Using the functional independence measure to assess adults with cerebral palsy: an exploratory report

The Functional Independence Measure (FIM) was selected as an assessment to be conducted annually with adults attending The Spastic Centre of New South Wales (SCNSW), Australia, an organisation specifically for individuals with cerebral palsy. Service-providers were trained in the administration of the FIM and in the use of a customised data base. Initially 173 adults with cerebral palsy were assessed, this number included 135 individuals in supported and open employment. The FIM is currently being used to assess all adults attending the SCNSW as part of an annual review. The data from this ongoing assessment procedure will assist in lobbying government to ensure that individuals have access to the attendant care services that they require to function optimally in the community and will provide a longitudinal data base for study of some of the effects of the ageing process on individuals with cerebral palsy. A case study is presented which illustrates the use of the FIM with a couple who live independently in the community.

Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomised controlled trial

Background

Many inpatients receive little or no rehabilitation on weekends. Our aim was to determine what effect providing additional Saturday rehabilitation during inpatient rehabilitation had on functional independence, quality of life and length of stay compared to 5 days per week of rehabilitation.

This was a multicenter, single-blind (assessors) randomized controlled trial with concealed allocation and 12-month follow-up conducted in two publically funded metropolitan inpatient rehabilitation facilities in Melbourne, Australia. Patients were eligible if they were adults (aged ≥18 years) admitted for rehabilitation for any orthopedic, neurological or other disabling conditions excluding those admitted for slow stream rehabilitation/geriatric evaluation and management. Participants were randomly allocated to usual care Monday to Friday rehabilitation (control) or to Monday to Saturday rehabilitation (intervention). The additional Saturday rehabilitation comprised physiotherapy and occupational therapy. The primary outcomes were functional independence (functional independence measure (FIM); measured on an 18 to 126 point scale), health-related quality of life (EQ-5D utility index; measured on a 0 to 1 scale, and EQ-5D visual analog scale; measured on a 0 to 100 scale), and patient length of stay. Outcome measures were assessed on admission, discharge (primary endpoint), and at 6 and 12 months post discharge.

We randomly assigned 996 adults (mean (SD) age 74 (13) years) to Monday to Saturday rehabilitation (n = 496) or usual care Monday to Friday rehabilitation (n = 500). Relative to admission scores, intervention group participants had higher functional independence (mean difference (MD) 2.3, 95% confidence interval (CI) 0.5 to 4.1, P = 0.01) and health-related quality of life (MD 0.04, 95% CI 0.01 to 0.07, P = 0.009) on discharge and may have had a shorter length of stay by 2 days (95% CI 0 to 4, P = 0.1) when compared to control group participants. Intervention group participants were 17% more likely to have achieved a clinically significant change in functional independence of 22 FIM points or more (risk ratio (RR) 1.17, 95% CI 1.03 to 1.34) and 18% more likely to have achieved a clinically significant change in health-related quality of life (RR 1.18, 95% CI 1.04 to 1.34) on discharge compared to the control group. There was some maintenance of effect for functional independence and health-related quality of life at 6-month follow-up but not at 12-month follow-up. There was no difference in the number of adverse events between the groups (incidence rate ratio = 0.81, 95% CI 0.61 to 1.08).

Providing an additional day of rehabilitation improved functional independence and health-related quality of life at discharge and may have reduced length of stay for patients receiving inpatient rehabilitation. 

