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Biomedical subjects

John Whyte

Publications and source records attributed to John Whyte.

At least 37 records · Page 2Linked to original sources
PubMed2003

Potential impact of the new medicare prospective payment system on reimbursement for traumatic brain injury inpatient rehabilitation.

OBJECTIVE: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation. DESIGN: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria. SETTING: Fourteen urban rehabilitation facilities throughout the United States. PARTICIPANTS: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes. RESULTS: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients. CONCLUSIONS: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.

Adult↗
PubMed2003

Concordance of patient and family report of neurobehavioral symptoms at 1 year after traumatic brain injury.

OBJECTIVE: To determine concordance between patient and family report of neurobehavioral symptoms and problems across 6 domains of function and 3 levels of injury severity at 1 year after traumatic brain injury (TBI). DESIGN: Prospective longitudinal design with follow-up between 10 and 14 months postinjury. SETTING: Seventeen Traumatic Brain Injury Model Systems centers. PARTICIPANTS: A total of 267 adults with primarily moderate and severe TBI who had completed self-ratings and whose neurobehavioral symptoms had also been rated by their significant others. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Neurobehavioral Functioning Inventory-Revised, a 70-item scale with subscales assessing frequency of symptoms in motor, somatic, memory and attention, depression, communication, and aggression domains. RESULTS: Twenty-three items showed significant differences or trends between the self- and other ratings; 18 of these were in the direction of the injured individual reporting less frequent problems. Differences were most pronounced on the depression, aggression, and memory and attention subscales. On the latter 2 subscales, patient-family concordance was higher for those with less severe injuries. However, severity effects were not clear cut. Analyses of selected rating patterns indicating clinically significant "underreporting" of symptoms revealed that these affected the depression, aggression, and memory and attention subscales more than the motor or somatic subscales. CONCLUSIONS: At 1 year post-TBI, concordance between self- and other report of neurobehavioral symptoms was moderately high overall, but varied by symptom domain. For persons with moderate and severe TBI, reports from significant others may be needed for a full picture of the range, severity, and clinical importance of the patient's emotional, behavioral, and cognitive difficulties.

Adolescent↗
PubMed2003

Early impaired self-awareness after traumatic brain injury.

OBJECTIVES: To evaluate predictors of early impaired self-awareness after traumatic brain injury (TBI); to examine interrelationships of the perceptions of patient, clinician, family, and significant other of how patients are functioning after TBI; and to determine how early impaired self-awareness helps to predict employability at rehabilitation discharge. DESIGN: Inception cohort. SETTING: Two inpatient rehabilitation programs. PARTICIPANTS: A total of 129 patients with TBI seen for inpatient rehabilitation at 1 of 2 rehabilitation centers. All subjects had emerged from posttraumatic amnesia before being assessed for this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Impaired self-awareness as measured by the Awareness Questionnaire (patient self-ratings, clinician ratings) and employability (rated on the Disability Rating Scale) at discharge from inpatient rehabilitation. RESULTS: Regression analysis revealed that early impaired self-awareness was predicted by age and functional status (FIM instrument total score) at admission to inpatient rehabilitation. Spearman correlation coefficients revealed that clinician, family, and significant other ratings of patient functioning were related (r(s) =.42, P<.001), but were not related to patient self-ratings. Multiple logistic regression analysis revealed that early impaired self-awareness was predictive of employability at discharge from inpatient rehabilitation. Clinician ratings of patient functioning showed a positive relation to employability (P =.05), whereas patient self-ratings showed a trend toward a negative relation to employability (P =.09). CONCLUSIONS: Our results support the importance of early impaired self-awareness assessment, its predictive value for complex functional activities, and the need for further research to determine if treatment programs for impaired self-awareness enhance functional outcomes.

Adult↗
PubMed2003

The influence of dynamic polyelectromyography in formulating a surgical plan in treatment of spastic elbow flexion deformity.

