from Hospital and One Year Later." D. L. McLellan, PhD (University of Southampton, Southampton, United Kingdom); A. Shiel, COT; B. A. Wilson, PhD; J.ES. Burns, DM; D. Henry, COT; J. Clark. Anecdotally there is a belief that increased intervention leads to better outcome but there is little empirical evidence to support this notion.

The aim of the study was to evaluate the impact of increasing rehabilitation input on outcome at discharge and one year later. A detailed prospective study of 60 adults recovering from traumatic brain injury (n = 52) or diffuse brain injury (hypoxia, encephalitis, or subarachnoid hemorrhage) (n = 8) was undertaken. An additional experienced rehabilitation professional was assigned to each of the two teams. Patients were randomised to receive routine treatment or routine treatment augmented by input from the additional staff member.

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Outcome was assessed in terms of functional, cognitive and psychosocial status. Community Integration was evaluated using the community Integration Questionnaire (CIQ). Patients receiving extra treatment were discharged home significantly earlier (p < .001). There were no significant differences between the groups on the CIQ at discharge but one year later, the group who received the most intensive treatment had significantly higher Home Integration scores (w= 144, p < .01). The same group also made significantly greater gains in Social Integration over the first year ( W = 66, p < .05). There were no differences between the groups on Productivity. The results suggest that subjects receiving more intensive treatment achieve greater Home and Social Integration in the first year after discharge.

"A Comparison of Needs, Coping Strategies, and Emotional Distress Between Family Members of Persons with Traumatic Brain Injury and Spinal Cord Injury." Angelle M. Sander, PhD (Baylor College of Medicine, Houston); Kim Robinson, MA; Jeffrey S. Kreutzer, PhD; Walter M. High, PhD; Daniel E. Graves, MEd; Jennifer Marwitz, MA. Previous research has documented high levels of emotional distress, unmet needs, and coping difficulties among family members of persons with TBI. However, conclusions have been limited by a lack of appropriate control groups. The current study was designed to compare family needs, coping strategies, and emotional distress between family members of persons with TBI and those of persons with SCI. Participants were 90 family members (62 TBI; 28 SCI) evaluated at 1 to 2 years following injury. The groups were equivalent with respect to age, education, and relationship to the injured person. However, there were more minority and lower income family members among the SCI group. After controlling for race and income, higher levels of anxiety and physical complaints were evident for TBI family members. TBI family members also showed more unmet needs in the area of community support. Regarding coping strategies, SCI family members used more positive reappraisal and escape avoidance. For TBI family members, the number of unmet needs and emotion-focused coping strategies were positively correlated with emotional distress. The results indicate that family members of persons with TBI and SCI respond to the traumatic event in similar ways, with both experiencing substantial levels of distress. However, TBI family members show greater distress and unmet needs in certain areas, which is likely attributable to the greater cognitive and behavioral deficits.

"Developing a Common Cognitive Scale for PECS and FIM." Richard M. Smith, Phi) (Rehabilitation Foundation, Inc., Wheaton, IL); Patricia A. Taylor, Dr PH. The co-calibration of existing functional outcome scales into common metrics that transcend the particulars of a given outcome system is primary to the development of universal scales. To that end this study investigates the similarity of structure of the 14 item PECS TM Cognition and Communication LifeScale and the 5 item FIM TM Cognitive subset. The complete set of items from both scales were administered to consecutive admissions to a freestanding acute rehabilitation hospital over a two month period. All diagnostic groups were included except pain and pediatric patients. The Rasch partial credit model was used to analyze the data. Supplemental principal component analysis was used to assist in the determination of the dimensionality of the data as unidimensionality is a requirement for the use of the family of Rasch models. A total of 415 patients were included in the study. The results indicated that the combined scale was unidimensional, with acceptable reliability (Pearson separation reliability > .90). There were several misfitting items, however, subsequent analysis of the residuals indicated that the misfit was the result of a relatively few individuals, less than 10% of those persons analyzed. There was also a high concordance between the ordering of similar items on the common metric. The resulting raw score to standard score conversion tables allow the measuresfrom either scale to be compared, further promoting the transparency of the instruments in the collection of cognitive outcome rehabilitation.

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Miscellaneous Topics "The Influence of Media on the Quality of Life of Disabled Children in China." Ping Nan, MS (Tongji Hospital, Wuhan, Hubei, People's Republic of China). Old fashioned thoughts are still strong in Chinese society. In rural areas, where disability may be due to marriage of blood-related partners or iodine deficiency, disabled children are regarded as punishment from God. Sixty-six percent of them live in a neglected, prejudiced, and negative state. In the cities, however, the situation had been improved much. Only 47% of disabled children live in a negative state; therefore, their quality of life is much higher. According to the results of a 6-year research, the media, which covers a greater area in cities than in rural areas, plays an important role in this difference. Media in China has shown great concern to the problems faced by disabled children. Chinese Disabled Monthly and Spring Breeze (a literature journal edited by CEPF) are special media. Under the Same Blue Sky is also a special TV program. An investigation shows that 49% of ordinary people are aware of the problems of the disabled through media, a higher percentage than through school education (31%) or personal contact (20%). The results of this research are inspiring. Disabled children's confidence and adaptability are 37% higher after contacting relevant media, and people's understanding of and sympathy for disabled children are 46% higher.

"Postpolio Syndrome in Persons With a History of Very Mild or Nonparalytic Poliomyelitis." Lauro Halstead, MD (National Rehabilitation Hospital, Washington, DC); Julie K. Silver, MD. Historically, acute poliomyelitis has been divided into two clinical entities, paralytic and nonparalytic. With the renewed interest in the late effects of polio, however, it has become clear that some individuals diagnosed with "nonparalytic" polio sustained variable damage to the central nervous system (CNS) and, in some instances, enough to later develop postpolio syndrome (PPS). Although the diagnosis of PPS requires a remote history of paralytic polio, many persons with typical symptoms of PPS have no clear history of paralytic disease and are being misdiagnosed. We describe three cases of PPS with a typical history, physical examination and electrodiagnostic evidence of extensive anterior horn cell disease. Two of the three had a brief febrile illness during childhood in the polio season. None was hospitalized nor given a specific diagnosis. All three had active childhoods and worked full time as adults. The onset of intense fatigue and new weakness occurred a mean of 41 and 46 years after polio, respectively. We describe the putative pathophysiology of PPS in persons with a history of "nonparalytic" polio and the diagnostic implications for individuals over 40 years of age who are experiencing unexplained new weakness, fatigue, and muscle or joint pain.

"Evaluating Amputee Rehabilitation Program Effectiveness: A Comparison of Two Methods." Jan Walker, MSc, (West Park Hospital, Toronto); Mark Tonack, MA; Mike Devlin, MD; Jane Turner, RN, BSc; Desa Marin BAA. The purpose of this study was to evaluate the effectiveness of an inpatient amputee rehabilitation program. Study participants included all new admissions over a 12-month period. Primary outcomes included the SF36 and the 2minute-walk test, recorded pre and post program. The sample consisted of 160 participants; mean age 66 years; 64% male. The first analysis assumed a pre/post single group design. Preprogram and postprogram results were compared. The second analysis assumed a time series design. Subjects were grouped based on admission date. Group 1 was all new admissions in months 1 to 3; group 2 was all new admissions in months 4 to 6, etc. The analysis compared change in outcome over time. Results for the 2minute-walk test were similar between the two methods (average. 12m/sec improvement). Despite small changes in the program, there was no statistically significant change in 2-minute walk over time. Results were similar for dimensions of the SF36. The results of this study help us to quantify the outcome of amputee rehabilitation, and begin to benchmark our performance. This presentation will discuss the outcomes of the study, and the advantages of the two methods of analysis, in particular with respect to program changes over time.

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Spinal C o r d I n j u r y "Correlates of Depression After Spinal Cord Injury." James S. Krause, PhD (Shepherd Center, Atlanta); Bryan Kemp, PhD; Jennifer Coker, BA. Depression is highly prevalent after traumatic spinal cord injury (SCI), yet little research has addressed the relationships between depression and stable traits or subjective aspects of quality of life. This presentation describes the results of a study of the interrelationship between depression and multiple traits and subjective outcomes among a sample of 1,391 individuals with SCI who completed a comprehensive health survey. The Older Adult Health and Mood Indicator (OAHMI) was used to measure depression. Depressed participants scored higher on the Neuroticism-Anxiety and Aggression-Hostility scales of the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) and the Chance and Powerful Others of the Multidimensional Health Locus of Control (MHLC); and lower on the Activity and Sociability scales of the ZKPQ and the Internal scale of the MHLC. With regards to subjective outcomes, depressed participants scored higher on the Negative Affect and Health Problems scales of the Life Situation Questionnaire-revised (LSQ-R), and lower on the Engagement, Career Opportunities, Finances, Living Circumstances, and Interpersonal Relations of the LSQ-R and the overall Purpose in Life scale (PIL). The results of this study suggest that even moderate levels of clinically significant symptomatology may be associated with particular traits and poorer overall outcomes.