Prediction of functional oucomes in stroke inpatients receiving rehabilitation

Background and Purpose: Early identification of predictive factors relevant to functional outcomes for stroke patients is important to the establishment of an effective continuing care program. The objective of this studywas to identify the predictive factors related to functional outcome at discharge after stroke rehabilitation therapy. Methods: 105 first-time stroke patients admitted to the inpatient rehabilitation department of a university-based medical center were recruited for this prospective study. The functional outcomes of the patients were assessed at admission and at discharge using the Functional Independence Measure (FIM). Severity of stroke was determined using the Canadian Neurological Scale (CNS). Age, gender, side of hemiplegia (SIDE), type of stroke (TYPE), onset to admission interval (OAI), and length of rehabilitation stay (LORS) were also included as predictor variables. Results: The mean (′SD) FIM score at discharge (76.6 ′ 26.4) correlated strongly (r = 0.78, p < 0.001) with the admission FIM score (56.3 ′ 24.1), moderately (r = 0.46, p < 0.001) with the admission CNS score (6.1 ′ 2.2), negatively (r = -0.38, p < 0.001) with age (63.2 ′ 12.3 years), negatively (r = -0.26, p = 0.009) with OAI (24.2 ′ 16.0 days), and negatively (r = -0.29, p = 0.002) with LORS (34.7 ′ 16.8 ays). Stepwise regression analyses indicated that admission FIM score, age, and admission CNS score were the stronge predictors of functional outcome and accounted for 66% of the total variation in discharge FIM total score. The admission FIM score was the best predictor and accounted for 61% of the variation. Conclusions: The findings of this study imply that the admission FIM scores for inpatients receiving stroke rehabilitation can be used to predict functional outcomes at discharge from hospital.

Achieving eating independence in an acute stroke ward : Developing a collaborative care plan

Aim: This article outlines the development and implementation of a collaborative feeding care plan (FCP) for stroke patients in an acute stroke ward. The aim of this pilot study was to evaluate the impact of an ecological intervention to improve eating independence in an acute stroke ward environment. Methods: An action research approach comprising seven stages—determine the initial problem, develop the care plan, act, reflect and monitor progress, evaluate, reflect, and refine plan—was used to track environmental changes during the development and implementation of the FCP in an acute stroke ward in an Australian regional hospital. During the evaluation phase, six allied health staff completed a survey on the FCP. The staff also completed an observation assessment integrating the Eating Disability Scale, Functional Independence Measure and Canadian Occupational Performance Measure with 12 participants with acute stoke (participants with FCP=6; participants without FCP=6). Results: The FCP group showed significant improvements in upper limb independence (p=0.046), when comparing mean admission scores (3.5±0.97) with discharge scores (4.17±2.14). Clinically significant improvements in levels of collaboration between health professionals were also demonstrated. Conclusions: The changes in team collaboration and the patient’s upper limb independence indicate how environmental change can influence acute stroke patient outcomes. It is recommended that this study be expanded to further explore the effect of ecological interventions and change.

Predicting the grade of disability 1 year after stroke following rehabilitation

The purpose of this study was to identify predictors of grades of disability at least 1 year after stroke rehabilitation therapy. We recruited stroke patients from the inpatient rehabilitation department of a university hospital. The degree of disability was graded using the disability evaluation at least 1 year after stroke onset. Functional ability was evaluated using the Functional Independence Measure instrument on admission, on discharge from the inpatient rehabilitation program, and at the 6-month follow-up visit after discharge. Major sociodemographic, medical, and rehabilitative factors were also collected during the hospitalization period. Of the 109 patients surveyed, 64 (58.7%) had severe or very severe grades of disability. The correlates of severe or very severe disability in logistic regression analyses were bilaterally affected (odds ratio, OR, 10.8), impaired orientation (OR, 3.6), and poorer functional ability at discharge (OR, 7.6). Based on the significant predictors identified, the logistic regression model correctly classified severe or very severe disability in 68.0% of subjects. The higher frequency of severe or very severe disability in this study may have been due to the relatively more severely affected stroke patient population in the inpatient rehabilitation service and the use of unique disability evaluation criteria. These results may provide information useful in planning continuous rehabilitation care and setting relevant socio-welfare policies for stroke victims.

Validation of comprehensive assessment of activities of daily living in stroke survivors

This study determined whether the Functional Independence Measure (FIM) and the Frenchay Activities Index (FAI) could be used together as a more comprehensive score to assess the activities of daily living (ADL) in stroke survivors. Subjects were recruited from stroke patients consecutively admitted to the inpatient neurology or rehabilitation department at a university hospital in southern Taiwan. We interviewed 209 first stroke survivors at least 1 year after stroke onset during their clinical visits, at home, or in long-term care institutions. Combinations of FIM and FAI as a comprehensive assessment of ADL were measured. All items of the FIM and the FAI were included in a non-parametric factor analysis to determine their underlying constructs. Two comprehensive functional independence scores were then computed as functions of the FIM and FAI scores. The distributional characteristics of the comprehensive scores were examined. Approximately 90% of the total variation was explained by three factors. One single factor comprised all the items from FIM, while the FAI items loaded on two other factors, suggesting that FIM supplements FAI without overlap in content. We further demonstrated that the presence of ceiling or floor effects when either the FIM or the FAI was used could be removed using combined scores of the two instruments. The FIM and the FAI assessed different domains with good construct validity. A comprehensive assessment of functional independence obtained by combining the FIM and the FAI scores is potentially more appropriate and useful for clinical and research applications in stroke patients.

