OBJECTIVE:To investigate the measurement properties of the WeeFIM instrument and examine the developmental differences in motor item difficulty in a pediatric inpatient rehabilitation sample. DESIGN:Database approach, retrospective study, using 814 WeeFIM records from 12 facilities. Rasch rating scale analysis was used for all analyses. Data for the complete sample were used to evaluate the dimensionality and item fit of the WeeFIM instrument. Patients were then divided into three age groups, <3 yrs of age (toddlers), 3-7 yrs of age (preschoolers and kindergartners), and >7 yrs of age (school-age children), and their data were used to compare the order of motor items by level of difficulty within and across different age groups. RESULTS:Principal component analysis of the WeeFIM suggests distinct motor and cognitive scales. Within the motor scale, bowel and bladder items misfit, suggesting they measure a distinct aspect of function. The order of motor item difficulty, an indicator of construct validity, varies across age groups, suggesting that motor tasks present different challenges to children at different developmental stages: toileting is the most difficult, whereas locomotion is the easiest motor item for toddlers. For children >3 yrs of age, eating is easiest and stair climbing is most difficult, followed by tub transfer and bathing. CONCLUSIONS:Similar to the adult FIMtrade mark instrument, the WeeFIM instrument has two distinct dimensions. The motor items form a unidimensional construct with acceptable measurement properties. Developmental differences in motor task mastery among children with disabilities are assumed but rarely tested. As evidenced by the age-specific item hierarchies found in this study, developmental differences among children with disabilities mimic that of children without disabilities.

Objectives: To classify therapy activities and to describe the type and pattern of activities provided during inpatient rehabilitation to persons with stroke.Design: Descriptive study.Setting: Eight acute and 5 subacute rehabilitation facilities across the United States.Participants: Persons with stroke (N = 177) who received rehabilitation services and had lengths of stay (LOSS) between 2 and 5 weeks.Interventions: Not applicable.Main Outcomes Measures: Weekly and total therapy units aggregated by discipline and activity type for each of 4 (2-wk, 3-wk, 4-wk, 5-wk) LOS groups.Results: Across LOS groups, significant differences in total therapy units were found by week of rehabilitation, discipline, and therapy activity type. Patterns in and significant interactions of time and activity type by discipline were also found. The amount of therapy provided by occupational and physical therapists was significantly more than that provided by speech-language pathologists.Conclusions: Patterns of time spent in therapy are similar for all LOS groups, but type of therapy received reflects a complex interaction of patient severity, rehabilitation discipline, and LOS.

OBJECTIVES:Relatively little is known about the treatment effectiveness and functional outcomes of pediatric rehabilitation therapies. This study was conducted to gain knowledge of the type and quantity of inpatient rehabilitation services provided to children who received acute inpatient rehabilitation and compare functional gains by age and diagnosis. METHOD:A retrospective cohort design was used. Records of rehabilitation therapies and functional assessments of 814 pediatric patients who received inpatient rehabilitation during 1996, 1997, and 1998 were collected. The admission and discharge item ratings of the WeeFIM instrument were first transformed into interval-level measures of self-care, mobility, and cognition. Parametric analyses were used to compare functional gains across impairment groups and to examine the relationship between amount of treatment and functional gains. RESULTS:Occupational therapy and physical therapy were the primary rehabilitation services received by patients across impairment groups (98% and 99%, respectively). A large proportion of children with traumatic brain injuries also received speech therapy (97%) and psychology services (60%). Across domains (self-care, mobility, cognition), the largest gains were made by children who were older than 7 years and had traumatic injuries. Functional gains were significantly related to the amount of discipline-specific treatment received, after controlling for age, impairment, and functional status at admission. CONCLUSION:Rehabilitation therapy provision in pediatric inpatient rehabilitation varies greatly depending on children's age and the nature of the impairment. Systematic reporting of type and quantity of rehabilitation therapies along with functional assessments before and after hospitalization would allow researchers to track functional changes and study the determinants of functional improvement.

Background and Purpose— The purpose of this study was to evaluate the relative importance of therapy focus, intensity, and length of stay on greater than expected functional gain, controlling for stroke severity. Methods— This observational study included 198 first-stroke patients who were recruited from 8 in-patient rehabilitation facilities and 5 subacute programs. Stroke severity (motor, sensory and cognitive impairment) at admission was measured using an instrument combining all 3 aspects; self-care, mobility, and cognitive status at admission and discharge were measured with the Functional Independence Measure. Time spent by physical, occupational, and speech-language therapists on function- and impairment-focused activities were used to compute therapy intensity by discipline and type of activity. Residual change scores, estimated by regressing discharge on admission functional status, were modeled using patient and therapy characteristics. Results— Controlling for the stroke severity, greater than expected gains in self-care were predicted by longer lengths of stay and more intensive function-focused occupational therapy, and greater than expected cognitive gains were predicted by longer stays alone. Predictors of residual change in mobility, however, differed by gender: greater than expected gains in mobility for men were predicted by longer lengths of stay and more intense function-focused physical therapy whereas, for women, they were predicted by stroke severity alone. Conclusions— Unlike previous studies using raw functional gains, therapies accounted for a significant proportion of the variance in residual functional change. The results support studies suggesting that both content and amount of therapy are important aspects.

