(1:; «3.1.4vsot (ZAJ”\\\\ L ' '31.] um “in 'II’ l J i ,. :w' ' V OVERDUE FINES: 25¢ per day per item RETURNING LIBRARY MATERIALS: Place in book return to remove charge from circulation records -m-‘h-o ' -(t‘. w .. . ‘ s , l ' 2'2"" Michigan State University School of Social Work S.W. 899 AN EXPLORATORY STUDY OF CEREBRAL VASCULAR ACCIDENT PATIENTS W IN A REHABILITATION MEDICAL CENTER E: I i l % Presented by Doris Holly b % East Lansing, Michigan g ‘i J. W. Heffernan May 19, 1964 Assistant Professor .y_ ‘ w—v ' “If, q. . - '.'."' n rut .,,__ Chapter II. III. IV. VI. I. II. III. TABLE OF CONTENTS PART I re EFFECT OF VARIABLES ON PROGRESS OF PATIENTS PLJRPOSE O O O O O O O O O O O O O O O O O O O O O O O 0 BACKGROUND AND SURVEY OF THE LITERATURE . . . . . . . . bIE TIIODS O . C O O C O 0 O O O O A. Sample 0 o o o o o o o 0 Bo COIIGCtion and AnaIYSIS Of Data 0 o o o o o o 0 Co StatiStiCS o o o o o o o D. Definitions of Independent Variables . . . . . . RESULTS OF THE STUDY . . . . . A. Age . . . . . . . . . . B. Severity of the Cerebral C. Other Variables . . . . DISCUSSION OF FINDINGS . . . . CRITICISM OF THE STUDY 0 o o 0 PART II -- SUMMARY OF PATIENTS' PHYSICAL THERAPY . . . . . . . OCCUPATIONAL THERAPY. . . . . . SOCIAL SERVICES . . . . . . . . APPENDIX 0 O O O O O O O O O O O O O O O BIBLIOGRAPIIY O O O O O O O O 0 O O O O O Page 10 10 10 11 15 16 17 18 24 PART I EFFECT OF SEVEN VARIABLES ON PROGRESS OF PATIENTS I. PURPOSE This is an exploratory study designed to gather information re- garding the eXperiences of cerebral vascular accident patients in Re- 1 habilitation Medical Center at Sparrow Hospital. The purposes of this study are: 1. to determine the amount of progress toward independence which the patients made during their hOSpitalization; and, to study this progress as it relates to seven independent variables.2 The Subjects will be classified along a self- management continuum both at admission and at discharge from the hOSpital. to assemble pertinent information regarding the patients' evaluation of three departments: physical therapy, occu- pational therapy. and social service. 1No attempt is made in this discussion to differentiate between causal factors: thrombosis, hemorrhage, embolism, etc. 2Progress toward independence means movement in an upward direc- tion toward self-management from one classification to another. II. BACKGROUND AND SURVEY OF THE LITERATURE The basic tenet underlying the establishment of medical rehabil- itation centers is that disabled people can be helped to regain func- tioning and to cope more satisfactorily with their environments. Numerous studies of rehabilitation centers have attempted to determine to what extent the centers are helping the disabled. Some research studies classify or evaluate the patients' abilities at the time of admission and at discharge and some are follow-up studies after discharge. There are a few studies which deal Specifically with cere- bral vascular accident patients. Rusk studied a very select group of 1,000 cerebral vascular ac- cident patients, whose average age was 63. He excluded three types of patients: 1. Those with cerebral arteriosclerosis to the degree that they are confused. 2. Those with low cardiac reserve. 3. Those with severe malignant hypertension whose life eXpec- tancy was low. He found that 90% could be taught to walk and to manage the acti- vities of daily living in at least a partialw independent way; 40% were able to return to some type of employment. To obtain a group more representative of all cerebral vascular 3Irving S. Wright and E. Hugh Luckey (ed.), Cerebral Vascular Diseases (New York: Grune & Stratton, 1955), p. 158. accident patients, Rusk and McCoy rejected only 6% of a cerebral vascular accident population as being "not feasible for training"; 55% progressed from a state of dependence to a limited degree of independence or self- manmfiment. Carroll studied a group of ninety-eight patients. His criteria for selection were essentially that patients be over twenty and that the cerebral vascular accident had occurred within one week prior to hospi- tal admission. Of these subjects who were quite representative of all cerebral vascular accident patients, 50% attained partially independent status. Age and the desire to return to work were significant factors in a study by Harvey and Reed. Only A of the sample of 50 patients were over 60 years of age. At the end of one year 64% of these patients were gainfully employed.6 Scull and others found that men with financial dependents and women with homemaking reSponsibilities were able to maintain the gains they had made better than other patients.7 4G. F. McCoy and Howard A. Rusk, An Evaluation 2f Rehabilitation, Rehabilitation Monograph 1, 1953, p. 29. 