In Singapore and worldwide, large numbers of people live with disabling illness. In the first part of this paper, we address the assessment of activities of daily living (ADL). Disability charting is important as a clinical tool to document functional recovery as well as to assess the effectiveness of medical and rehabilitation interventions. Disability assessment is also important epidemiologically, in developing social policies, planning disability resources and in medical research and education. We review the concepts and general principles of disability assessment with reference to the WHO International Classification of Functioning, Disability and Health (ICF) as well as to local contexts. We also describe in further detail 6 basic ADLs of feeding, dressing, toileting, transfers and mobility used in disability-related national schemes. In the second part of this article, we introduce how the concepts of frailty have changed the paradigm in which we approach geriatric rehabilitation, through interactive overlaps with the psychosocial, disability and comorbidity domains. We describe the consequences of functional deterioration in the frail elderly, and how to screen for frailty. We also outline therapeutic exercise as a form of prehabilitation to improve the resilience of these vulnerable people and possibly return them to robust health. Family physicians are best equipped in the management of frailty, as they have the holistic and comprehensive medical skill set to treat the associated comorbidity, disability and psychosocial domains in integrative geriatric rehabilitation.

The assessment of disability including activities of daily living (ADL) is important as a clinical tool to document functional recovery as well as to assess the effectiveness of medical and rehabilitation interventions. Disability assessment is also important epidemiologically, in developing social policies, planning disability resources and in medical research and education. In this article, we review the definitions, history and advances in the field of disability assessment. We then describe the general principles of disability assessment in adults with a further detailed focus on six basic ADLs: feeding, bathing, dressing, toileting, transfers and mobility. We use a practical framework of an independent category and four dependent categories corresponding to an increasing level of assistance for each ADL. Finally we summarise the inherent problems and difficulties in disability assessment and emphasise the important role of rehabilitation in improving functional outcomes including the basic ADLs.

The assessment of disability including activities of daily living (ADL) is important as a clinical tool to document functional recovery as well as to assess the effectiveness of medical and rehabilitation interventions. Disability assessment is also important epidemiologically, in developing social policies, planning disability resources and in medical research and education. In this article, we review the definitions, history and advances in the field of disability assessment. We then describe the general principles of disability assessment in adults with a further detailed focus on six basic ADLs: feeding, bathing, dressing, toileting, transfers and mobility. We use a practical framework of an independent category and four dependent categories corresponding to an increasing level of assistance for each ADL. Finally we summarise the inherent problems and difficulties in disability assessment and emphasise the important role of rehabilitation in improving functional outcomes including the basic ADLs.

INTRODUCTIONCancer is the leading cause of death and the second most common cause of hospitalisation in Singapore. Significant functional gains are achievable with cancer rehabilitation yet there are no formal cancer rehabilitation programmes in Singapore. This study aims to describe the demographics, clinical characteristics, complications and functional outcomes of cancer patients undergoing comprehensive inpatient rehabilitation at our unit and compare these with non-cancer patients. It also seeks to compare these data within sub-groups of the cancer cohort.

MATERIALS AND METHODSThis is a prospective cohort study. The Department of Rehabilitation Medicine database was reviewed for the period between 1 July 2002 and 31 December 2006. One thousand seven hundred and fifty patients had complete records, of which 58 are cancer patients. The primary outcome measures were the discharge total Functional Independence Measure (FIM), FIM gain and FIM efficiency. Other outcome measures included the length of rehabilitation stay, discharge destination, complication rates, rate of transfer back to the referring unit, the length of survival of the cancer patients upon discharge and the durability of the functional improvement made.

RESULTSThe mean age of the cancer patients was 57.4 +/- 16.1 years and 62% were male. The mean admission total FIM was 70.9 +/- 18.0 and the total discharge FIM was 86.2 +/- 18.3. The average FIM gain was 15.3 +/- 11.6 and the mean efficiency was 0.867 +/- 0.806. This improvement is highly significant, and there is no statistical difference in FIM gain or efficiency between the cancer and non-cancer cohort, or between the cancer subgroups. The length of stay was similar in cancer and non-cancer cohorts but cancer patients with spinal metastasis and those who underwent concomitant radiotherapy stayed longer. There were good rates of discharge home, transfer back, survivorship and durability in functional gains.

CONCLUSIONCancer patients benefit as much as non-cancer patients in undergoing a rehabilitation programme. More patients should be admitted to such programmes and these programmes should be better structured and refined.

Cohort Studies ; Female ; Humans ; Length of Stay ; Male ; Middle Aged ; Neoplasms ; rehabilitation ; Outcome Assessment (Health Care) ; Prospective Studies ; Treatment Outcome

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.
Disability Evaluation ; Disabled Persons ; classification ; rehabilitation ; Humans ; Practice Guidelines as Topic ; Rehabilitation ; methods ; standards ; trends ; World Health Organization

INTRODUCTIONThis article aims to provide an overview of the epidemiology, medical and rehabilitation issues, current evidence for traumatic brain injury (TBI) rehabilitation, recent advances and emerging practices. Special TBI population groups will also be addressed.

MATERIALS AND METHODSWe included publications indexed in Medline and the Cochrane Database of Systemic Reviews from 1974 to 2006, relevant chapters in major rehabilitation texts and Physical Medicine and Rehabilitation Clinics of North America and accessed Internet publications.