BACKGROUND:The relationship between the amount of rehabilitation therapy and functional outcome in stroke patients has not been established.OBJECTIVES:To evaluate the effectiveness of inpatient rehabilitation for post-acute stroke, and examine the relationship between intensity of therapies and functional status at discharge.METHODS:We evaluated 50 first-stroke patients, average age 63 years, in a prospective descriptive study. The impairment and Functional Independence Measurement were assessed both at admission to rehabilitation and at discharge. Patients were monitored weekly during their stay by means of discipline-specific measures of activity level. Predictor variables included intensity of physical, occupational and speech therapies; demographic characteristics; length of stay; and time since the stroke.RESULTS:A significant reduction in impairment was observed at discharge. The predictors of gains and activity level at discharge as well as motor vs. cognitive components of the FIM were neither consistent nor did they occur in the same trend of functional improvement. Greater FIM motor level at discharge was associated with younger age, higher admission motor and cognitive level, and receipt of any speech therapy, while greater FIM cognitive level was associated with higher cognitive level at admission, shorter interval from onset to admission, and more intense occupational therapy. More intense OT was associated with greater and more cognitive improvement during the hospitalization.CONCLUSION:Since the sample was relatively small and heterogenous in terms of the patients' functional abilities, the findings cannot be generalized to the whole population of stroke patients. Further efforts to identify the best timing, modalities, intensity and frequency of the various treatments are needed to improve the cost-benefit equation of rehabilitation in stroke patients.

OBJECTIVE:To examine the psychometric properties of the Moss Attention Rating Scale (MARS), a new observational rating scale for attention-related behaviors in traumatic brain injury (TBI).DESIGN:Prospective observational study.SETTING:Eight acute inpatient rehabilitation facilities that are part of the Traumatic Brain Injury Model Systems program.PARTICIPANTS:Two hundred twenty-eight patients with TBI requiring acute inpatient rehabilitation treatment.INTERVENTIONS:Not applicable.MAIN OUTCOME MEASURES:Rasch analysis on the 53-item MARS (45 attention items, 8 control items) as rated separately by the treating occupational therapist and physical therapist.RESULTS:The MARS appeared to measure a single dimension and demonstrated good person separation (5.69) and reliability (.97). In post hoc assessment, misfitting attention items may not have required attention and control items that fit the dimension may have required at least rudimentary attention. Occupational therapists rated patients as slightly less attentive than did physical therapists. Overall, the scale was well targeted to an acute inpatient rehabilitation population.CONCLUSION:Our results provide preliminary support for the viability of developing an observational attention rating scale for use in inpatient TBI rehabilitation. Further research will need to explore the existence of subdimensions and provide further validation with reference to other neuropsychologic measures of attention and knowledge of lesion severity and localization.

The need to measure and evaluate orthotics and prosthetics (O&P) practice has received growing recognition in the past several years. Reliable and valid self-report instruments are needed that can help facilities evaluate patient outcomes. The objective of this project was to develop a set of self-report instruments that assess functional status, quality of life, and satisfaction with devices and services that can be used in an orthotics and prosthetics clinic. Selecting items from a variety of existing instruments, the authors developed and revised four instruments that differentiate patients with varying levels of lower limb function, quality of life, and satisfaction with devices and services. Evidence of construct validity is provided by hierarchies of item difficulty that are consistent with clinical experience. For example, with the lower limb function instrument, running one block was much more difficult than walking indoors. The instruments demonstrate adequate internal consistency (0.88 for lower limb function, 0.88 for quality of life, 0.74 for service satisfaction, 0.78 for device satisfaction). The next steps in their research programme are to evaluate sensitivity and construct validity. The Orthotics and Prosthetics Users' Survey (OPUS) is a promising self-report instrument which may, with further development, allow orthotic and prosthetic practitioners to evaluate the quality and effectiveness of their services as required by accreditation standards such as those of the American Board for Certification in Orthotics and Prosthetics that mandate quality assessment.

