A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?

https://www.nejm.org/doi/pdf/10.1056/NEJMcp043511

Rehabilitation after Stroke

OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge.

DESIGN: Observational.

SETTING: Tertiary care hospital, community teaching hospital.

PARTICIPANTS: Older (aged ≥70) patients nonelectively admitted to general medical services (1993–1998).

MEASUREMENTS: Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point.

RESULTS: By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover.

CONCLUSION: For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.

Recovery of activities of daily living in older adults after hospitalization for acute medical illness

Objective To assess the effects of inpatient rehabilitation specifically designed for geriatric patients compared with usual care on functional status, admissions to nursing homes, and mortality.

Design Systematic review and meta-analysis.

Data sources Medline, Embase, Cochrane database, and reference lists from published literature.

Review methods Only randomised controlled trials were included. Trials had to report on inpatient rehabilitation and report at least one of functional improvement, admission to nursing homes, or mortality. Trials of consultation or outpatient services, trials including patients aged <55, trials of non-multidisciplinary rehabilitation, and trials without a control group receiving usual care were excluded. Data were double extracted. Odds ratios and relative risks with 95% confidence intervals were calculated.

Results 17 trials with 4780 people comparing the effects of general or orthopaedic geriatric rehabilitation programmes with usual care were included. Meta-analyses of effects indicated an overall benefit in outcomes at discharge (odds ratio 1.75 (95% confidence interval 1.31 to 2.35) for function, relative risk 0.64 (0.51 to 0.81) for nursing home admission, relative risk 0.72 (0.55 to 0.95) for mortality) and at end of follow-up (1.36 (1.07 to 1.71), 0.84 (0.72 to 0.99), 0.87 (0.77 to 0.97), respectively). Limited data were available on impact on health care or cost. Compared with those in control groups, weighted mean length of hospital stay after randomisation was longer in patients allocated to general geriatric rehabilitation (24.5 v 15.1 days) and shorter in patients allocated to orthopaedic rehabilitation (24.6 v 28.9 days).

Conclusion Inpatient rehabilitation specifically designed for geriatric patients has the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes.

https://www.bmj.com/content/bmj/340/bmj.c1718.full.pdf

Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials

An important goal in rehabilitation engineering is to develop technology that allows individuals with severe motor impairment to practice arm movement without continuous supervision from a rehabilitation therapist. This paper describes the development of such a system, called Therapy WREX or ("T-WREX"). The system consists of an orthosis that assists in arm movement across a large workspace, a grip sensor that detects hand grip pressure, and software that simulates functional activities. The arm orthosis is an instrumented, adult-sized version of the Wilmington Robotic Exoskeleton (WREX), which is a five degrees-of-freedom mechanism that passively counterbalances the weight of the arm using elastic bands. After providing a detailed design description of T-WREX, this paper describes two pilot studies of the system's capabilities. The first study demonstrated that individuals with chronic stroke whose arm function is compromised in a normal gravity environment can perform reaching and drawing movements while using T-WREX. The second study demonstrated that exercising the affected arm of five people with chronic stroke with T-WREX over an eight week period improved unassisted movement ability (mean change in Fugl-Meyer score was 5 points plusmn2 SD; mean change in range of motion of reaching was 10%, p<0.001). These results demonstrate the feasibility of automating upper-extremity rehabilitation therapy for people with severe stroke using passive gravity assistance, a grip sensor, and simple virtual reality software

/pdf/automating-arm-movement-training-following-severe-stroke-16dad98lxo.pdf

Automating Arm Movement Training Following Severe Stroke: Functional Exercises With Quantitative Feedback in a Gravity-Reduced Environment

Background/Objective. The authors previously developed a passive instrumented arm orthosis (Therapy Wilmington Robotic Exoskeleton [T-WREX]) that enables individuals with hemiparesis to exercise th...

/pdf/a-randomized-controlled-trial-of-gravity-supported-computer-4fsli2g7x5.pdf

A randomized controlled trial of gravity-supported, computer-enhanced arm exercise for individuals with severe hemiparesis.

ContextChanges in reimbursement have reduced length of stay (LOS) for patients
receiving inpatient medical rehabilitation. The impact of decreased LOS on
functional status, living setting, and mortality is not known.ObjectiveTo examine changes in LOS, functional status, living setting, and mortality
in patients completing inpatient rehabilitation.DesignRetrospective cohort study from 1994 through 2001 using information
submitted to the Uniform Data System for Medical Rehabilitation.Setting and ParticipantsData were analyzed from 744 inpatient medical rehabilitation hospitals
and centers located in 48 US states. A total of 148 807 patient records
from 5 impairment groups (stroke, brain dysfunction, spinal cord dysfunction,
other neurologic conditions, and orthopedic conditions) were examined. Patients’
mean age was 67.8 (SD, 15.8) years; the sample was 59% female and 81% non-Hispanic
white.Main Outcome MeasuresDischarge setting, follow-up living setting, change in functional status,
and mortality.ResultsMedian LOS decreased from 20 to 12 days (P<.001)
from 1994 to 2001. The proportional decrease in median LOS was greatest (42%)
for patients with orthopedic conditions. Mean days to follow-up remained constant
from 89 in 1994 to 90 in 2001. Functional status was clinically stable, while
efficiency (functional status change divided by LOS) increased significantly
(P<.001). Rates of discharge to home and living
at home at follow-up remained stable, ranging from 81% to 93%. However, mortality
at 80- to 180-day follow-up increased from less than 1% in 1994 to 4.7% in
2001.ConclusionsLength of stay for inpatient rehabilitation decreased substantially
from 1994 to 2001. Effectiveness as measured by change in functional status
did not change clinically, and living setting did not change. Efficiency for
functional outcomes improved but mortality at follow-up increased.

https://jamanetwork.com/journals/jama/articlepdf/199580/JOC32252.pdf

Santira B. Illig

Papers

Trends in length of stay, living setting, functional outcome, and mortality following medical rehabilitation.