5Douglas Carroll, "The Disability in Hemiplegia Caused by Cere- bral Vascular Disease," Journal g£_Chronic Diseases, XV (February, 1962), pp. 179-1880 6John Harvey and Julian Reed, "A TWO-Year Study of Intensive Rehabilitation," Journal 2; Chronic Diseases, XV (February, 1962), pp. 147. 7Edward Scull g£.gl., "A Follow-up Study of Patients Discharged from a Community Rehabilitation Center," Journal of Chronic Diseases, XV (February, 1962), pp. 212-215. There is agreement that the following observations are important: "The keystone of the approach in rehabilitation is the determination of the residual capacity of each chronically ill individual"8 and "The adoption of uniform classification and recording codes describing the patient and his progress in treatment would be an important step. With comparable data available from a large number of centers it would be possible to test out in a statistically significant way, various hypotheses concerning the ‘ 9 factors touched on in reports.” 8John Harvey and Julian Reed, "A Two-Year Study of Intensive Rehabilitation of Fifty Chronologically I11 and Indigent Medical Out- patients," Journal 2: Chronic Diseases, XV (February, 1962), pp. 141-147. 9Edward Scull §_t_ 31., "A Follow-up Study of Patients Discharged from a Community Rehabilitation Center," Journal of Chronic Diseases, XV (February, 1962), pp. 207-213. III. METHODS A. Sample The population in the present study consists of all discharged cerebral vascular accident patients at the Rehabilitation Medical Cen- ter who met thefollowing four conditions: 1. discharge prior to January 1, 1964 2. eXperience with the three services 3. residence in the immediate area 4. little or no Speech impairment. Since the social service department at the Rehabilitation Medi- cal Center was established quite recently, condition number two was the most restrictive. This procedure provided a total of 26 patients. Six of the above group have died since discharge, leaving a total of 20 interviewees. There were 14 males and 6 females. Their ages ranged from 51 to 82 with a mean age of 67. There was one Negro male; the rest of the sample were Caucasian. The mean hOSpital stay was 69 days. Eight pa- tients were discharged to institutions or convalescent homes, twelve to their own homes. B. Collection and Analysis 2f Data - 1 Each patient was interviewed individually. 0 Under Part C of the 10See interview schedule in Appendix. interview schedule, the interviewees were questioned about their ability to perform each of five activities: (a) eating, (b) dressing, (c) bath- ing, (d) walking, (e) toilet and transfer, at the time of admission and at the time of discharge. Each patient's discussion of his activities (e.g., eating, dressing, etc.) was evaluated by the author and given a rating of from 1 through 5, according to the following classifications. I. II. III. IV. V. Completely Independent Outside the Home An individual who is completely independent with or without apparatus (braces, prosthesis, crutches, wheelchair) in all. essential daily activities including elevation and public travel. Rquires Limited Assistance Outside the Home An individual who is capable of performing the essential acti- vities independently within the home, but who requires assist- ance occasionally or under Special circumstances for elevation, travel, or toilet activities, or else needs Special arrange- ments such as ramps, hand rails, toilet equipment, etc. Completely Independent 25.3222 An individual who is able to care for himself during the day without requiring assistance, thus