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*Poster 76: Physical and Occupational Therapy in Inpatient Stroke Rehabilitation: the Contribution of Therapists and Their Extenders
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2010 ACRM–ASNR JOINT EDUCATIONAL CONFERENCE ABSTRACTS
*Poster 76 Physical and Occupational Therapy in Inpatient Stroke Rehabilitation: the Contribution of Therapists and Their Extenders. Jean Hsieh (National Rehabilitation Hospital, Washington, DC), Koen Putman, Gerben DeJong, Randall Smout, Susan Horn. Disclosure: None declared. Objective: To understand the use of therapy extenders in stroke rehabilitation. Design: Prospective observational cohort study. Setting: 5 inpatient rehabilitation facilities. Participants: 298 moderate and 284 severe stroke patients based on case mix groups (CMGs) with complete physical therapy (PT) and occupational therapy (OT) data were included. Interventions: Not applicable. Main Outcome Measures: Amount, type, and proportions of therapeutic activities provided by therapists and their extenders in PT and OT. Results: Overall, occupational therapists and assistants contributed approximately 70% and 21% of all occupational therapy hours, respectively. For physical therapy, these percentages in the moderate group (60% vs 31%) differ from those in the severe group (65% vs 23%). Some variations in use of therapy-support personnel are noted in both disciplines across sites. Physical and occupational therapists are more involved in the delivery of advanced activities that involve ongoing integrated evaluation and treatment planning or modification (between 52% and 74% in PT; between 70% and 79% in OT). Their assistants are more involved in delivering lower-level activities such as bed mobility, transfers, dressing or nonfunctional activities (between 25% and 40% for PT assistants; between 26% and 31% for OT assistants). Therapists are also more likely to assign responsibility to assistants to treat less severely involved patients (P⬍.05). Conclusions: Characterizing therapy practice in stroke rehabilitation is multifactorial. A comprehensive picture requires taking into account, but not limited to, (1) type of therapy, (2) therapy activity, (3) therapy provider (eg, therapy extenders, expertise, and experience), and (4) severity of stroke. Future research to examine the association between use of therapy extenders and outcomes is recommended. Key Words: Occupational therapy; Rehabilitation; Stroke. Poster 77 Geographic Patterns in Rehabilitation Outcomes Following Stroke. Timothy Reistetter (University of Texas Medical Branch, Galveston, TX), James Graham, Anne Deutsch, Amol Karmarker, Karl Eschbach, Carl Granger, Kenneth Ottenbacher. Disclosure: None declared. Objective: To determine the geographic variations in length of stay (LOS), functional status, and community discharge for a national sample of individuals who received inpatient rehabilitation services following a stroke Design: Retrospective cross sectional design. Setting: 929 inpatient rehabilitation facilities in the United States who contribute to the Uniform Data System for Medical Rehabilitation across 10 geographic regions (Center for Medicare and Medicaid Services [CMS] regions). Participants: 144,929 patients discharged from inpatient rehabilitation in 2006 to 2007 following a stroke. Interventions: Not applicable. Main Outcome Measures: Regression models for region specific LOS, discharge FIM instrument rating and discharge destination (community vs institutional setting) adjusting for influential individual and illness severity covariates. Results: The mean age was 70.6 years. The sample was 51.6% female and 50% married. The most common stroke type was an ischemic event. The average number of comorbidities was 7.8 with an admission FIM rating of 56.2. The average LOS was 16.6 days with a discharge FIM rating of 81.4. 71% of the patients returned to the community following rehabilitation. After adjusting for covariates length of stay varied by 2 days, functional status varied by 5 FIM ratings points and community discharge varied by 17% across CMS regions. ConcluArch Phys Med Rehabil Vol 91, October 2010
sions: There is geographic variability in outcomes following inpatient rehabilitation for stroke even after adjusting for influential individual and illness severity covariates. These differences have implications for therapists and discharge planners who assist individuals in transitioning from rehabilitation to community or other settings. Facility administrators, advocates and policy makers should consider regional variation when allocating funds and developing programs to meet the rehabilitation needs of individuals within their communities. Additional research is needed to examine facility and regional factors that contribute to the variation in outcomes. Key Words: Outcomes assessment (health care); Rehabilitation; Stroke. Poster 78 Lower-Extremity Dressing for Persons With Quadriplegia: What are the Long-Term Outcomes? Nancy Flinn (Courage Center, Minneapolis, MN), Kim Storm. Disclosure: None declared. Objective: To determine the benefit of lower-extremity dressing training for individuals with quadriplegia. Design: Structured interviews with 29 former clients provided insight into the benefits of lower-extremity dressing for these clients. Setting: A 48-bed inpatient rehabilitation program in a skilled nursing facility. Participants: Participants had been clients in the skilled nursing facility in the last 7 years, with a spinal cord injury level C5 through C7. 