Prognosis in Neuro Conditions

Question 1

Prognostic questions for the PT

Answer 1

• What is the prognosis for my patient to return home versus unable to return home?
• How long do I envision we will be able to work together? Consider both your perspective of what you would recommend and external factors that will impact length of stay/episode of care
• What are the odds that this intervention will improve my patient’s gait speed, independent ambulation, ADL function, Q of L?
• What do I do now? (if patient is finishing therapy)

Question 2

What is prognosis?

Answer 2

• determination of level of optimal improvement that may be attained through intervention
• amount of time required to reach the optimal level
• planning for discharge needs for patient and family

Question 3

Day of evaluation in acute care

Answer 3

most case managers review PT evaluation to determine optimal discharge location

Question 4

inpatient rehabilitation

Answer 4

Must have medical needs, realistic
long term goals of home discharge, ability to tolerate 3 hours of therapy, approved diagnoses percentage of case mix

Question 5

subacute rehabilitation

Answer 5

Often housed as a unit in a skilled
nursing facility, receive nursing care but less frequent MD visits, amount of therapy determined by team in consideration of diagnosis, age, and initial evaluation; less
therapy per day than inpatient rehab, but will still have therapy daily most likely

Question 6

Skilled nursing

Answer 6

May receive some therapy services, palliative
services, or no services; therapy and MD visits would not be a required aspect of the stay; may stay long term

Question 7

day rehab

Answer 7

require patient to need more than one discipline, some have care conferences with rehab MD and team; likely some level
of inter-disciplinary discussion

Question 8

outpatient

Answer 8

patient seen for PT as a single service

Question 9

home health

Answer 9

need to be homebound
- leaving home is infrequent and requires considerable, taking effort

Question 10

caregiving services

Answer 10

• not covered by insurance
• home health nursing is but is only in the home for nursing related needs and for short periods of time

Question 11

3 strategies for determining prognosis

Answer 11

• decision making frameworks
• models of health and disease
• evidence

Question 12

what should you use the ICF to do?

Answer 12

identify facilitators and barriers to progress/recovery/improvement

Question 13

ICF factors

Answer 13

• health condition
• impairments (physical, cognitive, communication)
• activity/participation restrictions (functional levels, level of independence)
• personal factors (motivation, co-morbidities)
• environmental factors (duties, social, physical, financial)

Question 14

examples of positive prognostic factors

Answer 14

Support system
Motivation
Active and independent prior
younger
few co-morbidities
few cognitive issues
motor recovery

Question 15

examples of negative prognostic factors

Answer 15

impulsivity
neglect
no motor recovery

Question 16

if patient is in acute or inpatient rehab, when will medicare pay for equipment?

Answer 16

no more than 48 hours before discharge
- pt MUST be discharging home rather than another facility

Question 17

Trunk control in stroke –> relationship to ADLs

Answer 17

PASS score at 14 days accounted for 45% of the variance in predicting comprehensive ADL function
– slightly better than Fugl Meyer and Barthel Index for predicting ADL function

Question 18

Predicting Activities after stroke

Answer 18

• initial severity of stroke and extent of improvement within first weeks are important indicators of outcome at 6 months
• most recovery within 10 weeks (plateau 3 to 6 mo post)
• age and scores on scales assessing severity in early phase are associated with bADL outcome at 3 mo

Question 19

Predictors of ADL improvement

Answer 19

• younger age
• lower score on NIHSS (<10) at admission
• Barthel Index measures at 5 days or later
• urinary continence, good sitting balance, absence of aphasia, absence of DM

Question 20

what is a negative predictor of ADL improvement post stroke

Answer 20

posterior limb of internal capsule involvement

Question 21

what is a key determinant of success in ambulation post stroke

Answer 21

gait speed

Question 22

Ambulation post stroke

Answer 22

• 70-80% have ability to walk (only 30-40% in community ambulation)
• Sitting balance 2 weeks after stroke can predict 6 month ambulation ability
• <50 on Trunk Control Test 14 days after stroke predicts less likelihood of walking at 6 months

Question 23

what predicts community ambulation at 6 mo

Answer 23

• gait speed over .4m/sec and low fear of falling at 3 mo

Question 24

what is the twist tool

Answer 24

• tool that evaluates predictor of independent walking in first 6 mo post stroke
• Evaluated lower extremity lower limb muscle strength- hip flexion, knee extension, ankle dorsiflexion, Trunk Control Test, Berg Balance Test, visuospatial neglect (Star Cancellation Test)
• score of 4: independently ambulating in 4 weeks
• score of 0: dependent 6 mo post

Question 25

UE predictors

Answer 25

- baseline arm and hand function - Motricity index score of 64/100 or better at 4 weeks predicts ARAT of >35 at 6 mo - ability to shut and abduct shoulder at admission predicts good hand function at discharge - presence of finger extension at 7 days post predicts improved hand function at 6 mo - patient with active shoulder abduction and some active finger extension after mass grasp within 72 hr good improvement at 6 mo

Question 26

impact of pre stroke physical ability

Answer 26

- Active- dedicated leisure time physical activity for at least 30min/day for 3 days a week for more than 6 months prior to stroke - Fewer post stroke complications - Lower hospital mortality - Better functional outcomes at discharge, 1 month, 3 months, and 6 months post

Question 27

Return to work for young stroke

Answer 27

Return to work increases with time ◦ 41% between 0-6 months ◦ 53% at 1 year ◦ 56% at 1.5 years ◦ 66% between 2-4 years Greater independence in ADLS, fewer neurological deficits, and better cognitive ability are most common predictors of return to work.

Question 28

Two main issues of TBI

Answer 28

pre-injury demographics and clinical features

Question 29

what is associated with better cognitive function post TBI

Answer 29

Younger age, higher education, white race, shorter posttraumatic amnesia, having insurance, fewer co-morbidities, and fewer days from injury to inpatient rehabilitation admission

Question 30

What is associated with better motor function post TBI

Answer 30

Younger age, sex (male), white race, having insurance, fewer co-morbidities, lack of open head injury, shorter time from injury to inpatient rehabilitation, and accessing home support services or home modification

Question 31

What is the recovery time for TBI

Answer 31

- most recover within 3 months - up to 9 months but not past a year

Question 32

household walker

Answer 32

0 to 0.4 m/sec

Question 33

limited community ambulator

Answer 33

0.4 to 0.8 m/sec

Question 34

community ambulator

Answer 34

0.8- 1.2 m/sec

Question 35

cross the street and normal walking speed

Answer 35

greater than 1.2 m/sec

Question 36

walking speeds for independent ADLs

Answer 36

greater than 1 m/sec

Question 37

for stroke survivors, what gait speed at discharge of inpatient rehab is a predictor of community ambulation

Answer 37

0.5 m/sec or greater

Question 38

possible reasons for additional PT

Answer 38

◦ Reassessment to determine progression or decline ◦ Reassessment to determine need for further PT care ◦ Modification to functional mobility strategies ◦ Equipment assessment and modification ◦ Review/modification to physical activity and exercise programs

Question 39

Reasons for lifelong physical activity

Answer 39

◦ Promote functional independence through continued practice ◦ Promote recovery of function and neurologic status ◦ Develop and maintain social support ◦ Improve one’s quality of life ◦ Optimize physical and mental health