RESULTSTBI has been implicated by the World Health Organisation to be a 21st century epidemic similar to malaria and HIV/AIDS, not restricted to the developed world. One third of patients may suffer severe TBI with long-term cognitive and behavioural disabilities. Injuries to the brain do not only damage the cerebrum but may give rise to a multisystem disorder due to associated injuries in 20% of cases, which can include complex neurological impairments, neuroendocrine and neuromedical complications. There is promising evidence of improved outcome and functional benefits with early induction into a transdisciplinary brain injury rehabilitation programme. However, TBI research is fraught with difficulties because of an intrinsically heterogeneous population due to age, injury severity and type, functional outcome measures and small samples. Recent advances in TBI rehabilitation include task-specific training of cognitive deficits, computer-aided cognitive remediation and visual-spatial and visual scanning techniques and body weight-supported treadmill training for motor deficits. In addition, special rehabilitation issues for mild TBI, TBI-related vegetative states, elderly and young TBI, ethical issues and local data will also be discussed.

Accidents, Traffic ; statistics & numerical data ; Brain Injuries ; complications ; prevention & control ; rehabilitation ; Humans ; Ossification, Heterotopic ; etiology ; Persistent Vegetative State ; rehabilitation ; Prognosis ; Rehabilitation ; methods ; Singapore ; Task Performance and Analysis

INTRODUCTIONRehabilitation improves functional outcomes, but there is little data on the profiles and outcomes of patients undergoing inpatient rehabilitation in Singapore. The aims of this paper were to document the clinical characteristics and functional outcomes, using the Functional Independence Measure (FIM), of all patients admitted to an inpatient rehabilitation unit in a tertiary teaching hospital, and to identify and analyse factors significantly associated with better discharge functional scores and higher functional gains.

MATERIALS AND METHODSIn this prospective cohort study over a 4-year period, clinical and functional data for 1502 patients admitted consecutively to the Singapore General Hospital inpatient rehabilitation unit were charted into a custom-designed rehabilitation database. The primary outcome measures were the discharge total FIM scores, FIM gain and FIM efficiency. Multiple linear regression analysis was used to identify independent variables associated with better discharge FIM scores and FIM gain.

RESULTSThe mean age was 61.3 +/- 15.0 years and 57.2% of the patients were male. Stroke (57.9%) followed by spinal cord injury (9.7%) were the most common diagnoses. The average rehabilitation length of stay was 21.5 +/- 19.0 days. The mean admission total FIM score was 70.3 +/- 23.2 and the mean discharge total FIM score was 87.3 +/- 23.0, with this gain being highly significant (P <0.001). The mean FIM gain was 17.0 +/- 13.4 and FIM efficiency was 0.95 +/- 0.90 points/day. Factors associated with better functional outcomes were higher admission motor and cognitive FIM scores, male gender, a longer rehabilitation length of stay and the use of acupuncture. Factors associated with poorer functional outcomes were older age, clinical deconditioning, ischaemic heart disease, depression, pressure sores and the presence of a domestic worker as a caregiver.

CONCLUSIONSThe FIM is an easy-to-use, standardised and robust general measure of functional disability. Multiple demographic, clinical and socio-cultural variables are associated with the primary functional outcomes and should be taken into account in rehabilitation and discharge planning. Nevertheless, rehabilitation improves functional outcomes across a wide range of diagnoses. Further research should be aimed at evaluating long-term disability postdischarge from inpatient rehabilitation and translating these findings into improving rehabilitation and healthcare resource utilisation.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Databases, Factual ; Female ; Humans ; Male ; Middle Aged ; Outcome Assessment (Health Care) ; Prospective Studies ; Recovery of Function ; Regression Analysis ; Rehabilitation ; Singapore ; Treatment Outcome

INTRODUCTIONThe poststroke acute and rehabilitation length of stay (LOS) are key markers of stroke care efficiency. This study aimed to describe the characteristics and identify the predictors of poststroke acute, rehabilitation and total LOS. This study also defined a subgroup of patients as "short" LOS and compared its complication rates and functional outcomes in rehabilitation with a "long" acute LOS group.

MATERIALS AND METHODSA prospective cohort study (n = 1277) was conducted in a dedicated rehabilitation unit within a tertiary academic acute hospital over a 5-year period between 2004 and 2009. The functional independence measure (FIM) was the primary functional outcome measure in the rehabilitation phase. A group with an acute LOS of less than 7 days was defined as "short" acute LOS.

RESULTSIschaemic strokes comprised 1019 (80%) of the cohort while the rest were haemorrhagic strokes. The mean acute and rehabilitation LOS were 9 ± 7 days and 18 ± 10 days, respectively. Haemorrhagic strokes and anterior circulation infarcts had significantly longer acute, rehabilitation and total LOS compared to posterior circulation and lacunar infarcts. The acute, rehabilitation and total LOS were significantly shorter for stroke admissions after 2007. There was poor correlation (r = 0.12) between the acute and rehabilitation LOS. In multivariate analyses, stroke type was strongly associated with acute LOS, while rehabilitation admission FIM scores were significantly associated with rehabilitation LOS. Patients in the short acute LOS group had fewer medical complications and similar FIM efficacies compared to the longer acute LOS group.

CONCLUSIONConsideration for stroke type and initial functional status will facilitate programme planning that has a better estimation of the LOS duration, allowing for more equitable resource distribution across the inpatient stroke continuum. We advocate earlier transfers of appropriate patients to rehabilitation units as this ensures rehabilitation efficacy is maintained while the development of medical complications is potentially minimised.

Activities of Daily Living ; Acute Disease ; Brain Ischemia ; rehabilitation ; therapy ; Humans ; Intracranial Hemorrhages ; rehabilitation ; therapy ; Length of Stay ; statistics & numerical data ; Prospective Studies ; Stroke ; therapy ; Stroke Rehabilitation ; statistics & numerical data ; Treatment Outcome