29 clients agreed to participate in phone interviews. Clients had an average length of stay of 8.5 months and average age of clients of 46 years. Intervention: Structured interview by phone. Main Outcome Measures: Former clients were asked about their lower-extremity dressing status at discharge and currently, with specific focus on those clients who were not currently dressing independently. Results: At discharge, 21 of these clients needed assistance with lower-extremity dressing (53% dependent, 47% needed some assistance). At the time of the follow-up call, 20 of the clients needed assistance (80% dependent, 20% needed some assistance). Those clients who were currently independent in lower-extremity dressing stated that they had continued to make gains after their discharge, which made dressing easier. For those who needed assistance, when asked why they used assistance with lowerextremity dressing, 57% said it was easier to have someone help, 39% reported that they had never been independent in lower-extremity dressing, 26% reported too much pain and stiffness during lowerextremity dressing, and 21% reported that they preferred to save their energy for things they enjoyed. Conclusions: The appropriateness of lower-extremity dressing training should be evaluated on an individual basis, particularly in light of available assistance at home, pain or stiffness during the task, and the potential for successful performance of the task. Key Words: Rehabilitation; Self care; Spinal cord injuries. Poster 79 Task-Oriented Locomotor Training With and Without Load at the Ankle in Stroke Individuals. Cyril Duclos (Centre for Interdisciplinary Research in Rehabilitation, Institut de Re´adaptation Gingras-Lindsay-de-Montre´al; School of Rehabilitation, Faculty of Medicine, Universite´ de Montre´al, Montre´al, QC, Canada), Sylvie Nadeau, Laurent Bouyer, Carol L. Richards. Disclosure: None declared. Objective: To test the impact of a load placed at the ankle during treadmill locomotor training on the paretic hip muscle strength and gait performance in stroke patients. Design: Cross-design study. Setting: Research laboratory at a university-affiliated inpatient rehabilitation hospital. Participants: 10 chronic-stroke participants (56.3⫾10.5y) with hip weakness on the paretic side and reduced gait speed (0.66⫾0.19m.s-1). Intervention: Treadmill gait training during
2010 ACRM–ASNR JOINT EDUCATIONAL CONFERENCE ABSTRACTS
*Poster 76 Physical and Occupational Therapy in Inpatient Stroke Rehabilitation: the Contribution of Therapists and Their Extenders. Jean Hsieh (National Rehabilitation Hospital, Washington, DC), Koen Putman, Gerben DeJong, Randall Smout, Susan Horn. Disclosure: None declared. Objective: To understand the use of therapy extenders in stroke rehabilitation. Design: Prospective observational cohort study. Setting: 5 inpatient rehabilitation facilities. Participants: 298 moderate and 284 severe stroke patients based on case mix groups (CMGs) with complete physical therapy (PT) and occupational therapy (OT) data were included. Interventions: Not applicable. Main Outcome Measures: Amount, type, and proportions of therapeutic activities provided by therapists and their extenders in PT and OT. Results: Overall, occupational therapists and assistants contributed approximately 70% and 21% of all occupational therapy hours, respectively. For physical therapy, these percentages in the moderate group (60% vs 31%) differ from those in the severe group (65% vs 23%). Some variations in use of therapy-support personnel are noted in both disciplines across sites. Physical and occupational therapists are more involved in the delivery of advanced activities that involve ongoing integrated evaluation and treatment planning or modification (between 52% and 74% in PT; between 70% and 79% in OT). Their assistants are more involved in delivering lower-level activities such as bed mobility, transfers, dressing or nonfunctional activities (between 25% and 40% for PT assistants; between 26% and 31% for OT assistants). Therapists are also more likely to assign responsibility to assistants to treat less severely involved patients (P⬍.05). Conclusions: Characterizing therapy practice in stroke rehabilitation is multifactorial. A comprehensive picture requires taking into account, but not limited to, (1) type of therapy, (2) therapy activity, (3) therapy provider (eg, therapy extenders, expertise, and experience), and (4) severity of stroke. Future research to examine the association between use of therapy extenders and outcomes is recommended. Key Words: Occupational therapy; Rehabilitation; Stroke. Poster 77 Geographic Patterns in Rehabilitation Outcomes Following Stroke. Timothy Reistetter (University of Texas Medical Branch, Galveston, TX), James Graham, Anne Deutsch, Amol Karmarker, Karl Eschbach, Carl Granger, Kenneth Ottenbacher. Disclosure: None declared. Objective: To determine the geographic variations in length of stay (LOS), functional status, and community discharge for a national sample of individuals who received inpatient rehabilitation services following a stroke Design: Retrospective cross sectional design. Setting: 929 inpatient rehabilitation facilities in the United States who contribute to the Uniform Data System for Medical Rehabilitation across 10 geographic regions (Center for Medicare and Medicaid Services [CMS] regions). Participants: 144,929 patients discharged from inpatient rehabilitation in 2006 to 2007 following a stroke. Interventions: Not applicable. Main Outcome Measures: Regression models for region specific LOS, discharge FIM instrument rating and discharge destination (community vs institutional setting) adjusting for influential individual and illness severity covariates. Results: The mean age was 70.6 years. The sample was 51.6% female and 50% married. The most common stroke type was an ischemic event. The average number of comorbidities was 7.8 with an admission FIM rating of 56.2. The average LOS was 16.6 days with a discharge FIM rating of 81.4. 71% of the patients returned to the community following rehabilitation. After adjusting for covariates length of stay varied by 2 days, functional status varied by 5 FIM ratings points and community discharge varied by 17% across CMS regions. ConcluArch Phys Med Rehabil Vol 91, October 2010
sions: There is geographic variability in outcomes following inpatient rehabilitation for stroke even after adjusting for influential individual and illness severity covariates. These differences have implications for therapists and discharge planners who assist individuals in transitioning from rehabilitation to community or other settings. Facility administrators, advocates and policy makers should consider regional variation when allocating funds and developing programs to meet the rehabilitation needs of individuals within their communities. Additional research is needed to examine facility and regional factors that contribute to the variation in outcomes. Key Words: Outcomes assessment (health care); Rehabilitation; Stroke. Poster 78 Lower-Extremity Dressing for Persons With Quadriplegia: What are the Long-Term Outcomes? Nancy Flinn (Courage Center, Minneapolis, MN), Kim Storm. Disclosure: None declared. Objective: To determine the benefit of lower-extremity dressing training for individuals with quadriplegia. Design: Structured interviews with 29 former clients provided insight into the benefits of lower-extremity dressing for these clients. Setting: A 48-bed inpatient rehabilitation program in a skilled nursing facility. Participants: Participants had been clients in the skilled nursing facility in the last 7 years, with a spinal cord injury level C5 through C7. 29 clients agreed to participate in phone interviews. Clients had an average length of stay of 8.5 months and average age of clients of 46 years. Intervention: Structured interview by phone. Main Outcome Measures: Former clients were asked about their lower-extremity dressing status at discharge and currently, with specific focus on those clients who were not currently dressing independently. Results: At discharge, 21 of these clients needed assistance with lower-extremity dressing (53% dependent, 47% needed some assistance). At the time of the follow-up call, 20 of the clients needed assistance (80% dependent, 20% needed some assistance). Those clients who were currently independent in lower-extremity dressing stated that they had continued to make gains after their discharge, which made dressing easier. For those who needed assistance, when asked why they used assistance with lowerextremity dressing, 57% said it was easier to have someone help, 39% reported that they had never been independent in lower-extremity dressing, 26% reported too much pain and stiffness during lowerextremity dressing, and 21% reported that they preferred to save their energy for things they enjoyed. Conclusions: The appropriateness of lower-extremity dressing training should be evaluated on an individual basis, particularly in light of available assistance at home, pain or stiffness during the task, and the potential for successful performance of the task. Key Words: Rehabilitation; Self care; Spinal cord injuries. Poster 79 Task-Oriented Locomotor Training With and Without Load at the Ankle in Stroke Individuals. Cyril Duclos (Centre for Interdisciplinary Research in Rehabilitation, Institut de Re´adaptation Gingras-Lindsay-de-Montre´al; School of Rehabilitation, Faculty of Medicine, Universite´ de Montre´al, Montre´al, QC, Canada), Sylvie Nadeau, Laurent Bouyer, Carol L. Richards. Disclosure: None declared. Objective: To test the impact of a load placed at the ankle during treadmill locomotor training on the paretic hip muscle strength and gait performance in stroke patients. Design: Cross-design study. Setting: Research laboratory at a university-affiliated inpatient rehabilitation hospital. Participants: 10 chronic-stroke participants (56.3⫾10.5y) with hip weakness on the paretic side and reduced gait speed (0.66⫾0.19m.s-1). Intervention: Treadmill gait training during