Post-Stroke
Rehabilitation Outcomes Project (PSROP)
Data are from 2001-2003. Funded by National Institute of Disability and Rehabilitation Research. The goal of this study was to determine the optimal type, intensity, and duration of rehabilitation treatments for post-stroke patients. Using Practice Based Evidence Clinical Improvement research methodology, we examined the difference in post-stroke rehabilitation outcomes for various treatment modalities while controlling for severity of illness and other patient factors.
Opening the Black Box of Post-stroke Rehabilitation:
Stroke Rehabilitation Patients, Processes, and Outcomes. Gerben DeJong, PhD,
Susan D. Horn, PhD, Brendan Conroy, MD, Diane Nichols, PT, NCS, Edward B.
Healton, MD, MPH. Arch Phys Med
Rehabil 2005:86 (12 Suppl 2):S1-7.
This article introduces the journal’s
supplement devoted to the methods and findings of the 7-site Post-Stroke
Rehabilitation Outcomes Project (PSROP), a study designed to provide a very
granular in-depth understanding of stroke rehabilitation practice and how
practice is related to outcomes. The article summarizes current knowledge about
the effectiveness of post-stroke rehabilitation, outlines where the PSROP fits
into the broader traditions of stroke rehabilitation outcomes research,
underscores the study’s methodologic innovations, and summarizes the scope of
the articles that follow.
Key Words: Intervention
studies; Rehabilitation; Stroke; Treatment outcome.
Another
Look at Observational Studies in Rehabilitation Research: Going Beyond the Holy
Grail of the Randomized Controlled Trial. Susan D. Horn, PhD, Gerben DeJong,
PhD, David K. Ryser, MD, Peter J. Veazie, PhD, Jeffrey Teraoka, MD. Arch
Phys Med Rehabil 2005:86 (12 Suppl 2):S8-15.
This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the “black box” of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.
Key Words: Cerebrovascular accident; Clinical practice variations; Rehabilitation; Treatment outcomes.
Applying the Clinical Practice Improvement Approach to Stroke Rehabilitation: Methods Used and Baseline Results. Julie Gassaway, RN, MS, Susan D. Horn , PhD, Gerben DeJong, , PhD, Randall J. Smout , MS, Crystal Clark , MD, MPH, Roberta James, MStat. Arch Phys Med Rehabil 2005:86 (12 Suppl 2):S16-33.
Objectives: To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP).
Design: Prospective observational cohort study.
Setting: Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand.
Participants: Consecutive convenience sample of 1291 post-stroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs).
Interventions: Not applicable.
Main Outcome Measures: Change in FIM score, change in severity of illness, and discharge destination.
Results: For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4.
Conclusions: This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.
Key Words: Outcome assessment (health care), Rehabilitation, Severity of illness index, Stroke.
Timing of Initiation of Rehabilitation After Stroke. Sarah A. Maulden, MD, MS, Julie Gassaway , MS, RN, Susan D. Horn, PhD, Randall J. Smout, MS, Gerben DeJong, PhD, Arch Phys Med Rehabil 2005:86 (12 Suppl 2):S34-40.
Objective: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables.
Design: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities.
Setting: Six U.S. inpatient rehabilitation hospitals.
Participants: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records.
Interventions: Not applicable.
Main Outcome Measures: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS).
Results: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108–114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104–107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS.
Conclusions: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.
Physical Therapy During Stroke Rehabilitation for People With Different Walking Abilities. Nancy K. Latham, PhD, PT, Diane U. Jette, DSc, PT, Mary Slavin, PhD, PT, Lorie G. Richards, PhD, OTR, Adam Procino, PT, Randall J. Smout, MS, Susan D. Horn, PhD. Arch Phys Med Rehabil 2005:86(12 Suppl 2):S41-50.
Objective: To describe how physical therapy (PT) activities during post-stroke inpatient rehabilitation vary by admission walking ability and over time.
Design: Observational cohort study.
Setting: Six inpatient rehabilitation hospitals in the United States.
Participants: People receiving post-stroke PT (N=715) who were classified as walking at admission.
Interventions: Not applicable.
Main Outcome Measures: Percentage of time spent in 11 activities, percentage of patients who participated in each activity, and the FIM instrument scores.