"Consumer Strategies for Return to Employment Following Spinal Cord Injury." Mark Tonack, MA, (West Park Hospital, Toronto); Warren Raynard, BA; Ken Lipton, MA. Returning to the workforce following onset of spinal cord injury (SCI) remains an elusive goal for most people living with SCI. The purpose of this research project was to describe "return to employment" experiences of persons living with SCI. This project was qualitative in nature and utilized an emergent research design. Thirty-five people living with SCI in the community that were currently or recently employed participated in the study. A semistructured, face-to-face interview format was utilized for in-depth data collection. Participant

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responses were tape-recorded and transcribed for analysis in NUDIST II (Sage, 1994). Systematic analysis identified major themes and subthemes. The results provided a detailed description of the process of preparing for, seeking, attaining and maintaining employment. Social and environmental barriers and facilitators that accounted for success and/or failure were identified. Common problems and patterns of solutions were utilized to put forward strategies that consistently lead to successful participation in the workforce. The findings of this study will prove beneficial for consumers about to embark on or presently involved in the process of returning to work and will provide meaningful insight to vocational professionals providing services to persons living with SCI.

"Burden Among Caregivers of Spinal Cord Injury Survivors." David Weitzenkamp, BA (Craig Hospital, Englewood, CO); Susan Charlifue, MA; Steven Oberg, LCSW. Previous studies have shown a burden associated with being a caregiver for a spinal cord injury (SCI) survivor. To clarify which characteristics most influence poor outcomes of family members and caregivers of SCI survivors, data from four studies of aging with spinal cord injury were combined. In one of the studies, caregivers were questioned two times, three years apart, to determine whether this burden changes over time. To measure burden, caregivers were asked whether they experienced outcomes such as fatigue, burnout, or physical stress. Caregivers also completed the Center for Epidemiologic Studies Depression Scale and the Perceived Stress Scale. For analysis, subjects were categorized in four ways: whether they provided assistance, whether they were a family member, whether they were paid as a caregiver, and whether they were solely responsible for personal assistance. For the longitudinal study, there were no significant changes in outcomes. Cross-sectionally, those who provided care (paid or unpaid) experienced more physical stress (p < .001), emotional stress (p = .002), more fatigue (p = .001), and more fear for the future (p = .033). Paid caregivers experienced more physical stress (p = .011) and more isolation (p = .010). Spouses experienced more anger (t7 = .046). While the causes of burden are clearly multifaceted, burden appears stable over time and most associated with the act of caregiving.

Posters The following are abstracts of posters that will be offered concurrently on Friday, October 15, 1999, 12:15-2 pm, and 6:30-8pm.

Traumatic Brain Injury "A Randomized, Controlled Study of Declarative and Procedural Memory and Motor Learning in Individuals with Brain Injuries." Stephen J. Page, PhD (Kessler Medical Rehabilitation Research and Education Corporation, West Orange, NJ). It has been suggested that individuals with memory loss can not benefit from some therapies because of difficulty recalling interventions employed from one session to the next. However, case studies report dissociations of declarative and procedural memory which permit implicit skill learning. Using a linear-positioning task, this study compared the implicit motor skill learning abilities of 2 groups of 30 nondisabled volunteers with 2 groups of 30 individuals scoring below the normative means on the digit span and figural memory components of the Weschler Memory Scale Revised (WMS-R) and Mini-Mental Status Exam (MMSE). Depending on their randomly assigned grouping, subjects moved a handle to the right or left a particular distance under blinded conditions. During acquisition trials, no augmented feedback was given; during retention, no augmented feedback was given. In both groupings, subjects with declarative memory losses did not differ from nondisabled subjects in rate of acquisition and mean

absolute movement error (all p values > .2), indicating that the ability to acquire and retain open-loop motor skills is maintained despite declarative memory impairment. The authors encourage therapists to employ therapies that concentrate on direct skill acquisition and encourage researchers to test to what extent this dissociation exists in therapy and activities of daily living.

"Level of Handicap Many Years after Moderate to Severe Traumatic Brain Injury." A. Colantonio, PhD (University of Toronto, Toronto); G. Ratcliff, DPhil; S. Chase, CCC SLP; M. Escobar, PhD. There is a dearth of information on very long-term outcomes after traumatic brain injury (TBI) based on large US civilian populations. The aim of this paper is to provide data on the level of handicap in a large sample of adults, 8-24 years after moderate to severe TBI. The study utilized a retrospective cohort design. Consecutive medical records from a large rehabilitation hospital from 1973 to 1989 were reviewed. Eligible subjects were traced and then invited to participate in a face-to-face interview that included the London Handicap Questionnaire which was used to assess handicap. Data from 282 respondents reported the most handicap in the area of work, leisure and finances and

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less handicap in the areas of socialization and personal care. These items, however, are not often mentioned when respondents are asked what their main problems are in an open-ended question. The implications for rehabilitation and program planning are discussed. In addition, we discuss methodological issues with respect to the reporting of measures of impairment, disability and handicap by TBI survivors.

"Community Participation After TBI: Factors Predicting Return to Work and Life Satisfaction." Kara Sokol, MHSA/MPP (Rehabilitation Institute of Chicago, Chicago); Allen W. Heinemann, PhD; Rita K. Bode, PhD; Jin Yong Shin, PhD; Lyle Van deVenter, MA. The purpose of this study was to identify factors that predict community participation among persons with traumatic brain injury (TBI), as defined by return to full or part-time work, and overall life satisfaction. A total of 895 individuals with TBI responded to a mailed questionnaire as part of a statewide needs assessment. Quality of life was assessed using Diener's Satisfaction with Life Scale (SWLS); raw scores were converted to interval-level measures using Rasch analysis in order to perform parametric statistical analysis. Using multivariate regression, significant predictors of life satisfaction (adjusted R e = .42, p < .05) included a low level of unmet service needs; having a spouse or partner, a perception that TBI changed one's life minimally; completing education beyond high school; self-reported no change for the worse in friendships, employment, and one's living situation; a higher level of psychological well-being since TBI; and greater time since injury. Approaching significance (p < . 10) was having full or part time employment. Using logistic regression analysis, significant predictors of return to work (p < .05) included dependence in at least one ADL, (odds ratio = .51); having a paid job at time of TBI, (OR = 1.25); a perception that TBI changed one's life minimally, (OR = 1.78); and greater age at time of TBI (OR = .95).

"Assessment of Intermanual Visuoconstruction Skills and Rehabilitation of Writing Speed." Shane Bush, PhD (Staten Island University Hospital, Staten Island, NY); Thomas Bundick, PhD. Part one of this two-part study examined intermanual visuoconstruction skills. Clock-drawing tasks are frequently used in the assessment of visuoconstrnction skills. A/though clock drawings are usually performed with the dominant hand, many individuals who have sustained brain injuries have impaired function of the dominant upper extremity. While examiners may choose to have their patients complete clock drawings with their nondominant hand, normative data are only available based on standard administration with the dominant hand. The purpose of this study was to establish a baseline of performance with the nondominant hand. Twenty-four subjects without brain injuries completed freedrawn clocks with each hand. The intermanual difference was not significant [t(23) = 1.57, p = .13]. Thus, use of the nondominant hand for clock drawing appears to be a reasonable alternative for those who are unable to use their dominant hand. Part two of this study examined the effectiveness of practice on increasing dominant hand rote writing speed for a 23-year-old man who was 8 months post-TBI. Scores on 3 writing tasks were compared to the scores of 5 controls. Initial scores were approximately 3 times those of the controls. After 17 weekly sessions, writing speeds improved 28% to 40% and were approximately 3 times those required by controls. Issues of generalizability and of potential functional benefits (lecture note taking) from reduced resource allocation to the mechanical aspects of writing are discussed.

"Predicting Optimal Outcome After Brain Injury: Using Demographic, Funding, and Functional Gains to Predict Discharge Setting and Level of Supports." Barbara Benson Yody, MGA (ReMed, Conshohocken, PA); Mary Pat Murphy, MSN; Eli DeHope, PhD, MSW. As funding constraints have tightened resources, the need for accurate predictions of outcome and resource consumption has heightened in order to render the client quality care. For one provider of postacute community-based brain injury services, a multitude of settings are Arch Phys Med Rehabil Vol 80, August 1999

available from outpatient, comprehensive day programs to maximum supported residential assistance--in which to compare the client's outcome to resources without jeopardizing medical stability and quality of life outcomes. This study provides rehabilitation providers with guidelines for clinical practice related to the factors that influence a successful return to the community for individuals who have sustained an acquired brain injury. Using a sample of individuals served, specific factors were analyzed and used to develop a model of comparison. Factors included patient demographics, injury statistics, and severity of injury, funding, family resources, as well as ratings on specific scales. The three scales used at admission and at discharge include the Disability Rating Scale, the Supervision Rating Scale and the Mayo-Portland Adaptability Inventory. Analysis of this information allowed staff to project an optimal outcome and setting in which the person can maintain stability. The setting and level of support can be translated into the resources necessary to sustain a positive outcome.