releasing someone else from the home. Requires Assistance gt Home An individual who is capable of functioning at home with minimal attendant care. Requires Custodial Care An individual who may be able to sit in a wheelchair or stand with support, but who is essentially dependent upon attendant care for help in necessary personal care or daily activities such as eating, dressing, and toilet. Since some interviews occurred a year after discharge, the pa- tient's description of his activity was compared with hOSpital records. If there was any discrepancy between these two sources, the hOSpital record was used to rate the activity. Description of their activities at the time of admission could not be verified. The patient's rating at the time of discharge was subtracted from his rating at admission to obtain the degree of progress he had made. The maximal progress possi- ble for each patient was 20 points. This maximum would have necessi- tated a change from total dependence to complete independence in all of 12 the five activities. C. Statistics Using the Student's t test the means of each of the seven vari- ables were compared. For example, males were compared with females, patients below 70 were compared with patients 70 and older, according to progress made. The level of significance is .05. D. Definitions of Independent Variables The seven independent variables are: age; sex; marital status; the severity of the cerebral vascular accident; the presence of other 11Morton Hoberman and Charlotte F. Springer, "Rehabilitation of the Permanently and Totally Disabled Patient," Archives 2; Physical Medicine and Rehabilitation, XXXVIV, pp. 235-239. 12The data derived from Parts E, F, and G of the interview was analyzed and compiled in tabular form. See Appendix, p. 18:19. illnesses; history of previous cerebral vascular accidents; and dominant or non—dominant hemiSphere involvement. The classification used for marital status was: 1. 2. Married at the time of admission. Single, divorced, widowed, or separated at the time of admission. The classification used for severity of the cerebral vascular accident was:1 1. 3. Patient usually unaware of the cmbral vascular accident process (vertigo, some malaise, weakness) return of function within a short time, seldom treated. No loss of consciousness or only momentary loss. Paresis rather than paralysis, or paralysis with comparatively quick return of function. Loss of consciousness (less than one week). Complete paral- ysis of one side. Comatose for extended period. Complete paralysis of one side or bilateral paralysis, brain damage considered severe, frequently caused by massive cerebral hemorrhage or embolism. The means of these seven variables were compared using the statis- tical methods described above. 13 This classification was developed by the author after consul- tation with Dr. Richard W. Pomeroy and other staff members. IV. RESULTS OF THE STUDY Table I Mean Variables Progress t. score Significance* Male 7.79 -— .333 1. Sex Not significant Female 8.50 Below 70 9.73 2. Age 2.26 Significant 70 & above 5.89 . Married 8.0 3. Marital status 0 Not significant Non-married 8.0 Severe 9.27 4. Severity of 2.64 Significant the CVA** Very severe 4.20 Diabetic 7.83 5. Presence of - .112 Not significant Diabetes Non-diabetic 8.07 No previous CVA 8.29 6. History of .451 Not significant CVA** Previous CVA 7.33 Dominant 6.7 7. HemiSphere 1.40 Not significant Involvement Non-dominant 9.3 *Significance level .05 **CVA - Cerebral Vascular Accident 9 Table I shows the comparison of mean population of the seven variables. 10 Wherever the 5 score is significant, it is not considered as proof of any hypothesis. The author considers this to be only an indi- cation that further research may also find the association significant. A. Ace ._$-L_ There is a difference in the rate of progress of people below and above seventy. More progress is made within the group below 70. This is significant at the .05 level. B. Severity pf the Cerebral Vascular Accident Severity of the cerebral vascular accident is also related to progress made during hOSpitalization. The less severe the cerebral vascular accident, the more progress the patient makes toward self- management. The difference between the mean progress of these groups 14 is found to be significant at the .05 level. C. Other Variables Sex, marital status, the presence of diabetes, history of pre- vious cerebral vascular accidents and hemiSphere involvement are not related with recovery potential. The degrees of progress made within the groups were not statistically -- significantly different. 