A study protocol of a randomised controlled trial incorporating a health economic analysis to investigate if additional allied health services for rehabilitation reduce length of stay without compromising patient outcomes

Background
Reducing patient length of stay is a high priority for health service providers. Preliminary information suggests additional Saturday rehabilitation services could reduce the time a patient stays in hospital by three days. This large trial will examine if providing additional physiotherapy and occupational therapy services on a Saturday reduces health care costs, and improves the health of hospital inpatients receiving rehabilitation compared to the usual Monday to Friday service. We will also investigate the cost effectiveness and patient outcomes of such a service.
Methods/Design A randomised controlled trial will evaluate the effect of providing additional physiotherapy and occupational therapy for rehabilitation. Seven hundred and twelve patients receiving inpatient rehabilitation at two metropolitan sites will be randomly allocated to the intervention group or control group. The control group will receive usual care physiotherapy and occupational therapy from Monday to Friday while the intervention group will receive the same amount of rehabilitation as the control group Monday to Friday plus a full physiotherapy and occupational therapy service on Saturday. The primary outcomes will be patient length of stay, quality of life (EuroQol questionnaire), the Functional Independence Measure (FIM), and health utilization and cost data. Secondary outcomes will assess clinical outcomes relevant to the goals of therapy: the 10 metre walk test, the timed up and go test, the Personal Care Participation Assessment and Resource Tool (PC PART), and the modified motor assessment scale. Blinded assessors will assess outcomes at admission and discharge, and follow up data on quality of life, function and health care costs will be collected at 6 and 12 months after discharge. Between group differences will be analysed with analysis of covariance using baseline measures as the covariate. A health economic analysis will be carried out alongside the randomised controlled trial.
Discussion This paper outlines the study protocol for the first fully powered randomised controlled trial incorporating a health economic analysis to establish if additional Saturday allied health services for rehabilitation inpatients reduces length of stay without compromising discharge outcomes. If successful, this trial will have substantial health benefits for the patients and for organizations delivering rehabilitation services.

Measurement invariance across chronic conditions: a systematic review and an empirical investigation of the Health Education Impact Questionnaire (heiQ™).

To examine whether lack of measurement invariance (MI) influences mean comparisons among different disease groups, this paper provides (1) a systematic review of MI in generic constructs across chronic conditions and (2) an empirical analysis of MI in the Health Education Impact Questionnaire (heiQ™).

Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data

QUESTIONS: Among people receiving inpatient rehabilitation after stroke, does additional weekend physiotherapy and/or occupational therapy reduce the length of rehabilitation hospital stay compared to those who receive a weekday-only service, and does this change after controlling for individual factors? Does additional weekend therapy improve the ability to walk and perform activities of daily living, measured at discharge? Does additional weekend therapy improve health-related quality of life, measured 6 months after discharge from rehabilitation? Which individual, clinical and hospital characteristics are associated with shorter length of rehabilitation hospital stay? DESIGN: This study pooled individual data from two randomised, controlled trials (n=350) using an individual patient data meta-analysis and multivariate regression. PARTICIPANTS: People with stroke admitted to inpatient rehabilitation facilities. INTERVENTION: Additional weekend therapy (physiotherapy and/or occupational therapy) compared to usual care (5 days/week therapy). OUTCOME MEASURES: Length of rehabilitation hospital stay, independence in activities of daily living measured with the Functional Independence Measure, walking speed and health-related quality of life. RESULTS: Participants who received weekend therapy had a shorter length of rehabilitation hospital stay. In the un-adjusted analysis, this was not statistically significant (MD -5.7 days, 95% CI -13.0 to 1.5). Controlling for hospital site, age, walking speed and Functional Independence Measure score on admission, receiving weekend therapy was significantly associated with a shorter length of rehabilitation hospital stay (β=7.5, 95% CI 1.7 to 13.4, p=0.001). There were no significant between-group differences in Functional Independence Measure scores (MD 1.9 points, 95% CI -2.8 to 6.6), walking speed (MD 0.06 m/second, 95% CI -0.15 to 0.04) or health-related quality of life (SMD -0.04, 95% CI -0.26 to 0.19) at discharge. DISCUSSION: Modest evidence indicates that additional weekend therapy might reduce rehabilitation hospital length of stay.