"Measuring Substance Abuse Characteristics in a TBI Sample." Rita K. Bode, PhD (Rehabilitation Institute of Chicago, Chicago); Allen W. Heinemann, PhD; S. Vincent Miranti, PhD; Mervin J. Langley, PhD; W. Miles Cox, PhD. Adequate measures of substance use are needed to evaluate change in patient use during and following rehabilitation. In an evaluation of two substance abuse counseling program for adults following traumatic brain injury (TBI), we asked participants to report for alcohol and illicit drugs their intensity of desire, control over urges, frequency of use, and amount of use. Analysis of these individual aspects of substance use produced scales with considerable measurement error. Recording of item responses into ordered categories and co-calibration using rating scale (or Rasch) analysis produced a single measure of involvement with addictive substances that had good reliability and whose hierarchy of items provides a description of the characteristics of persons at various points along the continuum of involvement. Other than for caffeine, patients are more likely to desire substances (but have control over these desires) than they are to use them. The more desire and less control they feel over any of these substances, the more likely they are to use substances other than caffeine or beer. Few patients admit to using illicit drugs; they are more likely to report a desire for them but have sufficient control over this desire. These results provide a single index of substance involvement that can help target interventions based on individuals' level of involvement.

"Critical Pathways and Standards of Care for Brain Injured Patients." Richard Calvin, RN (Jackson Memorial Hospital, Miami); Lynn Hausman, SLP; Beverly Grapin, RN; Kathleen Klerk, RPT; Susan Server, OTR. Introduction/Problem: Our rehab center was faced with increased demands to provide outcome-oriented care and develop a consistent approach to treat brain injured patients while reducing LOS and maximizing staff treatment time. Methods/Design:Our interdisciplinary team moved beyond plans of care to the development and implementation of clinical pathways. Pathway sections include: activity, nutrition treatments, medications, patient/family education, interdisciplinary outcomes, FIM scores, consults and discharge planning. The pathway reflects all team documentation, FIM scoring, and goal setting. Results: The team developed a 3-day brain injury evaluation and three severity-leveled pathways. We reduced LOS, provided more consistent education, and oriented new staff using pathways as guidelines. Pathways are streamlined documentation tools, practice guidelines, and mark progress toward expected outcomes. They are a new means of focused, team communication with third party payers. Weekly F1M scoring is now an integral aspect of measuring patient progress and the team now reviews its clinical performance bimonthly. Conclusions: Patient care is more focused and more interdisciplinary utilizing pathways. The quality of care can be maintained while LOS's are reduced. Staff began to analyze their practice patterns and the process of ongoing clinical self-evaluation. Staff can adapt to new formats for understanding care delivery, documentation, and practice evaluation.

CONGRESS ANNUAL MEETING ABSTRACTS

Practice Management "Creating Scientific Works from Your Dormant Dossiers." Dr. Nicol Korner-Bitensky, PhD (Jewish Rehabilitation Hospital, Laval, Quebec); Isabelle G~linas, Phi). Increasingly, clinicians are collecting a wealth of information through the use of standardized measures. However, most often this information lies dormant, never to be looked at unless the client returns for another course of treatment. This presentation will take the participant through the process of using this often valuable data and turning it into a scientific publication. Specifically we will discuss: (1) how to frame the research question; (2) how to judge the quality of data available to yon; (3) a simple way to write a quality literature review; (4) how to write the procedures section; and (5) how to use easily understood statistics, tables, and figures. Selected examples of actual works that have been successfully published will be shared with participants.

"Clinic 2000 (C2K)." John Ritch, PT, (GNA, Grand Haven, MI); Christine E. Wright, PT; Cheryl R. Dix, PT. For rehabilitation programs to compete successfully in increasingly competitive markets, they must be able to reliably drive superior performance and value for each of their customer groups (referral sources, patients, regulatory organizations, and other clients). The way to achieve reliably superior services is to assemble a portfolio of standardized, high-impact technologies, tools, processes, and workflows that can be replicated quickly and easily in new and existing environments. Clinic 2000 represents GNA's high-leverage targets in the three key areas of operations, care management, and people management and outlines the specific objectives, goals, indicators/ measures, standards, and means/methods for each target. Administrators and clinical directors of rehabilitation programs would especially benefit from information about Clinic 2000 as would general healthcare administrators who are responsible for the performance of various clinical specialties. Medical directors would also benefit since best practice utilization is a cornerstone of the Clinic 2000 concept. The anticipated outcome of the session would be a knowledge of the tenets of Clinic 2000 as well as a working knowledge of how the Clinic 2000 concepts might be applied to a rehabilitation program.

"Client-Centered Interventions for Professional Development and Program Evaluation." Pam Roberts, OTR, (Cedars Sinai Medical Center, Los Angeles); Mary Evenson, OTR. Therapists in today's health care system are challenged to consistently incorporate client-centered interventions into their clinical practice (Gray, 1998). The market is demanding greater accountability in relation to functional outcomes, as well as delineation between professional disciplines. Research recommends the use of evidencebased evaluation measures to facilitate client-centered collaboration for client satisfaction and meaningful outcomes. This presentation describes a study using the Canadian Occupational Performance Measure (COPM) as part of the initial assessment in an inpatient rehabilitation setting for those individuals who have experienced a stroke. Themes to be examined via use of case studies include: (1) discussion of therapists' reflection of clinical reasoning during COPM goal setting with the client to guide clinical practice; (2) a study and analysis of therapeutic interventions over a 6-rnonth period; and (3) analysis of client's satisfaction and actual performance at discharge as compared to initial. The role of the manager in planning, implementation, and analysis for the stroke program will be outlined. This encompasses resource management, program development, and performance improvement.

Education "Web-Based Education: Application to Rehabilitation." Linda M. Hennig, EdD, RN (University of Central Florida School of Nursing, Orlando, FL); Kathleen Healy, MSN, ARNP; Mary Lou Sole, PhD, RN. Educational and health care institutions must use a variety of course delivery methods to provide greater access to educational programs. Alternative methods of education, other than the traditional classroom, are becoming more in demand. The internet is becoming an increasingly popular mode of delivery. Web-based instruction has tremendous

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possibilities for both professional education and patient/family teaching. Use of the lnternet in course instruction creates new challenges in course delivery. Challenges and experiences of faculty teaching web-based courses, an analysis of on-line student discussions in a web-based course, and using Internet resources to enhance rehabilitation outcomes will be included.

"How to Develop a Performance Improvement Plan in Accordance with Joint Commission Standards." Eileen F. Hamby, DBA PT (University of Central Florida). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) sets standards for different functions within a health care facility. This short course will discuss the rehabilitation standards as they relate to patient care, and the standards on performance improvement. The course participant will learn how to develop an organizationwide performance improvement plan in accordance with these standards. The key components of the plan will be addressed and a sample given for different health care settings. A sample rehabilitation evaluation/plan will also be provided that is comprehensive in nature, and also conforms to the JCAHO standards. Special emphasis will be made on functional outcomes and the corresponding appropriate documentation.

"Health Care Education for Tomorrow: Active Learning Strategies." Gina Musolino, EdD, (Florida Gulf Coast University, Fort Myers, FL); Catherine Page, PhD, PT. Educators must have the ability to guide and facilitate future clinicians to learn the skills necessary to keep current in the ever-changing health professions. This poster will highlight the principles and philosophies of problem-based learning and self-assessment, which are the foundations for life-long learning. The following queries will be considered: What is self-assessment and problem-based learning and the rationale behind the use of these learning methods? How are self assessment and problem-based learning organized for the clinic and classroom? What is the role of the learner? How do principles of adult learning and the new learning paradigms intermesh with selfassessment and problem-based learning? How do you use learning styles, theories and wellness inventories in the professional learning process? What facets of problem-based learning and self-assessment foster transfer of learning, to the clinical environment? How does the contemporary research support or not support active learning strategies?

"Using Preprinted Care Plans in Stroke Rehabilitation to Enhance Functional Outcomes." Peter Rigby, PT, MPH (Northwest Hospital, Seattle); Evan Cantini, MD; Susan Truscott, RN; Becky Hancock, MSW; Carolyn Grant, RN. Preprinted care plans, or "Health Tracks" (HTs) have gained popularity as pressure mounts on the field of neurologic rehabilitation to control costs while demonstrating improved functional outcomes. This study was undertaken on a 24-bed acute rehabilitation unit to determine the effect of HT utilization on functional outcomes in acute stroke rehabilitation. Representatives from each rehabilitation discipline agreed upon the day in which interdisciplinary training programs (ITPs) would be initiated with stroke patients. ITPs were developed for eating, bathing, toileting, self-administered medications and functional transfers. Appropriate HT utilization by team members was monitored with an ACCESS database. Functional outcomes were measured by clinicians certified under the FIM system. "FIM efficiency," calculated as FIM change/LOS, was used as the measure of functional outcome. A regression analysis was applied to determine the relative effect of the following 3 factors on FIM efficiency: (1) Appropriate HT utilization by clinicians (Met%); (2) Patient age, and (3) The "Function Related Groups" (FRGs), as assigned by USMDR software. Met% was found to be the only variable that showed a statistically significant correlation to FIM efficiency (correlation coefficient .386, p = .003, n = 55). We concluded that well-controlled use of the health tracks helped improve the FIM efficiency rating. Arch Phys Med Rehabi! Vol 80, August 1999

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"Project Enable: An Internet Gateway to Resources and Support for Individuals with Spinal Cord Injury." Mark F. Olson, MPH (Santa Clara Valley Medical Center, San Jose, CA).

a versatile tool generating outcome data that are quantitative and based on an individualized process.

