Gaylord Hospital

BackgroundImpaired balance regulation after stroke puts patients and therapists at a heightened risk of injury during rehabilitation. Body weight support systems (BWSS) allow patients to safely conduct gait and balance training while minimizing risk and the fear of falling. Integrating perturbation-based balance training (PBT) modules with a BWSS may lead to further improvements.ObjectiveThis study aimed to evaluate the impact of a ceiling-track-mounted BWSS plus an integrated PBT (BWSS-P) module on the rehabilitation of stroke-related gait and balance impairments.MethodsA multisite randomized active-comparator controlled trial was conducted. Inpatients with Berg Balance Scale (BBS) scores ≥21/56 were recruited from 4 sites. Participants completed 2-to-6 BWSS or BWSS-P study sessions. Both groups conducted the same balance and gait regimen, with the BWSS-P group also receiving 8 balance perturbations per session. BBS, Activities-Specific Balance Confidence, and 10 Meter Walk Test assessments were collected.ResultsA total of 126 patients were approached with 99 yielding sufficient data for analysis. With a corrected α level of .0054, both groups showed significant in-group changes over time for all outcomes evaluated (P≤.001). However, the primary outcome measure, the BBS, did not show evidence of a difference between BWSS and BWSS-P groups over time (F1,97=1.57; P=0.21) via linear mixed effects modeling with type III Wald F test with Kenward-Roger degrees of freedom. No significant between-group differences were noted for either secondary outcome measure, the Activities-Specific Balance Confidence scale (F1,94.99=0.36; P=.55), or 10 Meter Walk Test (F1,97=4.15; P=.04).ConclusionsAlthough significant between-group differences were not observed, participants in both groups demonstrated similar improvements from before to after assessment. This novel PBT technology shows promise as an option for gait and balance recovery training, especially for individuals with impaired balance control or fear of falling. The BWSS-P intervention contributed positively to rehabilitation outcome overall and should be considered as a viable treatment modality when clinically appropriate.

Measures of complex functional decision-making capacity can greatly aid in assessing mild cognitive impairment (MCI) and facilitating early intervention in dementia care. We examined the ability of the Assessment of Functional Capacity Interview (AFCI) to detect functional differences among older adults who were cognitively unimpaired (CU), or who presented with subjective cognitive decline (SCD) or MCI. A sample of 97 older adults (CU; n = 30, Mage = 74.64 ± 7.42 years; SCD; n = 34, Mage = 72.56 ± 6.43 years; MCI; n = 33, Mage = 78.28 ± 7.55 years) underwent neuropsychological testing and responded to the Financial Capacity Instrument (FCI-SF). Informants completed the Assessment of Functional Capacity (AFCI), an instrument of functional decision-making capacity, and responded to the Social Vulnerability Scale (SVS15) and Amsterdam Instrumental Activity of Daily Living (A-IADL-Q-SV), a measure of functional status, for comparison. According to informant-reported responses, the CU group had significantly lower AFCI total (and domain) scores, H(2) = 27.59, p<.001, relative to MCI. Additionally, the CU group had significantly lower AFCI scores in the Home and Personal Safety domain relative to the SCD group, H(2) = 14.06, p<.05. In the overall sample, AFCI total scores were associated with FCI-SF, SVS15, and A-IADL-Q-SV scores and cognitive measures. Our results demonstrate that the AFCI is sensitive to impairment in safety, social, financial, and medical functioning in MCI and is associated with measures of cognitive functioning and social vulnerability in older adults. Incorporating this instrument as a supplement to cognitive screening instruments may aid in the prevention of hazardous decision-making in older adults.

Patients with liver cirrhosis are known to have increased risk bleeding particularly from gastrointestinal tract. However, recent literature has shown that patients with liver cirrhosis are also at increased risk of developing deep venous thrombosis and pulmonary embolism. Therefore, it is important to consider prophylactic and therapeutic anticoagulation in cirrhotic patients. In this article, we have reviewed the available literature on the safety and efficacy of the utilization of prophylactic and therapeutic anticoagulation in cirrhotic patients.

doi: 10.1310/sci2201-13 Individuals with spinal cord injury (SCI) often experience complex health problems that, if untreated, can be costly and debilitating. In turn, they are high users of primary care. One study found that, during primary care visits, approximately 80% of the problems mentioned by patients with SCI were related to secondary conditions, such as urinary tract infections, pain, and skin problems. In a study of SCI patients in the Netherlands, over half (52%) of the contact with a primary care doctor was related to secondary conditions, with 34% considered to be preventable. Despite the necessity for quality health care, individuals with SCI face structural and environmental barriers, such as problems with transportation and inaccessible provider offices and equipment; studies have consistently found that these barriers hinder patients with disabilities from receiving needed care, including preventive screenings. Process barriers, such as physician’s lack of SCI knowledge, are also an ongoing problem. One study reported that emergency department (ED) residents displayed appropriate knowledge of 6 serious complications for SCI patients in the ED only 47% of the time. Other studies reported that SCI patients have difficulty finding knowledgeable doctors and feel the need to educate them about their disability. While potentially dangerous, limited provider knowledge can also pose a substantial hurdle for SCI patients in accessing primary health care. Lack of funding and service fragmentation are also cited as major process barriers. In navigating the numerous barriers within the health care system, individuals with SCI often struggle to get their health care needs met. When surveyed, 33% of patients with SCI expressed an unmet primary care need, with greater unmet needs related to lower income and poorer health status. A study of ED use by individuals with traumatic SCI classified half of ED visits as potentially preventable or of low urgency. Every consumer must navigate a complex interplay of socioeconomic, environmental, and physical factors unique to their situation as they try to access quality primary care. While many studies have documented barriers to care and health disparities, as well as recommended systems-level changes, few have focused on the navigation strategies utilized by consumers to effectively get their needs met. A fuller understanding of consumer-level strategies could facilitate the development of effective interventions – which

Background: The need for rehabilitation therapy after an acute hospitalization can be difficult to discern among patients with minor stroke. This study examined the guideline recommended components of a multidisciplinary assessment of rehabilitation needs and their association with discharge to inpatient rehabilitation among patients with a minor stroke. Methods: We analyzed data from a Northeast Cerebrovascular Consortium feasibility study of 22 Get With The Guidelines-Stroke participating hospitals that completed a standardized assessment of rehabilitation needs for 792 ischemic and hemorrhagic stroke patients. Patients with TIA or who died in hospital, left AMA, or were discharged to another hospital or hospice were excluded. Multivariable logistic regression was used to identify patient characteristics and acute hospital measures of impairment, complications and caregiver support associated with discharge to inpatient rehabilitation (IRF) or skilled nursing facilities (SNF) compared to discharge home among patients with a NIH Stroke Scale score&lt;=4. Results: Among the 351 patients with minor stroke, 31% were discharged to inpatient rehabilitation (24% IRF, 7% SNF). In univariate analyses comparing patients discharged to rehabilitation vs. home there was no significant difference in gender, race, ethnicity, education, history of myocardial infarction or coronary artery disease, hypertension or dyslipidemia, hospital documented deep vein thrombosis, or caregiver availability after hospital discharge. In the multivariable model, only pre-stroke disability was associated with discharge to rehabilitation compared to discharge home. Conclusions: Rehabilitation needs were documented for patients with minor stroke and almost one third were discharged to receive inpatient rehabilitation in an IRF or SNF. Taking pre-stroke disability into consideration for transition planning from acute care could facilitate earlier communication and planning with the next point of care.