Exploring psychometric properties of the SF-6D, a preference-based health-related quality of life measure, in the context of spinal cord injury

PURPOSE: The validity of the SF-6D, a preference-based measure of health-related quality of life, is not well explored in the context of spinal cord injury (SCI). The aim of this analysis was to assess appropriate measurement properties of the SF-6D in a sample of individuals living with SCI. METHODS: Longitudinal data from the Rick Hansen Spinal Cord Injury Registry were used. Responses to the 36-item short-form health survey were transformed into SF-6D utility scores. We investigated practicality, floor and ceiling effects, and responsiveness to change. Responsiveness to change was explored using three different anchors that reflected changes in self-reported health, functional independence, and life satisfaction. Discriminative validity was assessed by ten a priori defined hypotheses, with a distinction made between 'strong' and 'weak' hypotheses. RESULTS: Three hundred and fifty-eight individuals with SCI were included in this analysis. Practicality was deemed acceptable based on a completion rate of 94%. The SF-6D showed low responsiveness to detect important health changes over time, and differences in responsiveness were found between individuals with paraplegia and tetraplegia. All five strong hypotheses and three weak hypotheses were confirmed. CONCLUSION: The SF-6D demonstrated good practicality and discriminative validity in this sample. The failure to detect self-reported and clinically important health changes requires further consideration. Comparative performance of the SF-6D (i.e., how the SF-6D performs against other preference-based measures) is unknown in the SCI context and requires further research.

Is rehabilitation associated with change in functional status among nursing home residents?

Assessing functional status of residents in nursing homes is one way to evaluate the quality of care provided. The purpose of this study was to investigate whether rehabilitation interventions could lead to improved functional independence. A prospective study was carried out to examine the change in activities of daily living (ADL) of 310 residents aged 65 or above over a period of 6 months. About 41.3% (n = 128) received rehabilitation therapy. Functional improvement was observed in 30.6% of the participants. The corresponding figures for stabilization and functional decline were 45.2% and 24.2%, respectively. Using a multinomial logistic regression, we found that factors significantly associated with change in functional status included baseline ADL score, family visit, number of beds in the institution, and transfer to acute hospitals. After adjusting for these confounding variables, change in functional status of those who received rehabilitation and those who did not was not significantly different.

Risk of falls and motor vehicle collisions in glaucoma

PURPOSE. To investigate the risk of falls and motor vehicle collisions (MVCs) in patients with glaucoma.

METHODS. The sample comprised 48 patients with glaucoma (mean visual field mean deviation [MD] in the better eye = −3.9 dB; 5.1 dB SD) and 47 age-matched normal control subjects, who were recruited from a university-based hospital eye care clinic and are enrolled in an ongoing prospective study of risk factors for falls, risk factors for MVCs, and on-road driving performance in glaucoma. Main outcome measures at baseline were previous self-reported falls and MVCs, and police-reported MVCs. Demographic and medical data were obtained. In addition, functional independence in daily living, physical activity level and balance were assessed. Clinical vision measures included visual acuity, contrast sensitivity, standard automated perimetry, useful field of view (UFOV), and stereopsis. Analyses of falls and MVCs were adjusted to account for the possible confounding effects of demographic characteristics, medications, and visual field impairment. MVC analyses were also adjusted for kilometers driven per week.

RESULTS. There were no significant differences between patients with glaucoma and control subjects with respect to number of systemic medical conditions, body mass index, functional independence, and physical activity level (P > 0.10). At baseline, 40 (83%) patients with glaucoma and 44 (94%) control subjects were driving. Compared with control subjects, patients with glaucoma were over three times more likely to have fallen in the previous year (odds ratio [OR]adjusted = 3.71; 95% CI, 1.14–12.05), over six times more likely to have been involved in one or more MVCs in the previous 5 years (ORadjusted = 6.62; 95% CI, 1.40–31.23), and more likely to have been at fault (ORadjusted = 12.44; 95% CI, 1.08–143.99). The strongest risk factor for MVCs in patients with glaucoma was impaired UFOV selective attention (ORadjusted = 10.29; 95% CI, 1.10–96.62; for selective attention >350 ms compared with ≤350 ms).