OBJECTIVE: To determine the influence of motor-control analysis with dynamic electromyography on surgical planning in patients with spastic elbow flexion deformity. DESIGN: Prospective observational design. SETTING: A Traumatic Brain Injury Model Systems-affiliated specialty referral center for the evaluation and treatment of mobility problems associated with neurologic injury and disease. PARTICIPANTS: Twenty-one patients with spastic elbow flexion deformity. INTERVENTIONS: Two surgeons each formulated a detailed surgical plan for each individual muscle-tendon unit. Patients then underwent motor-control analysis in which kinetic and polyelectromyographic data were collected by using a standard protocol. Each surgeon formulated another surgical plan after independently reviewing the laboratory study. MAIN OUTCOME MEASURES: The frequency of change and degree of agreement in the surgical plans after review of the laboratory data were used as measures of the effect of the laboratory studies. RESULTS: Fifty-seven percent of the surgical plans were changed after the motor-control study. The frequency of change did not differ by clinical experience. There was a trend toward higher agreement between surgeons after the study than before. CONCLUSIONS: Detailed electromyographic motor-control analysis alters surgical planning for patients with spastic elbow flexion deformity. Clinical assessment alone does not accurately identify the muscles responsible for the deformity or dysfunction. More clinical experience does not result in greater accuracy. Motor-control analysis produces higher agreement between surgeons in planning surgery.

Adult↗
PubMed2003

Characterization and correlates of medical and rehabilitation charges for traumatic brain injury during acute rehabilitation hospitalization.

OBJECTIVE: To identify factors associated with specific categories of charges during acute inpatient rehabilitation treatment after traumatic brain injury (TBI). DESIGN: Prospective observational study. SETTING: A single Traumatic Brain Injury Model Systems (TBIMS) center. PARTICIPANTS: Eighty-four consecutive TBIMS patients. One exploratory analysis also included all 350 patients with TBI admitted during 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Average daily charges for specific categories of resource use (eg, room and board, rehabilitation therapies, functional labs). RESULTS: Room and board and rehabilitation therapy accounted for almost 90% of average daily charges. There was no linear component of change in average daily charges, but certain categories of charges were significantly higher during the first week than thereafter. Functional status at rehabilitation admission correlated with charges for respiratory, medical, and surgical supplies and with pharmacy and radiology, but not the other categories. Specific medical variables also correlated with specific charge categories. Focused chart reviews of patients with low and high charges in specific categories led to the formulation of additional predictive hypotheses. CONCLUSION: Certain categories of charges correlated with functional scores and acute medical variables that are known before admission to acute inpatient rehabilitation, allowing for better inpatient admission planning under prospective payment. Further research is needed to identify and correlate resource use that is bundled within the room and board category.

Brain Injuries↗
PubMed2003

The Moss Attention Rating Scale for traumatic brain injury: initial psychometric assessment.

OBJECTIVE: To examine the psychometric properties of the Moss Attention Rating Scale (MARS), a new observational rating scale for attention-related behaviors in traumatic brain injury (TBI). DESIGN: Prospective observational study. SETTING: Eight acute inpatient rehabilitation facilities that are part of the Traumatic Brain Injury Model Systems program. PARTICIPANTS: Two hundred twenty-eight patients with TBI requiring acute inpatient rehabilitation treatment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rasch analysis on the 53-item MARS (45 attention items, 8 control items) as rated separately by the treating occupational therapist and physical therapist. RESULTS: The MARS appeared to measure a single dimension and demonstrated good person separation (5.69) and reliability (.97). In post hoc assessment, misfitting attention items may not have required attention and control items that fit the dimension may have required at least rudimentary attention. Occupational therapists rated patients as slightly less attentive than did physical therapists. Overall, the scale was well targeted to an acute inpatient rehabilitation population. CONCLUSION: Our results provide preliminary support for the viability of developing an observational attention rating scale for use in inpatient TBI rehabilitation. Further research will need to explore the existence of subdimensions and provide further validation with reference to other neuropsychologic measures of attention and knowledge of lesion severity and localization.