Results: The majority of PT time was spent in gait activities. Even people with the most limited mobility spent 25% to 38% of PT time in gait activities during the first 6-hour treatment block. Treatment progression was evident, and a shift to more advanced activities occurred over time (e.g., less bed mobility and more advanced gait). However, even in the final 6-hour block, a small proportion of time was spent on community mobility activities (1.2%–5.2%), and most people received no community mobility training.
Conclusions: PT activities focused on specific functional tasks at the ability level of each individual patient and provided higher-level activities as patients improved their function. However, although there is increasing recognition that the environment influences task performance, little time was spent in community mobility activities before discharge.
Key Words: Clinical practice patterns, Physical therapy, Rehabilitation, Stroke, Walking
Characterizing Occupational Therapy Practice in Stroke Rehabilitation. Lorie G. Richards, PhD, OTR, Nancy K. Latham, PhD, PT, Diane U. Jette, PhD, PT, Lauren Rosenberg, OTR, Randall J. Smout, MS, Gerben DeJong, PhD. Arch Phys Med Rehabil 2005:86 (12 Suppl 2):S51-60.
Objectives: To describe how occupational therapy (OT) activities during stroke inpatient rehabilitation vary by admission functional status and over time and how time spent in these various activities relates to functional status at discharge.
Design: Observational cohort study.
Setting: Six inpatient rehabilitation hospitals in the United States.
Participants: People (N=713) receiving 4 to 19 hours of post-stroke OT.
Interventions: Not applicable.
Main Outcome Measures: Patients were categorized by number of 4-hour blocks of OT received and by admission upper-extremity (UE) dressing score on the FIM instrument. In each group, the percentage of time spent in 16 activities and the percentage of patients who received each activity were calculated. The amount of time in activities was compared for those patients scoring 1 or 2 at admission who achieved at least a level of supervision for UE dressing (a score of ≥5) using Wilcoxon 2-sample tests.
Results: The majority of OT time was spent in impairment-focused activities (37.5%) or training basic activities of daily living (31.9%). Treatment progressed to more advanced activities over time (eg, less bed mobility, more home management), yet little time was spent on community integration or leisure activities and with very few patients. Successful patients received more higher-level activities, whereas unsuccessful patients received larger amounts of basic-level activities.
Conclusions: OT activities focused on a combination of remediating impairments and retraining specific functional tasks, at the ability level of each individual patient, and provided higher-level activities as patients improved their function. More time in higher-level activities was related to greater success in rehabilitation. However, higher-level activities remain the least common activities provided during inpatient rehabilitation.
Key Words: Activities of daily living, Clinical practice patterns, Cerebrovascular accident, Occupational therapy, Rehabilitation.
Characterizing Speech and Language Pathology Outcomes in Stroke Rehabilitation. Brooke Hatfield, MS, CCC-SLP, Deborah Millet, MS, CCC-SLP, Janice Coles, MS, CCC-SLP, Julie Gassaway, MS, RN, Brendan Conroy, MD, Randall J. Smout, MS. Arch Phys Med Rehabil 2005:86 (12 Suppl 2):S61-72.
Objectives: To describe a subset of speech-language pathology (SLP) patients in the Post-Stroke Rehabilitation Outcomes Project and to examine outcomes for patients with low admission FIM levels of auditory comprehension and verbal expression.
Design: Observational cohort study.
Setting: Five inpatient rehabilitation hospitals.
Participants: Patients (N=397) receiving post-stroke SLP with admission FIM cognitive components at levels 1 through 5.
Interventions: Not applicable.
Main Outcome Measure: Increase in comprehension and expression FIM scores from admission to discharge.
Results: Cognitively and linguistically complex SLP activities (problem-solving and executive functioning skills) were associated with greater likelihood of success in low- to mid-level functioning communicators in the acute post-stroke rehabilitation period.
Conclusions: The results challenge common clinical practice by suggesting that use of high-level cognitively and linguistically complex SLP activities early in a patient’s stay may result in more efficient practice and better outcomes regardless of the patient’s functional communication severity level on admission.
Key Words: Auditory perceptual disorders, Clinical practice patterns, Problem solving, Rehabilitation, Speech therapy, Stroke.
