Prognosis in Neuro Conditions Flashcards
Prognostic questions for the PT
- 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)
What is prognosis?
- 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
Day of evaluation in acute care
most case managers review PT evaluation to determine optimal discharge location
inpatient rehabilitation
Must have medical needs, realistic
long term goals of home discharge, ability to tolerate 3 hours of therapy, approved diagnoses percentage of case mix
subacute rehabilitation
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
Skilled nursing
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
day rehab
require patient to need more than one discipline, some have care conferences with rehab MD and team; likely some level
of inter-disciplinary discussion
outpatient
patient seen for PT as a single service
home health
need to be homebound
- leaving home is infrequent and requires considerable, taking effort
caregiving services
- not covered by insurance
- home health nursing is but is only in the home for nursing related needs and for short periods of time
3 strategies for determining prognosis
- decision making frameworks
- models of health and disease
- evidence
what should you use the ICF to do?
identify facilitators and barriers to progress/recovery/improvement
ICF factors
- 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)
examples of positive prognostic factors
Support system
Motivation
Active and independent prior
younger
few co-morbidities
few cognitive issues
motor recovery
examples of negative prognostic factors
impulsivity
neglect
no motor recovery
if patient is in acute or inpatient rehab, when will medicare pay for equipment?
no more than 48 hours before discharge
- pt MUST be discharging home rather than another facility
Trunk control in stroke –> relationship to ADLs
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
Predicting Activities after stroke
- 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
Predictors of ADL improvement
- 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
what is a negative predictor of ADL improvement post stroke
posterior limb of internal capsule involvement
what is a key determinant of success in ambulation post stroke
gait speed
Ambulation post stroke
- 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
what predicts community ambulation at 6 mo
- gait speed over .4m/sec and low fear of falling at 3 mo
what is the twist tool
- 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
UE predictors
- 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
impact of pre stroke physical ability
- 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
Return to work for young stroke
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.
Two main issues of TBI
pre-injury demographics and clinical features
what is associated with better cognitive function post TBI
Younger age, higher education, white race, shorter posttraumatic amnesia, having insurance, fewer co-morbidities, and fewer days from injury to inpatient rehabilitation admission
What is associated with better motor function post TBI
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
What is the recovery time for TBI
- most recover within 3 months
- up to 9 months but not past a year
household walker
0 to 0.4 m/sec
limited community ambulator
0.4 to 0.8 m/sec
community ambulator
0.8- 1.2 m/sec
cross the street and normal walking speed
greater than 1.2 m/sec
walking speeds for independent ADLs
greater than 1 m/sec
for stroke survivors, what gait speed at discharge of inpatient rehab is a predictor of community ambulation
0.5 m/sec or greater
possible reasons for additional PT
◦ 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
Reasons for lifelong physical activity
◦ 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