Adult↗
PubMed2003

Pediatric critical care medicine: planning for our research future.

OBJECTIVE: To introduce to the pediatric critical care medicine community a new program in pediatric critical care medicine at the National Institutes of Health. DATA SOURCE: Summary of literature review and conference proceedings. DATA SYNTHESIS: At the National Institute of Child Health and Human Development (NICHD), a new program in pediatric critical care and rehabilitation research has been established in the National Center for Medical Rehabilitation Research. The program is directed by a pediatric intensivist and is focused on developing research directed toward improving long-term outcomes in pediatric critical care and on incorporating pediatric rehabilitation medicine as a partner in this goal. To provide strategic direction for the new program, the NICHD sponsored a planning conference May 3-4, 2002, at the NICHD in Bethesda, MD. The conference invitees represented a broad range of pediatric critical care medicine clinical and research interests, expertise, and career stages. It also included individuals with expertise in rehabilitation research. CONCLUSION: The composition of the new program, including its link to physical medicine and rehabilitation, is discussed. In addition, recommendations by the conference participants and program director are provided to foster the development of more randomized, controlled clinical trials and to develop successful clinician scientists in pediatric critical care medicine.

Child↗
PubMed2003

It's more than a black box; it's a Russian doll: defining rehabilitation treatments.

Research on treatment efficacy and effectiveness requires that the treatments of interest be objectively defined. Such definitions are relatively straightforward for pharmacologic and surgical treatments, in which the active ingredients can be specified in terms of chemical structure or anatomic result. Definitions of treatment are more difficult for the many experience-based interventions employed in rehabilitation. This has led to the criticism that much clinical rehabilitation research has characterized the treatments of interest as a "black box," allowing little insight into the active ingredients contained therein. Moreover, rehabilitation care may involve the simultaneous application of multiple different treatments, raising the question of whether to define the individual components or the service delivery system. In this article, we consider how the levels of analysis considered in rehabilitation (disease, impairment, activity, and participation) and the role of theory shape the definition of treatment, and we address the need to develop protocol-based treatments and tools to objectively verify their contents. Rigorous definition of rehabilitation treatments, supported by theory, will facilitate needed efficacy research, will allow replication of that research, and will ultimately foster dissemination of effective treatments into clinical practice.

Health Services Research↗
PubMed2003

Clinical trials in rehabilitation: what are the obstacles?

Across rehabilitation, there is a shortage of treatments that have demonstrated efficacy and effectiveness through rigorously controlled clinical trials. Although rehabilitation efficacy and effectiveness research present many of the obstacles that are found in research on other biomedical domains, they also present a number of obstacles that are specific to the conceptual framework underlying rehabilitation practice. In this article, I review the specific challenges presented by the need to rigorously define the research participants, the treatment under investigation, and the outcomes by which treatment response will be measured. I also suggest research that will be necessary to surmount some of these obstacles.

Evidence-Based Medicine↗
PubMed2002

A comparison of the effects of exercise and lifestyle modification on the resolution of overuse symptoms of the shoulder in polio survivors: a preliminary study.

OBJECTIVE: To compare the effectiveness of exercise and lifestyle modification therapy in treating shoulder symptoms in polio survivors with lower-extremity weakness. DESIGN: A randomized parallel group study. SETTING: Research laboratory. PARTICIPANTS: Twenty-three subjects recruited from a cohort of 194 polio survivors who had participated in a previous study had bilateral hip-extensor and knee-extensor weakness and reported experiencing shoulder pain on a regular basis with daily activity. INTERVENTIONS: Subjects were randomly assigned to 1 of 3 treatment groups. Members of group 1 were placed on a home exercise program that focused on strengthening their hip and knee extensors. Members of group 2 were instructed in lifestyle modification techniques designed to avoid shoulder overuse. Members of group 3 received both interventions. MAIN OUTCOME MEASURES: Shoulder symptoms were quantified in terms of number and severity. Isometric strength of bilateral hip and knee extensors was measured with a hand-held dynamometer. RESULTS: Symptoms improved in all 3 groups. However, members of the exercise-only group (group 1) were the only ones to show a significant difference in both number and severity of symptoms when pre- and posttreatment values were compared. CONCLUSIONS: Both exercise and lifestyle modification therapies that focus on reducing the stress related to lower-extremity weakness are effective in treating shoulder overuse symptoms in polio survivors. A trend toward greater improvement in shoulder symptoms in subjects who participated in the exercise program and who also showed a trend toward increased knee-extensor strength supports muscle strength and/or endurance as a key factor.