Introduction: Does an accessible computer with interact access make a difference in rehabilitation outcome for patients with spinal cord injury (SCI)? As we embark on the 21st century, "State of the Art" in rehabilitation must include a component that enables patients to utilize the wealth of information and resources available on the interact. Key components of Project Enable include SCI education, SCI resources, peer support, and enhanced occupational therapy treatment, and vocational rehabilitation. Methods: A high speed internet access computer was made available to patients and the treating staff for a period of nine months. A survey was administered to patients and therapy staff to determine the usefulness of Project Enable and to gather general comments and feedback about this program. Results: Survey results have been universally positive about the usefulness of Project Enable. Through adaptive input devices and software, Project Enable has opened up new treatment approaches for our occupational therapists. The psychological impact has also been positive, offering hope for self sufficiency and future vocational possibilities. A print version of the Project Enable website will be available, as well as a brochure of interact resources for spinal cord injury.

"Interdisciplinary Use of the Objective Structured Clinical Examination in Evaluating Clinical Competency Skills of Rehabilitation Professionals." Mary Eyles, MA, RN (Kessler Medical Rehabilitation Research Education Corporation, West Orange, NJ); Ann C. Smith, BS.

"Patient/Caregiver Education as a Cross-Discipline Goal." Camille M. O'Reilly, RN (Rehabilitation Institute of Chicago, Chicago); Patrick Semik, BA; Rita K. Bode, PhD; Christa Ambrose, BA; Alien W. Heinemann, PhD. Patient and caregiver education is a vital component of rehabilitation with long-range implications for patients' health management. In this study we examined the frequency with which clinicians set patient or caregiver education as a rehabilitation goal, the frequency of goal attainment, and barriers to goal attainment. Data were collected at eight rehabilitation hospitals for 314 inpatients with primary diagnoses of spinal cord injury (28%), traumatic brain injury (24%), and stroke (48%). Nurses and physical and occupational therapists reported a variety of treatment goals, the patients' admission status for the goals, and the level of goal attainment at discharge. Patienffcaregiver education was one of the possible goals for each discipline. If a goal was not met, clinicians reported barriers to goal attainment. Nurses reported a goal of patient/caregiver education more frequently (90%) than did physical (53%) or occupational therapists (39%). Rates of education goal attainment were roughly equivalent for nursing and physical and occupational therapy (76%). Barriers to goal attainment were similar across disciplines with family issues (family nonpartieipation in teaching; family not recognizing care giving consequences of disability) cited most frequently as barriers to goal attainment. These results reveal the importance of coordinating patient education goals across disciplines and assuring that goals are met so that postrehabilitation health is maximized.

Evaluation "Evaluating Treatment Outcomes Using Goal Attainment Scaling." Brian J. Dudgeon, PhC (University of Washington, Seattle) Arlene K. Libby, BS, OTR; Jean C. Deitz, PhD. Goal attainment scaling (GAS) is a method for systematically evaluating outcomes for clients, The literature describes use of this method in clinical work with a variety of populations such as infants and children with motor impairments, adults with brain injuries, and older adults who are frail. In addition to client specific assessment, GAS has been used in program evaluation and as a research tool in evaluating the efficacy of specific interventions. This method uses individualized criterion referenced goals and provides a framework for the development of goals that are measurable and socially, functionally, and contextually relevant. It involves a collaborative process of goal planning (eg, client, family, health care providers) which progresses through a seven steps process to quantitative analysis of outcomes. This method is important to rehabilitation for several reasons. First, it supports collaborative goal setting that is important to client- and family centered care. Second, it encourages the prioritizing of goals which is significant in view of the necessity for both cost containment and focusing of interventions on goals that are most valued. Third, it is Arch Phys Med Rehabil Vol 80, August 1999

The "quality of health care" is a major concern to everyone. Proper selection, training, and evaluation of those entering, as well as those practicing in the health profession is part of the criteria used to judge "quality of care" in today's rapidly changing health care environment. Avoiding exposure of patients and their families to health professionals with marginal clinical competencies has been a major focus of evaluating clinical competencies within training programs. Evaluation efforts in the working environment are based on standardized written formats completed by a supervisor, who may or may not have observed the competency of the individual's clinical skills. Add the constraints of fewer staff and less time, observance of staff skills may be minimal thus jeopardizing patient safety. Research has shown the Objective Structured Clinical Examination (OSCE) to be a valid and reliable method of evaluating clinical competencies.

"Effect of Clinical Pathway on Length of Stay Efficiency." Marggi Diercks, MA (Pinecrest Rehabilitation Hospital, Delray Beach, FL). Objective: To evaluate the variation in length of stay efficiency (FIM change/length of stay) between patients who have undergone hip and knee replacement following a 5-day clinical pathway versus those on a general care plan. Both groups were seen in an acute rehabilitation hospital. Method: Outcome statistics (Functional Independence Measures) were recorded against length of stay for a period of 1 year for two hip and knee replacement populations: one on a 5-day clinical pathway following discharge day 2/3 from acute care, and the other on a general care plan (260 vs 311 patients). Results: Patients who followed the 5-day clinical pathway exhibited significantly greater length of stay efficiency (6.7) than those admitted under a general care plan (3.95).

"Improved Cost-Effectiveness by Patient Participation in Rehabilitation Planning." Mark N. Ozer, MD (National Rehabilitation Hospital, Washington, DC); Jacqueline Ennis, PhD. Improving cost-effectiveness of rehabilitation requires the enlistment of all resources. One relatively untapped resource is the energy that can be committed by patients to the implementation of the rehabilitation plan. It was hypothesized that optimization of patient participation in the planning and ongoing review of their treatment plans can lead to greater commitment of energy and strategies to their implementation with subsequent improved cost-effectiveness. The implementation of such an approach in the context of cost constraints provided an opportunity to test this hypothesis. Attention to the measurement of patient participation in the team planning process was carried out within an in-patient stroke program. Implementation was documented as carried out over a year. Costs were measured by charges. Outcomes were measured by the Functional Independence Measure. Patient satisfaction, charge efficiency and length of stay efficiency were measured and compared to that achieved on other service units not implementing the patient participation initiative. Data show significant improvement in charge efficiency on the stroke unit while either static or declining on the other service units. Implementation of patient participation as a specific objective can contribute to increased cost-effectiveness of rehabilitation services of persons with stroke.

Research Methods "Customer-ized Rehabilitation Outcomes: Single Subject Designs and Frequency Measurement for Clinical Practice and Research." Nancy Hansen, PhD (Illinois Institute of Technology, Chicago); Mike Mazzoni, PhD; Charles Merbitz, PhD; Robert Guenther, PhD. Rehabilitation outcome measures need to be accurate and sensitive to important changes among patients with various impairments. Further-

CONGRESS ANNUAL MEETING ABSTRACTS more, they should be usable as process measures, ie, be capable of informing ongoing treatment decisions with individual clients. Likerttype rating scales are widely used in rehabilitation outcomes measurement, but they are not the only route toward increased accountability and effectiveness of treatment. Most such measures omit important rehab foci (eg, employment, treatment adherence), and questions remain as to their reliability, validity, and utility in clinical settings (Merbitz, Morris, & Grip, 1989; Karunas, Hansen, Forchheimer, & Ardner, 1997). We will present from a perspective of 10 years of research on the use of process and outcome measures, and will discuss desirable characteristics of measures, logical constraints, and the inexact correspondence between more traditional indicators (such as questionnaire responses by clients or therapists) and the desired target behaviors (such as exercise, or pressure lift-offs). We will present concepts and potential implications of frequency measurement and single subject designs, including empowerment of clients as they help select goals and measure progress and then view graphic displays of that progress.

"Using Focus Groups for Data Collection in Clinical Practice." Lee Zaslow, EdD (MCP Hahnemann University, Philadelphia); William B. Inverso, Jr., PhD. The focus group has emerged as an important data collection tool. The current healthcare environment has focussed increasingly on assessment based outcomes to client contact. Clinical practices benefit from collecting data that is valid and usable in documenting these outcomes, Rehabilitation professionals, such as physicians, clinicians, and managers, can use this qualitative research technique to collect data about clients and existing progrmns. This poster provides basic information so that the reader can determine if the focus group (1) meets their needs, and (2) is an appropriate and efficacious data collection tool.

