Biomechanical Analysis of Pedalling for Rehabilitation Purposes: Experimental Results on Two Pathological Subjects and Comparison with Non-pathological Findings

In this paper the experimental results obtained by means of a prototype measuring device dedicated to the evaluation of the rehabilitation level of the lower limb are presented. The analysis of the experimental data collected on non-pathological subjects allows the identification of the characteristic meaning of the most significant parameters typical of healthy subjects. These data have been employed for a systematic comparison with the same parameters measured on two pathological subjects, in order to define quantitative indicators of the rehabilitation degree of the lower limbs and indicators of the “quality” of the movement.     

An electromyographic study of human gait both in water and on dry ground

The purpose of the present study was to define the degree of muscular activation while walking in water in order to aid rehabilitation therapists in their choice of exercises for daily clinical practice in aquatherapy. This study compares the electromyographic (EMG) activity of the rectus femoris, the soleus of the right lower limb and the contra-lateral lumbar erector spinae, during gait in water and on dry ground. The study was carried out on a group of seven healthy female subjects without past rachidian pathology. EMG recordings in water were taken with immersion to the umbilicus at "comfortable" speed. A total of five recordings were made at this speed, in water and on dry ground, with a one-minute rest between recordings. Integrated EMG results, averaged on eight gait cycles, show, for all the subjects, more erector spinae activity in water than on the ground (p<0.01). Soleus activity is greater during gait on dry ground for the whole group (p<0.01). For four subjects, the electromyographic (EMG) activity of the rectus femoris over the entire cycle is greater than that exhibited on dry ground.In the two experimental situations, no differences have been found either on amplitudinal peaks or on the shape of the patterns. The speed and gait cycle length are reduced in water (60% and 25%). Walking in water at an umbilical level increases the activity of the erector spinae and activates the rectus femoris to levels near to or higher than walking on dry ground.These data should be taken into account by the physiotherapist when designing a rehabilitation programme.     

A complex experimental assessment for objective description of hierarchical psychophysiological behavior as human regulatory phenotype

For the objective and valid identification of different human regulatory phenotypes it should be useful to analyze the behavior of different regulatory subsystems (Anochin 1976) in one multivariate design. Therefore in a DARA supported project a fully computerized and reliable laboratory assessment was developed and tested. We used a set of electrophysiological parameters that should indicate the activity of different functional regulation systems on different "behavioral levels". Skin conductance, skin temperature and voice pitch were used as indicators of sympathico-parasympathical activity. Breathing, heart rate variability and bloodpressure should indicate cardiovascular activity and electromyogram and mimic variablity were thought as indicators of locomotional external behavioral activity. To identify physiological reactions which are influenced by emotional stress we used voice stress measures. Even in the field of aviation and space medicine there exist data about the correlation of voice pitch with emotional excitation (Hecker et. al. 1968, Williams et.al. 1969, Friedrich, Vaic 1978, Vaic et.al. 1981,1982, Griffin, Williams 1987). In our former study (MOSAIC-study, Johannes 1990) the voice pitch and its variation range correlated with perceived emotional excitation but were independent of real bloodpressure variations. Two different types of pitch reaction to this experimental design were correlated to psychological personality scales and assigned subjects to "sensitizers" and "suppressors".     

Lessons from practice: assessing early progress and success in river rehabilitation

This article comprises a literature analysis of 41 river rehabilitation projects to assess the short-term (5 years) ability of indicator groups to demonstrate progress towards river rehabilitation goals. Positive indications were compared to land-use, river size, rehabilitation intervention and time. A questionnaire was developed to investigate river manager’s interpretation of rehabilitation success and to assess their level of adherence to recommendations in the literature with regard to rehabilitation assessment on a conceptual level. A total of 54 responses were received from respondents based in Germany, The Netherlands and the United Kingdom. The results indicate that macroinvertebrate indicators, while widely used in assessing river rehabilitation efforts, exhibited a lower frequency of positive responses than most other indicator types in the short term. Conversely, terrestrial floodplain indicators exhibited the most frequent level of positive response for all ecological type indicators leading to recommendations for further investigations into their use for short-term monitoring. Assessment procedures recommended in literature are largely followed, illustrating the advances that have been made with regard to assessment planning. Indicator responses are influenced by scale factors, for example, land-use and river size, that are often not considered by rehabilitation managers. While an emphasis is placed on ecological, hydrological and morphological indicators in monitoring schemes, the socioeconomic perspective (emphasized in the literature as forming an integral part of the river system) is neglected.     