ContextRespiratory complications are frequent in patients with acute cervical spinal injury (CSI); however, the importance of respiratory complications experienced during the initial hospitalization following injury is unknown.ObjectiveTo determine if respiratory complications experienced during the initial acute-care hospitalization in patients with acute traumatic cervical spinal injury (CSI) are more important determinants of the length of stay (LOS) and total hospital costs than level of injury.DesignA retrospective analysis of an inception cohort for the 5-year period from 1993 to 1997.SettingThe Midwest Regional Spinal Cord Injury Care System, a model system for CSI, at Northwestern Memorial Hospital, a tertiary referral academic medical center.PatientsFour hundred thirteen patients admitted with acute CSI and discharged alive. Patients with concurrent thoracic injuries were excluded.Main outcome measuresInitial acute-care LOS and hospital costs.ResultsBoth mean LOS and hospital costs increased monotonically with the number of respiratory complications experienced (p < 0.001, between none and one complication, and between one and two complications; p = 0.24 between two and three or more complications). A hierarchical regression analysis showed that four variables—use of mechanical ventilation, occurrence of pneumonia, need for surgery, and use of tracheostomy—explain nearly 60% of the variance in both LOS and hospital costs. Each of these variables, when considered independently, is a better predictor of hospital costs than level of injury.ConclusionsThe number of respiratory complications experienced during the initial acute-care hospitalization for CSI is a more important determinant of LOS and hospital costs than level of injury.

Background and Purpose— The aim of this study was to investigate the associations between tracheostomies, enteral feeding tubes, and indwelling urinary catheters and functional outcome measures, incidence of medical complications, and resource use in an inpatient stroke rehabilitation program. Methods— A cohort of 1553 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke characteristics, impairment (National Institutes of Health Stroke Scale) and disability level (Functional Independence Measure [FIM]), preexisting medical conditions, and the presence of tracheostomies, enteral feeding tubes, and indwelling urinary catheters were recorded at admission. The occurrence of medical complications during rehabilitation, discharge disability level, length of rehabilitation stay, and rehabilitation hospital charges were recorded at discharge. Results— Compared with patients with no medical tubes, patients with 3 medical tubes had significantly higher National Institutes of Health Stroke Scale scores, lower admission and discharge FIM scores, reduced FIM efficiency scores (average FIM score change per day), and twice the number of medical complications. Patients with 3 medical tubes stayed 28 days longer in acute hospitalization and 20 days longer in rehabilitation compared with patients with no medical tubes. The presence of even a single medical tube was associated with longer length of stay, more medical complications during rehabilitation, and greater disability level at discharge. Conclusions— The presence of ≥1 medical tubes is associated with more severe and disabling strokes, an increased number of medical complications, longer acute and rehabilitation hospitalizations, and greater resource use.

OBJECTIVES:(1) To develop a comprehensive list of needs and services appropriate for persons with traumatic brain injury (TBI); (2) to determine whether these needs and services formed unidimensional hierarchies from least common to most common; (3) to describe the relationship between unmet needs and services received; and (4) to estimate the extent to which a variety of demographic, injury, and service characteristics predict unmet needs.DESIGN:Statewide mailed survey.SETTING:Illinois communities.PARTICIPANTS:A total of 895 persons who had had a TBI recruited from Brain Injury Association members and rehabilitation service recipients. The median time post-TBI was 7 years; the median age was 37 years.INTERVENTIONS:Not applicable.MAIN OUTCOME MEASURES:A 27-item instrument assessing service needs and utilization of services, and equal-interval measures of needs and services derived with Rasch analysis.RESULTS:The most prevalent unmet needs were improving memory or problem-solving skills (51.9%), increasing income (50.5%), and improving job skills (46.3%). The instrument defined unidimensional and reliable constructs of needs and services. Persons with greater unmet needs tended to receive fewer services; to report lower life satisfaction and worse medical health and psychologic well-being since injury; to be younger, single, black, dependent in 1 or more daily activities; and to have more recent injuries.CONCLUSIONS:The results show the common pattern of unmet needs and services and emphasize the importance of comprehensive, statewide assessment of services and needs in developing policies.

Bode RK, Heinemann AW. Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury. Arch Phys Med Rehabil 2002;83:100-6. Objective: To examine functional improvement patterns of persons with stroke, traumatic brain injury (TBI), and spinal cord injury (SCI). Design: Statistical analysis of data from a multisite study evaluating rehabilitation outcomes. Setting: Eight inpatient rehabilitation facilities. Participants: A total of 314 consecutive admissions of persons with stroke, SCI, and TBI who received acute medical rehabilitation between 1994 and 1998. Intervention: Calibration of motor and cognitive items from the FIM™ instrument, grouping of cases by number of weeks of rehabilitation (length of stay [LOS] groups), and plotting of weekly averages across time. Main Outcome Measures: Weekly motor and cognitive functional status. Results: With the exception of cognitive functioning for persons with SCI, LOS was related to initial functional status, with patients with greater disability having longer LOS (eg, initial motor status for persons with stroke was 48.3 for those with a 2-week stay, 36.8 for a 6-week stay, with the averages between decreasing monotonically). With the exception of cognitive gains for person with TBIs, the amount of functional gain during rehabilitation was essentially the same for all LOS groups (eg, the overall average total motor gain for persons with SCI is 22.3, with no patterns of increase or decrease across LOS groups); however, the rate of improvement in motor (but not cognitive) functioning differed across LOS groups, with patients with shorter stays having the greater rates of improvement (eg, the overall average weekly motor gain for persons with SCI was 3.6, with the averages by LOS group monotonically decreasing from 6.4 for those with 4-week stays to 2.7 for those with 9-week stays). Conclusions: When examined separately for persons grouped by LOS, functional status improved linearly during the rehabilitation stay, with differences in rate of improvement depending on initial functional status. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

