k FELLW-UP mm W REMPLEBW mm: MSBHABSW FRESH THE REMMUTHIOI NSTWME EF WWW “Em HER WE BEBREE flf ERA. mmm STATE “MYERS!“ noun: a. mum \985 THESIS LIB R A R Y L} Michigan State University This is to certify that the thesis entitled A Follow-up Study of Hemiplegic Patients Discharged from the Rehabilitation Institute of Chicago presented by Douglas E. Inkster has been accepted towards fulfillment of the requirements for Ed.D. degree inmand Counseling A".»-—u." IAO '. Date e/Z’Z'E. .o m w sH mm mH o: pHoH .a .> .o o m s mH om m: panm .< .> .o mommo w: ooCqupcoocH mommo m: mSoHnoam noomam mommo 03 Hmpoa omsoo .monGHpcoocH can nooomm mo maoHnoam UopoHos mo hocmsvosh and nHonmHSon mo thHOHpm In .N oHndB lililrfi.‘ Iii. .l Wig. 29 table gives rise to some question as to the meaning of CVA on the medical report when the doctor is stating the etiology of the hemiplegic condition. It seems unlikely that there would be such an extreme variation between the two studies by chance. Table 3. -- Distribution of population by sex and age at onset. Age Total Male Female 20-35 13 10 3 36-45 20 6 14 46-55 27 15 12 56—65 40 24 16 Totals 100 55 45 Table 3 clearly shows the incidence of cerebrovascular disorders resulting in hemiplegia increasing directly with age. Because the study was limited to individuals 65 and under, the table goes no higher. However, one would expect this progression to continue. Between 36 and 45 years of age, the female hemiplegic out-numbers the male two to one. Between the ages of 56 and 65 years of age, the male hemiplegic out-numbers the female three to two. The 55 men to 45 women ratio in this study closely coincides with the 54 percent males and 46 percent females reported in the Bellevue Medical Center Study of 1958 (13). 30 h m OH ON OH m N wN NH NH NH 0: mHmpOB m N m OH 0 H d #H HH 0 S :N molmm o H m z N m m m N 3 m NH mmlw# N o m m N H O m i H m m m#u©m o o H H o H O H o H H N mMION commoawom oHpopm co>osdaH Hmpoe commonwom oHpopm co>osgaH Hopes commoawom oHpopm cm>onmaH Hopes oHdaom mHoz Hanna ow< .GOHpocfih mo meadaopCHdE on COHpoHoH QH can pomco pd own can How an acute QSIZOHHOM Ho COHpanhpmHQ II .3 oHme 31 A study of Table 4 seems to indicate that the young female hemiplegic has more success in maintaining function after leaving the Institute than does the male. The male "improve-and-regress-ratio" is about the same regardless of age. This difference may be related to the ease with which families return the responsibilities of homemaking to the female hemiplegic. When she returns home, she returns to her work station which enhances the gradual resumption of her work activities in the home. She is able to begin by dusting and then as she feels better; can do dishes, gradually assume the ironing responsibilities, and some sewing, until she is finally doing the laundry and heavier housekeeping chores. The fact that her con- valescence is taking place within her work environment keeps constantly before her the need for her services which stimulates the necessary motivation to recover. The male hemiplegic, on the other hand, does not have accessibility to his work environment as a general rule. Employers do not encourage nor do they desire to have marginal employees in a profit motivated organization. They are interested primarily in having the patient return to work only when he is capable of assuming full responsibility for some phase of the work. Therefore, it is more difficult for the male hemiplegic to feel that he is needed and that he still has a contribution to make in the world of work. This is one of the observations supporting the recommendation made in the final chapter of this study; 32 that a programmed plan be developed for the reintegration of the hemiplegic back into his usual role in society. Lapse of Time Between Discharge and Follow Up. Fifteen of the 46 cases had been discharged for a period of two to three years. An additional fifteen had been discharged for a period of three to four years. Twelve had been discharged for a period of four to five years, two a period of five to six years, and two a period of six to seven years. Two- thirds of the follow-up sample, therefore, had been dis- charged from the Institute for a period of two to four years. Table 5. -- Marital status in relation to maintenance of function. Status Total Improved Static Regressed Single 5 l 3 1 Married 31 12 7 12 Separated 4 2 0 2 Widowed 3 2 O 1 Divorced 3 0 2 1 Totals 46 l7 12 17 Table 5 could lead one to naively entertain the hypothesis that there is some relationship between marriage and a cerebrovascular disorder. Maintenance of function apparently is unaffected by the marital status of the patient 33 when one considers only the statistical evidence of marriage. This does not support the hunch expressed in the Hartford study (12) that responsibility for others may affect a patient‘s progress after discharge. However, no related factors are considered and such things as compatibility, family harmony, etc., may exercise considerable influence. Table 6. -— Sibling orientation related to maintenance of function. Number of Children Total Improved Static Regressed Only child 10 3 1 6 l of 2 9 4 4 l l Of 3 3 l l l l of 4 7 2 1 4 1 of 5 or more 17 7 5 5 Totals 46 17 12 17 It seemed "reasonable" to expect that a patient coming from a large family wouldbe more likely to persevere in seeking independence because of the necessity of having to fend for himself during childhood more than would be required of an only child. The results in Table 6 indicates a slightly skewed distribution which would support such a hypothesis, but not statistically significant enough to say that patients with siblings do better than an only child in terms of maintaining physical function after 34 discharge. A Chi-Square test did not reject a hypothesis of equal occurance across the maintenance of function scales at a Significant level, exhibit 11 in appendix. Table 7. -- Education related to maintenance of function. Years Total 46 Cases Improved Static Regressed 0 - 4 8 2 0 l l 5 - 8 29 16 6 3 7 9 -12 47 19 8 7 4 13-16 12 6 2 l 3 17-20 4 3 l 0 2 Totals 100 46 17 12 17 Table 7 reflects a normal distribution of educational achievement for the total group. Other than a slight tendency for high school level patients to do better in improving their physical function since discharge from the Institute, there does not seem to be any significant relationship between educational achievement and maintenance of physical function after discharge. This does not support the hunch that achievement to levels of education prepares one for dealing more effectively with a severe physical impairment. It fails to support Dr. Heather's