An Exploration of Central Nervous System Medication Use and Outcomes in Stroke Rehabilitation. Brendan Conroy, MD, Richard Zorowitz, MD, Susan D. Horn, PhD, David K. Ryser, MD, Jeff Teraoka, MD, Randall J. Smout, MS, Arch Phys Med Rehabil 2005:86 (12 Suppl 2):S73-81.
Objective: To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables.
Design: Observational cohort study of post-stroke rehabilitation.
Setting: Six inpatient rehabilitation hospitals in the United States.
Participants: Patients with moderate or severe strokes (N=919).
Interventions: Not applicable.
Main Outcome Measures
Discharge disposition, FIM score change, and rehabilitation length of stay (LOS).
Results: Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neurostimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counterintuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation.
Conclusions: There are many opportunities to enhance a stroke survivor’s ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.
Key Words: Antipsychotic agents,
Clinical practice variations, Rehabilitation, Stroke, Treatment outcome.
Nutrition Support (Tube Feeding) as a Rehabilitation Intervention.
Roberta James, MStat,
Deon Gines, RD, CD, PhD,
Angela Menlove, MS, CCC-SLP, Susan D. Horn, PhD, Julie Gassaway,
MS, RN, Randall J. Smout, MS.
Arch Phys Med
Rehabil 2005:86 (12 Suppl 2):S82-92.
Objective: To describe site variation in use of enteral feeding and its association with stroke rehabilitation outcomes, controlling for a variety of confounding variables.
Design: Prospective observational cohort study.
Setting: Six inpatient rehabilitation facilities in the United States.
Participants: Patients (N=919) from the Post-Stroke Rehabilitation Outcomes Project database with moderate or severe stroke who were discharged to home, community, or skilled nursing facility.
Interventions: Not applicable.
Main Outcome Measures: Change in total, motor, and cognitive FIM instrument scores and change in severity of illness.
Results: Monitoring of nutritional status and the frequency of tube-feeding interventions for patients with moderate and severe stroke varied significantly among sites. Patients with tube feeding had higher severity of illness and lower functioning on admission compared with patients who did not receive tube feeding. However, when we controlled for severity of illness, admission FIM score, and other important covariates, we found that patients with severe strokes who were tube fed for more than 25% of their stay had greater increases in total, motor, and cognitive FIM scores and greater improvement in severity of illness by discharge.
Conclusions: Nutrition support (tube feeding) is an effective therapy in rehabilitation service for patients with severe strokes and is associated with greater motor and cognitive improvements, even in patients with the most severe strokes.
Key Words: Cerebrovascular accident, Nutrition, Outcome assessment (health care), Rehabilitation, Severity of illness index, Tube feeding.
The Early Impact of the Inpatient Rehabilitation Facility Prospective
Payment System on Stroke Rehabilitation Case Mix, Practice Patterns, and
Outcomes. Gerben DeJong, PhD, Susan D.
Horn, PhD,
Randall J. Smout, MS,
David K. Ryser, MD.
Arch Phys Med Rehabil
2005:86(12 Suppl 2):S93-100.
Objective: To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes.
Design: Prospective observational cohort study.
Setting: Three IRFs in the United States.
Participants: Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs.
Interventions: Not applicable.
Main Outcome Measures: Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination.
Results: The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities.
Conclusions: For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study’s findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS.
Key Words: Prospective payment system, Rehabilitation
Stroke
Rehabilitation Patients, Practice, and Outcomes: Is Earlier and More Aggressive
Therapy Better?
Susan D. Horn, PhD,
Gerben DeJong,
PhD.,
Randall J. Smout, MS, Julie Gassaway, MS, RN, Roberta James, MStat., Brendan Conroy, MD. Arch Phys Med Rehabil 2005:86 (12 Suppl 2):S101-14.
Objective: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients.
Design: Prospective observational cohort study.
Setting: Five U.S. inpatient rehabilitation facilities.
Participants: Post-stroke rehabilitation patients (N=830; age, >18y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database.
Interventions: Not applicable.
Main Outcome Measures: Discharge total, motor, and cognitive FIM scores and discharge destination.
Results: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes.
Conclusions: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.
Key Words: Cerebrovascular accident, Outcome assessment, Rehabilitation, Severity of illness, Stroke.