OBJECTIVES:To determine the measurement properties of the Galveston Orientation and Amnesia Test (GOAT) using the Rasch model and rating scale analysis (RSA).DESIGN:Calibration of data collected weekly during rehabilitation.SETTING:Six inpatient rehabilitation facilities.PARTICIPANTS:77 patients admitted for their first rehabilitation after traumatic brain injury.RESULTS:Rescoring the items as dichotomies, three strata of posttraumatic amnesia (PTA) were identified. All items cohered to define a single construct and the item hierarchy confirmed their hypothesized ordering.CONCLUSIONS:Equal-interval measures of PTA were developed that exhibited good reliability and validity. A self-scoring key was developed to more efficiently assess PTA.

OBJECTIVE:Evaluate the measurement properties of the Agitated Behavior Scale (ABS) using rating scale analysis. SAMPLES:Sample 1: 900 observations of 100 individuals with traumatic brain injury; Sample 2: 204 observations of 102 persons with dementia; Sample 3: 241 observations of 6 individuals with anoxia. RESULTS:The calibration indicated that the rating scale was used as intended. The hierarchies of item difficulty were similar across samples. Person and item separation values were within the acceptable range for the TBI sample. Generally, the items work well together, however 3 items misfit the measurement model moderately. CONCLUSIONS:Agitation as measured by the ABS is best represented as a unitary construct. Results provide additional support for the reliability and validity of the ABS.

Objectives: To explore (a) how spiritual well-being, emotional wellbeing, life satisfaction, and functional status change during and after rehabilitation; (b) the relationships among these variables over time; and (c) associations with demographic and clinical characteristics, Study Design: Longitudinal assessment across 3 time points. Participants and Setting: 155 adults admitted to a freestanding rehabilitation hospital. Main Outcome Measures: Spiritual Well-Being Scale, Life Satisfaction Questionnaire, Short-Form Health Survey, and the Functional Independence Measure(TM). Results: Emotional well-bring increased during rehabilitation, whereas life satisfaction and spiritual well-being did not change; however, substantial subgroups of individuals experienced changes in life satisfaction and spiritual well-being over time. Measures of spiritual well-being, emotional well-being, and life satisfaction were moderately correlated within and across time points. Persons making smaller functional gains during inpatient rehabilitation were least likely to experience increased emotional well-being. Although African Americans as a group reported greater spiritual well-being than other racial-ethnic groups on admission, they were least likely to increase in emotional well-being over time. Persons with less than a high school education were more likely to experience significant declines in life satisfaction, whereas persons with more than a high school education were least likely to experience significant gains in spiritual well-being over time. Conclusions: Interventions designed to target spiritual well being, emotional well-being, or life satisfaction are likely to have salutary effects for each of these aspects of well-being. Race and education are potentially important predictors of spiritual and emotional distress among rehabilitation inpatients. Examining individual patterns of change over time may help in further clarifying these relationships and developing appropriate clinical interventions.

Objective: Evaluate the measurement properties of the Neurobehavioral Cognitive Status Examination (NCSE) using rating scale analysis. Design: Calibration of item responses collected as part of a study examining characteristics of case-management programs and treatment outcomes. Setting: Three outpatient rehabilitation facilities. Participants: Convenience sample of 186 community-dwelling adults with TBI. Results: Several rating scale analyses were performed to construct a unidimensional measure. Deletion of easy and misfitting items created a better targeted test (generated more spread among individuals) without increased error. Conclusions: If used with a community-based sample, three strata can be differentiated despite a skewed distribution. Recommended applications are with samples with considerably more cognitive impairment.

The objectives of this study were to develop and validate an equal-interval measure of neurologic impairment from the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients developed by the American Spinal Injury Association. These standards were used to rate impairment at admission and discharge to Model System facilities. The results demonstrate that the standards fulfill their purpose of characterizing sensory-motor impairment. Developed was a self-scoring key that rehabilitation clinicians can use to obtain a measure of severity that combines sensory and motor level ratings and completeness classifications to describe impairment more precisely and illustrate the magnitude of reductions in impairment. This measure can be used to monitor improvement over time and compare severity across individuals or groups.