The relationship between self-esteem and functional outcome in the acute stroke-rehabilitation setting.

Objective: To explore the relationship between self-esteem and functional recovery in patients with acute stroke. Design: A nonconsecutive sample of stroke survivors received ratings of functional status and completed self-report measures of self-esteem and depressive symptoms. Bivariate correlational analyses and multivariate regression analyses explored the relationships of functional status and self-report of self-esteem and depressive symptoms. Setting: Acute inpatient rehabilitation hospital. Participants: A group of 176 right- or left-hemisphere stroke participants. Main Outcome Measures: Self-care and mobility domain scores (based on Functional Independence Measure ratings) at admission and discharge. Efficiency scores for each domain. Visual Analogue Self-Esteem Scale (S. M. Brumfitt & P. Sheeran, 1999) and Geriatric Depression Scale (J. A. Yesavage et al., 1983). Results: Regression analyses indicated that lower self-esteem ratings were related to poorer discharge self-care and mobility scores and poorer efficiency in these domains, whereas ratings of depressive symptoms were not. However, interactions between self-esteem ratings and ratings of depressive symptoms were noted. Exploratory analyses suggested that self-esteem ratings mediated the relationship between ratings of depressive symptoms and functional outcome indices. Conclusions: Self-esteem ratings may have a mediating/moderating role in the relationship between emotional functioning and functional outcome. This may have implications for research in this area and the type of mental health treatment available to stroke rehabilitation patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation.

Objective: To explore self-esteem change during inpatient stroke rehabilitation and moderators of change. Research Method: One hundred twenty survivors of stroke serially completed the State Self-Esteem Scale (SSES) during inpatient rehabilitation, as well as measures of mood and perceived recovery as potential moderators of change. Age, gender, prior stroke, prestroke depression, stroke laterality, and admission Functional Independence Measure (FIM) self-care, mobility, and cognitive scores were also included as moderators. Results: Multilevel modeling of the repeated administrations of the SSES indicated that self-esteem significantly improved during rehabilitation. Female gender, left hemisphere stroke, prior stroke, and lower admission FIM cognitive scores were associated with lower self-esteem ratings at admission, but only age and admission FIM self-care and mobility scores were associated with self-esteem change. Older individuals showed less self-esteem improvement than younger individuals, and higher self-care and mobility scores at admission were associated with greater self-esteem improvement. While mood change significantly covaried with self-esteem, the rate of mood change did not appear to influence rate of self-esteem change. Greater improvement in self-esteem over time was related to lower levels of perceived recovery, but this was likely because of the relationship between perceived recovery and self-esteem at rehabilitation admission. Implications: These results suggest that self-esteem improves during inpatient rehabilitation, and this change may be partially dependent on functional status. Implications for facilitating self-esteem change by the clinician are discussed, as well as future research directions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-esteem stability and depressive symptoms in acute stroke rehabilitation: Methodological and conceptual expansion.

Objectives: Explore the relationship of self-esteem level, self-esteem stability, and other moderating variables with depressive symptoms in acute stroke rehabilitation. Measures: One hundred twenty participants completed measures of state self-esteem, perceived recovery, hospitalization-based hassles, impairment-related distress, and tendency to overgeneralize negative self-connotations of bad events. Self-report of depressive symptoms was collected at admission and on discharge. Four regression analyses explored the relationship of self-esteem level and stability and each of 4 moderating variables (perceived recovery, hassles, impairment-related distress, and overgeneralization) with depressive symptoms at discharge. Results: Analyses indicated significant 3-way interactions in the 4 regression models. In general, individuals with unstable high self-esteem endorsed greater depressive symptoms under conditions of vulnerability (e.g., lower perceived recovery) than did individuals with stable high self-esteem. Under conditions of vulnerability, participants with stable low self-esteem indicated the highest levels of depressive symptoms. Implications: Self-esteem level and stability interact with psychological, environmental, and stroke-specific variables to predict depressive symptoms at discharge from stroke rehabilitation. This suggests the viability of self-esteem stability in exploring depressive symptoms in this setting and the complexity of emotional adjustment early after stroke. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The association of level and stability of self-esteem and depressive symptoms in the acute inpatient stroke rehabilitation setting.