A Comparison of
Stroke Rehabilitation Practice and Outcomes Between New Zealand and United
States Facilities. Harry McNaughton, PhD,
Gerben DeJong, PhD., Randall J. Smout, MS, John L. Melvin,
MD, MMSc.,
Murray Brandstater, MD.
Arch Phys Med Rehabil
2005:86(12 Suppl 2):S115-20.
Objective: To compare stroke rehabilitation practice and outcomes between New Zealand (NZ) and the United States.
Design: Prospective observational cohort study.
Setting: Seven inpatient rehabilitation facilities (IRFs) in the United States and NZ.
Participants: Consecutive convenience sample of 1161 patients in 6 U.S. IRFs and 130 in 1 NZ IRF (age, >18y) after acute stroke.
Interventions: Not applicable.
Main Outcome Measures: Change in FIM score and discharge destination.
Results: NZ participants were older than U.S. participants (mean: 74.1y vs 66.0y, respectively; P<.001). Measures of initial stroke severity were higher for U.S. participants. Mean rehabilitation length of stay (LOS) was shorter for U.S. participants (18.6d vs 30.0d, P<.001), but physical and occupational therapy time per patient was considerably higher despite the shorter LOS. U.S. therapists were involved in more active therapies for more of the time. Outcomes were better for U.S. participants, with fewer discharged to institutional care (13.2% vs 21.5%, P=.006) and larger changes in FIM scores.
Conclusions: U.S. participants with acute stroke who were selected for rehabilitation had better outcomes than NZ participants, despite shorter stays in the rehabilitation facility. U.S. participants had more intensive input from physiotherapists and occupational therapists, which may explain some of the larger increases in FIM scores. This suggests that further studies with tighter controls on case mix may add additional information on the effects of therapy intensity on patients with stroke.
Key Words: Cerebrovascular accident, Health care systems, Outcome assessment (health care), Rehabilitation.
The Post-Stroke
Rehabilitation Outcomes Project. Kenneth J. Ottenbacher, PhD, Arch Phys Med Rehabil
2005:86 (12 Suppl 2):S121-3.
The Post-Stroke Rehabilitation Outcomes Project (PSROP) examined a large sample of patients from multiple facilities receiving inpatient stroke rehabilitation services. This commentary describes strengths and potential limitations of the investigation including selection bias, observation bias, confounds, and interpretation. The PSROP is an important study that will advance our understanding of effective treatment for persons with stroke.
Key Words: Rehabilitation, Stroke
The Post-Stroke Rehabilitation Outcomes Project. Alan M. Jette, PT, PhD
The Post-Stroke Rehabilitation Outcomes Project (PSROP) provides an important example of the value of observational study designs in rehabilitation. The strength of the PSROP lies in the extensive, in-depth data collected on the specific rehabilitation interventions provided to patients and their relationship to short-term outcomes as well as the wide generalizability of the study’s findings. Although providing valuable insights, one has to be extremely cautious in drawing direct practice recommendations from the PSROP given several internal validity threats inherent in the PSROP design.
Key Words: Rehabilitation, Stroke
Prophylaxis for and Treatment
of Deep Venous Thrombosis After Stroke: The Post-Stroke Rehabilitation Outcomes
Project (PSROP)
Deep venous thrombosis (DVT) is a common and preventable complication after a stroke. Although the treatment of DVT is simple and straightforward, its prevention remains controversial. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the incidence and temporal sequence of DVT and trends in the prevention and treatment of DVT. Of the 1,161 patients in the PSROP database, 383 (32.99%) patients without DVT and 8 (0.69%) with DVT had no documented orders for anticoagulant medications. Sixty-five (5.60%) patients had DVTs during the inpatient rehabilitation facility stay. Of 10 (0.86%) patients with DVTs in the common femoral vein, 4 (40%) were diagnosed within 24 hours of admission. Nine (90%) of these 10 patients were classified as moderate or severe strokes. All patients with common femoral DVT received appropriate therapy. Although much is known about the prevention, diagnosis, and treatment of post-stroke DVT, clinicians need to learn and apply treatment protocols to prevent DVTs and allow more quality time for rehabilitation.
