A Prospective Cohort Study

JD Reinhardt, X Zhang, JE Gosney & J Li

Long-term effectiveness and efficiency of rehabilitation services delivery for victims

with disabilities from the 5/12 Sichuan earthquake

THE QUAKE

• Sichuan earthquake

• Date: May 12, 2008

• Strike Time: 14:28:01 CST

• Deaths/Missing Persons: 86,000

• Injured: 374,640

• Severely injured: 10,000

• Direct economic loss: 692 billion Chinese Yuan, (100 billion USD)

IMPACT

• Rehabilitation needs: many new long bone fractures, spinal cord injury (SCI), traumatic brain injury (TBI), amputation, crush syndrome, peripheral nerve injury (PNI), etc.

• Diminished capability to meet needs: lack of rehab system at baseline; severely degraded medical infrastructure, scarcity of rehabilitation professionals, inadequate funding, etc.

THE INTERVENTION

‘NHV’rehabilitation services management model

•1. (N) international NGOs provided funding, knowledge, technical devices

•2. (H) local Health Departments provided medical infrastructure and space for newly established rehabilitation wards

•3. (V) rehabilitation Volunteers from other Chinese provincesprovided initial rehab services and trained local professionals to achieve sustainable rehab capacity.

STUDY PURPOSE

to evaluate the long-term effectiveness of the NHV rehabilitation services program on •physical function, •pain severity, •post traumatic stress, •and life satisfaction

of earthquake victims with disabling injuries.

METHODSSetting:

NHV-E

NHV-L

Control

METHODSParticipants• Eligibility: 18 years or older, musculoskeletal injury from

5/12 Sichuan earthquake, living in one of the intervention or control counties, able to communicate in Mandarin

• 591 patients originally enrolled

• 403 completed all 3 assessments• NHV-E: 246 subjects (75%)

• NHV-L: 79 subjects (72%)

• Control: 78 (52%)

METHODS - CONTINUED

Outcome Measures

• Physical Function: Barthel Index

• Pain Severity: Visual Analogue Scale (VAS)

• Post-Traumatic Stress: PCLC (only measured 2010/11 and 2012)

• Life Satisfaction: Lisat-9 (only measured 2010/11 and 2012)

METHODS - CONTINUED

Data Analysis• Barthel Index/VAS: Longitudinal Tobit regression

introducing random intercepts for subject and random slope for time; non-linear (quadratic) modeling of time

• PCLC: Linear mixed effects regression with random intercept for subject and random slope for time

• Lisat-9: Ordinary least squares regression• All models are adjusted for gender, age, marital status,

years of formal education and injury type

RESULTS – INCREASE IN PHYSICAL FUNCTION IS GREATER IN THE REHAB GROUPS

RESULTS – PAIN DECREASES MOST IN THE EARLY REHAB GROUP

RESULTS – POST-TRAUMATIC STRESS IS LOWER IN REHABILITATION GROUPS BUT DECREASED

STRONGER IN CONTROLS

RESULTS – HIGHER LIFE SATISFACTION IN CONTROLS AT STUDY ENDPOINT

DISCUSSION - SUMMARY

• First study to evaluate effectiveness of rehabilitation of earthquake victims over a four year period considering multiple outcomes

• Long-term effectiveness of rehabilitation on physical function was clearly demonstrated

• Late implementation of NHV was even more efficient (greater improvement over time)

• Early rehabilitation was effective in pain reduction; late rehabilitation effect not significant (time period to short?)

DISCUSSION - SUMMARY CONTINUED

• Rehabilitation groups show less post-traumatic stress symptoms, but rehabilitation effects are unclear due to lack of baseline assessment

• A rehabilitation effect on life satisfaction is unlikely (concept to broad, to many non-health related determinants, role of drop outs?)

DISCUSSION - LIMITATIONS

• Lack of baseline measurement of PCLC and Lisat-9 preclude determination of initial rehabilitation effects (between 2008/09 and 2010/11)

• Population averaged estimation of rehabilitation effect; sub-groups (e.g. SCI) may differ

DISCUSSION - LIMITATIONS

• Study from Wen et al. (2013) showed that pain did not significantly decrease in patients with SCI from NHV-E

2009 2010 July 2012 Oct 20124

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DISCUSSION - LIMITATIONS

• Lack of baseline measurement of PCLC and Lisat-9 preclude determination of initial rehabilitation effects (between 2008/09 and 2010/11)

• Population averaged estimation of rehabilitation effect; sub-groups (e.g. SCI) may differ

• Study from Wen et al. (2013) showed that pain did not significantly decrease in patients with SCI from NHV-E

• Non-linear time effects could not be studied in PCLC and Lisat-9 because of too few measurement points

DISCUSSION - IMPLICATIONS RESEARCH

• Include baseline measurements for all potentially relevant outcomes: physical function, pain, mental health (post-traumatic stress, depression)

• Include assessment point at discharge from institutional rehabilitation to determine effect of hospital vs. community-based rehabilitation

• Record exposures to different rehabilitative therapies (PT, TCM, etc.)

DISCUSSION - IMPLICATIONS RESEARCH

• Improve pain management (particularly in SCI), consider TCM (acupuncture) and exercise

• Life satisfaction may not be an appropriate outcome (qualitative research needed to better understand contributing factors)

CONCLUSION

• Physical Rehabilitation of earthquake victims is effective in improving primary outcomes including physical function and (with some reservation) pain

• Effects on mental health and life satisfaction are less clear and need to be examined by future research

• More consistent and more frequent assessment of outcomes and determinants is recommended