"Psychometric Properties of Spirituality Measures." Rita K. Bode, PhD (Rehabilitation Institute of Chicago, Chicago); Jennifer Jo Kim, BA; Allen W. Heinemann, PhD; Patrick Semik, BA; Rosemarie B. King, PhD. The importance of spirituality in the lives of persons with disabilities is coming to be recognized by rehabilitation providers. Unfortunately, the psychometric properties of widely used spirituality scales have not been evaluated for rehabilitation populations. This study evaluated the measurement properties of two instruments used with nondisabled populations: Ellison's Spiritual Well-Being Index (SWB) and Genia's Spiritual Experience Index (SEI). The construct validity of both

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instruments was examined using rating scale (or Rasch) analysis with a sample of 369 inpatients at a rehabilitation hospital. Most of the SWB items were congruent with a single dimension of spiritual well-being. The SEI items did not confirm the two factors suggested by the scale's author. While we found that the items designed to measure spiritual support did define a congruent set, the items designed to measure spiritual openness did not hold together. Instead, a different group of items cohered to define dogmatic religious beliefs. These results support the need for sample-free analytic techniques determining the validity of insmaments. Changes in spirituality dimensions during and following rehabilitation will be described. These instruments can be applied to examine the nature of spiritual concerns during and following rehabilitation.

"Community Integration Questionnaire: Psychometric Properties and Concurrent Validity with Brain Tumor Patients." Candia P. Kaplan, PhD (MUSC, Charleston, SC). Thirty-three outpatients (16 male, 17 female; mean age 46.3; mean education 13.7) with biopsy-confirmed malignant brain tumors were tested with the CIQ, Mood Assessment Scale, State Trait Anxiety Inventory, and Chronic Illness Problem Inventory prior to chemotherapy. CIQ scores were positively skewed: CIQ total score Mean = 15.2, Mdn = 13.75, SD = 6.65; Home Integration Mean = 4.14, Mdn = 3.75, SD = 3.1; Social Integration Mean = 8.27, Mdn = 8.0, SD = 2.3; Productivity Mean = 2.79, Mdn = 2.0, SD = 2.32. Gender effects were observed, married women reported significantly greater Home Integration (r = .49, p < .01). Age effects indicated older patients experienced significantly poorer community integration [CIQ Total (r = -.52, p < .005); Home Integration (r = -.39, p < .05); Social Integration (r = -.44, p < .01); and Productivity (r = -.54, p < .005)]. Education was related to CIQ Total (r = .32, p < .05) and Productivity scores (r = .37, p < .05). CIQ Home Integration was predicted by age, gender, and marital difficulties [R2 = .733, p < .0001, df(3,30)]. CIQ Social integration was predicted by marital overprotection and inactivity [R2 = .394, p < .001, df(2,30)]. Lower Social Integration related to more depressive symptoms (r = -.36, p < .01), greater Trait Anxiety (r = -.31, p < .05), marital overprotectiveness (r =-.41, p < .01), and concern about physical appearance (r = -.47, p < .01). Lowered CIQ Productivity was related to higher Trait Anxiety (r = -.39, p < .05). CIQ total scores were predicted by age, marital difficulties, and problematic non-marital relationships [R2=.384, p < .003, df (3,29)]. Results are consistent with Lewinsohn's model of negative affect and provide moderate concurrent validity.

The following are abstracts of posters that will be offered concurrently on Saturday, October 16, 1999, 10-10:30 am, noon-l:3O pm, and 4:15-4:45 pm.

Spinal C o r d I n j u r y T r e a t m e n t s "Qualitative Aspects of Caregiving in Long-Term Spinal Cord Injury." Steven Oberg, LCSW (Craig Hospital, Englewood, CO); Susan Charlifue, MA; David Weitzenkamp, BA. While many studies concentrate on quantifiable needs and outcomes of caregivers of spinal cord injury (SCI) survivors, few attend to the more qualitative issues. By asking caregivers what they would change about the past and future, this study attempts to more fully understand the actual impact of providing care to a SCI survivor. Participants came from four studies of aging with spinal cord injury. The 127 respondents were 85% female and averaged 47.8 years of age; 79.5% were spouses or significant others. When asked about changing their past, many caregivers wished they had decreased their own burden by allowing more outside help and by encouraging their partners to be more independent. Some mentioned school and counseling for themselves and their family, wishing they'd focused more on their own needs rather than exclusively on needs of their partner with SCI. When asked, "How would you change the future?" caregivers instead frequently responded with concerns for the future. These included fears that their partners would require more assistance

and they would need to move to more accessible homes. The experiences and concerns of these "seasoned" caregivers offer much that is relevant and useful in educating newly injured SCI survivors and their partners.

"Improvement of Sleep Apnea and Carpal Tunnel Syndrome in a Cerebral Palsy Patient: A Case Report." Stacy Fuller, MD (Rehabilitation Institute of Chicago, Chicago); Deborah Gaebler-Spira, MD. Intrathecal baclofen (ITB) is an effective means to reduce spasticity in cerebral palsy. Some benefits of ITB therapy include lessened muscle spasms, and improvement of activities of daily living and mobility. The role of ITB therapy in patients with carpal tunnel syndrome (CTS) or sleep apnea have not been reported. This case study describes a 29-year-old woman with mixed spastic athetoid qnadriparetic cerebral palsy with dystonia, Gross Motor Function IV. She received ITB with the goal to improve her seating and positioning and decrease her excessive movements. The patient began having symptoms of CTS of the right hand about 2 months prior to the initiation of ITB. Electrodiagnosfic testing was performed showing evidence of carpal tunnel syndrome. She also had sleep apnea, requiring nightly CPAP. Arch Phys Med Rehabil Vol 80, August 1999

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Her spasticity and dystonia improved both subjectively and clinically following ITB. Fourteen months after the ITB was started, she had a repeat electrodiagnostic study showing no evidence of CTS. She also had improvement of her sleep apnea, with repeat polysomnography done 9 months after initiation of ITB showing she no longer required CPAP. It is proposed that by decreasing the spasticity and dystonia of her upper extremities, and the spasticity her repiratory muscles, ITB conlributed in the improvement of her CTS and sleep apnea.

"EGb 761 (Ginkgo biloba): Efficacy in Treating Stroke and Traumatic Brain Injury." Bruce J. Diamond, PhD (Kessler Institute, West Orange, NJ); Samuel C. Shiflett, PhD; Amy Lothian; Nancy Feiwel, MD; Paul Cooke, MD; Olga Noskin, BA; Neha Dixit; Jennifer A. Richards. The effects of EGb 761 (ginkgo biloba) on cognition, mood, and cardiovascular activity were examined in patients with traumatic brain injury (TBI) and anterior communicating artery aneurysms (ACoA). Twenty-one subjects who provided informed consent participated in this randomized, triple-blind, placebo-controlled study. Subjects took 240mg of ginkgo per day for 30 days. EGb 761 was found to be safe with no adverse events reported or observed on physical examination. No significant differences between the ginkgo and placebo groups were found on processing speed, verbal memory, or mood. However, the EGb 761 group showed improved verbal fluency as well as greater mean heart rate (HR) and variability. Improved fluency may reflect enhanced executive function and word retrieval speed. The increased mean heart rate was not an undifferentiated sympathetic response but was accompanied by increased heart rate variability. This is a clinically important distinction as decreased HR variability is associated with an increased risk of adverse cardiac events. Ginkgo's reported concentration dependent metabolic (ie, altered cerebral activation) and neurotransmitter regulatory effects (ie, enhanced serotonin uptake) may mediate these findings. Overall, EGb 761 shows promise in treating some of the symptoms associated with stroke and TBI. Future work should identify the active ginkgo components and their optimal dosages.

"The Effect of a New-Designed Exercise Training Program for Chronic Obstructive Pulmonary Disease Patients." Tyng.Guey Wang, MD (National Taiwan University Hospital, Taipei, Taiwan); Ssu-Yuan Chen, MD; Shu-Fang Hsiao, BA; Kuang-Hua Lin, PhD; I-Nan Lien, MD. The purpose of this study was to evaluate the effect of a new-designed exercise-training program based on the maximum work rate for the individuals with chronic obstructive pulmonary disease (COPD). Sixteen patients (13 male, 3 female) with moderate COPD attended this study but only six of them completed the training program. Cycle ergometry was used to test and train the patients. The training period was 3 months with the frequency of three times per week and 30 to 40 minutes in each section. The intensity of training was 40 % to 80% of the maximum work rate obtained by the exercise test. During the test or training program, low flow oxygen was provided to maintain the oxygen saturation of the patients above 90% in the test and 88% in the training. The results showed that the maximum work rate of the six patients completing the training program increased from 73.3 +_ 28.8 watts to 91.7 - 31.8 watts with statistical significance (p = .028). However, there were no significant changes in the spirometric indices. We concluded that the new designed exercise training program based on the maximum work rate was simple and effective for the patients with COPD.