thesis (11) that the pre-morbid educational level is a substantial factor in determining improvement. It should be noted that the 35 more affluent patients continued treatment after discharge. There was no observable benefits derived from this extra expenditure of funds. Table 8. -- Primary source of support before onset and at follow-up. Source Before Onset At Follow-up Employment 33 3 Spouse 7 7 Children 0 2 Parents 1 0 Investments 0 5 Pension (OASI) 1 22 Public Assistance 4 7 Totals 46 46 Table 8 indicates that only three of the 46 cases followed up were found to be working. This is considerably lower than the 48.2 percent reported in the Bellevue Study (13). However, it should be noted that the Bellevue Study screened the patients prior to their admission to the services. Only those patients who were considered feasable for substan- tial rehabilitation improvement were admitted. Therefore, many patients with severe or complicating impairments were not referred for evaluation and were not included in the study. Such was not the case in this study. All of the inpatient 1|!l4 3‘ .mr 36 hemiplegic cases were considered and comprised the total population including those with severe and complicating organic brain damage and other secondary impairments. Another factor is the existence of disability insurance benefits under the Old Age and Survivors Insurance (OASI) program. A considerable number of formerly employed patients started drawing this type of pension after the onset of their disability as can be seen in Table 8. Table 9. -- Occupations related to maintenance of function. Occupation Total Improved Static Regressed Professional and Managerial l2 5 2 5 Clerical and Sales 4 O 4 0 Service Occupations l2 5 2 5 Agricultural O 0 O 0 Skilled Occupations 5 l 2 2 Semiskilled Occupations 4 O l 3 Unskilled Occupations O , 0 0 O Homemaker 9 6 l 2 Totals 46 17 l2 l7 37 One might expect, as did Dr. Heather (11), that persons engaging in professional and managerial occupations such as store owners, pharmacy, contracting, law and the other professions would be better equipped to cope with disability and manage their rehabilitation process more effectively. However, Table 9 indicates there is no difference between the maintenance of physical function of the professional and managerial workers and those patients engaged in service occupations such as domestics, janitors, and gas station attendants. The results do indicate that being a homemaker might enhance ones chances of improving ones physical function after discharge. An explanation for this related to the availability of the work station is discussed under Table 4. It is interesting to note that there were no patients engaging in agricultural occupations or in occupations classified as unskilled in this sampling. Table 10. -- Time lapse from onset to admission related to maintenance of function. Months Total Improved Static Regressed l to 3 15 10 2 3 31:06 7 3 2 2 Over 6 24 4 8 l2 Totals 46 l7 l2 l7 38 It should be noted that 60 percent of the improved cases were admitted to the Institute within three months after onset. A Chi-Square test was run on the "l to 3 month" group assuming an hypothesis of equal occurance of improved, static, and regressed cases. A Chi-Square value of 7.6 was obtained. With one degree of freedom, the one and five percent levels of significance are 6.6 and 3.8 respectively. A similar test run on the "over 6 months" group resulted in a Chi-Square value of 4.0, which was significant at the five percent level, exhibit 11 in appendix. This further sub- stantiates the fact that early inauguration of a functional management program correlates with a greater return of physical function. One would expect to see the distribution skewed toward early admission after onset. The benefits that might accrue to long time chronic patients is interesting. One of these cases was admitted to the Institute sixteen years after onset and still received some measurable benefit from the services provided. One of the problems in a rehabilitation center is being able to identify when a point of diminishing returns has been reached by the patient. Institute services are expensive and it is "unfair" to the individual and the agency underwriting the cost to continue the patient beyond the point where benefits are not forthcoming from services being rendered. By plotting the length of hospitalization against maintenance of function ratings, perhaps a time pattern will appear. 39 Table 11. -- Length of hospitalization related to maintenance of function. Weeks Total Improved Static Regressed Less than 2 weeks 9 3 2 4 2 to 4 weeks 11 6 2 3 4 to 6 weeks 6 1 3 2 6 to 8 weeks 4 2 O 2 8 to 10 weeks 3 2 1 0 Over 10 weeks 13 3 4 6 Totals 46 17 12 17 The results of such plotting in Table 11 indicate that 50 percent of the improved cases spent less than four weeks at the Institute. One should not ignore the fact that 13 cases stayed 10 weeks or more with one case being hospitalized for a period of seven months. About 25 percent of these long-stay-cases were able to improve their physical function after discharge. However, these improved cases might have been improved cases at the end of four weeks but still showed potential for improvement. Four to six weeks is the typical length of stay in the studies of the hemiplegic reviewed here. If early services were sold in a six week evaluation package, insurance companies might show more interest in evaluating the potential of hemiplegics for self care at a rehabilitation center. 40 A study of services rendered to each group might have supported a hunch that a higher intensity of service correlates with better post hospital performance. Table 12 shows only the density of service for each group which tends to support the hunch, but not to a significant degree. Intensity could not be measured. Table 12. -- Frequency of services rendered in relation to maintenance of function. Service Total Improved Static Regressed Assistive Devices 22 10 5 7 Exercise 41 15 12 14 Ambulation Training 37 14 10 13 Speech Therapy 24 7 7 10 .ADL Training 37 13 10 14 Social Service 33 13 9 ll Psychological Service 22 10 6 6 Prevoc ational Service 12 2 4 6 To tals 228 84 63 81 The most frequent services received regardless of madJltenance of function ability were exercise, ambulation training, and activities of daily living training. These were closely followed by social service. Specificity 0f 41 these services did not differentiate between the functional capacity of the patient after discharge. The type of service provided may be related to the initial severity of the disability and hence may not be considered as a constant