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PubMed2003

Benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke.

OBJECTIVE: To analyze the benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation hospital in Japan. PARTICIPANTS: A total of 1056 patients with stroke were divided into 3 groups based on the interval between stroke onset and admission to the rehabilitation hospital: group I, within 90 days (n=507, 48%); group II, 91 to 180 days (n=377, 36%); and group III, more than 180 days (n=172, 16%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional outcome (A to D; independent to totally dependent) in walking, affected upper extremity, and activities of daily living (ADLs) and discharge disposition. RESULTS: Walking status improved in 70.9% of nonambulatory patients in group I, in 54.8% in group II, and in 43.9% in group III. Similarly, ADLs improved in 66.7% of the totally dependent patients in group I and in approximately 50% in groups II and III. Functional gain in those with a totally nonfunctional upper extremity at admission was poor (29.7%). Initial functional categories affected each outcome (P<.0001). On discharge, 73.8% in group I and approximately 60% in groups II and III went home. CONCLUSION: Approximately half of all patients regained their abilities in walking and ADLs after inpatient multidisciplinary rehabilitation up to 1 year after stroke. However, there was considerable limitation in functional recovery of the affected upper extremity.

Activities of Daily Living↗

PubMed2006

[Multidisciplinary management of skull base and craniocervical chordoma].

BACKGROUND: Craniocervical chordomas often only become manifest in an advanced stage. The localisation and locally-destructive growth require a multidisciplinary diagnostic and therapeutic concept early on. The goal of the present study was to present a reproducible strategy for quality assurance. PATIENTS AND METHOD: We retrospectively analysed the hospital records of 10 consecutive patients (4 women and 6 men) whom we had treated during a period of 7 years. RESULTS: The first step in therapy was tumour resection in 9 cases. One patient initially underwent stereotactic radiation. Postoperative radiation was not included a priori, but discussed individually depending on the degree of resection, the patient's age and physical condition. After an average 5 years follow up, 100 % of patients are alive. In all patients, tumour control was achieved. CONCLUSIONS: The prognosis for patients with chordomas of the skull base has improved considerably in recent years. New technologies like intraoperative navigation and improved radiation procedures have contributed to this improvement. The basis for treatment remains, however, the greatest possible surgical exstirpation with minimal surgical morbidity. Special attention should be paid in this connection to the stability of the cervical spine and the craniocervical transition border. In advanced tumour growth, complete resection is often not possible. Proton and heavy-ion radiation are promising new forms of therapy, which can also be applied after conventional radiation has been performed. A directed multidisciplinary procedure guarantees years of survival with good quality of life in many cases.

Adult↗

PubMed1995

A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.

BACKGROUND: Congestive heart failure is the most common indication for admission to the hospital among older adults. Behavioral factors, such as poor compliance with treatment, frequently contribute to exacerbations of heart failure, a fact suggesting that many admissions could be prevented. METHODS: We conducted a prospective, randomized trial of the effect of a nurse-directed, multidisciplinary intervention on rates of readmission within 90 days of hospital discharge, quality of life, and costs of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social-service consultation and planning for an early discharge, a review of medications, and intensive follow-up. RESULTS: Survival for 90 days without readmission, the primary outcome measure, was achieved in 91 of the 142 patients in the treatment group, as compared with 75 of the 140 patients in the control group, who received conventional care (P = 0.09). There were 94 readmissions in the control group and 53 in the treatment group (risk ratio, 0.56; P = 0.02). The number of readmissions for heart failure was reduced by 56.2 percent in the treatment group (54 vs. 24, P = 0.04), whereas the number of readmissions for other causes was reduced by 28.5 percent (40 vs. 29, P not significant). In the control group, 23 patients (16.4 percent) had more than one readmission, as compared with 9 patients (6.3 percent) in the treatment group (risk ratio, 0.39; P = 0.01). In a subgroup of 126 patients, quality-of-life scores at 90 days improved more from base line for patients in the treatment group (P = 0.001). Because of the reduction in hospital admissions, the overall cost of care was $460 less per patient in the treatment group. CONCLUSIONS: A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure.