"New Method for Treatment of Patients with Cerebral Palsy." Vladimir Kozijavkin, MD, PhD (Institute for Medical Rehabilitation, Lviv, Ukraine). Introduction: We established that patients with cerebral palsy have changes of the spine movements biomechanics in the form of functional vertebral blockages (verterbral subluxation complexes). These blockages increase muscle tone disturbances and motor developmental delay. The biomechanical correction of the spine created in our rehabilitation center became the basis of new method of treatment - Intensive Neurophysiological Rehabilitation System (INRS). Elimination of the vertebral blockages results in the restoration of the normal flow of the proprioceptic information and formation of the new Arch Phys Med Rehabil Vol 80, August 1999

functional status of the patients' nervous system. Methods: INRS is performed according to our established treatment programs, which include: biomechanical correction of the spine, reflexotherapy, special massage techniques, physical therapy exercises, joints mobilization, apitherapy, mechano- and play- therapy. Results: In 1997, the INRS was evaluated in cooperation with the German Academy for the Developmental Rehabilitation using a group of 1,006 patients. Good long-term results were noted in the 91% of the cases. Summary: INRS was officially approved in Ukraine and has received much international attention. More than 10,000 cerebral palsy patients, including approximately 5,000 from Germany and other Westem Europe countries, have been rehabilitated in our center with positive results.

"Transdermal Delivery of Compounded Medications for Musenioskeletal Injuries." Mac Yahara MS, PT, ATC (Pinecrest Rehabilitation Hospital, Delray Beach, FL); Scott Snyder, RPh; Mark Rubenstein, MD The philosophy involved in the treatment of musculoskeletal injuries with custom formulated topical gels is applicable to physicians and therapists searching for efficacious treatment modalities with minimal side effects. Participants will understand the concept of compounding and transdermal delivery of medication as well as conditions under which this modality has been effective. Case studies will be presented. In addition to the application to clinical practice, research opportunities will be discussed.

"Effects of an In-Patient Phase One Cardiac Rehabilitation Treatment Protocol on Functional Outcomes of Postoperative Coronary Bypass and Valve Replacement Patients." Zahra Ghasemi, MS (Cedars-Sinai Medical Center, Los Angeles, CA); Terry Martin, PT; Melissa Leet, MS; Michael Gilewski, PhD; Bernice Coleman, MN. Introduction: The efficacy of cardiac rehabilitation during the acute post--cardiac surgical phase remains unclear. The objectives of this project were to describe the functional outcomes for postoperative coronary bypass and valve patients receiving a standardized Cardiac Rehabilitation physical therapy protocol, and determine the relationship of age and gender on functional improvement. Method: A one group prospective design was used. A sample of 84 postoperative coronary bypass and valve replacement patients with the mean male age of 65.60 years _+ SD 11.3, and mean female age of 71.36 +- SD 8.6 were included in this study between May and July 1998. All patients received a standardized physical therapy protocol. Initial and discharge data were compared. Data were analyzed using repeated measures MANOVA and regression analysis. Results: A 60% improvement in intensity of exercise as measured by change in cardiac rehabilitation level from 2.1 to 3.4 (p < .05); and a 59% change in ambulation velocity from 62.7ft/min to 106.3ft/min (p < .001) was found. Females and older age patients had less favorable outcomes. Conclusion: Patients receiving standardized physical therapy treatment following cardiac surgery demonstrated significant improvement in intensity of exercise and ambulation velocity at discharge.

"A Comparative Analysis of Polypropylene and Thermoplastic Elastomer Ankle-Foot Orthoses in a Hemiparetic Patient." Jeannette A. Beach, PT (Siskin Hospital for Physical Rehabilitation, Chattanooga, TN); Locke H. Davis, CPO; Michael W. Whittle, MD, PhD; Karen Hood, PT. It is a common practice to prescribe a solid-ankle ankle-foot orthosis (AFO) for the post--cerebral vascular accident (CVA) patient with hemiparesis. Clinical evaluation was performed to determine if a solid-ankle AFO made of thermoplastic elastomer (TPE) produced a more normal gait pattern than a conventional polypropylene AFO. Gait analysis was performed on a 4-year post-CVA patient using a Vicon television/compnter system measuring kinetics and kinematics as well as ambulatory electromyography (EMG). The subject was assessed ambulating without a brace, with a solid-ankle polypropylene AFO and with a solid-ankle TPE AFO. The subject's gait parameters were compared to normal gait parameters, The physical properties of polypropylene and TPE are described in order to clarify the physical differences of the AFOs. Quantitative differences were found in a number of the gait parameters including the subject's stride length and

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walking speed which were closest to normal parameters when wearing the TPE AFO. This case study indicates that further research in the use of TPE in lower extremity bracing could yield beneficial results for patients with neuromotor dysfunction.

"The Response Enhancement Program: An Interdisciplinary Program to Improve Treatment Consistency and to Reduce Financial Costs of Minimally Responsive Patients." Cynthia L. Beaulieu, PhD (Brooks Rehabilitation Hospital, Jacksonville, FL); Theresa J. Gates, PT. The Response Enhancement Program (REP) is an interdisciplinary program designed to use quantitative data in assessing minimally or inconsistently responsive patients. The REP assumes that quantitative data collection across multiple disciplines is the most objective method for assessing a patient's "rehab readiness." In addition to determining readiness, the REP should reduce long-term medical management costs. It is proposed that long-term costs are reduced through (1) more accurate diagnosis leading to shorter lengths of stay, (2) more accurate prognosis leading to quicker long-term placement, (3) caregiver education and preparation, and (4) reduced redundancy in treatment and education. To investigate these proposals, data were collected on minimally responsive brain injury patients admitted to a freestanding, acute rehabilitation hospital from 1996 to 1998. Preliminary analyses reveal shorter lengths of stay for REP patients versus non-REP patients (28.2 days vs 55.8 days, respectively) and more efficient long-term placement of patients who do not improve during their admission (102 non-REP days vs 30 REP days). It is concluded that the REP is an appropriate and efficient method to assess and determine "rehab readiness" in minimally responsive patients, and that acute inpatient rehabilitation hospitals are appropriate settings to establish and implement programs similar to the RER

"Treatment of Confabulation: A Case Study." Jeffrey S. Smigielski, PhD (Mayo Medical Center, Rochester, MN); Walter Stobaugh, LICSW; Susan Lepore, OTR. Confabulation may be described as a tendency to give false accounts of past events, without awareness or deceptive intent (Sohlberg and Ehlhardt, 1998). The clinical management of this problem in patients with brain injury can be challenging and frustrating. We describe a treatment procedure utilized successfully in the care of an individual demonstrating severe and persistent confabulation tendencies, in the context of postacute rehabilitation 2½ years after traumatic brain injury. Utilizing a conceptual model described by Deluca (1991) that postulates three levels of awareness of confabulation (intellectual, emerging, and anticipatory awareness), we describe specific techniques and procedures employed and their application within a team context as part of a group treatment approach to postacute comprehensive integrated rehabilitation for brain injury. The linkage of treatment for confabulation with training in memory compensation strategies is described. Specific methods of feedback from treatment staff as well as patient peer group members are presented. The critical importance of education for family for purposes of follow-through and continuity is emphasized. Outcome information is described and 1-year follow-up is included. The clinical utility and effectiveness of an organized and theoretically based approach to the treatment of this difficult condition is supported by the variable outcome in this case.

Orthopedic "Orthotic Use and Predictors of Orthotic Use Among Stroke Patients." Stephen J. Page, PhD (Kessler Medical Rehabilitation Research and Education Corporation, West Orange, N J); Mark V. Johnston, PhD; SueAnn Sisto, PhD, PT, Kessler Medical Rehabilitation Research and Education Corporation, West Orange, NJ. Health professionals are encouraged to make equipment decisions early in the rehabilitation process, while inpatient hospital stays have become shorter and patients are admitted sooner from acute care. Clinicians may make premature equipment decisions resulting in more bracing than necessary and larger monetary commitments. Information on frequency use/disuse is of little value if it cannot be predicted at the point of prescription and fitting. The purpose of this study was to identify factors predicting lower extremity orthosis use versus nonuse.

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The Functional Independence Measure (FIM), speed of ambulation, patient attitudes, and numerous other factors were used with employed 99 stroke inpatients in 4 rehabilitation hospitals. Device usage was determined 3 months after discharge by structured telephone interview. At follow-up, 26.3% (26/99) were not using othoses even once per week, while slower patients (r = .256-.383, p < .024-.003, over 50-150', tested with the delivered brace), patients rated less safe in ambulation (r = .204-.309, p < .043-.003), and patients with paralysis and proprioreceptive impairments used their braces significantly more. Results suggest that there are clinically practical predictors of usage and that there is a gap between patient function in the clinic and function months later at home. The researchers encourage long-term follow-up and routine assessment.