variable. Assistive devices and psychological services would seem to be closely related to maintenance of function. Being shown how to cope with ones environment in spite of severe physical limitations and learning to live a pro- ductive life with these conditions would seem to be among the basic elements for sound rehabilitation. Table 12 does not give any predictive clues for improvement. Table 13. -- Patient social activity in the Institute related to maintenance of function. Degree of Activity Total Improved Static Regressed Inactive l7 5 6 6 Active in Room 5 3 1 1 Active in Both Room and on Ward 24 9 5 10 Totals 46 17 12 17 Patient socializing activity was measured by making a judgement based on the nursing notes in the medical file. Consequently, it must be recognized that the socially inactive patient may have been worse off initially on a physical basis with complicating medical problems or the socially inactive patient may have been socially active 42 in the treatment areas and fatigued upon returning to the nursing floor. Keeping these limitations in mind, it would seem reasonable to expect that a patient who is socially active in the room and on the ward might do better in maintaining function gains after discharge. Table 13 indicates that there is no significant difference between a socially inactive patient and a socially active patient in terms of predicting which patients will maintain or improve their physical function after discharge. Social activity on the "nursing floor" does not appear to be a reliable predictor of future patient improvement. It should be noted, however, that further qualifications might result in a more accurate definition and classification of patient activities. Table 14. -- Patient activity at follow-up related to maintenance of function. Degree of Activity Total Improved Static Regressed Inactive 13 2 3 8 Active in Home 11 3 2 6 Active Both Inside and Outside Home 22 12 7 3 Totals 46 17 12 17 The distribution of figures in Table 14 reflects the method of evaluating improvement and regression. The cases 43 sH mH sH on sH mH sH m: aHsoos mH 0H 6H mm m m H m cocooanao o: no coco H m H s HH 6 mH om hoaHss m o o m m H m s aHssoHoosz commosmmm 0Hpmpm oo>oamSH Hmpoa commoswom oHpmpm oo>oamSH Hmpoe moH< QSnSOHHom p< owsocomHm p< .GOHpocdH mo oocmCochms on oopoHoH mausoHHom no one owsonomHo as com: moH< In .mH oHnoB 44 identified as showing improvement are active both inside and outside the home. Cases identified as showing regression are inactive. By the very nature of the study's definition, improvement varies directly with the amount of activity inside and outside the home, whereas regression varies indirectly with increased activity. The statistics show that 60 percent of the sample population was able to go from a walker to a cane after discharge. Table 15 indicates that improvement in each area of classification is reflected in the general reduction in the use of the wheelchair and the walker and the increase in the use of the cane or no assistive device at all. It is apparent that ambulation is one of the greatest benefits that results from intensive rehabilitation center service to hemiplegics. Attitudes of Patients. An attempt to measure and record incidents of cooperative behavior versus incidents of uncooperative behavior was made. However, there were so many judgmental variables involved in so many treatment areas that it was thought best to eliminate this global evaluation. Statistical Results. A Chi-Square test for multiclass sample of multiclass pOpulations was applied to certain tables to test the null hypothesis for equal division of hypothesized frequencies among the several categories. Selection of tables was on the basis of inspection for 45 wide frequency variations. Tables 6, 7, and 10 were chosen. Only Table 10, however, yielded a Chi-Square value which was significant at the one percent level with one degree of freedom. There is a statistically significant relation- ship, therefore, between early hospitalization after onset and maintenance of function after discharge. Generally speaking, the limited size of the sample in this study did not lend itself to meaningful statistical analysis. Chi-Square Tables are found in exhibit 11 in appendix. Observations The most striking fact in conducting this study was not the statistical data per se, but the observed type of personality change that was evident in 90 percent of the cases visited. People who had been dynamic individuals prior to the onset of the disability were now facing the world with a lethargic indifference. A successful builder was content to meet with the "boys" once a week for his entire week's entertainment. A successful heating con- tractor goes to the gym two days each week and this is his entire activity for that period. This attitude was not restricted to certain occupa- tional categories as the same "personality change" was manifested in the domestic workers and the janitors. Less than 10 percent of the individuals had hobbies to keep them busy and few of them did little more than watch T.V. and do a little dusting around the house. The similarity 46 of these personality characteristics in most of the patients suggests that there may be an organic base for the change. One might also hypothesize that the "dynamic, driving person" welcomed a kind of conversion reaction which made inactivity acceptable and the "welfare recipient" now had a socially acceptable reason for his continued inactivity. However, it is suspect that a group of more than 40 separate : Anna-.1 :- individuals would develop such a "uniform personality" with so many similar characteristics unless it was a typical manifestation of an organic impairment. Such evidence indicates the organic components of personality change need further investigation. The family and/or spouse was often content to accept this new personality as it made it easy to care for the patient. One woman viewed it as a blessing. The social life structure of these families were vastly altered as the patient returned home. Old friends disappeared and a new group of social relationships deve10ped. Usually the social aetivity was sharply reduced. This presented a difficult adaptation problem to the family members as their needs had not changed, only the heavy demands being made on them were new. However, old ways of leisure were usually no longer available. (e. g., attending the theatre can no longer be a last-minute decision, it is now a planned excursion.) It was impossible not to notice a lack of, or a need for continued support on the part of the Spouse or family 47 to cope with the personality change, the personal needs and the changed