14Since no patients in this study were classified as l in sever- ity of cerebral vascular accident, and only one patient was classified as 2, classifications 2 and 3 were combined and labelled severe. The severe group was compared to group 4, very severe. V. DISCUSSION OF FINDINGS Age, not surprisingly, is a significant factor in the amount of progress patients make toward independence.* The results of the present study conCUr with several investigations.15 However, since it is true that "There is little evidence that the patient's age alone is directly related to therapeutic performance",16 other factors should also be considered in the selection of patients for rehabilitation. Severity of the cerebral vascular accident is another factor to consider. The present study shows that there is a significant differ- ence in the progress made by patients suffering from severe and yggy severe cerebral vascular accident. Boyle and Scalzitti found this fac- tor important.l7 *The oldest man in this population at Rehabilitation Medical Cen- ter, however, experienced the most dramatic recovery after discharge from the hOSpital. A type 4 cerebral vascular accident left him totally disabled and disoriented; four months later he appeared to have little, if any, residual effects. 15Staff of Benjamin Rose HoSpital, "Multidisciplinary Study of Illness in Aged Persons," Journal pf Chronic Diseases, VII (April, 1958), pp. 332-345; R. A. Rosenthal, "Five-Year Follow-up Study of the Patients Admitted to the Rehabilitation Center of the Hospital of the University of Pennsylvania," American JOurnal pf Physical Medicine, XLI (October, 1962), pp. 198-211; Harvey and Reed, 22.Igi£.; Hoberman and Springer, 22. 315.; Wright and Luckey, 22..gig.; and Scull, 22. £15. 16Theodore J. Litman, "Influence of Age on Physical Rehabilita- tion,” Geriatrics, (March, 1964), pp. 202-207. 17Robert Boyle and Peter D. Scalzitti, "A Study of 480 Consecu- tive Cases of CVA," Archives 2; Physical Medicine and Rehabilitation, 44 (January, 1963), pp. 19-28. ll 12 The five other variables were not significantly related to pro- gress. Included among these were the findings in regard to hemiplegic involvement. When a cerebral vascular accident occurs in one side of the brain, the Opposite side of the body is affected. If the cerebral vascular ac- cident damages the dominant hemiSphere of the brain, the opposite side of the body becomes paralyzed and aphasia is a frequent concomitant. The opinion has been quite generally accepted that cerebral vascular accident patients whose dominant hemiSphere is involved have a poorer prognosis than those where the cerebral vascular accident affected the other hemis- phere. This theory has been challenged recently. For example, Dr. Miland E. Knapp explains that "Patients with left-sided paralysis often have serious defects, concerned with v13uomotor, temporal and Spatial concepts and particularly with judgment and abstract generalization re- lated to these concepts, which may cause more difficulty in rehabilita- tion than would loss of speech. Right-sided hemiplegic patients mani- fest Speech and language defects but are more frequently returned to work than are left-sided hemiplegic patients who exhibit visu03patial defects which militate against return to competitive employment."18 This subject has serious implications for selection and treatment of cerebral vascular accident patients. While the results of the present study are not significant, they agree with the theory that a patient with a dominant hemiSphere involve- ment has a poorer prognosis. The bias mentioned earlier of excluding 18Miland E. Knapp, M.D., "Problems of the Hemiplegic Patient," Journal pf the American Medical Association, 169 (January 17, 1959), pp. 224-229. 