"Biomechanical Effect of the Foot Orthosis for Rheumatoid Arthritic Patients." Naoto Shiba, MD (Kurume University Rehabilitation Center, Fukuoka, Japan); Kisei Imaishi, PT; Chang-You Li, MD; Takeshi Goto, MD; Yoshihiko Tagawa, PhD. Purpose: To evaluate the effect of the foot orthosis, foot pressure during walking was measured for the rheumatoid arthritic patients who had foot pain during walking. Method: F-SCAN was used to measure the foot pressure with and without the foot orthosis, and its effect was evaluated. Force plate (Kistler 9281B) also was used simultaneously to calibrate the data of the F-SCAN for the accuracy. Results: Concentration of the foot pressure was observed at the area where the patients felt pain. The locus of the center of gravity in patients was shorter than that in normal subjects, and stopped at the area of concentration of the foot pressure. After using the foot orthosis, concentration of the pressure was improved, and the pressure pattern was altered equally. The locus of center of gravity also was changed, and it became straight and longer. Its pattern was not equal to that of normal subjects. Conclusion: Foot orthosis was effective for the painful foot of the rheumatoid arthritic patients, and their foot pressure pattern also changed clearly.

"Fever Workup in Orthopedic Rehabilitation." Sarmistha Chaudhuri, MD (Marianjoy Rehabilitation Foundation, Wheaton, IL); Norman Aliga, MD; Richard M. Smith, PhD. The incidence of low-grade temperature after an orthopedic surgical procedure raises the question: At what threshold does an elevated temperature warrant further investigation--at >98.9°F versus current practice of > 100.4°F? It is beneficial for patient care to determine if a temperature of >98.9°F results in a significant difference in the rate of wound infection, DVT, hematoma, pneumonia, or UTI. The patients most concerning are those in the traditionally high-risk postsurgical group who have had a hip replacement, knee replacement, or insertion of other artificial material. Through this retrospective chart review of 250 patients admitted to a freestanding rehabilitation hospital in a 12-month period, the frequency of elevated temperature between 98.9 ° F and 100.3 ° F, within 5 days and after 5 days of an orthopedic procedure was documented. Thirty-six percent of the patients had no fever, 21% had a temperature between 98.9 °F and 100.3 °E and 14% developed a temperature of >100.3 ° E Frequency analysis of the results indicates that there is a significant difference in the rate of infection, DVT, etc, in patients with a temperature of >98.9°F, compared to those with a temperature of <98.9°F (p < .05). These findings support the practice of testing patients for infection, DVT, etc, and treating them at this earlier point of intervention, thus reducing overall length of morbidity and improving patient quality of care.

"Overuse Shoulder Injury History, Conditioning Methods and Wheelchair Dependence Differences Between Wheelchair Basketball Players of Differing Player Classification." J. Nyland, EdD (University of South Florida, Tampa, FL); D. Caborn, MD. Introduction: Overuse shoulder injuries are common among wheelchair athletes. Overuse shoulder injury history, conditioning methods and wheelchair dependence of wheelchair basketball players of differing classification were assessed to identify possible training and daily living related shoulder injury factors. Methods: This prospective study surveyed 89 players (Class 1 = 27, Class 2 = 33, Class 3 = 29) at a tournament for overuse shoulder injury history, upper extremity weight training practices, wheelchair dependence, and use of alternative conditioning strategies. Pearson chi-square tests (p < .05) enabled Arch Phys Med Rehabil Vol 80, August 1999

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comparisons by player class. Results/Conclusions: Sixty one percent of all players had an overuse shoulder injury history. Class 1 players had a greater percentage of shoulder injury than Class 2 or Class 3 players (p = .03). Class 1 players were more wheelchair dependent than Class 2 or 3 players (p = .01). Class 1 players did not perform medicine ball training to the same extent as Class 2 or 3 players (p = .005). Only 2 of 89 total players regularly performed push-up type movements. No other variables differed between classes. Class I players may be at greater risk for overuse shoulder injuries. Traditional weight training and wheelchair dependence may contribute to this risk.

"Simulation of Compensatory Actions and Their Reduction Methods in Abnormal Gait." Y. Tagawa, PhD (Kurume Institute of Technology, Fukuoka, Japan); N. Shiba, MD; Y. Nakashima, PT; Y. Harano, PT; A. Inoue, MD. Introduction (Objectives): To simulate the differences of characteristics between normal and abnormal gaits in terms of compensatory actions due to the functional loss of the diseased joint of the lower extremity. Methods: Our model can simulate human normal and abnormal gaits and consists of eight massive elements. The diseased joint is located at one of ankle, knee, and hip joints. Compensatory actions will be required to make up for the functional loss of the diseased joint in different patterns of variables, such as moments at sound joints and motions of upper torso. Conditions of the diseased joint and the abnormal gait are changed to reduce the excessive compensations. Effects of walking-aids such as a cane and an ischial weight-bearing, brace are formulated based on our experiments as a reduction method. Results: According to the location of the diseased joint, the compensatory actions showed different patterns and magnitudes in moments at sound joints and motions of upper torso. Gait patterns observed in the aged or the infant gait reduced the compensatory actions effectively. The walking-aids decreased the vertical component of the load at the diseased joint directly, and adjusted the posture of the upper torso to be upright.

Assessments "Neuroplasticity: Role in Rehabilitation." Martin Grabois, MD (Baylor College of Medicine, Houston, TX); Richard Herman, MD; Smart Yablon, MD. This presentation will be the initial phase of a program to develop a clinical and research neuroplasticity initiative. Ultimately this will include an interest group, reference list, research agenda and ongoing educational program. The presentation will present what is neuroplasticity and how it can be utilized clinically in the rehabilitation of patients. The scientific literature will be reviewed and presented. Specific examples of how neuroplasticity can and should be incorporated into traditional rehabilitation programs will be presented. These examples will focus on brain injury, cardiovascular accidents and spinal cord injury. A future research agenda will be presented that will increase understanding and utilization of neuroplasticity in rehabilitation.

"The Accuracy of Detecting Tear of Supraspinatus Tendon in Sonographic Examination.Compare to Arthrogram." Hsin-Shui Chen, MD (China Medical College Hospital, Pei-Kang, Yun-Lin, Taiwan); Tyng-Guey Wang, MD; Nien-Tsu Han, MD; Chun-Yi Lee, MD; Meng-Yi Chen, MD. The purpose of this study was to evaluate the accuracy of sonographic examination in detecting the supraspinatus tendon tear. Thirty-six patients (19 men, 17 women) with suspected rotator cuff tear received sonographic examination equipped with 7.5MHz transducer and double contrast arthrogram study simultaneously. The diagnostic criteria of the supraspinatus tendon tear were according to the studies of Middleton and Marnix. Twenty of the 36 patients were diagnosed as a complete tear of supraspinatus tendon on sonographic examination. Fourteen of them also demonstrated a complete tear of the supraspinatus tendon on arthrogram examination. None of the 16 patients with negative sonographic examination had abnormal arthrogram findings. The results showed that there was 100% sensitivity and 73% specificity of sonographic examination in detecting the complete tear of supraspinatus tendon. The high sensitivity and adequate specificity imply that sonographic examination is a good alternative method on regular shoulder examination.

"Vitamin D Status and Nonhemiplegic Bone Mass in Patients Following Stroke." Haruko Kuno, MD (Kurume University Medical Center, Fukuoka, Japan); Masahide Kaji, MD; Naoto Shiba, MD;Yoshihiro Sato, MD; Kotaro Oizumi, MD. To assess bone changes in hemiplegic stroke patients, vitamin D status and bone density on hemiplegic and intact sides of sunlight deprived stroke patients were evaluated. Sera were collected from 88 hemiplegic stroke patients and 34 controls. The sera were assayed for 25hydroxyvitamin D (25-OHD) and 1, 25 dihydroxyvitamin D (1, 25-[OH]2D). Bone density was measured bilaterally from radiographs of the hands using computed X-ray densitometry (CXD) and the Z-score of bone mineral density was calculated. Serum 25-OHD and 1, 25-[OH]2D concentrations were significantly lower in patients (11.5 _+ 5.4ng/mL, 23.1 + 10.3pg/mL) than in controls (21.6 -- 3.1ng/mL, 49.6 _+ 9.2pg/mL) (p < .0001). The patients' Z-scores for osteopenia were lower on the hemiplegic side than on the nonhemiplegic side. Even on the intact side, the Z-scores were significantly lower as compared to controls. In addition to the strong positive correlation between the Z-scores on the hemiplegic side and degree of hemiplegia, the Z-scores on both sides in patients correlated positively with the serum 25-OHD concentration. These results suggest that vitamin D deficiency and disuse can cause osteopenia on the hemiplegic side and may increase the risk of hip fracture. In addition, it was demonstrated that hypovitaminosis D decreased bone mass on the nonhemiplegic side. This hypovitaminosis D might be corrected readily by the routine use of vitamin D supplements.