Aged↗

PubMed2001

A single-institutional, multidisciplinary approach to primary sarcomas involving the chest wall requiring full-thickness resections.

OBJECTIVE: Primary sarcomas involving the chest wall requiring full-thickness excision are rare. We reviewed our experience with these lesions in a tertiary referral cancer center by using multidisciplinary approaches. METHODS: A 10-year retrospective study identified 51 patients referred with primary sarcomas of the chest wall: 40 for initial treatment and 11 after previous unsuccessful surgical excisions elsewhere (secondary referral). Presenting symptoms were pain alone in 23 (45%) of 51 patients, pain with an associated mass in 8 (16%) patients, and an asymptomatic mass alone in 13 (25%) patients. Median symptom duration was 241 days in the primary group and 225 days in the recurrent group. Tumor locations were the sternum (n = 11), the rib alone (n = 36), and the posterior rib with extension into vertebral bodies (n = 4). Histologic types included the following: chondrosarcomas (n = 15), malignant fibrous histiocytomas (n = 9), osteosarcomas (n = 4), Ewing sarcomas (n = 3), desmoid tumors (n = 7), and other types (n = 13). The median tumor volume of those referred initially was 311 cm(3) compared with 84 cm(3) in patients with recurrent lesions. RESULTS: Twenty-six (51%) of 51 patients received treatment before resection, including chemotherapy alone (n = 22), radiation alone (n = 3), and combined chemotherapy and radiation therapy (n = 1). The complete sternum was removed in 6 of 11 patients, and the average number of ribs requiring resection was 3.8. Four patients had vertebral body resections. Prosthetic meshes alone were required in 16 of 51 patients, and meshes with methylmethacrylate were required in 18 of 51 patients. Muscle flap reconstructions by plastic surgery were required in 24 patients. Negative margins were obtained in 47 of 51 patients. There were no perioperative deaths with morbidities occurring in 12 (24%) of 51 patients (wound [n = 3], prolonged air leak [n = 1], prolonged ventilator requirement [n = 1], arrhythmias [n = 3], doxorubicin (Adriamycin)-induced cardiomyopathy [n = 1], and other [n = 3]). Postoperative treatment was administered to 13 patients (chemotherapy alone, n = 9; chemotherapy with radiation therapy, n = 4). The cumulative 5-year survival of all patients was 64% (initial referral, 61.3%; secondary referral, 72.7%). The average follow-up is 44.7 months. CONCLUSIONS: A combined aggressive multidisciplinary approach to primary sarcomas of the chest wall resulted in no treatment-related deaths and a cumulative 5-year survival of 64% in patients referred to our tertiary care cancer center.

Adolescent↗

PubMed2003

Calciphylaxis and nonhealing wounds: the role of the vascular surgeon in a multidisciplinary treatment.