social life structure. This gives rise to the question of who has the respon- sibility for the continued follow-up support that a family and patient need. The family or spouse must be prepared to assume the job of meeting the nursing needs, adapting to the changed social structure and the new social relation- ships that develop, and learning to allow the patient to conduct his own activities, and even "force assist" him to carry them out when it is much easier to do it yourself. Although this training is made available in the Institute and is provided in the patient's home, it should be a service offered on a continuing basis. Periodic contact with the Institute has value for maintaining functional gains. Insurance companies, family physicians, and other referral sources would do well to foster such periodic reviews of the patient's status. Post~discharge home care is an area still needing considerable exploration. It is important to re-educate the person in the function of their habitual occupation or a reasonable substitute in keeping with the persons functional and intellectual abilities at the time, in order to permit their return home and to a certain independence if possible. It is equally important to follow them up once they have returned to their home, and to bring them into contact with groups of patients with the same impairment. Personal experience in military hospitals where groups of amputees fit 48 were collected together in a single hospital for intensive treatment revealed that a psychological benefit to the patient was derived that was not a part of the medical program. The association of individuals with similar impairments did much to develop an acceptance of limitations on the part of patients. Perhaps "group work" with hemi- plegics might bring about such an objective approach to their problems through mutual discussion and consideration of particular cases among them. Personal interaction could have the result of making their own situation less formid- able and easier to cope with. It would be expected that as the patient became more accustomed to living with his residual impairments he would become less active in such a group and more involved with his own life situation. One woman would not permit inactivity on the part of her spouse. She insisted he get out daily if it was no more than sitting in the lobby of their apartment hotel and passing the time of day with other residents. He went to ball games, political meetings, civic functions, dinners, and continued to socialize with their circle of friends. He enrolled in an art course that met daily and his art activities were encouraged to the point where he became a prolific painter producing approximately two dozen oil paintings in the period of two years since his discharge from the Institute. During this two year period, his attention Span had gradually increased to the point where he could play a game of checkers and even a game of chess. 49 He was able to go to, sit through, and follow the action of a ball game for the entire nine innings. During the latter months before contact, he was beginning to obtain more and more control of his urinary incontinence so that he could go for progressively longer periods of time without special equipment. On the basis of observing this patient and other patients followed up in the study it would seem apparent that there is some need for further research in family fac- tors affecting the hemiplegic's return to an active social life. Recognizing that motivation in an individual is a psychological phenomenon which takes place in a social environment and that the social factors which exert a favorable influence on one individual may have little affect on another because of differences in background, age, sex, occupation, family status, economic status, education, ethnic origin, location, religion, and attitudes, it would seem that investigation into such factors appears high of the priority list of needed research with hemiplegic patients. CHAPTER V SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR FURTHER RESEARCH Summary The Problem. It was the purpose of this study to assess w the demographic, functional, active, and economic character- _ --A nuanc- r - \ istics of certain hemiplegic patients of the Rehabilitation Institute of Chicago at two points in time and note any changes that occurred in these characteristics. The patients were grouped into improved, static, and regressed categories. These categories were examined to discover any special or significant characteristics that were peculiar to any one of the groups and that might explain or predict the degree of functional return that can be expected in similar cases. The Sample. The total sample consisted of 100 hemi- plegic individuals who had been inpatients of the Rehabili- tation Institute of Chicago, who were 65 years of age or younger at the date of admission, and who had been discharged for a period of two years or more. The follow-up sample consisted of 46 of the total sample cases who could be located, were living, and would provide detailed follow-up information. Methodology. Two points in time were selected; the date of discharge from inpatient status at the Rehabilitation Institute, and the date of follow-up contact. The patient's ability to perform or his status in each of twelve areas was SO 51 rated numerically. This rating was made at both points in time. Differences between the sum of the ratings at each point in time were charted for each subject. The distribu- tion was divided into three parts. The parts were labeled improved, static, and regressed, referring to the patient's change in ability to perform or his status in the twelve areas. The demographic characteristics were then studied in relation to these labeled categories to discover any qfifilQilz“..