Aged↗
PubMed2002

Traumatic brain injury rehabilitation: are there alternatives to randomized clinical trials?

Randomized clinical trials (RCTs) are widely considered to be the gold standard of evidence for treatment efficacy, but they have not been widely applied to rehabilitation or, more specifically, traumatic brain injury rehabilitation. Ethical, scientific, and resource factors may limit the application of RCTs. Thus, rigorous observational alternatives to the RCT would be of great value. In the article by Powell et al, an attempt to rigorously apply an observational design to assess the relative effectiveness of inpatient rehabilitation versus home discharge failed to control for important confounding factors. It appears nearly impossible to successfully apply observational designs when the factors leading to the applications of different treatments are strongly related to the patient's perceived prognosis. However, observational designs may be successfully applied when regional or temporal variations in care are studied. Moreover, a number of developments in measurement, study design, and statistical analysis may expand the role of observational studies in answering questions of rehabilitation efficacy and effectiveness.

Craniocerebral Trauma↗
PubMed2002

Clinical trials in head injury.

Traumatic brain injury (TBI) remains a major public health problem globally. In the United States the incidence of closed head injuries admitted to hospitals is conservatively estimated to be 200 per 100,000 population, and the incidence of penetrating head injury is estimated to be 12 per 100,000, the highest of any developed country in the world. This yields an approximate number of 500,000 new cases each year, a sizeable proportion of which demonstrate significant long-term disabilities. Unfortunately, there is a paucity of proven therapies for this disease. For a variety of reasons, clinical trials for this condition have been difficult to design and perform. Despite promising pre-clinical data, most of the trials that have been performed in recent years have failed to demonstrate any significant improvement in outcomes. The reasons for these failures have not always been apparent and any insights gained were not always shared. It was therefore feared that we were running the risk of repeating our mistakes. Recognizing the importance of TBI, the National Institute of Neurological Disorders and Stroke (NINDS) sponsored a workshop that brought together experts from clinical, research, and pharmaceutical backgrounds. This workshop proved to be very informative and yielded many insights into previous and future TBI trials. This paper is an attempt to summarize the key points made at the workshop. It is hoped that these lessons will enhance the planning and design of future efforts in this important field of research.

Brain Injuries↗
PubMed2002

Psychostimulant use in the rehabilitation of individuals with traumatic brain injury.

BACKGROUND: Psychostimulants are used commonly in the rehabilitation of individuals with traumatic brain injury (TBI), despite the dearth of well-controlled studies of their effects. The available literature suggests that these drugs predominantly affect the speed of cognitive processing and certain observational ratings of mood and behavior. Effects on sustained attention, distractibility, and memory are less clear. OBJECTIVE: This article reviews the controlled research literature on the use of these drugs in TBI and presents preliminary data from the authors' laboratory that extends these findings. Some of the common research pitfalls that have limited progress in research on these drugs are discussed.

Amphetamine↗
PubMed2002

Use of a portable voice organizer to remember therapy goals in traumatic brain injury rehabilitation: a within-subjects trial.