OBJECTIVE: Calciphylaxis, a disorder of calcium-phosphate metabolism that can result in arterial calcification, skin and solid organ calcium deposits, and nonhealing ulcerations, is associated with significant morbidity and mortality. Although its most common cause is secondary hyperparathyroidism in patients with renal failure, vascular surgeons are frequently called on to evaluate these nonhealing extremity wounds. We reviewed our experience of a multidisciplinary approach in treating patients with calciphylaxis and nonhealing ulcers. PATIENTS AND METHODS: Over a 14-month period at a tertiary center, five patients were seen with calciphylaxis and nonhealing leg wounds. Demographics, disease characteristics, surgical treatment, and outcomes were analyzed. RESULTS: All five patients were black women aged 40 +/- 8.9 years with hypertensive renal failure undergoing long-term hemodialysis (80 +/- 43 months). They had large, painful lower extremity wounds or necrotic ulcers (mean size, 135 cm(2)) that had developed over 2 to 4 months. Three patients had palpable pedal pulses, one patient had Doppler pedal signals, and one patient had absent pedal flow. Arteriogram was performed in the latter two patients, and one patient underwent lower extremity revascularization because of superficial femoral artery stenosis with symptomatic improvement. Four patients underwent aggressive debridement by the vascular surgical service, and two needed plastic surgeon-performed skin grafting. All patients had elevated parathyroid hormone levels (mean, 1735 pg/mL; > 25 x normal level); mean preoperative calcium levels were normal (10 mg/dL). After either subtotal (n = 4) or total (n = 1) parathyroidectomy by an experienced endocrine surgeon, a significant reduction in parathyroid hormone and calcium levels was seen (122 pg/mL and 7.9 mg/dL, respectively; P <.05). There were no postoperative complications or amputations; one patient died 12 months after parathyroidectomy of severe preexisting cardiopulmonary disease. Complete wound healing was observed by 4.8 +/- 2 months. During a mean follow-up period of 9 months (range, 1 to 18 months), all wounds remained healed without ulcer recurrence. CONCLUSION: The diagnosis of calciphylaxis should be considered in patients with end-stage renal disease with atypical tissue necrosis or subcutaneous nodules. Early recognition of calciphylaxis and multidisciplinary treatment, including diligent wound care, frequent debridement, parathyroidectomy, and appropriate skin grafting or revascularization, can result in improved wound healing and limb salvage.

Adult↗

PubMed2003

Community integration following multidisciplinary rehabilitation for traumatic brain injury.

PRIMARY OBJECTIVE: To determine the extent to which participation in a multidisciplinary rehabilitation programme and patient characteristics predict improvement in community integration following mild-to-moderate traumatic brain injury (TBI). RESEARCH DESIGN: A non-randomized case-control study was conducted employing a pre-test-post-test multiple regression design. METHODS AND PROCEDURES: Archival data for 42 patients with mild-to-moderate TBI who completed the Community Integration Questionnaire (CIQ) at intake and again 6-18 months later were analysed. Half the sample participated in an intensive outpatient rehabilitation programme that provided multi-modal interventions, while the other half received no rehabilitation. The two groups were matched on age, education and time since injury. RESULTS: On the CIQ Home Integration scale, participation in rehabilitation and female gender predicted better outcome. On the Productivity scale, patients with a lower age at injury had better outcome. Outcome on both of these scales, as well as on the Social Integration scale, was predicted by the baseline pre-test score (initial severity). CONCLUSIONS: Overall, multidisciplinary rehabilitation appeared to increase personal independence. It is also concluded that: (1) multivariate analysis can reveal the relative importance of multiple predictors of outcome; (2) different predictors may predict different aspects of outcome; and (3) more sensitive and specific outcome measures are needed.

Adult↗

PubMed1998

Evaluation of a structured multidisciplinary day care program in rheumatoid arthritis. A similar effect in newly diagnosed and long-standing disease.

The present study evaluated a multidisciplinary structured day-care programme in patients with rheumatoid arthritis of less than 2 years (n = 41) and more than 2 years disease duration (n = 46). During the 3 week intervention, outcome measures reflecting disability (HAQ, SOFI), the patient's perception of disease and pain (VAS for patient's global assessment and pain), Ritchie articular index (RAI), a 44 swollen joint count, and overall disease activity (DAS) improved significantly in the group as a whole. The improvements remained significant after 15 weeks and were of a similar magnitude in the patient groups with short and long disease duration. At week 3 and 15, the ACR and the EULAR criteria for individual response, for the total study group was fulfilled by 28% and 26%, and 36% and 52% respectively. Evaluation of a subgroup 6 weeks prior to admission indicated that the outcome measures were stable at the time of the intervention. Furthermore, administration of intraarticular glucocorticosteroids (GC) could only partly explain the observed improvement. This uncontrolled observational study supports that a multidisciplinary day-care rehabilitation program is beneficial and feasible for patients with rheumatoid arthritis of both short and long duration.

Adult↗

PubMed1982

Childhood versus adult onset obesity in a comprehensive, multidisciplinary weight reduction program.