Key Words: cerebrovascular disorders, cerebrovascular accident, rehabilitation, venous thrombosis
Antiplatelet and
Anticoagulant Medication Usage During Stroke Rehabilitation: The Post-Stroke
Rehabilitation Outcomes Project (PSROP)
Secondary prevention of strokes is an important issue during the admission to the inpatient rehabilitation facility (IRF). There are many clinical practice guidelines with strong levels of evidence that address the secondary prophylaxis of strokes. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the frequency that antiplatelet and/or anticoagulant medications are prescribed for the secondary prophylaxis of a stroke. Of the 1,161 participants in the PSROP, 890 (76.66%) had non-hemorrhagic strokes. Of the participants with non-hemorrhagic strokes, 169 (18.99%) did not receive any antiplatelet or anticoagulant medication. Of 717 participants who did not have an embolic event, 140 (19.5%) did not receive a salicylate, antiplatelet agent, or warfarin. Of 173 participants who had an embolic event, 29 (16.8%) did not receive a salicylate, antiplatelet agent, or warfarin. Unless patients have any medical contraindications to these medications, they should receive these evidence-based treatments for secondary stroke prophylaxis. As more stroke survivors receive antiplatelet and/or anticoagulant medications, it is more likely that the incidence of recurrent strokes will decrease.
Key Words:
anticoagulants, cerebrovascular accident, cerebrovascular disorders,
platelet aggregation inhibitors, rehabilitation
Antihypertensive
Medication Usage During Stroke Rehabilitation: The Post-Stroke Rehabilitation
Outcomes Project (PSROP)
Blood pressure management is an important issue for the primary prevention, acute management, and secondary prevention of a stroke. Rehabilitation professionals need to consider the timing in lowering blood pressures in stroke survivors, the types of medications that should be used in managing hypertension, and the target pressures to achieve. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the types of antihypertensive medications prescribed to stroke survivors, compare prescription patterns with current practice guidelines of the management of hypertension after a stroke, and determine whether systolic and diastolic blood pressures decrease during admissions to inpatient rehabilitation facilities (IRFs). Of the 1,161 patients in the PSROP database, the most commonly prescribed antihypertensive medications were the angiotensin-converting enzyme antagonists and angiotensin II antagonists, followed by beta-blockers, calcium-channel blockers and diuretics, adrenergics (alpha-blockers), and other (minoxidil, hydralazine) medications. Systolic, diastolic, and mean arterial pressures declined in participants during admissions to IRFs. However, blood pressures were significantly higher throughout IRF stays in participants receiving antihypertensive medications when compared to those not receiving antihypertensive medications. Rehabilitation professionals need to be cognizant of the relationship between stroke and hypertension, clinical practice guidelines that provide evidence-based management tools for hypertension, and patient issues that may hinder the effective treatment of hypertension.
Key Words: cerebrovascular accident, cerebrovascular disorders, hypertension, rehabilitation
Neurostimulant Medication
Usage During Stroke Rehabilitation: The Post-Stroke Rehabilitation Outcomes
Project (PSROP)
Motor recovery after a stroke depends upon many upon
different modalities. Intensive therapy using compensatory and facilitory
techniques is the primary method to improve movement and function in affected
extremities. However, medications used to modulate neurotransmitters may be
useful in augmenting therapy approaches. The Post-Stroke Rehabilitation Outcomes
Project (PSROP) database was used to describe the frequency of prescribing
neurostimulant medications; the types of neurostimulant medications used; and
how the use of neurostimulant medications affected rehabilitation length of
stay, motor recovery, cognitive recovery, and discharge destination. Of the
1,161 patients in the PSROP database, 929 (80.0%) patients did not receive any
treatment with methylphenidate, modafinil, levodopa, amantadine, or
bromocriptine. Patients who received neurostimulant medications did not have any
more significant changes in length of stay, motor recovery, cognitive recovery,
or discharge destination than patients who did not receive neurostimulant
medications. Much research needs to be completed before clinicians know
precisely whether and how rehabilitation therapies and medications interact to
assist in functional recovery.