Extraction of quasi-linear viscoelastic parameters for lower limb soft tissues from manual indentation experiment.

A manual indentation protocol was established to assess the quasi-linear viscoelastic (QLV) properties of lower limb soft tissues. The QLV parameters were extracted using a curve-fitting procedure on the experimental indentation data. The load-indentation responses were obtained using an ultrasound indentation apparatus with a hand-held pen-sized probe. Limb soft tissues at four sites of eight normal young subjects were tested in three body postures. Four QLV model parameters were extracted from the experimental data. The initial modulus E0 ranged from 0.22 kPa to 58.4 kPa. The nonlinear factor E1 ranged from 21.7 kPa to 547 kPa. The time constant tau ranged from 0.05 s to 8.93 s. The time-dependent materials parameter alpha ranged from 0.029 to 0.277. Large variations of the parameters were noted among subjects, sites, and postures.     

Data entry on a computer terminal: repetitive work strains on the oculomotor and central nervous systems

Continuous telemetric recordings including E.K.G., E.O.G., and E.E.G. were carried out on two subjects during 4 working days: 1 day of "reference work" or classical clerical activities, 3 days of "data entry work". Although the time allowed for the task was not limited, the performance assessed from oculomotor patterns remained stable throughout the day, from one day to the next and from one subject to another. This stability was reflected on the stereotyped E.E.G. patterns recorded during the work period, the differences occurring between reading and typing were more acute in the left cortical hemisphere than in the right. As a result of these stable patterns, the ultradian oscillations of the behavioural and physiological parameters were less during data entry than during work reference. The only possible time adjustments were the interruptions or breaks between two document pages and their variations could be considered as indicators of work load.     

Spatio-temporal parameters of gait measured by an ambulatory system using miniature gyroscopes

In this study we describe an ambulatory system for estimation of spatio-temporal parameters during long periods of walking. This original method based on wavelet analysis is proposed to compute the values of temporal gait parameters from the angular velocity of lower limbs. Based on a mechanical model, the medio-lateral rotation of the lower limbs during stance and swing, the stride length and velocity are estimated by integration of the angular velocity. Measurement's accuracy was assessed using as a criterion standard the information provided by foot pressure sensors. To assess the accuracy of the method on a broad range of performance for each gait parameter, we gathered data from young and elderly subjects. No significant error was observed for toe-off detection, while a slight systematic delay (10 ms on average) existed between heelstrike obtained from gyroscopes and footswitch. There was no significant difference between actual spatial parameters (stride length and velocity) and their estimated values. Errors for velocity and stride length estimations were 0.06 m/s and 0.07 m, respectively. This system is light, portable, inexpensive and does not provoke any discomfort to subjects. It can be carried for long periods of time, thus providing new longitudinal information such as stride-to-stride variability of gait. Several clinical applications can be proposed such as outcome evaluation after total knee or hip replacement, external prosthesis adjustment for amputees, monitoring of rehabilitation progress, gait analysis in neurological diseases, and fall risk estimation in elderly.     

A selection of safeguard subjects and state indicators for sustainability assessments

Purpose

The purpose of this work is to identify and select safeguard subjects and state indicators that are suitable for sustainability assessment in product and production development, using an interpretation of the Brundtland definition of sustainable development. The purpose is also to investigate how indicators selected in this way differ from other selections in the literature.

Methods

We use a top-down approach, which starts with reviewing the Brundtland definition of sustainability and identifying the corresponding human basic needs to be satisfied. For each basic need, we identify relevant satisfiers, and for each satisfier, a number of safeguard subjects. The safeguard subjects represent critical resources for making satisfiers available. For each safeguard subject, a number of state indicators (=endpoint category indicators) are selected that are relevant for describing impacts from product life cycles on the safeguard subject.