The weight loss of 16 obese patients (greater than 130% ideal body weight) who participated for three months in a comprehensive, multidisciplinary weight reduction program was studied. Patients were divided into two groups based on the reported time of onset of their obesity. Childhood-onset obesity was defined in this study as marked weight gain by the age of 11. Adult-onset obesity was defined as weight gain occurring at 18 years of age or later. Each group of patients consisted of two males and six females. The childhood-onset obesity group lost significantly more weight than the adult-onset obesity group during this three-month period (19.45 +/- 3.6% versus 16.17 +/- 2.8%). This preliminary study suggests that patients with childhood-onset obesity tend to lose more weight in a comprehensive multidisciplinary weight reduction program than patients with adult onset obesity.

Adult↗

PubMed2001

Defecation problems in children with Hirschsprung's disease: a prospective controlled study of a multidisciplinary behavioural treatment.

UNLABELLED: Constipation, faecal incontinence, soiling and difficult toilet training remain significant problems in children with Hirschsprung's disease after corrective surgery. Chronic defecation problems can have various negative implications. At the University Medical Centre Nijmegen, a multidisciplinary behavioural treatment was developed to treat defecation problems. In this paper, a prospective controlled study is presented concerning the effect of this treatment upon children suffering from chronic defecation problems following corrective surgery for Hirschsprung's disease. The effect of treatment was studied in 27 children (21M, 6F, mean age 5.2y, range 2-11 y). Fourteen children were allocated to the experimental treatment group. The 13 children allocated to the waiting-list control group were also treated following a waiting period of 6 mo. On all outcome variables, children in the experimental treatment group had significantly better results after treatment than children in the waiting-list control group after the waiting period. No effect of age upon treatment was found. The effect of treatment remained significant on all outcome variables at a mean follow-up of 7 mo after the end of treatment. CONCLUSION: Multidisciplinary behavioural treatment is successful in decreasing chronic defecation problems in children with Hirschsprung's disease.

Behavior Therapy↗

PubMed1989

A multidisciplinary approach to the evaluation and treatment of temporomandibular joint and cervical spine dysfunction.

This article presents a multidisciplinary approach to the management of temporomandibular joint (TMJ) and cervical spine dysfunction in a heterogeneous population of patients. A methodology for the systematic evaluation and treatment of patients is outlined; case histories are used to illustrate the workings of the model. A study to assess the efficacy of treatment was performed on 27 female and three male adult patients. Results indicated that patients achieved an 87% recovery rate at discharge with an 83% success rate six months after discharge. A control study was undertaken using 16 female and three male adults to establish indications for TMJ occlusal splint therapy in patients who present with questionable TM dysfunction. The multidisciplinary model presented in this article provides a system of patient evaluation and treatment that can be easily adopted by clinicians involved in a team approach to TMJ and cervical spine dysfunction.

Adult↗

PubMed1991

Multidisciplinary treatment of chronic craniomandibular disorder: a preliminary investigation.

Historically, chronic pain patients have been treated utilizing an acute care model with little success. The present study examined the effectiveness of using a multidisciplinary team approach for chronic pain patients diagnosed with craniomandibular disorders. Preliminary findings showed that patients made significant functional improvements across both physical and psychological measures, despite the persistence of reported pain at the time of follow-up evaluation. These results demonstrate the relative benefits associated with the treatment of chronic craniomandibular disorder patients in a multidisciplinary pain facility.

Adult↗

PubMed1998

Multidisciplinary approach to chronic pain from myofascial pain dysfunction syndrome: a four-year experience at a Brazilian center.