Key Words:
amantadine, bromocriptine, cerebrovascular accident, cerebrovascular disorders,
levodopa, methylphenidate, modafinil, rehabilitation
Usage
of Pain Medications During Stroke Rehabilitation: The Post-Stroke Rehabilitation
Outcomes Project (PSROP)
Pain remains one of the most
common, yet most challenging, medical problems in health care today, and it is
one of the most common complications that occur after a stroke. Pain can affect
the course of stroke rehabilitation adversely, and it occasionally may be a
cause for transfer back to an acute care hospital. The Post-Stroke
Rehabilitation Outcomes Project (PSROP) database was used to describe the
incidence of pain by body location and trends in the use of different
classifications of medications to treat pain. Of the 1,122 participants in the
PSROP database, the most common locations of pain in stroke survivors were the
head, leg, back, and shoulder. The most frequently prescribed classifications of
pain medications were other analgesics (acetaminophen and tramadol), followed by
narcotic analgesics, non-steroidal anti-inflammatory drugs (NSAIDs),
anticonvulsants, and tricyclic antidepressants. After acetaminophen, the most
frequently prescribed medications in each classification, respectively, include
hydrocodone APAP, cox-2 inhibitors, gabapentin, and amitriptyline. Other
frequently prescribed pain medications included sumatriptan (migraine
analgesic), cyclobenzaprine (muscle relaxant), and baclofen (antispasticity
muscle relaxant). Medications should be chosen based upon the medical condition
causing pain, the ability of the stroke survivor to comply with administration
of the medication, and the cost of the medication. Appropriate and timely
treatments of painful conditions result in maximum function and the ability to
lead active lives and maintain an adequate quality of life.
Key Words:
cerebrovascular accident, cerebrovascular disorders, pain, rehabilitation
Physical therapy
interventions for patients with stroke in inpatient rehabilitation facilities.
Jette
DU, Latham
NK, Smout
RJ, Gassaway
J, Slavin
MD, Horn
SD.
Phys Ther. 2005;85:238-248.
Background and Purpose: The purpose of this study was to describe
physical therapy provided to patients with stroke in inpatient rehabilitation
facilities.
Subjects and Methods: Data were collected from 972 patients with stroke receiving physical therapy services at 6 rehabilitation facilities in the United States. Descriptive statistics were derived to describe physical therapy sessions, including proportion of therapy time spent in specific functional activities and proportion of those activities that included any of 59 interventions.
Results: Mean length of stay was 18.7 days (SD=10.3), and patients received physical therapy, on average, 13.6 days (SD=7.8). Patients attended, on average, 1.5 (SD=0.3) physical therapy sessions per day, with each session lasting 38.1 minutes (SD=17.1). Gait and prefunctional activities were performed most frequently (31.3% and 19.7% of total treatment time, respectively). For gait activity, physical therapists used balance and postural awareness training in more than 50% of sessions and used strength training for more than 50% of sessions of prefunctional activities. Eighty-six percent of the patients received evaluation, and 84% of the patients and families received education.
Discussion and Conclusion: Therapists selected an eclectic approach to intervention rather than specific intervention techniques. The approach to patients' care included interventions to remediate impairments and to compensate for functional limitations. Therapists also reported frequently using motor control and motor learning approaches to facilitate all activities. This approach to care is largely consistent with existing stroke care guidelines and advances in the scientific theories of motor control and motor learning.
Key Words: Physical therapy, Rehabilitation, Stroke
Toward a taxonomy of rehabilitation interventions: Using an inductive approach to examine the "black box" of rehabilitation. Dejong G, Horn SD, Gassaway JA, Slavin MD, Dijkers MP. Arch Phys Med Rehabil. 2004 Apr;85(4):678-86.
A barrier in outcomes and effectiveness research is the ability to characterize the interventions under review. This has been the case especially in rehabilitation in which interventions are commonly multidisciplinary, customized to the patient, and lack standardization in definition and measurement. This commentary describes how investigators and clinicians, working together, in a major multi-site stroke rehabilitation outcome study were able to define and characterize diverse stroke rehabilitation interventions in a comprehensive, yet parsimonious, fashion and thus capture what actually transpires in a hospital-based stroke rehabilitation program. We consider the implications of the study's classification system for a more comprehensive taxonomy of rehabilitation interventions and the potential utility of such a taxonomy in operationalizing practice standards, medical record keeping, and rehabilitation research.