"Low-Back Pain: Identifying Those at Increased Risk." Steven H. Sanders, PhD (Siskin Hospital Center for Pain Rehabilitation, Chattanooga, TN).

"The F-wave Studies in L5 Radiculopathic Patients receiving Automatic Percutaneous Lumbar Disectomy." Chien-Hung Lai, MD (Taipei Medical College Hospital, Taipei, Taiwan); NfingShium Hsieh, MD; Yu-Chin Chen, MD; Jing-Hwa Way, MD; Shih-Ching Chen, MD.

The prevalence and cost of acute and chronic low-back pain in adults are truly epidemic throughout the industrialized world. This has prompted an enormous amount of recent research aimed at trying to better predict the occurrence of both acute and chronic low-back pain. One area of this research has focused on the identification of empirically based risk factors for back pain. The session will review those risks factors with the strongest empirical basis for predicting the onset of acute and/or development of chronic disabling low-back pain. Methods for assessing these risks factors by rehab providers across disciplines will be presented and guidelines for their accumulative usage in clinical practice will be provided. Finally, limits of application and future needs for research will be outlined. Application and extension of this very important clinical knowledge base has enormous potential to improve the quality and cost effectiveness of rehabilitative care for both acute and chronic low-back pain patients

Introduction: Radiculopathy may prolong F-wave Latency and reduce F-wave persistence. In this study, we investigate the relationship between F-wave parameters and clinical symptom/sign in L5 radiculopathic patients before and after APLD (Automatic Percntaneous Lumbar Discectomy). Method: F-wave latency and persistence of deep peroneal nerve were studied in 8 patients with L5 radiculopathy, who received APLD and had good results. To enhance the F-wave response, we used specific conditions, ie, surface electrodes, stronger stimulus and facilitating maneuver. The L5 radiculopathy was diagnosed by radicular pain, motor/sensory deficit and the MR/showed a compressive root lesion. Results: The mean value of deep peroneal F-wave persistence was 42.5 and 66.3 before and after APLD respectively. It showed significant increase of persistence after APLD (p < .05). The F-wave latency was 46.19 and 44.76 msec before and after APLD respectively. Although it showed no significant change (p > .05), but a

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trend of shortening of latency after APLD was noted. Conclusion: The improvement of clinical symptom and sign were well correlated with significant increase of F-wave persistence. Further studies will focus on intraoperative monitoring to promote the success rate of APLD.

"Familial Congenital Muscular Torticollis: Case Report and Review of the Literature." Yu-Ching Lin, MD (Show Chwan Memorial Hospital, Changhua, Taiwan); Chein-We Chang, MD; MingChou Ku, MD. Congenital muscular torticollis is a well-known clinical entity that has been recognized for centuries. Its real cause, however, is still unknown. Several theories have been proposed, such as intrauterine malposition, birth trauma, and ischemia resulting from venous occlusion, but none completely explain all the situations. The hereditary theory has not been well accepted because family histories are uncommon. We report a family of four siblings with three cases of torticollis. There are no identified environmental factors or perinatal insults, and the parents are not consanguineous. Complete radiologic studies ruled out the possibilities of congenital abnormalities or inherited diseases of the cervical spine. This family we report indicates that genetic factors may play a more important role than has previously been suspected in congenital muscular torticollis.

"Evaluation of Muscle Activities By Surface Electrode FES Using MRI." Misa Ogino, MD (Kurume University Rehabilitation Center, Fukuoka, Japan); Takaslii Maeda, PT; Naoto Shiba, MD; Shigeaki Matsuo, BS; Toshiyasu Yamamoto, PhD. Introduction: It has been reported that the signal intensity of magnetic resonance imaging (MRI) in the skeletal muscle increases after exercise. Making use of this phenomenon, activity of skeletal muscle can be evaluated noninvasively. The purpose of this study is to know the efficacy of this method for evaluating the muscle activities by surface electrode functional electric stimulation (S-FES). Method: Subject was young healthy man and the age was 26 years old. MRI was performed for the thigh before and after S-FES. The stimulation time was 15 minutes, and its pattern was usual gait pattern. Three parts of ROI, such as surface, medium, and deep layers of the vastus medialis muscle were examined, Result: The change of signal intensity was recognized visually, and T2 value in each layer was increased after stimulation significantly (p < .001). Conclusions: The activated muscles by S-FES can be evaluated using MRI. MRI will be helpful to determine the indication and limitation of S-FES.

Miscellaneous Topics

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"Medication Errors." Linda Stedman, BSN (Siskin Hospital for Physical Rehabilitation, Chattanooga, TN); Diane Johnson, MS. Driven in part by the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) new sentinel event policy and Health Care Financing Administration's (HCFA) "zero tolerance" of significant medication errors, one organization found it desirable to implement new strategies for prevention of medication errors. The project objective was to develop an audit system which promoted root cause analysis, examined potential, as well as actual harm to the patient, and incorporated the existing performance improvement process in the correction and elimination of the causes of medications errors. As no such tools or processes could be found through a review of current literature, one was developed based on analysis of institutional history of documented medication errors. The outcome resulted in revisions to existing processes allowing quantitative evaluation and comparison of errors as to potential harm to the patient, as well as the patient's actual reaction to the medication. Consequences of nursing errors were identified through a decision tree as to the level and frequency of the medication error(s), creating an objective system for follow-up actions. An interdisciplinary committee responsible for evaluating clinical practices was utilized for further analysis and recommendation of system changes which needed to occur as a result of the error(s).

"Referral to Rehabilitation One Year Postinjury: A Comparative Injury Analysis." William C. Yoels, PhD (University of Alabama, Birmingham, AL); Alfred A. Bartolucci, PhD; Wen@ Sykes-Horn, MPH. Using standardized data abstracted from 9 hospitals and i-year postinjury telephone interviews, we analyzed significant social and clinical factors in acute care discharge referral patterns for 1,115 persons with either traumatic brain injury (TBI), spinal cord injury (SCI), severe bums, or fractures. Independent variables included clinical injury characteristics, access to care, and sociodemographic characteristics. Multivariate linear regression showed that nearly 80% of SCI patients went to inpatient rehabilitation; more than 60% of the other injury referrals were to home self-care or nonskilled home care. For all injuries but fractures, injury severity most powerfully explained variance in discharge disposition. Controlling for injury type, being seen by a rehabilitation physician (an access to care variable) most powerfully predicted discharge dispositions. Those with fractures or severe burns were referred directly to higher levels of care without being seen by rehabiliation physicians. SCI patients were referred to higher levels of care based on severity alone. Increased severity led to higher levels of care for TBI patients who were not seen by rehabilitation physicians. For TBI patients seen by rehabilitation physicians, private insurance was the only significant predictor of discharge disposition. We show the relative importance of specific variables in the discharge disposition process.

"Sexuality Information Among Women With and Without Physical Disabilities." Laurie Jeanne Walter, PhD (Baylor College of Medicine, Houston, TX); Margaret A. Nosek, PhD.

"Ethical Decision-Making in Rehabilitation." Nicky Ozbek, PhD (Siskin Hospital for Physical Rehabilitation, Chattanooga, TN); Keith Munford, MDiv; David Eberle, MD Liv Miller, BS.

A paucity of information is available on the acquisition of sexuality information by women with physical disabilities. The purpose of this study was to compare differences in how women with disabilities and without disabilities learned about their sexuality. Questionnaires and postage-paid envelopes were mailed to approximately 1,060 women with physical disabilities. Each woman was also sent a similar questionnaire and postage-paid envelope to give to a nondisabled friend. Four hundred seventy-five women with disabilities and 406 women without disabilities between ages 18 and 65 returned questionnaires. Women with disabilities learned about the physical aspects of sexual intercourse at the same age as women without disabilities. More women with disabilities reported learning about sexuality from a college course than did women without disabilities, and more received advice or information from a woman with a disability and a rehabilitation counselor. Women with physical disabilities had their first date later than women without physical disabilities. Age in acquiring sexuality information was not associated with either frequency of intimate touch or frequency of sexual intercourse. Environmental and attitudinal barriers may explain these differences.

Participants attending an ethics seminar sponsored by a physical rehabilitation hospital were asked to complete a survey outlining two case vignettes: one involved a family member, and one where alcohol consumption contributed to injury. It was hypothesized and substantiated from this survey that the two factors of relationship to the patient, as well as presumption of blame, would change the decision-making process regarding discharge planning. When choosing between options for the patient with alcohol-related injury, less expensive treatment options, such as Day Hospital, were frequently selected by respondents. When making choices for family members, indications of costconsciousness decreased from 30% to 10% and were replaced by an attitude of "doing everything possible" to maximize an inpatient stay when it was perceived as desirable. Data also indicated that underlying reasons for choices made changed as well, based on relationship to patient and respondent's opinion regarding blame. This sample of personal values influencing rehabilitation decision-making is applied to the principles of bioethics within general rehabilitation settings. An ethics checklist to use during review of policies and procedures is also provided.

Arch Phys Med Rehabil Vol 80, August 1999