Purpose: Explore the relationship of level and stability of self-esteem with self-reported depressive symptoms during acute inpatient stroke rehabilitation. Research Method: A consecutive sample of 79 participants was administered measures of state self-esteem and mood twice a day for 4 consecutive days. The Geriatric Depression Scale (GDS) was administered at the end of the 4 days. Self-esteem level was calculated by averaging the total self-esteem scores across the assessments, and self-esteem stability was operationalized as the standard deviation of self-esteem total scores. Mood level and stability were calculated likewise. Results: Regression analysis indicated that self-esteem stability moderated self-esteem level in predicting GDS scores, with stable lower self-esteem level associated with the most reported depressive symptoms. Unstable higher self-esteem levels were associated with more depressive symptoms than stable higher self-esteem. This interaction was demonstrated after controlling for mood level and stability, suggesting the independence of self-esteem stability from mood characteristics. Conclusion: Self-esteem stability may be an important variable in identifying individuals at risk for emotional disturbance following stroke. Further exploration of self-esteem stability correlates in this setting is warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional outcome after brain tumor and acute stroke: a comparative analysis

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke. DESIGN: Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit. SUBJECTS: Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion. MAIN OUTCOME MEASURES: The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01). CONCLUSION: Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.     

Home alone: the role of cognition in return to independent living

OBJECTIVE: To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation. DESIGN: Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition. SETTING: A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit. PATIENTS: Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed. MAIN OUTCOME MEASURE: Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS). RESULTS: Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs. CONCLUSION: Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.     

A comparative study of postmortem MR imaging and pathological examination of human brain specimens

OBJECTIVE: To determine typical outcome "benchmarks" for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared. SUBJECTS: Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation. METHODS: Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation. MAIN OUTCOME MEASURES: Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates. RESULTS: The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities. CONCLUSION: The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.     

Posttraumatic amnesia: its relation to functional outcome

OBJECTIVE: To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS: Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES: Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS: Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION: Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.     

Increased serum levels of macrophage colony-stimulating factor (M-CSF) in alpha- and beta-thalassaemia syndromes: correlation with anaemia and monocyte activation

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.     

Assessment of functional abilities among geriatric patients: A MIMIC model of the functional independence measure.

Objective: To investigate the influence of population heterogeneity among geriatric patients on the factor structure and differential item functioning on the Functional Independence Measure (FIM) and thereby evaluate the appropriateness of using 2 factor composite scores (FIM motor and FIM cognition) among geriatric patients. Design: A specific application of structural equation modeling (i.e., multiple indicators, multiple causes [MIMIC] model) was conducted on FIM admission scores from 718 geriatric rehabilitation patients. Setting: A large urban rehabilitation hospital. Participants: 718 inpatients referred for medical rehabilitation (M?=?77.5 yrs; 62% African American; 68% female). Measurements: All participants' functional abilities were rated on the FIM by trained physical and occupational therapists on admission to the rehabilitation hospital. In addition, all patients completed the Geriatric Depression Scale. Results: Three motor functioning items and 3 cognitive functioning items differed systematically across groups within this geriatric sample (i.e., young-old vs old-old, male vs female, depressed vs nondepressed) even after controlling for group differences on levels of overall motor and cognitive functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Negative symptoms in stroke patients and length of hospital stay

The purpose of this study was to assess whether the presence and severity of psychiatric symptoms in stroke patients correlate with their length of stay (LOS) in a rehabilitation unit, with special emphasis on the role of negative symptoms (NS). Twenty-three stroke patients, consecutively recruited from the inpatient rehabilitation unit, were evaluated on admission with the Mini-Mental State Examination (MMSE), the Positive and Negative Symptom Scale (PANSS), the Hamilton Depression Rating Scale (HDRS), the Scale for Assessment of Negative Symptoms (SANS), and the Functional Independent Measure (FIM). NS scores significantly correlated with LOS, with SANS total score being the most informative, and the attentional impairment subscale the least. The group of patients with pronounced NS stayed in the hospital twice as long as patients with the score on the NS subscale of PANSS below 16. These two groups did not differ in their cognitive performance or in the positive symptom subscale of PANSS scores. Total FIM score on admission was lower and HDRS scores higher in patients with pronounced NS. However, these differences, unlike those of LOS, have not reached statistical significance. The presence and severity of NS in stroke patients are associated with a longer hospital stay. Identification and treatment of NS might lead to a faster discharge from rehabilitation unit.     