Results and discussion

Ecosystem services, access to water, and abiotic resources are identified as environmental safeguard subjects. Technology for transports, environment, textiles, housing, food, information, and energy, together with income, are identified as economical safeguard subjects. Human health, land availability, peace, social security, continuity, knowledge, jobs/occupation, and culture are identified as social safeguard subjects. In comparison with the other selections of safeguard subjects in literature, our safeguard subjects are structured differently and delimited in scope, but there are also many similarities. The best agreement is on environmental issues, but we classify human health as a social issue. For social issues, we identify fewer safeguard subjects and state indicators than recommendations from UNEP/SETAC. For economic issues, we diverse from current LCC and approach UNECE measures of sustainability.

Conclusions

Identification and selection of safeguard subjects and state indicators benefit from a clear definition of sustainability, needs to be satisfied, and satisfiers. The interpretation of the sustainability concept has a large influence on which safeguard subjects that are included and which indicators that are needed to describe their state. Capacity building is an important sustainability indicator, which should be developed further for use in life cycle sustainability assessment. The top-down approach offers a good arena for a further research and discussions on how to structure and focus LCSA. Our results shall be seen as one example of which safeguard subject that may be identified with the top-down approach presented here.

     

Monitoring Intervention Coverage in the Context of Universal Health Coverage

Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups—promotion/prevention, and treatment/care—as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors'' Summary

Summary Points

• Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health.
• Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage.
• Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal.
• Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and people''s expectations, the indicator sets will not be the same everywhere.
• Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure.
• A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights.
• Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention.
• Targets should be set in accordance with baseline, historical rate of progress, and measurement considerations.
• The main data sources of intervention coverage indicators are household surveys and health facility reports. Investments in both are needed to improve the ability of countries to monitor progress towards UHC.
• It is essential to find effective ways of communicating progress towards UHC in ways that are meaningful to the general public and that capture the attention of policy makers.

This paper is part of the PLOS Universal Health Coverage Collection.

     

Model of head–neck joint fast movements in the frontal plane

The objective of this work is to develop a model representing the physiological systems driving fast head movements in frontal plane. All the contributions occurring mechanically in the head movement are considered: damping, stiffness, physiological limit of range of motion, gravitational field, and muscular torques due to voluntary activation as well as to stretch reflex depending on fusal afferences. Model parameters are partly derived from the literature, when possible, whereas undetermined block parameters are determined by optimising the model output, fitting to real kinematics data acquired by a motion capture system in specific experimental set-ups. The optimisation for parameter identification is performed by genetic algorithms. Results show that the model represents very well fast head movements in the whole range of inclination in the frontal plane. Such a model could be proposed as a tool for transforming kinematics data on head movements in neural equivalent data, especially for assessing head control disease and properly planning the rehabilitation process. In addition, the use of genetic algorithms seems to fit well the problem of parameter identification, allowing for the use of a very simple experimental set-up and granting model robustness.     

Mite (Acari) colonization of vegetated mine tailings near Sudbury,Ontario, Canada

INCO Ltd. near Sudbury, Ontario is rehabilitating nickel- and copper-mine tailings using vegetating techniques that have resulted in habitats of varying age and complexity. Mite (Acari) communities and soil quality characteristics were used to evaluate soil ecosystem development on four tailings sites, 0, 8, 20 and 40 years post rehabilitation in comparison with that on four control sites. Abundance, species richness, diversity (H) and community structure of soil mites were sensitive indicators of tailings rehabilitation and soil formation. Mite density on older and botanically diverse tailings sites was comparable to that on control sites; however, species richness of oribatids and mesostigmatics was lower than on control sites. Mite species richness and diversity on tailings were lower at less botanically diverse sites regardless of age. Similarity of tailings-mite communities to control-site communities generally increased with age; however, similarities were all less than 60% (Sorenson's quantitative index, C _N). Mite assemblages on tailings were dominated by a few colonizing species, whereas control sites had a diverse assemblage of species. Soil pH and organic matter (SOM) of rehabilitated tailings improved with age and degree of botanical complexity. Mite density and diversity was positively related to SOM particularily for the Oribatida. SOM and mites were mainly restricted to the 0–5-cm horizon.     

