PM&R - Articles in Press

Self-Reported Issues With Driving in Patients With Chronic Pain - Corrected Proof

2012-01-24

Objective: To assess the driving habits, driving patterns, and barriers to driving reported by patients with chronic pain. Design: Cross-sectional mail survey with self-administered questionnaires. Setting: University-affiliated hospital. Participants: A sample of 223 patients seen in consultation by a physiatrist through the Chronic Pain Rehabilitation Service. Interventions: Not applicable. Main outcome measurements: Percentage of subjects who were current drivers, percentage of subjects experiencing difficulty with driving, and driving characteristics. Results: Response rate was 48.9%. Of the subjects, 79% were current drivers; of the nondrivers, 56% reported stopping driving because of chronic pain. A significantly greater percentage of nondrivers (80%) than drivers (62.9%) were women (P = .039). Nondrivers reported greater levels of pain than drivers (P = .027). The mean Pain Disability Index total score was significantly lower for drivers (42.3) than for nondrivers (48.7; P = .006). Of all subjects, 70% indicated that pain limited their driving in some manner; 41% of this group indicated that they experienced quite a bit or a great deal of difficulty driving. Factors that limited driving included pain (88.9%), fatigue (50.6%), limited joint mobility/stiffness (48.3%), and weakness (19.4%). The most frequently reported difficulties related to driving were sitting for any length of time (79.6%) and getting into the driver's seat (66.5%). Only 2.4% of current drivers had been referred for a driving assessment. Conclusions: Most people with chronic pain continue to drive and overall appear to have better functioning than those who cannot continue driving because of chronic pain. Despite being able to drive, a significant proportion of drivers with chronic pain are facing challenges not only with driving the vehicle but also with entering and positioning themselves within the vehicle. Our results suggest that chronic pain does have an impact on driving. However, it appears to be generally unrecognized as a factor for driving other than when the implications of narcotic use are considered.

Initial Recovery Trajectories Among Patients With Hip Fracture: A Conceptual Approach to Exploring Comparative Effectiveness in Postacute Care - Corrected Proof

2012-01-16

Objective: To assess whether clusters of patients with hip fracture and with distinct initial recovery trajectories (IRT) could be identified by using practice-based evidence data and to examine the validity of these data. Design: Analysis of multisite prospective observational cohort study database. Setting: Eighteen skilled nursing and inpatient rehabilitation facilities. Patients: Patients with hip fractures (N = 226) treated with joint replacement and admitted to skilled nursing or inpatient rehabilitation facilities, subset (n = 85), with telephone follow-up results approximately 8 months after rehabilitation discharge. Patients' ages were 76.8 ± 11.4 years; the majority were women (78%) and white (87%). Methods: Measurements included medical severity by using the Comprehensive Severity Index and functional levels by using Functional Independence Measure (FIM). The IRT was calculated for each patient as the rate of change in function from the time of surgery to rehabilitation admission. We used cluster analysis to partition patients into subsets that shared common IRT scores. Validity was explored by comparing subgroups across patient characteristics and treatment patterns. Significance was defined as P ≤ .05. Main Outcomes Measurements: IRT grouping, Comprehensive Severity Index, FIM, discharge location, living location at follow-up. Results: We identified 3 patient clusters with differentiated IRT scores: group 1: 4.96 ± 2.45 (range, 0.4-8.6) FIM point change per day; group 2: 12.42 ± 2.51 (range, 8.9-17.0); group 3: 26.80 ± 13.78 (range, 17.5-70.0). Clinical group validation was established from statistically different Comprehensive Severity Index scores on admission; FIM scores at admission, discharge, and follow-up; and discharge and 8-month living settings. Calculation of IRT recovery curves by using FIM scores and associated time in days through logarithmic regression curves confirmed each group's IRT remained distinct through rehabilitation and follow-up. Conclusions: The IRT concept appears to be valid in patients with hip fracture who were treated with hip arthroplasty, and may assist in evaluating and comparing the effectiveness of postacute rehabilitation services.