Risk factors for stress in children after parental stroke.

Objectives: To assess risk factors for stress in children 3 years after parental stroke. Participants: Questionnaires were filled in by 44 children aged 7–18 years, parents who suffered a stroke and healthy spouses from 29 families recruited in 9 participating rehabilitation centers across the Netherlands. Method: We measured patient functioning (cognitive disorders, communicative disorders and ADL dependency), parental depression and perceived quality of marital relationship at 4 assessments, from the start of rehabilitation until 3 years post-stroke. Children assessed their stress level 3 years after parental stroke. Results: Girls experienced more stress than boys. Spouses' depressive symptoms during the first year after stroke were positively correlated with stress in children. Patients' depressive symptoms 2 months post-rehabilitation (2 months after discharge from the rehabilitation center), 1 year and 3 years post-stroke were also positively correlated with stress in children. The perceived quality of marital relationship decreased over time and at 2 months postrehabilitation, it was related to stress in children. Stress was not related to patient gender and functioning. Conclusions: Early prediction of long-term stress in children after parental stroke may be most accurate on the basis of children's female gender and depressive symptoms of the patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system

OBJECTIVES: Function-related groups based on the Functional Independence Measure have been proposed as a model for a prospective payment system for medical rehabilitation. This study describes discharge destination and motor function outcomes in a sample of patients with stroke from the FIM-FRG STR1 classification. STUDY DESIGN: A retrospective review of 293 cases of stroke from the years 1993 to 1995. The demographic and outcome characteristics of this sample were described. RESULTS/CONCLUSIONS: Forty-five percent of the patients were discharged to home after a mean length of stay of 23.8 days in acute medical rehabilitation. Patients who were discharged home had higher admission and discharge motor FIM scores than those discharged to a subacute facility or long-term care facility, although the correlation between motor FIM score and discharge destination was low to moderate. Median discharge motor FIM scores indicate considerable residual disability in this classification after rehabilitation. Research problems that address methods to improve the usefulness of the FIM-FRG system in a prospective payment system are discussed.     

Trunk control test as an early predictor of stroke rehabilitation outcome

BACKGROUND AND PURPOSE: The aim of this study was to investigate the construct and predictive validity of the Trunk Control Test (TCT) in postacute stroke patients by comparing TCT scores at admission and discharge with the Functional Independence Measure (FIM) scores. METHODS: Forty-nine patients participated in the study. The TCT examines four movements: rolling from a supine position to the weak side (T1) and to the strong side (T2), sitting up from a lying-down position (T3), and sitting balance (T4). The FIM is an 18-item scale (13 motor [motFIM] and 5 cognitive [cognFIM]) used to determine the level of dependence of patients in daily life. RESULTS: Thirty-six patients (73%) increased their TCT overall score at discharge. The TCT item-total correlations were high, both at admission and discharge (P < .0001). The individual TCT items were intercorrelated. Furthermore, the homogeneity of the TCT was confirmed by a high Cronbach's index. High correlations were found between admission and discharge scores in the different tests (TCT, FIM, and motFIM; P < .0001) and between TCT at admission and FIM (P < .0001) and motFIM (P < .0001) at admission. TCT at admission alone explained 71% of the variance in motFIM at discharge. CONCLUSIONS: The TCT showed a good sensitivity to change in assessing recovery of stroke patients. The high item-total correlation and Cronbach's alpha value of the TCT suggest that there is one homogeneous construct underlying the item list. The TCT construct validity was confirmed by the correlation between this test and the FIM scores. TCT at admission predicted motFIM at discharge even better than motFIM at admission alone. Possibly, the TCT captures basic motor skills that foreshadow the recovery of more complex behavioral skills described by the FIM.     