CONCLUSIONS. There is an increased risk of falls and MVCs in patients with glaucoma.

Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial

BACKGROUND: Our previous work showed that providing additional rehabilitation on a Saturday was cost effective in the short term from the perspective of the health service provider. This study aimed to evaluate if providing additional rehabilitation on a Saturday was cost effective at 12 months, from a health system perspective inclusive of private costs. METHODS: Cost effectiveness analyses alongside a single-blinded randomized controlled trial with 12 months follow up inclusive of informal care. Participants were adults admitted to two publicly funded inpatient rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus additional Saturday rehabilitation. Incremental cost effectiveness ratios were reported as cost per quality adjusted life year (QALY) gained and for a minimal clinical important difference (MCID) in functional independence. RESULTS: A total of 996 patients [mean age 74 years (SD 13)] were randomly assigned to the intervention (n = 496) or control group (n = 500). The intervention was associated with improvements in QALY and MCID in function, as well as a non-significant reduction in cost from admission to 12 months (mean difference (MD) AUD$6,325; 95% CI -4,081 to 16,730; t test p = 0.23 and MWU p = 0.06), and a significant reduction in cost from admission to 6 months (MD AUD$6,445; 95% CI 3,368 to 9,522; t test p = 0.04 and MWU p = 0.01). There is a high degree of certainty that providing additional rehabilitation services on Saturday is cost effective. Sensitivity analyses varying the cost of informal carers and self-reported health service utilization, favored the intervention. CONCLUSIONS: From a health system perspective inclusive of private costs the provision of additional Saturday rehabilitation for inpatients is likely to have sustained cost savings per QALY gained and for a MCID in functional independence, for the inpatient stay and 12 months following discharge, without a cost shift into the community. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213 .

Health-related quality of life in people with Parkinson’s disease receiving comprehensive care

Objectives: The aim of the present study was to quantify the baseline variation in health-related quality of life (HRQOL) between individuals with Parkinson’s disease (PD) referred to a comprehensive care program and those attending standard neurological services.

Methods: Participants included individuals with PD receiving conventional care from neurologists in private practice and individuals referred to a comprehensive inter-professional team hospital out-patient service. The Parkinson’s Disease Questionnaire-39 (PDQ-39) and the EuroQoL (EQ-5D-3L) were used to quantify HRQOL.

Results: Participants referred to an inter-professional service were more likely to have poorer indices on PD-specific measures but not for generic HRQOL compared with individuals receiving standard neurological services. After adjusting for age, gender, disease severity and duration, people referred to a comprehensive care program were more likely to have a higher score for the PDQ-39 summary index (PDQ-39 SI; mean ± s.d. 27.2 ± 11.0; 95% confidence interval (CI) 25.5, 28.9) compared with individuals receiving standard neurological services (PDQ-39 SI mean 0.2 ± 12.8; 95% CI 18.0, 22.4).

Conclusions: Compared with those attending standard neurological out-patient clinics, individuals referred to an inter-professional PD program are more likely to have advanced disease and poorer HRQOL. This observation has implications for the way in which people with PD are recruited for future clinical trials, because uneven recruitment from different sources may be a potential source of bias.
What is known about the topic? Given that PD is associated with a complex array of motor and non-motor symptoms, an inter-professional team approach to service provision is argued to be optimal for individuals living with this debilitating condition.
What does this paper add? This paper has shown that individuals referred to an inter-professional service are more likely to have advanced disease and complex care needs. Compared with those referred to neurologist private clinics, those referred to an inter-professional clinic had less functional independence and lower PD-specific HRQOL when first assessed, even after controlling for disease severity.
What are the implications for practitioners? When recruiting for future trials to examine the efficacy of multidisciplinary care programs in people with PD, it is important to take into account whether these individuals have been referred to an inter-professional service. There may be a potential source of bias if participants were recruited predominantly from such services.