13 aphasic patients may have changed the outcome. This is another area wherein future research is indicated. Since both personnel and financial resources are limited, selec- tion of patients for rehabilitation services should be carefully made. A larger body of knowledge regarding the importance of age, severity of the cerebral vascular accident, hemiSphere involvement, and other pertinent factors, will make a wiser use of existing facilities possi- ble. Another social implication related to improvement in selecting patients for rehabilitation is the return to employment of more former- ly disabled persons. Return to employment of a maximal number of handi- capped persons has economic importance to the taxpayer as well as social and economic importance to persons involved. VI. CRITICISM or THE STUDY One reason for the lack of more significant results may be the size of our sample. The four criteria we used limited the sample. A suggestion for future research in this area is that there be more than one judge to rate patients according to a classification Schedule, thereby excluding possible biases. Other factors in addition to those considered in this study may affect progress of cerebral vascular accident patients. 14 PART II SUMMARY OF PATIENTS' EVALUATION OF OCCUPATIONAL THERAPY, PHYSICAL THERAPY, AND SOCIAL SERVICE I. PATIENTS' EVALUATION OF PHYSICAL THERAPY Eleven patients rated physical therapy very helpful, six consi- dered it helpful, and only two. not helpful. In general, the patientfs ability to use physical therapy to advantage decreased with increasing age. Five of the twenty patients mentioned the fact that range of mo- tion exercises had been eSpecially beneficial both in the hOSpltal and after discharge. They still use them.19 Their criticism of physical therapy included: -- the complaint that the eXperience had been unnecessarily painful (2/20) -- the opinion that the referral of patient for treatment had been delayed too long (2/20) -- an expression of a need for closer communication between the department and the patient's family to expedite planning (5/20). Thirteen of those patients who regained some ability to walk ex- pressed appreciation for the help received in physical therapy. At the time of discharge one patient was completely independent in walking, twelve were independent at home, four could walk with assistance, and three were unable to walk.20 19See Table II on page 21. 2 . 0The figures ignore the use or non-use of mechanical aid. 15 II. PATIENTS' EVALUATION OF EXPERIENCES IN OCCUPATIONAL THERAPY Five patients rated occupational therapy very helpful, seven found it helpful, and five, not helpful.21 Six of the above patients considered activities of daily living e3pecially useful in helping them to adjust to their disabilities. To five patients occupational therapy had been an enjoyable diversion during hospitalization. The cost of occupational therapy was misunderstood by three patients. Need for out-patient occupational therapy as a continuation of activi- ties begun in the hospital was expressed by three patients. Return of arm and hand function was good in four cases, fair in three. 2 1See Table III on page 22. 16 III. PATIENTS' EVALUATION OF SOCIAL SERVICES Social services gave assistance to patients and their families in four main areas: assistance with discharge planning, referrals to other agencies, help with financial planningyand assistance in obtain- ing appropriate help in the home.22 Several family members expressed the opinion that social service could be a more effective liaison between the hOSpital and its services and the patient's family. Two family members eXpressed resentment over the worker's attempts to expedite planning so that the patient could be discharged. 22See bar graph on page 23. 17 A. B. C. APPENDIX INTERVIEW SCHEDULE Name Number Sex Age Race Are you at present: Single, Married, Divorced, Separated, Widowed? How many days were you in the hospital? What were the effects of the cerebral vascular accident? The inter- viewer will ask a series of questions about the cerebral vascular accident such as: 1. Were you unconscious? -- How long? 2. How did your doctor describe your stroke? 