OBJECTIVE: To test the efficacy of a portable voice organizer in helping people with traumatic brain injury (TBI) to recall therapy goals and plans discussed with their clinical case managers. DESIGN: Prospective within-subjects trial, in which individualized therapy goals were randomly assigned to intervention or no intervention. SETTING: Comprehensive postacute TBI rehabilitation program. PARTICIPANTS: Ten people with moderate to severe TBI enrolled from 3 months to 18 years after injury. OUTCOME MEASURE: Memory for therapy goals. Clinicians generated statements describing six current therapy goals, half of which were randomly assigned to be recorded on a voice organizer during the next case management session. Participants selected three times per day to listen to the recorded goals, prompted by an alarm. One-week recall was tested using both free- and cued-recall formats. RESULTS: Recorded goals were recalled better than unrecorded goals and appeared to be associated with better awareness or follow-through with therapy objectives. CONCLUSION: Portable electronic devices have the potential to assist with treatment areas beyond tasks involving prospective memory.

Adult↗
PubMed2002

The impact of instrumented gait analysis on surgical planning: treatment of spastic equinovarus deformity of the foot and ankle.

BACKGROUND: Despite the logic behind instrumented gait analysis, its specific contribution to clinical and surgical decision making is not well known. Our purpose in this study was to determine the influence of gait analysis with dynamic electromyography upon surgical planning in patients with upper motor neuron syndrome and gait dysfunction. METHODS: Two surgeons prospectively evaluated 36 consecutive adult patients with a spastic equinovarus deformity of the foot and ankle. After an initial history and physical exam, each surgeon independently formulated a surgical plan. Surgical treatment options for each individual muscle/tendon unit crossing the ankle included lengthening, transfer, release or no surgery. After the initial clinical evaluation and surgical planning, all patients then underwent instrumented gait analysis collecting kinetic, kinematic and poly-EMG data using a standard protocol by a single experienced physiatrist. Each surgeon reviewed the gait studies and patients independently and again formulated a surgical plan. The surgical plans were compared for each surgeon before and after gait study. The agreement between the two surgeon's surgical plans was also compared before and after gait study. Each patient was evaluated for the clinical outcome of surgery. RESULTS: Overall a change was made in 64% of the surgical plans after the gait study. The frequency of changing the surgical plan was not significantly different between the more and less experienced surgeons. The agreement between surgeons increased from 0.34 to 0.76 (p=0.009) after the gait study. The number of surgical procedures planned by each surgeon converged after the gait studies. Correction of the varus deformity was seen in all patients that underwent surgical treatment. CONCLUSION: Instrumented gait analysis alters surgical planning for patients with equinovarus deformity of the foot and ankle and can produce higher agreement between surgeons in surgical planning. CLINICAL RELEVANCE: The equinovarus deformity is due to a variety of deforming forces and a single, best operation does not exist to correct all equinovarus deformities. Rather, a muscle specific approach that identifies the deforming forces will produce the best outcomes when treating the spastic equinovarus deformity.

Ankle↗
PubMed2002

Internet resources for traumatic brain injury: A selective review of websites for consumers.

This article provides a selective review of brain injury resources found on the Internet. It is geared toward the needs of survivors of brain injury and their families. Provided are listings of websites that focus on brain injury, those with sections pertaining to brain injury, and those with brain injury information found by searching the site. Sites that afford communication in the form of chatrooms, message boards, and mailing lists are described and listed. The value of this technology for consumers, as well as some of the challenges in searching for relevant materials on this topic, is discussed.

Brain Injuries↗
PubMedDate not supplied

The vegetative and minimally conscious states: current knowledge and remaining questions.

In the last 2 decades, the minimally conscious state has been distinguished conceptually from the vegetative state and operational criteria for these diagnoses have been published. Standardized and individualized assessment tools have been developed to assist with the diagnosis of severe disorders of consciousness and the measurement of clinical improvement. The natural course of recovery and the importance of key prognostic predictors have been elucidated. Important advances have also been made in defining the similarities and differences in the pathophysiology of these two states, and functional imaging modalities have begun to explicate the neural substrate underlying the behavioral features of these disorders. Research on the efficacy of treatments for severe disorders of consciousness lags behind, due to the practical and ethical difficulties in executing large rigorously controlled clinical trials. The past and future scientific developments in this area provide an important background for continuing discussions of the ethical controversies surrounding end-of-life decision making and resource allocation.

Brain↗