- relationships which might be of significant predictive value. Also, empirical observations were noted and reported. Review of Findings. An analysis was conducted using the 100 hemiplegic patients 65 years of age or younger who received inpatient services from the Rehabilitation Institute of Chicago prior to July 1, 1962. Particular emphasis was placed on the characteristics of the patient on admission, their status on discharge, at follow-up, and factors affect- ing their rehabilitation. The family physician was the most common referral source, referring better than 50 percent of the cases studied. Welfare was the next best source referring 30 percent of the cases. The third most frequent referral source was the Division of Vocational Rehabilitation who referred approximately 13 percent of the cases. On admission, there were 55 percent males and 45 percent females with a median age of 52 years for the total sample. The majority (67 percent) of the 46 study cases followed up 52 were married. Thirty-seven percent of the total population had less than a 9th grade education. Sixteen percent had some college with four percent having attended graduate school. In general the educational status of the patients was superior to that of the general pOpulation. Of the 46 cases studied on follow-up, 70 percent were employed prior to the onset of their impairment whereas only seven percent v were employed at the time of follow-up. The interval from the onset of illness to admission to the Institute for rehabilitation services varied from less W than one month to sixteen years in one case. Of the 46 cases that were contacted on follow-up, 17 were classified as improved since their discharge from the Institute. Sixty percent of these improved cases were admitted to the Institute within three months after onset. It should be noted that there is a high relationship between early inauguration of a functional management program with a high return of physical function. The length of hospitalization varied from less than one week to seven months. The median length of stay, however, was from four to five weeks. Ambulation at the time of discharge in the 46 cases studied in the sample was still a problem. Thirty patients were still using a walker and seven were using a wheelchair. On follow-up, only four were using a walker and three were using a wheelchair. The study shows, therefore, that 60 percent had improved in ambulation at the time of follow-up. This compares favorably with the Bellevue study (13) which ‘llln:f.l-.u I‘ 53 shows 63.5 percent had improved in ambulation. The results of the tabulated information in this study correspond generally with the findings of previous studies of hemiplegic cases. It is reasonable to assume on the basis of these findings that this study was made on a reasonably represen- tative sample of this disability group. One of the most significant differences is the fact that only three of the 46 cases were working at the time of follow-up. One was self-employed as a tavern owner, one was a traffic manager for a large company, and one was managing an apartment house. One other case had been employed after leaving the Institute, but retired before a follow-up contact was made. This represents less than 10 percent of this pOpulation that was employed at the time of follow-up. The factors in this study which appeared to directly affect the achievement of patients and their rehabilitation include age, marital status, occupation, severity of the residual impairment, and time lapse from the original stroke until admission to the Institute for rehabilitation services. The most important single factor consequent to becoming a hemiplegic patient appeared to be the "personality change” which followed the onset of the disability. This ”person- ality change" made the job of stimulating motivation in the patient difficult. Factors which were found in the study to have little or no significant affect on the results obtained in rehabilitation were; sex, education, occupation, and the miscellaneous physical characteristics of the patients. . uw‘J-fl‘qytfip .3} “*7- Jay 54 Late in the study it was discovered that proper notation of the nature and extent of the speech problem was not made on the study's evaluation instruments. In most of the studies done in the past there has been little attention given to the specific diagnosis of speech problems and their progress through treatment and status at follow-up. This information would be extremely helpful in determining the importance of this impairment in effecting the rehabilita- tion of the hemiplegic patient. Although speech problems were noted, the specific nature of the speech problem was not identified and therefore generalizations or implications cannot be stated. Conclusions 1. Rehabilitation agencies offering services to hemi- plegic patients must continue to be concerned with the spouse or parents of the patient and assume responsibility for preparing them to cope with the changed personality structure and relationships that will be forthcoming as well as the responsibilities for patient care. Such prepar- ation should include follow-up visits to the patient's home for discussion of problems in the setting where they occur. 2. Early inauguration of a function management program enhances a greater return of physical function. 3. The probability of a cerebrovascular accident increases directly with age. 4. The female hemiplegic under age 55 has the best chance of maintaining physical function after discharge ‘QHL Li .‘mmmafisgr 41..-..- .. vi 55 from the Institute. 5. The most frequent benefit from Rehabilitation Institute services to hemiplegic patients is the ability to ambulate. 6. Demographic characteristics of hemiplegic patients have little apparent influence on their ability to maintain physical function after discharge. 7. The "true" vocational potential of a hemiplegic patient cannot be determined until post-discharge services are designed, implimented, and evaluated over a period of time. Implications for Further Research Much is yet undone in the area of research for the stroke or hemiplegic patient. The following implications for further research were apparent in this study: 1. It is strongly indicated that further research be done on family factors affecting the hemiplegic's return to an active social life. The empirical evidence indicates that untapped potential for functional return is available if a programmed plan is instituted to assist the individual in assuming a realistic role in society. 2. A comparative study of left and right hemiplegic patients might form a foundation for basic research into the etiology and differential effect of such lesions in the central nervous system. 3. A demonstration study on the effectiveness of "group work" techniques on hemiplegic patients recently "' WI “ff—“Tu? arc-n- 56 discharged from a hospital or rehabilitation center might show surprising results. 4. There is need to definitely explore the nature of the apparent ”personality change" that takes place as a result of cerebrovascular accident. The patterns and the personality traits were so similar among the subjects studied as to lead one to consider that it may be organic in nature. E This change seemed to be directly related to a reduction of ; motivation. This reduction in motivation is also directly 3 related to rehabilitation as "motivation to recover" is r commonly regarded as the single most important factor in the success or failure of services rendered to hemiplegic patients. A group of hemiplegic patients could be followed up with a programmed plan for re-integration into society that required their active participation. There is reason to believe that the findings of such a study would cause state and local agencies to reassess the possibility of evaluating their hemiplegic clientele for vocational potential. Findings imply that this disability group could prove to be a more fruitful source of rehabili- tated clients than presently considered. 