3. How complete was the paralysis? etc. She will then rate the severity of the cerebral vascular accident 1 - 4. See classification on page 6. \ Were you living at home before the cerebral vascular accident? Did you go from the hOSpital to your home? to an institution? What other illnesses did you have at the time of the cerebral vascular accident? What was your occupation? Are you working now? Have you had previous cerebral vascular accidents? If so, how many? The interviewer will ask each subject a series of questions about each activity. (i.e.) Feed yourself 1. Could you feed yourself when you entered the hoSpital? 2. Could you cut your meat without help? 3. Could you drink from a cup or glass unaided? 4. Which hand did you use for eating, writing, etc. when you entered the hOSpital? before your cerebral vas- cular accident? 18 D. E. F. G. 19 Interview Schedule -- COntinued She will then rate the subject in each of the following activities 1'5. Feed yourself Dress yourself Bathe yourself Toilet and transfer yourself Walk (including elevation) See classification on page 6. By the time this series has been completed, the interviewer will also record whether the cerebral vascular accident affected the patient's dominant or non-dominant hemiSphere. Repeat Section C, this time describing your abilities at the time of discharge. Can you suggest any services or help you did not receive but would like to have had from: Physical therapy Occupational therapy Social Services Do you care to comment concerning the above services? Was physical therapy: Very helpful -- Helpful -- Not helpful? Was accupational therapy: Very helpful -- Helpful -- Not helpful? Was Social Service: Very helpful -- Helpful -- Not helpful? In which of the following areas was Social Service helpful to you? 1. Making discharge plans 2. Relationships with doctors, nurses, other personnel 3. Acceptance of my illness 4. Acceptance of permanent disability 5. Attitudes of family toward Illness or disability 6. Assistance in contacting the apprOpriate agency 7. Assistance in locating apprOpriate help in the home Nursing, V.N., home aids? 8. Help with financial planning 9. Psychological support and encouragement 20 Changes in Independent Variables A decision was made to omit the factor of reSponsibility for others because the mean age of the group was 67, ten of the sample had retired prior to the cerebral vascular accident, and only one had a child living in his home. Six people in this sample have diabetes; one person has arthritis. No other illnesses were reported. The author decided to test for signi- ficance of diabetes rather than combining the illnesses according to the previous plan. The author decided to add the factor of hemiSphere involvement. Table II PATIENTS' EVALUATION OF EXPERIENCES IN PHYSICAL THERAPY Rating : No. E of Very Not i Cases Helpful Helpful Helpful By Sex Males l4 6 6 2 Females 6 5 l 0 By Age Under 70 11 8 3 0 i 70 and over 9 3 4 2 :' ! By Occupation -1¢"~' ‘-..b..r.1-. -’~“TL.-“ Professional 2 l l O Supervisory and skilled 6 3 2 l a Semi-skilled, un- 12 7 4 1 ‘ “‘4 skilled & housework By Severity of CVA 2 1 l 0 0 3 14 10 3 1 4 . 5 0 4 1 By Side Affected Non-dominant 10 6 3 1 Dominant 10 5 4 1 By Marital Status Married 16 9 5 2 Non-married 4 2 2 0 e . o . 1.. ‘-A _ ' 21 Table III PATIENTS' EVALUATION OF EXPERIENCES IN OCCUPATIONAL THERAPY N0. of Cases By Sex Males l4 Females 6 ' By Age Under 70 11 70 and over 9 By Occupation Professional 2 Supervisory and skilled 6 Semi-skilled, un- 12 skilled & housework By Severity of CVA 2 1 3 l4 4 5 By Side Affected L 10 R 10 By Marital Status Married 16 Non—married 4 Rating Very , Not Helpful Helpful Helpful Undecided 2 6 ‘3 2 3 l l l 1 5 2 3 4 2 3 0 O 0 2 O O 4 l l 5 3 2 2 l O 0 0 4 6 2 2 0 l 3 1 3 2 2 3 2 5 3 0 3 5 5 3 2 2 0 0 22 PATIENTS' EVALUATION OF SOCIAL SERVICES Patients 20 19 18 17 16 15 14 13 12 11 10 run—“an“, m 'f" r l L Discharge Referrals Financial Obtaining Dissatisfaction Plans Planning Help in Home 23 BIBLIOGRAPHY Boyle; Robert and Scalzitti, Peter D. "A Study of 480 Consecutive Cases of CVA," Archives pf Physical Medicine and Rehabilitation, 44 (January, 1963), pp. 19-28. Carroll, Douglas. "The Disability in Hemiplegia Caused by Cerebral Vascular Disease," Journal pf Chronic Diseases, XV (February, 1962), pp. 179'188. David, N. J. and Heyman, A. "Factors Influencing the Prognosis of Cere- bral Thrombosis and Infraction due to Atherosclerosis," Journal 2: Chronic Diseases, XI (April, 1960), pp. 394-403. Feldman, Daniel J. and Rusk, Howard A. "A Comparison of Functionally Oriented Medical Care and Formal Rehabilitation in the Management of Patients with Hemiplegia Due to Cerebral Vascular Disease," Journal pf Chronic Diseases, XV (March, 1962), pp. 297-310. Feldman, Daniel J. "Medical Rehabilitation: The Clinical Management of Disability," Journal pf Chronic Diseases, (December, 1963) pp. 1313-1318. Harvey, John and Reed, Julian. "A Two-Year Study of Intensive Rehabil- itation of Fifty Chronologically Ill and Indigent Medical Out- patients," Journal of Chronic Diseases, XV (January, 1962), pp. 141-147. Hoberman, Morton and Springer, Charlotte F. "Rehabilitation of the Permanently and Totally Disabled Patient," Archives pf Physical Medicine and Rehabilitation, XXXVIV, pp. 235-239. Knapp, Miland E., M.D. "Problems in Rehabilitation of the Hemiplegic Patient," Journal pf the American Medical Associppion, 169 (January 17, 1959), pp. 224-229. Litman, Theodore J. "Influence of Age on Physical Rehabilitation," Geriatrics, (March, 1964), pp. 202-207. Lowenthal, Tobis and Howard, I. R. "An Analysis of the Rehabilitation Needs and Prognosis of 232 Cases of Cerebral Vascular Accident Patients," Archives pf Physical Medicine and Rehabilitation, XL (May, 1959), pp. 183-189. Pomeroy, Richard. "Grass Roots Planning for Rehabilitation." Presented to the American Personnel and Guidance Association Convention, Cleveland, Ohio, 1959. 24 25 Bibliography -- Continued Ratcliff, J. D. "How Science is Saving Stroke Victims," Today's Health, (March, 1962). Rehabilitation Medical Center, Sparrow HOSpital. Annual Report. 1961. Rehabilitation Reports: Hemiplegic Cases from Allegan Health Center. April, 1962, p. 494. Robinson, R. W., pg 31. "Life-Table Analysis of Survival After Cerebral Thrombosis; Ten-Year Experience," Journal pf American Medical Association, CLXIX (March, 1959), pp. 1149-1152. Rosenthal, R. A. "Five-Year Follow-up Study of the Patients Admitted to Scull, the Rehabilitation Center of the Hospital of the University of Pennsylvania," American Journal pf Physical Medicine, XLI (October, 1962), pp. 198-211. Edward, 25,21. "A Follow-up Study of Patients Discharged from a Community Rehabilitation Center," Journal 2: Chronic Diseases, XV (February, 1962), pp. 207-213. Shatin, Leo, 25 pl. "Psychological Remotivation of the Chronically Ill Medical Patient: A Quantitative Study in Rehabilitation Metho- dology," Journal pf Chronic Diseases, XIV (October, 1961), pp. 452-467. Shontz, Franklin C. and Pink, Stephen L. "A Method for Evaluating Psy- chosocial Adjustment of the Chronically Ill," American Jourpgl pf Physical Medicipel XL (1961), pp. 63-69. Snow, William B. "Psychosocial Aspects of Disability," American Journal 2; Physical Medicine, XL (1961), pp. 249-255. Sokolow, J., 35 21. "Functional Approach to Disability Evaluation," JOurnal pf American Medical Association, CLXVII.(1958), p. 1575. Sokolow, J., 33 31. "A Method for the Functional Evaluation of Disabil- ity," Archives pf Physical Medicine and Rehabilitation, XL (October, 1959), pp. 421-427. Staff of Benjamin Rose HOSpital. "Multidisciplinary Study of Illness in Aged Persons," Journal pf Chronic Diseases, VII (April, 1958), pp. 332-345. Wylie, C. M. "CVA Deaths in U. 3., England and Wales," Journal pf Chronic Diseases, XV (January, 1962), pp. 107-115. 26 Bibliography -- Continued Books McCoy, Georgia F. and Rusk, Howard A. A3 Evaluation pf Rehabilitation. Rehabilitation Monographs, l, 1953. Ritchie, Douglas. Stroke. New York: Doubleday and Company, 1961. Wright, Irving 8. and Luckey, E. Hugh (ed.). Cerebral Vascular Diseases. New York: Grune and Stratton, 1955. ;. - O . O ‘ ' 3| I 1‘ III—v.41." ‘ ‘I.r..‘l\ru..“ "'Wfiifilfiflflifl'tjlfliflflfflifli 1111111111111“