Chronic pain is the major complaint of myofascial pain dysfunction syndrome (MPDS) and is a complex problem which involves physical, psychological and social aspects. The etiology of MPDS is multifactorial and the multidisciplinary approach is essential for differential diagnosis and for comprehensive treatment planning. In 1993, the Dental School of Piracicaba-UNICAMP, Brazil, opened a Center for Pain Studies (CPS), staffed by health care providers including, dentists, psychologists, physicians, physiotherapists and phonoaudiologists. The major aims of the CPS are to provide clinical care and to develop basic and applied research. Sixty-two MPDS patients had been admitted to the CPS by 1997. There were 60 females and 2 males, mean age-32.5 years. The mean duration of chronic pain was 48 months. Pain intensity and unpleasantness were measured employing the Visual Analogue Scale. The tendency to develop stress-related diseases was assessed by the Social Readjustment Scale. There was a mean reduction of chronic pain of 69.89% and 71.78% relative to intensity and unpleasantness, respectively. The experience of clinical attendance at a multidisciplinary center showed the relevance of a team consisting of health care providers from different specialties with well-established aims, completely integrated and sensitive enough to understand the painful complaints of MPDS patients.

Adolescent↗

PubMed2002

HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care.

The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. Though it is now accepted as the international standard of care, it represents a significant departure from methods of care for other infectious diseases, and debate continues regarding the effectiveness of its interventions. The debate has been largely uninformed by data; for example, little is known about the relationship between ancillary support services and primary care outcomes. We hypothesized that support services increase access to and retention in HIV primary care in an inner city public hospital clinic. We conducted a retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago from 1997-1998 to investigate the relationship between four support services-case management (CM), transportation (TRANS), mental health (MH) and chemical dependency (CD)-and access to and retention in HIV primary care. We found that patients who received each of these services were significantly more likely to receive any care, regular care and had more visits than patients with no service, and retention increased by 15-18%. Female gender, younger age, self-pay status and IDU predicted less regular care. Need for all services was substantial and significantly greater in women. Outcomes improved to the greatest extent among patients who needed and received each service. We conclude that support services significantly increased access to and retention in HIV primary care. Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes. Further testing of changes in health care delivery to meet the rapidly changing needs of people living with HIV disease and respond to the constantly changing practice of HIV medicine is urgently needed to maintain and extend the advances in HIV care outcomes of the past decade.

Adolescent↗

PubMedDate not supplied

Music therapy with patients in low awareness states: approaches to assessment and treatment in multidisciplinary care.

This paper outlines the rationale for and role of music therapy as a clinical intervention and diagnostic tool in multidisciplinary (MDT) rehabilitation programmes for patients in low awareness states. A review of the literature indicates that music is a useful clinical tool in stimulating a range of behavioural, physiological and expressive responses in patients in low awareness states. Referral criteria for music therapy with this patient group are provided, along with suggested methods for collaborative multidisciplinary work. A case vignette is presented of a client whose diagnosis of vegetative state (VS) was contradicted by her purposeful responses within music therapy assessment, contributing towards a changed diagnosis to minimally conscious state (MCS). The case illustrates the particular role of music therapy in assisting with diagnosis in complex cases. Music therapy provides a clinical forum in which recovery of function can be assessed in an informal way, using a medium which does not rely on language, is non-evasive and elicits emotional responses.

Awareness↗

PubMed2005

Late multidisciplinary rehabilitation in young people after stroke.

PURPOSE: Stroke has a major impact on physical and cognitive ability, and quality of life. This study aims to examine the effect of multidisciplinary rehabilitation on outcome in an Irish young stroke population. METHODS: Fifty consecutive patients younger than 65 were prospectively recruited to this observational study. Physical and cognitive ability, and quality of life were measured on admission and discharge. RESULTS: All patients were transferred to the rehabilitation unit from the acute hospital where they had received their initial management. Median length of time from stroke onset to transfer was 112 days. After a median of 70 days, 43 patients were discharged home. Patients made significant gains in physical (Barthel index 12 to 18) and cognitive ability (mini-mental state examination 22 to 25). Quality of life improved in all eight domains of the 36-items Short Form with four domains returning to level seen in the general population. CONCLUSIONS: This study documents the improvements in physical and cognitive abilities, and quality of life in a sample of patients in rehabilitation. A comprehensive rehabilitation programme that includes acute and late multidisciplinary phases can improve the outcome of patients following stroke.