10. ll. 12. REFERENCES Adams, G. F. and Hurwitz, L. J. 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Women's Ass'n, XIX, No. l (1964), 29-34 0 Heather, A. J. "A Two Year Follow-up Study of the Patients Admitted to the Rehabilitation Center of the University of Pennsylvania," American Journal of Physical Medicine, XXXVII, No. 5 (1958). Komisar, D. D. A Follow-up Study of Patients Discharged from a Community Rehabilitation Center. The Hagtford Rehabilitation Center, Hartford, Connecticut, 19 O. 57 — ‘.’l' —.‘- Ll" _‘-“Q3F»"1Q-Pr. . Tit—W .: _"‘.: l3. l4. l5. l6. 17. 18. 19. 20. 21. 58 Lee, P. R. "An Evaluation of Rehabilitation of Patients with Hemiparesis or Hemiplegia due to Cerebral Vascular Disease," Rehabilitation Monggraph, XV. The Institute of Physical Medicine and Rehabilitation, New York University - Bellevue Medical Center, 1958. Lesser, M. S. and Darling, R. C. "Factors Prognostic for Vocational Rehabilitation Among the Physically Handicapped," Archives of Physical Medicine, II (1953). Lorenze, E. J. and Cancro, R. "Dysfunction in Visual Perception with Hemiplegia," Arch, Phys. Med. and Rehabilitation, XLIII, No. 10 (1962), Bin-517. this . .II‘II-"cW‘M . Nathanson, M., Bergman, P. S. and Gordon, G. G. "Denial 1 of Illness," Arch, Neurol. and Psychiatgy, XLVIII r (1952), 380-387. Reed, H. B. 0., Jr. and Reitan, R. M. "Intelligence Test Performance of Brain Damaged Subjects with Lateralized Motor Deficits," J. Consult. Psychology, XXVII, No. 2 (1963), 102-106. Ullman, M. "Reactive States Following Strokes," J. Arkansas Med. Soc., LVIII, No. 7 (1961), 265-270. Ullman, M. "The Psychiatrist and the Stroke Patient," Proceedings of the Third World Congress of Psychiatry, R. A. Cleghorn, Ed., Toronto, Canada: University of Toronto Press, 1962. Ullman, M. and Gruen, A. "Behavioral Changes in Patients with Strokes " American Journal of Psychiatry, CXVII, No. 11 (1961), 1004-1009. Whitehouse, F. A. "Stroke; Some Psychosocial Problems it Causes," American Journal of Nursing, LXIII, 4.1..- q... APPENDICE S 59 EXHIBIT I CASE IDENTIFICATION SHEET CODE NAME ADDRESS 60 PHONE SPOUSE, PARENT OR GUARDIAN'S NAME ADDRESS PHONE TYPE OF CASE l ACCEPTED AND SCHEDULES COMPLETED 2 ACCEPTED BUT SCHEDULES NOT COMPLETED 3 NOT ACCEPTED IF 2 0R 3, WHY? 61 EXHIBIT 2 FILE REVIEW SCHEDULE - SOCIAL Code (1,2,3) REFERRAL SOURCE (4) X Interested Individual Federal Employee Physician Hospital V. R. Agency I. P. A. C. C. C. W. D. Health Department Private Agency Workman's Compensation Insurance Company Other (Spec.) u:a>~soxu:¢1u]h>rac>r< SEX Male 2 Female (5) DATES Admission Discharge Months Hospitalized (6,7) NUMBER OF SIBLINGS Brothers (8.9) Sisters SUBJECT'S WORKING STATUS AT TIME OF ONSET OF DISABILITY (10) 1 Not Working 2 Working Part-time 3 Working Full-time 4 Student 5 Other (Spec.) IF WORKING AT ONSET Occupation D. O. T. Code (11.12.13) Card 1 SUBJECTS AGE AT TIME OF INITIAL (l4) DEPARTURE FROM FAMILY OF ORIENTATION 0 Never Departed 1 Under 15 Years of Age 2 Between 15 and 19 3 Between 20 and 24 4 Between 25 and 29 5 30 Years or Over REASON FOR LEAVING (15) 0 Not Applicable 1 To Get Married 2 To Attend School 3____Just to Live Independently 4 To Go Into Service 5 Other (Spec.) SUBJECT'S ATTITUDE TOWARD PARENTS AT INITIAL DEPARTURE (16) O Favorable 1 Unfavorable 2 Indifferent 3 Other (Spec.) COOPERATIVENESS IN HOSPITAL AT ADMISSION (l7) 1 Cooperative 2 Indifferent 3____Uncooperative DURING TREATMENT (18) 1 Cooperative 2 Indifferent 3 Uncooperative AT DISCHARGE (19) l Cooperative 2 Indifferent 3 Uncooperative FILE REVIEW PRIMHRX'DISORDER DIAGNOSIS 62 EXHIBIT 3 SCHEDULE - IMPAIRMENT Card 1 (20.21.22) Code ETIOLOGY SECONDARY DISORDERS FUNCTIONAL INVOLVEMENT OF EXTREMITIES O Fracture 1 “Mcnoplegia 2“ _Diplegia 3 _Triplegia 4— _Quadrip1egia 5* Hemiplegia 6 Paraplegia _Shortening of Extremity 7 8_ _Amputee 9 _Other (Spec.) (23.24.25) Code AGE AT ONSET YEARS (31.32) (26) LAPSE OF TIME BETWEEN ONSET AND ADMISSION YRS MOS (33.34) MEDICAL OBJECTIVE 1_ Full Activity 2:Slight1y Limited Activity 3:Marked1y Limited Activity 4: Self Care Only 5: NO Improvement 6: Other (Spec.) 1 Bladder 2 Fecal 3 Both 4 Irregular SPEECH IMPAIRMENT 1 Functional 2 Organic HEARING IMPAIRMENT 1 Partial Hearing 2 Deaf 3 Other (Spec.) (27) REMEDIAL TREATMENT (36) x Nursing Y “Medication 0“ _Surgery 1* _Assistive Devices 2: Exercise (28) 3_—Ambu1ation Training 4* _Speech Therapy 5 A. D. L. Training 6 _Soeia1 Service (29) 7 :Psychological Services 8 :Pre-vocational Services 9: Other (Spec.) VISUAL IMPAIRMENT 1_One Partial 2* _Both Partial 3: One Blind 4— _Legally Blind 5_ _Tptally Blind 6 _Other (Spec.) HEALTH PROBLEMS IN FAMILY OF ORIENTATION (30) CHRONIC PERIODIC SELDOM NA ILLNESS ILLNESS ILL Mbther (37)0 Father (38)0 Sister(s) (39)0 Brother(s) (40)O Comments 63 EXHIBIT 4 FILE REVIEW AND HOME VISIT SCHEDULE - SOCIAL Code (1,2,3) AGE EDUCATION (6,7) Elementary O 1 2 3 4 5 6 7 8 High School 9 10 ll 12 College 13 14 15 16 Graduate 17 18 19 20 Trade or Business 21 22 23 MARITAL STATUS 1 Married Single _Separated _Divorced DivorceddRemarried Widow/Widower Widow/Widower-Remarried Non-legal Cohabitation *Other (Spec.) 2 3 4.— 5— 6 7 8 9 NUMBER OF LIVING CHILDREN Biological Children Adopted Children (10)... _, Step-children (11) TYPE OF HOUSING _Hemeless (12) 1_ Private Home 2 Public Housing-Apartment 3 Other Apartment 4 Boarding House 5 Rented Roam 6____Nursing Home 7 Trailer 8 Institution(Spec.) :' Other (Spec. ) (4.5) OWNERSHIP OF HOUSING 1 2 3 4,-— 5 6 7: (8) FAMILY.ANNUAL INCOME ( 1_ 2 3 4 5 6 7 8 9 O x Y $ S 12 0 1: 2* 3— Cards 2 and 3 (13) N/A - Does not live in home, apartment, or trailer Owns place of living _Buying place of living Rents place of living Lives in parents home _Lives in childs home Other (Spec.) (14) In hundreds of dollars) Full-time competitive personal work or business Part-time sheltered or home- bound personal work or business _Spouse' 8 work :Child(ren) work (living with ~c11ent) _Parent(s) work (living with —client) Earnings on savings bonds, investments, etc. Bureau of WOrkman's Compensation V. A.. pension or compensation OASI pension or DIB benefit Other pensions, insurance, etc. Welfare agencies “Other (Spec.) Total (15,16,17) E OF COMMUNITY OF RESIDENCE _Open Country Town of less than 25,000 _City of 25,000 to 249, 999 _City of 250,000 or More EXHIBIT 5 64 FILE REVIEW AND HOME VISIT SCHEDULE - PHYSICAL FUNCTION ACTIVITIES OF DAILY LIVING WRITING (19) 1 Complete 2 Partial 3___;None SPEECH (21) 1 Complete 2 Partial 3 None AMBULATION (23) 1 Complete 2 Partial 3____ane PERSONAL HYGIENE (25) 1 Complete 2 Partial 3 None STAIRS (27) 1 Complete 2 Partial 3 None SUBWAY TRAVEL (29) 1 Complete 2 Partial 3 None EATING (20) 1 Complete 2_ Partial 3: None DRESSING (22) 1 _Complete 2 _Partial 3: None WHEELCHAIR (24) 1 Complete 2 Partial 3____None BED ACTIVITIES (26) 1 Complete 2 Partial 3;___None AUTO TRAVEL (28) 1 Complete 2 Partial 3 None BUS TRAVEL (30) 1 Complete 2 Partial 3____None ACTIVITY, GENERAL 1 Inactive Card 2 and 3 3 2 _Active Inside 4_ PROSTHESES X Adequate Y Does not use 0 B/K 1_ No B/K 2: A/K 3* No.A/K BRACES lh___pE 2h___Two UE 3~___jl. 4 Two LL AMBULATION.AIDS 1 Wheelchair 4 5: 6 7: 8“ 9 (31) Active Outside Both (32) _B/E Two B/E :A/E Two AJE *Eye :Other(8pec. ) (33) SL _Two SL _Back Ill *Other(Spec. ) 4— 2 Hand Controls 5 3____Lift NON-AMBULATION.AIDS 1 Dentures 2 Hearing Aids 3 Glasses 6 (34) Special Shoes Walker Other(Spec.) 4 5 6 (35) Urinals ADL‘Aids Other(Spec.) 65 EXHIBIT 6 HOME VISIT SCHEDULE - VOCATIONAL Code (1,2,3) Card 4 EMPLOYMENT STATUS :l 'UNEMPLOYED :; (4) OCCUPATION ESTIMATED LOSS OF SKILL DUE TO IMPAIRMENT (12) D. o. 1*. CODE (5,6,7) l___Negligib1e 2 _Slight HOW DID SUBJECT OBTAIN THIS 3* Moderate EMPLOYMENT (8) 4: Severe 1 _____Own Efforts 5____ -—Total 2.—_ Public Employment Serv. 3 ivate Employment Serv. RACE, CREED, COLOR AND NATIONAL ORIGIN 4 Advertisement AS A HANDICAP TO EMPLOYMENT (13) 5 6‘— ____Contact by Employer 1_____ No Handicap VR or Other Agency 2_ ___Slight Handicap Friends 3____ Moderate Handicap 8 Relatives 1:— ____Severe Handicap 9 Other (Spec. Ls MOTIVATION FOR SECURING EMPLOYMENT(14) JOB SATISFACTION (9) l ___Higth Motivated 1__Very Dissatisfied 2:Moderate1y Motivated 2_ ____Dissatisfied 3_____ _Motivated but needs 3.— Undetermined encouragement 4 Satisfied 4 Low Motivatipn, Needs 5 ____Very Satisfied Constant Encouragement 5 Completely lacking in REASON FOR JOB SATISFACTION(10,11) Motivation Chgcoe three and rank according FUTURE VOCATIONAL GOALS (15) to order of importance begin- 1__ Definite specific goals ntng with 1 gs most important 2— ____Somewhat formqlated goals reason, 2 second most, etc. 3— ____Only hpzy nation of goals 00...;4‘“ .Ehhrtunity for creativity 4“. ____No goals but amenable to ideas 01‘? sasant working conditions 5“ ____No intention of working §:.__Good pay ___Jcb security DEGREE OF MARKETABIE SKILL (16) “Opport snity for advancement 05 “bordiality of work associates 1 Very highly skilled :Independence in work situation 2 ___Highly skilled 07 ..__Challen.ging work 3 ___Moderate1y skilled 08......Little effort required 11—- _____Slightly skilled 09 ____..0thnr(Spec ) 5 ____Unskilled Ilia“ lino". 66 EXHIBIT 7 INTERVIEWER'S IMPRESSIONS OF HOME VISIT SCHEDULE TO WHAT DEGREE DOES THE SUBJECT BLAME HIS DISABILITY ON THE FOLLOWING? RATE DEGREE ON A FIVE POINT SCALE Card 4 1 g;f a; 4 5 NOT AT ALL SLIGHTLY MDDERATELY STRONGLY ENTIRELY 1 2 3 4 5 Himself (His own care- 1 2 3 4 5 A firm, company, or lessness or oversight)(17) owner (19) 1 2 3 4 5 Heredity (20) 1 2 3 4 5 Another person or persons (not employer)(18) 1 2 3 4 5 Just circumstances,(21) no one's fault DISTRACTIONS DURING INTERVIEW (22) SUBJECT'S TENSION LEVEL DURING INTERVIEW 1 No distractions At At Start During Close 2 Some occasional distractions (26) (27) (28) 3 Much distraction(radio,TV,etc.) Nervous Fidgety 1 1 1 4 Much distraction(other people) Sporadically Nervous 2 2 2 COOPERATIVENESS DURING INTERVIEW Mostly At At Relaxed 3 3 3 Start During Close (23) (24) (25) ATTITUDE TOWARD INTERVIEW (29) Mostly l Friendly Cooperative l l 1 2 Indifferent 3____Hostile Sporadically 4 Suspicious Cooperative 2 2 2 5 Solicitous 6 MBnipulative Mostly 7 Evasive Uncooperative 3 3 3 8 Other(Spec.) 67 EXHIBIT 8 LETTER TO PATIENTS NOT CONTACTED DIRECTLY REHABILITATION INSTITUTE OF CHICAGO 401 East Ohio Street Chicago, Illinois 60611 Mr. Douglas E. Inkster is conducting follow-up interviews with former patients of the Rehabilitation Institute of Chicago. This is part of a research study being carried out under the supervision of Michigan State University. Mr. Inkster has not been able to schedule a visit to your home; however, he has prepared a checklist which, when complete, will provide him with basic essential information. Although you are not required to participate in this study, your responses will be very helpful to other patients in discovering how rehabilitation services might be improved. We have been assured that your responses will not be identified with your name. Mr. Inkster is interested in group statistics. That is why the checklist has a number and not a name to identify it. It is expected that this study to find out what has happened to former patients of the Institute will be of benefit to all of us. We hope you will help him, and indirectly us, look at what is needed in rehabilitation. Sincerely yours, William Kir-Stimon, Ph.D. Director, Personal Services WKS:jeh No. 68 EXHIBIT 9 FOLLOW-UP CHECK LIST Please check the items as they apply to your own situation and return this form to us in the enclosed return envelope. WRITING can write a letter can only sign my name am not able to write at all can eat without any assistance need help only cutting meat, etc. am not able to feed myself DRESSING can dress completely without assistance need help only with Buttons and pull overs am not able to dress myself have no trouble speaking can say some words and sentences am not able to Speak WALKING can walk two blocks or more without help can walk only around the house without help am not able to walk can walk up one flight of stairs or more without help can walk up a few steps with handrails am not able to manage steps PERSONAL HYGIENE I I _____I can wash, toilet and comb my hair without help can wash, toilet and comb my hair with some help am not able to wash, toilet or comb my hair 69 FOLLOW-UP CHECK LIST (Continued) Please check the items as they apply to your own situation. TRAVEL I can board a bus, train and auto without help I can get into an auto without help, but not a bus or train I am not able to use transportation without assistance AIDS USED IN GETTING ABOUT I use no aids or only a cane I use a walker or hang onto furniture I use a wheelchair only I use no braces or slings I use a short leg brace but no sling I use an arm sling but no brace I use a brace and arm sling U1 {3 :1> 0 