Functional status, symptoms of depression, and the outcomes of hospitalization in community-dwelling elderly patients

OBJECTIVE: To assess the relationship between symptoms of depression at admission and postdischarge medical outcomes in hospitalized elderly patients. DESIGN: Prospective cohort study. METHODS: Patients screened for symptoms of depression at admission using the Geriatric Depression Scale underwent assessment 1 month after discharge to determine outcomes of hospitalization. SETTING: A 370-bed, acute care, community hospital. PATIENTS: A sample of 197 cognitively intact, community-dwelling elderly patients, aged 70 years and older, hospitalized with medical diagnoses, with expected lengths of stay of 48 hours or more. MAIN OUTCOME MEASURE: The Medical Outcomes Study Short-Form instrument was used to obtain data on 1-month postdischarge medical outcomes with respect to physical functioning, health status, and mental status. RESULTS: On admission, a total of 23.9% had symptoms of depression (Geriatric Depression Scale score, > or = 11) that were significantly related to preadmission functional status. In multivariate analyses, depressive symptoms at admission were significantly related to 1-month medical outcomes, independent of functional status. CONCLUSIONS: Findings suggest that depressive symptoms in hospitalized elderly may be reactive to physical disability and characterize a group of patients who have poorer functional status prior to admission. The effect of depressive symptoms on 1-month postdischarge medical outcomes, however, appears to be independent of and in addition to the effects of preadmission functional status.     

Mood improvement in elderly women after in-hospital physical rehabilitation

OBJECTIVE: To evaluate the relationship between change in depressive symptoms and in-hospital physical rehabilitation in elderly women. DESIGN: Longitudinal study. SETTING: Hospital facility (geriatric evaluation and rehabilitation unit). PATIENTS: One hundred twenty-three elderly inpatient women (mean age: 78.4+/-6.9 years, range 60 to 93) with good cognitive status (Mini Mental State Examination: 23.1+/-5.1) consecutively admitted over a 7-month period. INTERVENTION: Physical therapy tailored to individual needs (five sessions a week of 30 to 45 minutes each). MAIN OUTCOMES MEASURES: On admission: cognition (MMSE), depressive symptoms (Geriatric Depression Scale [GDS]), functional status (basic and instrumental activities of daily living [BADL, IADL], Tinetti scale), and somatic health. On discharge: depressive symptoms and gait and balance performances (Tinetti scale). RESULTS: Seventy-five patients (61%) did not show changes on Tinetti scale over the hospitalization period and 48(39%) had a change of 3 or more points. Nonresponders had no change of GDS over the hospitalization period for all levels of physical disability on admission, whereas responders had relevant improvement of depressive symptoms when markedly disabled on admission, and progressively smaller improvements of depressive symptoms with increasing function on admission. CONCLUSIONS: The study provides evidence that mood status changes synchronically with disability.     

Sonographically guided placement of peripherally inserted central venous catheters: review of 355 procedures

OBJECTIVE: To test whether Wallerian degeneration (WD) of the pyramidal tract as signaled by MRI affects rehabilitation outcome in patients with subcortical infarction (internal capsule or corona radiata). BACKGROUND: Recent radiologic evidence suggests that WD occurs no earlier than 3 months after a subcortical infarction. METHODS: A total of 77 consecutive patients with pure motor hemiparesis due to an initial subcortical infarction were assessed on admission and discharge with the Functional Independence Measure (FIM) for disability and Stroke Impairment Assessment Set (SIAS, full = 25) for impairment. WD was defined by a high-intensity area detected along the pyramidal tract below the level of lesion on T2-weighted MR image (WD+). RESULTS: Age, sex, side of stroke, Mini-Mental State Examination score, and volume of lesion were comparable for each group. Length of stay (LOS) was significantly longer (p < 0.05) in WD+ (130 days) than in WD- (105 days). There was no difference in the change of FIM (WD+, 99 to 111; WD-, 95 to 107) or SIAS measures (WD+, 12 to 16; WD-, 13 to 16) made on admission and discharge, nor was there any effect of the timing of the rehabilitation experience (< or = 90 days or >90 days after stroke). CONCLUSIONS: After stroke, apparent WD of the pyramidal tract may slow functional recovery but does not limit final rehabilitation outcome of pure motor hemiparesis. Study of the mechanisms of compensation for this delayed pyramidal tract degeneration will enhance the scientific basis for rehabilitation.