Activities of Daily Living↗

PubMedDate not supplied

Coordinated multidisciplinary rehabilitation after hip fracture.

PURPOSE: To review the topic of coordinated multidisciplinary rehabilitation after hip fracture from a research perspective and to provide information to guide the provision of rehabilitation services for patients with hip fracture. METHODS: Literature review including searches of Medline, Embase, Cochrane Collaboration and evidence based clinical guidelines, checking of references of publications and consultation with researchers. RESULTS: The research evidence is heterogeneous and remains inclusive. Programs that assist patients with hip fracture to regain function and return home as soon as feasible are likely to be effective as they appear to increase the percentage of patients who return home and remain there after hip fracture. Rehabilitation programs that achieve this are likely to be cost effective. These programs involve health professionals from multiple disciplines (nurses, allied health professionals and medical practitioners) who work collaboratively, may operate in several settings, and routinely provide specific treatments that are supported by strong evidence of effectiveness. CONCLUSIONS: Patients with hip fracture should be offered a coordinated a multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements.

Accidental Falls↗

PubMed2003

Experience with a multidisciplinary antenatal diagnosis and management model in fetal medicine.

BACKGROUND: Fetal medicine is a new and evolving specialty. Complex fetal conditions may require the multidisciplinary input of clinicians from many different specialties. METHODS: Referral of fetal patients was made to a multidisciplinary antenatal diagnosis and management (MADAM) board if more than one specialty (in addition to maternal-fetal medicine) needed to be intimately involved in the evaluation or care of the fetus; consultation would probably lead to alterations in fetal or perinatal management; or development or revision of management guidelines was anticipated. The case log of the MADAM conferences was reviewed retrospectively for number and type of fetal anomalies, and outcome of the presentation to the MADAM board. RESULTS: During a 5-year period, 1% of 25654 pregnant women who were evaluated required consultations with individual pediatric and pediatric surgical specialists. Of these, 114 patients were referred to one of 77 MADAM conferences for consensus recommendation. Of these 77 discussions, 32 (42%) led to an alteration in prenatal management, 14 (18%) led to co-ordination of postnatal management and 12 (16%) led to the establishment of a new treatment guideline, or the modification of an existing one. In all, perinatal management was altered in 75% of cases. CONCLUSION: The MADAM model functions as a forum for exchange of up-to-date scientific information, development of evidence-based treatment protocols and continuity of care through the pre-, peri- and postnatal periods.

Female↗

PubMed2006

The effect of a multidisciplinary program on HAART adherence.

Although emerging evidence suggests differing interventions may improve antiretroviral adherence, there has not been a formal evaluation to identify the impact of a clinic-based multidisciplinary program designed to provide education and identify and correct potential adherence barriers prior to the initiation of highly active antiretroviral therapy (HAART). A retrospective cohort study utilizing a historical control group was conducted to compare duration on antiretrovirals, clinical indicators, and adherence rates, as captured by pharmacy refill records. Two hundred sixty-one patients met criteria for inclusion (109 subjects, 152 controls). Time to stopping antiretrovirals, as evidenced by Kaplan-Meier plot, was significantly higher in Protocol group than Controls (log-rank p = 0.023): the median duration on HAART for the intervention group was greater than 360 days but only 210 days for the control group. Thus, more subjects in the protocol group continued on therapy for the full year: 60 (55%) versus 65 (43%) for the control group. The mean reduction in log10 viral loads between HAART initiation and 12 months was greatest for the intervention group with viral load at HAART initiation 100,000 copies per milliliter or more, -3.57 versus -1.78 for controls with viral load less than 100,000 copies per milliliter (p < 0.001). For the intervention group, the mean number of adherence barriers identified per person was 4% and 72% were found to have three or more barriers. Patients at high risk for poor adherence benefit from multidisciplinary education and proactive identification of adherence barriers by exhibiting prolonged duration on therapy and greater reduction in log10 viral loads.

Adult↗