早期心脏康复对老年急性心肌梗死PCI术后心功能及心理状态的影响

摘要 目的：探讨早期心脏康复对老年急性心肌梗死（acute myocardial infarction, AMI）患者经皮冠状动脉介入（percutaneous coronary intervention, PCI）术后心功能及心理状态的影响。方法：2018年1月~2018年12月间成功实施PCI的62例老年AMI患者随机分为研究组（n=31）和对照组（n=31），同时选择30例健康体检者作为健康组。对照组按照《中国经皮冠状动脉介入治疗后康复程序》给予常规康复训练，研究组结合根据6 min步行试验（6min walking test, 6MWT）制定个性化的康复训练方案，包括院内、院外心脏康复干预、心理干预及随访，为期6个月。比较两组术后心功能、心理状态、终点事件的发生情况。结果：康复后6个月，两组左心室舒张末期内径(left ventricular end-diastolic diameter, LVEDD)、左室收缩末期内径（left ventricular end-systolic diameter, LVESD）、左心室射血分数(left ventricular ejection fraction, LVEF)各心功能指标均较康复前明显提高，且研究组明显优于对照组(P<0.05)。研究组康复后6个月LVEF与健康组比较，差异无统计学意义(P>0.05)。康复后6个月，两组90项症状自评量表（symptom check list-90, SCL-90）各项目中除敌对、偏执外，其余项目评分均显降低，且研究组躯体化、强迫症状、抑郁、焦虑、精神病性显著低于对照组(P<0.05)。康复随访期间，研究组终点事件的总发生率9.7%，显著低于对照组25.8%，且6 min步行距离（6 min walking distance, 6MWD亦较对照组明显增加(P<0.05)。结论：早期心脏康复可明显促进老年AMI患者PCI术后心功能恢复，改善心理状态，降低术后不良终点事件发生风险。     

Symmetry-based resistance as a novel means of lower limb rehabilitation

Robotic devices hold much promise for use as rehabilitation aids but their success depends on identifying effective strategies for controlling human-robot interaction forces. We developed a robotic device to test a novel method of controlling interaction forces with the intent of improving force symmetry in the limbs. Users perform lower limb extensions against a computer-controlled resistive load. The control software increases resistance above baseline in proportion to lower limb force asymmetry (balance between left and right limb forces). As a preliminary trial to test the device and controller, we conducted two experiments on neurologically intact subjects. In experiment 1, one group of subjects received symmetry-based resistance while performing lower limb extensions (n=10). A control group performed the same movements with constant resistance (n=10). The symmetry-based resistance group improved lower limb symmetry during training (ANOVA, p<0.05), whereas the control subjects did not. In experiment 2, subjects (n=10) successfully used symmetry-based resistance to alter their lower limb force production towards a target asymmetry (ANOVA, p<0.05). These studies suggest that symmetry-based resistance may hold rehabilitation benefits after orthopedic or neurological injury. Specifically, performing strength training therapy with this controller may allow hemiparetic individuals to focus better on increasing strength and neuromuscular recruitment in their paretic limb while experiencing symmetric limb forces.     

Pilot Study on the Influence of Nutritional Counselling and Implant Therapy on the Nutritional Status in Dentally Compromised Patients

Objectives

To investigate the impact of implant-prosthetic rehabilitation combined with nutritional counseling on the nutritional status of patients with severely reduced dentitions.

Design

An explorative intervention study including an intra-individual comparison of 20 patients with severely reduced dentitions in terms of nutrition- and quality of life-related parameters recorded at baseline and at six and twelve months after implant-prosthetic rehabilitation.

Participants

Twenty patients from the Department of Prosthetic Dentistry of Justus-Liebig University of Giessen, with an mean age of 63 years, who had fewer than ten pairs of antagonists.

Measurements

The baseline data collection included dental status, a chewing ability test, laboratory parameters, anthropometric data (body mass index), energy supply, a 3-day dietary record, an analysis of the oral health-related quality of life (OHRQoL) with the OHIP-G14, the Mini-Mental Status (MMS) and Mini Nutritional Assessment (MNA). Six months after implantation and prosthetic rehabilitation, individual nutritional counseling was performed by a dietician. Data were again collected and analyzed. A final follow-up was conducted 12 months after prosthetic rehabilitation.