A Cost-Effectiveness Analysis of Screening Methods for Dysphagia After Stroke - Corrected Proof

Richard D. Wilson, Evan C. Howe — 2011-12-26

Objective: To provide a cost-effectiveness analysis of dysphagia screening in the acute poststroke period with use of a videofluoroscopic swallowing study, a clinical bedside swallowing evaluation, or a combined approach. Design: Decision-analysis model. Methods: A decision-analysis model was used with information derived from multiple data sources, including meta-analyses and other relevant clinical studies. Univariate and probabilistic sensitivity analyses were performed. Main Outcome Measures: The analysis assessed direct medical costs of pneumonia. Strategies were compared on the basis of an incremental cost-effectiveness analysis, with effectiveness measured in quality-adjusted life-years. Results: The strategy of having each patient undergo a videofluoroscopic swallowing study for dysphagia was more effective and less costly than the strategies of clinical bedside swallowing evaluation alone or a combined approach. The model was most influenced by the reduction in the risk of pneumonia attributable to the treatment of mild/moderate and severe dysphagia, the effectiveness of treatment with clinical bedside swallowing evaluation, the baseline probability of pneumonia, and the cost of a videofluoroscopic swallowing study. Conclusions: A videofluoroscopic swallowing study is cost-effective and often saves costs compared with a clinical bedside swallowing evaluation alone or a combined approach. Research aimed at improving the understanding of the effectiveness of treatment for dysphagia in the prevention of aspiration pneumonia and resulting mortality would improve the model.

Application and Performance of Two Stroke Outcome Prediction Models in a Chinese Population - Corrected Proof

Wen-Juan Li, Zhi-Yu Gao, Yang He, Guang-Zhi Liu, Xu-Guang Gao — 2011-12-23

Objective: To apply and examine the performance of 2 acute stroke outcome prediction models, the Six Simple Variable Model (SSV model) and the One-Year Mortality Model (OYM model), in patients in China who had either a cerebral infarction or a cerebral hemorrhage. Design: An observational study that used both retrospective and prospective study methods. Setting: A regional acute care facility in China. Participants: Two hundred and forty-eight consecutive patients who had an acute stroke who were admitted to the hospital between October 2007 and March 2009. Interventions: Not applicable. Main Outcome Measures: Survival and daily activity independence 6 months after a stroke and 1-year mortality. Results: The study sample had a mean age of 68.6 years (SD 11.1); 52.8% of the subjects were men, 66.5% had a cerebral infarction, and 33.5% had a cerebral hemorrhage. In the cohort, 107 patients (43.1%) achieved daily activity independence at 6-month follow-up, and 52 patients (21.0%) had died within 1 year. The area under the receiver operating characteristic curve was 0.966 (0.935-0.998) for patients who had a cerebral infarction and 0.859 (0.766-0.952) for patients who had a cerebral hemorrhage in the prediction of 6-month survival and daily activity independence with use of the SSV model. The area under the receiver operating characteristic curve was 0.894 (0.846-0.965) for patients who had a cerebral infarction and 0.937 (0.904-0.988) for patients who had a cerebral hemorrhage in the prediction of 1-year mortality when the OYM model was used. Conclusions: Both the SSV and OYM prognostic models can be used for function and mortality outcome prediction for patients in China who have had a stroke. Variation existed in the precision of prediction between patients who had a cerebral infarction and those who had a cerebral hemorrhage. Other potential factors influencing functional recovery and mortality after stroke must be considered in outcome prediction.

An Assessment of the Compliance and Utility of a Home Exercise DVD for Caregivers of Children and Adolescents With Brachial Plexus Palsy: A Pilot Study - Corrected Proof

2011-11-17

Objective: To investigate the impact of a video-based educational resource on home exercise compliance among caregivers of children with neonatal brachial plexus palsy (NBPP).Design: Retrospective analysis of self-reported caregiver home exercise habits and resultant shoulder range of motion (ROM) and biceps power in patients with NBPP.Setting: Home-based exercise program.Participants: Adult caregivers of children with NBPP followed up through the Brachial Plexus Program at the University of Michigan (N = 83 surveyed initially, with N = 37 completing the final survey).Methods: Caregivers completed surveys before and approximately 3, 6, and 12 months (times A, B, and C, respectively) after receiving the “Home Exercise Therapy Program for Brachial Plexus Palsy” digital video disk (DVD). A retrospective analysis of shoulder ROM and biceps power of patients was completed as representative of arm function during the study.Main Outcome Measurements: Surveys assessed home exercise compliance, resources used to guide exercises, and caregiver confidence in the correctness of exercises being performed. Functional outcomes analyzed include biceps strength and shoulder active and passive ROM.Results: Home exercise compliance increased from 74% initially to 96% at time A (P < .001), remained at 94% at time B (P < .001), and fell to 84% at time C (P = .016). Use of the DVD to guide home exercise decreased from 69% at time A to 57% at time B and C (P = .026). After receiving the DVD, exercise frequency and caregiver confidence increased. Although some measures of shoulder active ROM and biceps power improved during the course of the study, there was no consistent statistically significant relationship between increased caregiver confidence and functional outcomes. No causal relationship exists between DVD content and functional status at this time.Conclusions: As the first formal evaluation of a video-based resource guiding exercise therapy for children with NBPP, we suggest that this population may be receptive to alternative media and may benefit from dynamic modeling of home exercises.