till U) ACTIVITY I am active both inside and outside my home How many times a week do you go out? Where do you go and what do you do? I am active inside my home What do you do around the house to keep busy? I am not able to be active either in or outside my home 70 FOLLOW-UP CHECK LIST (Continued) Please check the items as they apply to your own situation EMPLOYMENT Yes 'Ng Are you working now? If yes, full-time or part-time ? Give a brief description of your 306 duties Have you worked since you were hospitalized? If yes, full-time or part-time ? Give a brief descripfion of your 306 duties If no to above, have you tried to find work? Yes No Are there Jobs you think you can do with your handicap? If yes, please list Please tell us how you feel about the Rehabilitation Institute of Chicago. Did you get good service? Do you have any suggestions where we could improve our services? DO NOT SIGN THE FORM: Fold the checklist, insert it in the enclosed stamped return enve10pe, seal it and mail it immediately. Checklists received after October 25, 1964, will not be considered in the study, so please give this your immediate attention. 71 EXHIBIT 10 POINT VALUES TALLY SHEET F-Up Amt. Dis. Maintenance of Function Items 11 12 9 10 8 1 Case Tot. Chg. Tot. +10 . + 27 15 21 17 22 16 26 29 33 21 23 30 14 18 24 16 20 27 333333333 333333333 31141311....) b112232.l..2 111112122 111112122 1.1.1.1.1.7.1.1.1. ........ 122223122 347.21.34.22 232233123 212224122 111232122 312222111 ...... .. 121223112 312122111 .... 131133122 311323112 .. . 221323112 211223123 n..- 111333112 112112112 . ... 111222212 213133112 .. ... 121333123 10 12 13 14 17 21 + 3 2 19 1-1 1-1 1-1 1-1 2-3 1-3 1-1 2-3 2-3 1-1 3-2 3-3 23 755632234249344241322215122024241651732036011 1 +....+.+..._++.+..+.+....++.. ++ ++ 3/47489888858633232208941694791690230 311112112211121222121212112212113222 1..«Huron/25049170428154282782243023664229 312122212312121222112212222223112221 333233333333231333133323333333333333 .... . 33323333333323].333133323333333333333 311%123243141221...323121311111311123332 . . . . ............... .... 3121....233b3331111r3331113131311131.“..3111 .I.111:.21122212221111111112122221112221 . ........ 112221112212121121112112222221111.222 311112111111121323111311111111111221 ...... ..... 3221.21112212122223122321222223222222 31:.2123213212132222122323223322222222 ... .. ... 323223213212122233113332323233222332 311.l.23112211121211121312122322113222 ... . . . . -... ..- 212122112111122211112111122113111..122 3111.1311211112122211131.1112212112231 ... .. . - ..... 3221.13112212122233123322222133111222 311112113111121222111311112212223221. . .. . . ... .- 322123112211122221112311222223112221.. 31211112342211A1311311fidll3244413112 ...... . ....... . ..... 2121.21213_I..222.I..1...121I.12111...21Ln0212113111 31..1|.21322221112111211331.229-2331113113 . ... u .. .-.-.. .- 31.2212112111111112111321221123112221 2111.1211.2111111121111111111112113111 ..... . .......... . . 211221212111121111111111211113112111 312113222112211121122213122213132111 . . - .u. . 3131.1221...31121221221212131222131.12211. 5681350237905 :678 151256 2223334444455 5555 5667777 100 101 791/458 93/459 778888 89999 72 EXHIBIT ll Chi-Square Table l. -- Sibling orientation related to main- tenance of function, only child. Classification f F (f-F) (r-F)2 (f—F)2/F Improved 3 3.33 - .33 .109 .03 Static l 3.33 -2.33 5.428 1.63 Regressed 6 3.33 +2.66 7.075 2.12 x2 = 3.78 IS not significant df = l x2 = 3.841 .05 Chi-Square Table 2. -- Sibling orientation related to main- tenance of function, 1 of 2 children. Classification r F (f—F) (f—F)2 (f-F)2/F Improved 4 3 l l 1/3 Static 4 3 l 1 1/3 Regressed l 3 —2 4 4/3 Totals 9 9 0 - 2.0 2 . . . 2 x = 2 IS not Significant df = l x = 3.841 .05 73 Chi-Square Table 3. -- Sibling orientation related to main- tenance of function, 1 of 3 children. Classification f F (f-F) (f-F)2 (f-F)2/F Improved l l 0 0 0 Static l l O O O Regressed l l O 0 0 Totals 3 3 0 - 0 x2 = 0 Is not significant df = 1 x2 — 3.841 .05 Chi-Square Table 4. —- Sibling orientation related to main- tenance of function, 1 of 4 children. Classification r F (f-F) (f-F)2 (f-F)2/F Improved 2 2.33 - .33 .108 .047 Static 1 2.33 -1.33 1.768 .758 Regressed 4 2.33 +1.66 2.755 1.180 Totals 7 7.00 o - 1.985 x2 = 1.985 Is not significant df = 1 x2 = 3.841 .05 74 Chi-Square Table 5. -- Sibling orientation related to main- tenance of function, 1 of 5 or more children. Classification f F (f-F) (f-F)2 (f-F)2/F Improved 7 5.66 1.34 1.59 0.281 Static 5 5.66 -0.66 0.435 0.763 Regressed 5 5.66 -0.66 0.435 0.763 Totals 17 17.00 0 - 1.707 x2 = 1.707 Is not significant df = 1 x2 = 3.841 .05 Chi-Square Table 6. -- Education related to maintenance of function, 0 - 4 of schooling. Classification f F (f-F) (f—F)2 (f-F)2/F Improved 0 .66 -.66 .4356 .66 Static 1 .66 .33 .1089 .16 Regressed l .66 .33 .1089 .16 Totals 2 2.0 0 - .98 x2 = .98 Is not significant df = 1 x2 = 3.841 75 Chi-Square Table 7. -- Education related to maintenance of function, 5 - 8 of schooling. Classification f F (f-F) (f-F)2 (f-F)2/F Improved 6 5.33 + .66 .4356 .081 Static 3 5.33 -2.33 5.428 1.018 Regressed 7 5.33 +1.66 2.756 .517 Totals 16 16 0 - 1.62 x2 = 1.62 IS not significant df = l x2 — 3.841 .05 Chi-Square Table 8. -- Education related to maintenance of function, 9 - 12 of schooling. Classification f F (f-F) (f-F)2 (f-F)2/F Improved 8 6.33 1.67 2.788 .440 Static 7 6.33 0.67 .449 .070 Regressed 4 6.33 -2.33 5.43 .857 Totals 19 19.0 0 - 1.367 2 . 2 x = 1.367 IS not significant df = l x = 3.841 .05 76 Chi-Square Table 9. -- Education related to maintenance of function, 13 — 16 of schooling. Classification f F (f-F) (f-F)2 (f-F)2/F Improved 2 2 0 0 Static 1 2 -1 1/2 Regressed 3 2 1 1/2 Totals 6 6 O l x2 = 1 Is not significant df = 3.841 .05 Chi-Square Table 10. -- Education related to maintenance of function, 17 - 20 of schooling. Classification f F (f-F) (f-F)2 (f-F)2/F Improved l l 0 0 Static O l -l l Regressed 2 1 l 1 Totals 3 3 0 2 x2 = 2 Is not Significant df — 3.841 77 Chi-Square Table 11. —- Time lapse from onset to admission related to maintenance of function, 1 to 3 months. Classification f F (f-F) (f—F)2 (f-F)2/F Improved 10 5 +5 25 5.0 Static 2 5 -3 9 1.8 Regressed 3 5 -2 4 8 Totals 15 15 0 - 7.6 x2 = 7.6 Significant at 1 percent level df = 1 x2 = 3.841 .05 Chi-Square Table 12. -- Time lapse from onset to admission related to maintenance of function, over 6 months. Classification f F (f-F) (f-F)2 (f-F)2/F Improved 4 8 -4 16 2.0 Static 8 8 0 0 0 Regressed 12 8 +4 16 2.0 Totals 24 24 0 - 4.0 x2 = 4.0 Significant at 5 percent level df = l x2 = 3.841 _...,- (h_~‘.. .JGS7’firm37FXZQ'JUI‘ 5%..er EVIL |.ral..._|.u....vf.'|