Results

Despite the highly significant improvement in masticatory ability and OHRQoL after implant-prosthetic rehabilitation, no significant changes were observed regarding MNA, anthropometric data or energy supply. Except for cholinesterase (p = 0.012), ferritin (p = 0.003), folic acid (p = 0.019) and vitamin A (p = 0.004), no laboratory parameter changed significantly during the investigation period. In addition, no general significant differences were observed for nutrient intake or food choice.

Conclusion

The present study does not confirm the assumption that the implant-prosthetic rehabilitation of patients with severely reduced residual dentitions with or without an individual nutritional counseling influences nutritional status.     

A semiparametric method for estimating population size for capture-recapture experiments with random covariates in continuous time

A semiparametric estimation procedure is proposed to model capture-recapture data with the aim of estimating the population size for a closed population. Individuals' covariates are possibly time dependent and missing at noncaptured times and may be measured with error. A set of estimating equations (EEs) based on covariate process and capture-recapture data is constructed to estimate the relevant parameters and the population size. These EEs can be solved by an algorithm similar to an EM algorithm. Simulation results show that the proposed procedures work better than the naive estimate. In some cases they are even better than "ideal" estimates, for which the true values of covariates are available for all captured subjects over the entire experimental period. We apply the method to a capture-recapture experiment on the bird species Prinia flaviventris in Hong Kong.     

Some metabolical aspects of physical exercise under laboratory and field conditions

Parameters of exercise physiology were studied in nearly 300 subjects to resolve whether these indices were equally suitable under laboratory and field conditions to assess the level of physical fitness and optimum work load. Respiratory gas exchange, heart rate and exercise acidosis parameters were studied. The inference drawn on the basis of the obtained data has been that both the mode and the intensity of the imposed exercise exert significant influence on the variation of physiological parameters. During running either on the treadmill or in the field test, blood lactate levels were comparable, but performances related to these concentrations were not the same. When different modes of exercise were employed, also lactate levels differed between the laboratory and field studies. The performance of patients under or after exercise rehabilitation following acute myocardial infarction by using instrumental monitoring in the laboratory was found to excel that attained during rehabilitation exercise training. Any change in the level of physical fitness can only be reliably followed when physiological parameters are obtained with the same mode of exercise and intensity under the same environmental conditions. Modern training planning of sports and exercise should take into account the data derived from both the laboratory and the field studies concerning cardiorespiratory system and metabolism.     

Determination of patient-specific multi-joint kinematic models through two-level optimization

Dynamic patient-specific musculoskeletal models have great potential for addressing clinical problems in orthopedics and rehabilitation. However, their predictive capability is limited by how well the underlying kinematic model matches the patient's structure. This study presents a general two-level optimization procedure for tuning any multi-joint kinematic model to a patient's experimental movement data. An outer level optimization modifies the model's parameters (joint position and orientations) while repeated inner level optimizations modify the model's degrees of freedom given the current parameters, with the goal of minimizing errors between model and experimental marker trajectories. The approach is demonstrated by fitting a 27 parameter, three-dimensional, 12 degree-of-freedom lower-extremity kinematic model to synthetic and experimental movement data for isolated joint (hip, knee, and ankle) and gait (full leg) motions. For noiseless synthetic data, the approach successfully recovered the known joint parameters to within an arbitrarily tight tolerance. When noise was added to the synthetic data, root-mean-square (RMS) errors between known and recovered joint parameters were within 10.4 degrees and 10 mm. For experimental data, RMS marker distance errors were reduced by up to 62% compared to methods that estimate joint parameters from anatomical landmarks. Optimized joint parameters found using a loaded full-leg gait motion differed significantly from those found using unloaded individual joint motions. In the future, this approach may facilitate the creation of dynamic patient-specific musculoskeletal models for predictive clinical applications.     

Galvanic vestibular stimulation improves the results of vestibular rehabilitation

Here, we present findings from a three-step investigation of the effect of galvanic vestibular stimulation (GVS) in normal subjects and in subjects undergoing vestibular rehabilitation (VR). In an initial study, we examined the body sway of 10 normal subjects after one minute of 2 mA GVS. The effect of the stimulation lasted for at least 20 minutes in all subjects and up to two hours in 70% of the subjects. We then compared a group of patients who received conventional VR (40 patients) with a group that received a combination of VR and GVS. Results suggest a significant improvement in the second group. Finally, we attempted to establish the optimal number of GVS sessions and to rule out a placebo effect. Fifteen patients received "systematic" GVS: five sessions, once a week. Five patients received "nonsystematic" galvanic stimulation in a sham protocol, which included two stimulations of the clavicle. These data were analyzed with Fisher's exact test and indicated that the best results were obtained after three sessions of GVS and no placebo effect was observed.     

Cephalometric indicators of the vertical dimension of occlusion

The aim of this investigation was to establish precise indicators of the vertical dimension of occlusion (VDO) which could be used as objective parameters in prosthodontic treatment providing exact control of the reconstructed vertical dimension of occlusion, early detection of errors and correction of the vertical dimension of occlusion during complete denture manufacturing. A total of 60 lateral cephalometric radiographs of subjects with natural dentition and class I skeletal jaw relationship, of Serbian nationality from the region of Vojvodina, were included in the investigation. Thirty subjects were males, and thirty females, their age range was 20 to 29 years. Cephalometric analysis was performed by using "Dr. Ceph" computer software (FYI Technologies, GA, USA). By evaluation of the craniofacial complex in subjects with natural dentition, horizontal dentofacial developmental growth was established in the examined sample and it was based on the relationship between the posterior and anterior total facial height (S-Go:N-Me, female X=68.96%, male X=72.8%) and statistically significant differences were found between the sexes in almost all linear dimensions and in the relation between the posterior and the anterior total facial height. Highly significant differences (p<0.001) between the sexes were found in regard to anterior total facial height (N-Me, male X=120.75 mm, female X=112.72 mm) and the anterior lower facial height (ANS-Me, male X=67.87 mm, female X=61.50 mm) (p<0.05). The proportions of the upper and lower anterior facial heights (N-ANS:ANS-Me, male X=79.36%, female X=80.63%) were within normal values in both sexes. Facial harmony existed both in men and women. Cephalometric study of the subjects with complete natural dentition included in this study provided important and specific parameters for optimal reconstruction of vertical dimension of occlusion in the treatment of edentulous patients.     

Factors Associated with Nursing Home Placement of All Patients Admitted for Inpatient Rehabilitation in Singapore Community Hospitals from 1996 to 2005: A Disease Stratified Analysis

Objectives

To (1) identify social and rehabilitation predictors of nursing home placement, (2) investigate the association between effectiveness and efficiency in rehabilitation and nursing home placement of patients admitted for inpatient rehabilitation from 1996 to 2005 by disease in Singapore.

Design

National data were retrospectively extracted from medical records of community hospital.

Data Sources

There were 12,506 first admissions for rehabilitation in four community hospitals. Of which, 8,594 (90.3%) patients were discharged home and 924 (9.7%) patients were discharged to a nursing home. Other discharge destinations such as sheltered home (n = 37), other community hospital (n = 31), death in community hospital (n = 12), acute hospital (n = 1,182) and discharge against doctor’s advice (n = 24) were excluded.

Outcome Measure

Nursing home placement.

Results

Those who were discharged to nursing home had 33% lower median rehabilitation effectiveness and 29% lower median rehabilitation efficiency compared to those who were discharged to nursing homes. Patients discharged to nursing homes were significantly older (mean age: 77 vs. 73 years), had lower mean Bathel Index scores (40 vs. 48), a longer median length of stay (40 vs. 33 days) and a longer time to rehabilitation (19 vs. 15 days), had a higher proportion without a caregiver (28 vs. 7%), being single (21 vs. 7%) and had dementia (23 vs. 10%). Patients admitted for lower limb amputation or falls had an increased odds of being discharged to a nursing home by 175% (p<0.001) and 65% (p = 0.043) respectively compared to stroke patients.

Conclusions

In our study, the odds of nursing home placement was found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes.