Showing papers in "Journal of Rehabilitation Medicine in 2005"

ICF linking rules: an update based on lessons learned.

Abstract: Objective Outcome research seeks to understand the end results of health services. Researchers use a wide variety of outcome measures including technical, clinical and patient-oriented measures. The International Classification of Functioning, Disability and Health (ICF) as a common reference framework for functioning may contribute to improved outcome research. The objective of this paper is to provide an updated version of the linking rules published in 2002 and illustrate how these rules are applied to link technical and clinical measures, health-status measures and interventions to the ICF. Results Three specific linking rules have been established to link health-status measures to the ICF and one specific linking rule has been created to link technical and clinical measures and interventions. A total of 8 linking rules have been established for use with all different outcome measures and with interventions. Conclusion The newly updated linking rules will allow researchers systematically to link and compare meaningful concepts contained in them. This should prove extremely useful in selecting the most appropriate outcome measures among a number of candidate measures for the applied interventions. Further possible applications are the operationalization of concrete ICF categories using specific measures or the creation of ICF category-based item bankings.

Reliability of gait performance tests in men and women with hemiparesis after stroke

Abstract: Objective: To assess the reliability of 6 gait performance tests in individuals with chronic mild to moderate post-stroke hemiparesis. Design: An intra-rater (between occasions) test-retest reliability study. Subjects: Fifty men and women (mean age 58 6.4 years) 6–46 months post-stroke. Methods: The Timed “Up & Go” test, the Comfortable and the Fast Gait Speed tests, the Stair Climbing ascend and descend tests and the 6-Minute Walk test were assessed 7 days apart. Reliability was evaluated with the intraclass correlation coefficient (ICC 2,1), the Bland & Altman analysis, the standard error of measurement (SEM and SEM%) and the smallest real difference (SRD and SRD%). Results: Test-retest agreements were high (ICC2,1 0.94–0.99) with no discernible systematic differences between the tests. The standard error of measurement (SEM%), representing the smallest change that indicates a real (clinical) improvement for a group of individuals, was small (9%). The smallest real difference (SRD%), representing the smallest change that indicates a real (clinical) improvement for a single individual, was also small (13–23%). Conclusion: These commonly used gait performance tests are highly reliable and can be recommended to evaluate improvements in various aspects of gait performance in individuals with chronic mild to moderate hemiparesis after stroke.

Heterotopic ossification: a review.

Abstract: Heterotopic ossification is defined as the presence of lamellar bone at locations where bone normally does not exist. The condition must be distinguished from metastatic calcifications, which mainly occur in hypercalcaemia, and dystrophic calcifications in tumours. It is a frequent complication following central nervous system disorders (brain injuries, tumours, encephalitis, spinal cord lesions), multiple injuries, hip surgery and burns. In addition to this acquired form, hereditary causes also exist, such as fibrodysplasia ossificans progressiva, progressive osseous heteroplasia and Albright's hereditary osteodystrophy. Although these conditions are extremely rare, they can provide useful information on the physiopathology of heterotopic ossification, and thus lead to novel and causal treatment modalities. Heterotopic ossification is no trivial complication. A limitation of the range of joint motion may have serious consequences for the daily functioning of people who are already severely incapacitated because of their original lesion. Increased contractures and spasticity, pressure ulcers and increasing pain further compromise the patient's capabilities. Consequently, we feel that attention should be paid to the pathogenesis and particularly the prevention and treatment of this disorder.

Summary of the WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury.

Abstract: This report aims to summarize the key findings of a recent, systematic review of the literature performed by the WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury published in a supplement of the Journal of Rehabilitation Medicine. The Task Force performed a comprehensive search and critical review of the literature published between 1980 and 2002 to assemble the best evidence on the epidemiology, diagnosis, prognosis and treatment of MTBI. The Task Force identified 38,806 citations and 743 relevant studies, of which 313 (42%) were accepted on scientific merit and formed the basis of the best evidence synthesis.

Relation between stimulation characteristics and clinical outcome in studies using electrical stimulation to improve motor control of the upper extremity in stroke

Abstract: Objective: Electrical stimulation can be applied in a variety of ways to the hemiparetic upper extremity following stroke. The aim of this review is to explore the relationship between characteristics of stimulation and the effect of electrical stimulation on the recovery of upper limb motor control following stroke. Methods: A systematic literature search was performed to identify clinical trials evaluating the effect of electrical stimulation on motor control. The reported outcomes were examined to identify a possible relationship between the reported effect and the following characteristics: duration of stimulation, method of stimulation, setting of stimulation parameters, target muscles and stage after stroke. Results: Nineteen clinical trials were included, and the results of 22 patient groups were evaluated. A positive effect of electrical stimulation was reported for 13 patient groups. Positive results were more common when electrical stimulation was triggered by voluntary movement rather than when non-triggered electrical stimulation was used. There was no relation between the effect of electrical stimulation and the other characteristics examined. Conclusion: Triggered electrical stimulation may be more effective than non-triggered electrical stimulation in facilitating upper extremity motor recovery following stroke. It appears that the specific stimulus parameters may not be crucial in determining the effect of electrical stimulation.

Qualitative methodology for rehabilitation research.

Abstract: Qualitative research methodology focuses on individuals' lived experiences as they are presented in thoughts, ideas, feelings, attitudes and perceptions. In addition, the research approach emphasizes human behaviour and social interaction. It explores the quality of a phenomenon, not the quantity. This article outlines the major characteristics of qualitative research methodology and gives applications and examples. The aim of qualitative methodology is to develop new knowledge based on participants' own beliefs and experiences, not on pre-defined, testable hypotheses. It is inductive rather than deductive, and it is interpretative rather than predictive. The design is flexible, iterative and emergent and therefore requires of the researcher an ability to change and adapt the research process in accordance with emerging results. Qualitative research is thus different from quantitative research as it allows for flexibility throughout the research process. Several data collection methods can be used, such as individual interviews, focus group discussions or participant observations, in order to gain a deeper understanding of health, illness and rehabilitation. It can be used in combination with quantitative studies, but also as a research method of its own. In health research, the qualitative methodology has gained increasing credibility during the last decade. However, it is not yet frequently used in rehabilitation research. As rehabilitation outcomes are dependent on people's attitudes, thoughts and motivation regarding the rehabilitation process, and as the rehabilitation process in itself builds on social interaction, studies with a qualitative design could become useful tools in the development and improvement of rehabilitation.

Contemporary measurement techniques for rehabilitation outcomes assessment.

Abstract: In this article, we review the limitations of traditional rehabilitation functional outcome instruments currently in use within the rehabilitation field to assess Activity and Participation domains as defined by the International Classification of Function, Disability, and Health. These include a narrow scope of functional outcomes, data incompatibility across instruments, and the precision vs feasibility dilemma. Following this, we illustrate how contemporary measurement techniques, such as item response theory methods combined with computer adaptive testing methodology, can be applied in rehabilitation to design functional outcome instruments that are comprehensive in scope, accurate, allow for compatibility across instruments, and are sensitive to clinically important change without sacrificing their feasibility. Finally, we present some of the pressing challenges that need to be overcome to provide effective dissemination and training assistance to ensure that current and future generations of rehabilitation professionals are familiar with and skilled in the application of contemporary outcomes measurement.

Standing balance in persistent whiplash: a comparison between subjects with and without dizziness.

Abstract: Objective: Dizziness and unsteadiness, associated with altered balance, are frequent complaints in subjects suffering persistent whiplash associated disorders. Research has been inconclusive with respect to possible aetiology. This study assessed balance responses in subjects with whiplash associated disorders, taking into account several possible causes. Design: A prospective, 3 group, observational design. Subjects: 100 subjects with persistent whiplash associated disorders, 50 complaining of dizziness, 50 not complaining of dizziness and 50 healthy controls. Methods: The Clinical Test for Sensory Interaction in Balance was performed in both comfortable and tandem stance. The sway trace was analysed using wavelet analysis. Conclusion: The results indicated that the energy of the sway signal for comfortable stance tests was significantly greater in the group with dizziness compared with the group without dizziness. In the group without dizziness the energy was greater than controls for all tests, but significantly different on selected tests. In selected tandem stance tests, subjects with dizziness were significantly less able to complete the test than subjects without dizziness and controls. These deficits could not be attributed to medications, compensation, anxiety or age and are likely to be due to disturbances to the postural control system possibly originating from abnormal cervical afferent input.

Controlled study of neuroprosthetic functional electrical stimulation in sub-acute post-stroke rehabilitation.

Abstract: Objective: Assess the effects of daily neuroprosthetic (NESS Handmaster) functional electrical stimulation in sub-acute stroke. Design: Controlled study, patients clinically stratified to 2 groups; no active finger movement (10), and partial active finger movements (12), and then randomized to control and neuroprosthesis groups. Observer blinded evaluations at baseline and completion of the 6-week study. Subjects: 22 patients with moderate to severe upper limb paresis 3‐6 months post-onset. Methods: Patients in day hospital rehabilitation, receiving physical and occupational therapy 3 times weekly. The neuroprosthesis group used the device at home. Results: The neuroprosthesis group had significantly greater improvements in spasticity, active range of motion and scores on the functional hand tests (those with partial active motion). Of the few patients with pain and oedema, there was improvement only among those in the neuroprosthesis group. There were no adverse reactions. Conclusion: Supplementing standard outpatient rehabilitation with daily home neuroprosthetic activation improves upper limb outcomes.

Self-estimated life situation in patients on long-term sick leave.

Abstract: Objective To analyse the influence of long-term sick leave on patients' life situation. Design and subjects Cross-sectional study based on 1350 individuals with a consecutive sick leave period of 12-18 months. Half were still on sick leave, half were no longer sick-listed. Methods A total of 862 participants answered a postal questionnaire including 24 questions on consequences of their sick leave on daily life. Results were analysed by gender, age and type of sick leave diagnosis. Associations between consequences and return to work were analysed by multiple logistic regression. Results and conclusion Negative effects of long-term sick leave were particularly related to leisure activities, sleep and psychological well-being. A reduced alcohol intake was more prevalent than increased consumption. Among individuals with psychiatric diagnoses the consequences were polarized, with few persons unaffected, while the effects were more unipolar and negative in other diagnostic groups. Women experienced positive consequences more often than men, attributed to relationships with children and partner, sleep and psychological well-being. Improved sleep was associated with return to work, particularly among older individuals. Negative consequences on life situation are far more common than positive consequences among patients on long-term sick leave. Benefits as well as adverse effects differ depending on diagnosis, age and gender.

Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables.

Abstract: Objective: To identify a most useful and simple clinical screening tool to predict videofluoroscopic aspiration in patients with stroke. Design: Factor analysis of multiple dysphagia variables and sensitivity and specificity testing with chi-square test. Patients: Sixty-one consecutive stroke patients with symptoms suggestive of dysphagia admitted to a university hospital and its 4 affiliated hospitals in Japan. Methods: Factors were extracted from 6 oromotor examinations (lip closure, tongue movement, palatal elevation, gag reflex, voice quality and motor speech function), 2 swallow screen tests (saliva swallowing test and our modified water swallowingtestusing30 mlofwater)and4parameters evaluated with a videofluoroscopic swallow study. Sensitivity and specificityofeachdysphagia-relatedvariablewasdetermined against aspiration in a videofluoroscopic swallow study. Results: Factor analysis revealed that cough/voice change in the water swallowing test and aspiration on videofluoroscopic swallow study belonged to the same factor. Chi-square analysis showed that cough/voice change in the water swallowing test was the only variable that was significantly associated with aspiration on videofluoroscopic swallow study, with a sensitivity of 72% (95% CI: 61‐83%) and a specificity of 67% (CI: 55‐79%) as a predictor of aspiration (p < 0.05). Conclusion: We recommend our modified 30 ml waterswallowing test as a useful single task-screening tool to detect aspiration.

Disability, pain, psychological factors and physical performance in healthy controls, patients with sub-acute and chronic low back pain: a case-control study.

Abstract: Objective: To compare measures of disability, psychological factors, pain and physical performance in healthy controls, and patients with sub-acute and chronic low back pain. To evaluate the concept of the deconditioning syndrome and to explore factors that may contribute to chronicity. Design: Case-control study. Subjects: Three age- and gender-matched groups were included in the study; healthy controls (n = 45), patients sick-listed 8–12 weeks (n = 46) and patients with chronic low back pain on a waiting list for lumbar instrumented fusion (n = 45). Methods: Measures of disability, pain, psychological factors, and physical performance were obtained from the 3 groups using validated measures. Results: Gender, age, body weight and height were not significantly different between the groups. Comparable scores were found for self-rated working ability, fear-avoidance beliefs for physical activity and aerobic capacity in the 2 patient groups. Oswestry Disability Index, pain, emotional distress, abdominal and back muscle endurance were significantly different between the 3 groups. Self-efficacy for pain and fear-avoidance beliefs for work was significantly different between the 2 patient groups. Conclusion: The results suggest a stepwise deterioration of impairment and disability from healthy controls to patients with chronic low back pain. Most variables distinguished between healthy controls and patients with sub-acute or chronic low back pain. Deconditioning was more related to psychophysical measures of abdominal and back muscle endurance than to cardiovascular fitness. Comparable scores for fear-avoidance and working ability in the 2 patient categories suggest that these factors appear at an early stage and contribute to the transition from acute to chronic low back pain.

One-year follow-up of mild traumatic brain injury: post-concussion symptoms, disabilities and life satisfaction in relation to serum levels of S-100B and neurone-specific enolase in acute phase.

Abstract: OBJECTIVE: To investigate, in patients with mild traumatic brain injury, serum concentrations of S-100B and neurone-specific enolase in acute phase and post-concussion symptoms, disabilities and li ...

Perceptions of participation and predictors of perceived problems with participation in persons with spinal cord injury.

Abstract: OBJECTIVE: To describe how persons with spinal cord injury perceived their participation in life situations and to determine the relationship between their participation and perceived problems th ...

Relations between coping strategies and health-related quality of life in patients with spinal cord lesion.

Abstract: OBJECTIVE: Although the use of appropriate coping strategies has been suggested to be a key factor in determining successful adjustment to severe physical illness/disability, little systematic supp ...

Participation after stroke compared to normal aging.

Abstract: Objective: To examine the reduction in participation of people who have had a stroke compared with healthy people with normal aging. Design: Participation of people who had a stroke was compared with participation of healthy subjects. Subjects/patients: Forty-six people who had a stroke for 2–4 years and 46 healthy participants matched on age, sex and living environment. Measurements: Participation was estimated with the Assessment of Life Habits (LIFE-H). The LIFE-H (short version 2.1) is composed of 58 daily activities and social roles associated to the 12 categories of the Disability Creation Process model. The LIFE-H gives separate scores for each category, for 2 main subsections “Daily activities” and “Social roles” and a total score. Results: Scores of healthy subjects did not reach the maximum value (9/9) of the LIFE-H, their mean scores varying from 6.3 to 8.6, according to the categories. These scores are higher than of the participants with stroke for all categories (scores varying from 3.9 to 6.5; p-values from 0.002 to <0.001), except the interpersonal relationships category (score of 7.8 vs 8.0) where no difference was found ( p = 0.49). The disruption in participation after stroke varies according to the categories of the LIFE-H, but is more important in the daily activities categories. Conclusion: The comparison of the scores obtained by the 2 groups suggests that a part of the reduction in participation in daily activities and social roles after stroke is attributable to normal aging and not entirely to the stroke itself. It helps to focus interventions on activities and roles disruption domains that are really attributable to stroke.

Effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients: a systematic review of randomized controlled trials

Abstract: Objective: Assessment of the available evidence regarding the effect of augmented feedback on motor function of the upper extremity in rehabilitation patients.Methods: A systematic literature search was performed to identify randomized controlled trials that evaluated the effect of augmented feedback on motor function. Two reviewers systematically assessed the methodological quality of the trials. The reported effects were examined to evaluate the effect of therapeutic interventions using augmented feedback and to identify a possible relationship with patient characteristics, type of intervention, or methodological quality.Results: Twenty-six randomized controlled trials were included, 9 of which reported a positive effect on arm function tests. Follow-up measurements were performed in 8 trials, 1 of which reported a positive effect. Different therapeutic interventions using augmented feedback, i.e. electromyographic biofeedback, kinetic feedback, kinematic feedback, or knowledge of results, show no difference in effectiveness.Conclusion: No firm evidence was found of effectiveness regarding the use of augmented feedback to improve motor function of the upper extremity in rehabilitation patients. Future studies should focus more on the content, form and timing of augmented feedback concerning the therapeutic intervention. It should be emphasized that motor learning effects can only be determined by re-examining the population after a follow-up period.

S100 and cognitive impairment after mild traumatic brain injury

Abstract: Objective: The aim of this study was to explore the relationship between the proteins S100B and S100A1B and symptoms and signs of cognitive impairment for 3 months after mild traumatic brain injury (MTBI). Methods: Serum concentrations of S100A1B and S100B were examined in a prospective cohort study of patients with MTBI and a Glasgow Coma Scale score of 14 or 15. Cognitive performance was assessed by repeated computerized neuropsychological testing and an extended neuropsychological test. Symptoms were assessed using the Rivermead Post-Concussion Symptoms Questionnaire. Results: Concentrations of S100B and S100A1B were above cut-off in 31% and 48% respectively. Eight percent of the patients had signs of cognitive impairment according to the computerized neuropsychological tests and 30% according to the extended test. Symptoms of cognitive impairment were reported by 44% of the patients on the first day post-injury and by 26% at 3 months. No significant associations between S100B or S100A1B concentrations and symptoms or signs of cognitive impairment were found. Conclusion: Abnormal S100 serum concentrations and symptoms or signs of cognitive impairment were not significantly associated in patients with MTBI and a Glasgow Coma Scale score of 14 or 15.

Predictors of return to work in patients sick listed for sub-acute low back pain: a 12-month follow-up study.

Abstract: Objective: To investigate whether personal and work-related factors, physical performance and back-specific questionnaires predict return to work. Design: A prospective study identifying prognostic factors for return to work. Subjects: Ninety-three patients sick-listed for 8–12 weeks for non-specific sub-acute low back pain included in a randomized controlled trial. Methods: Patients were examined with regard to demographic variables, a battery of back-specific questionnaires and physical tests before entering a randomized controlled trial. A stepwise backward Cox regression model was established to identify the most powerful predictors. Results: During follow-up 78.5% of the patients have returned to full-time work. Fear-avoidance beliefs for work (relative risk (RR) for 1 SD change 0.49; 95% confidence interval (CI) 0.38–0.64), disability (RR 1.39, 95% CI 1.02– 1.88) and cardiovascular fitness (RR 1.42, 95% CI 1.12–1.79) were identified as the best predictors for return to work. The prevalence of correct predictions was 69.3%. Conclusion: The predictors identified in the present study may reflect personal risk factors in a patient who gets acute low back pain. On the other hand, they may support that fear of pain and injury may be more disabling than pain itself, and that deconditioning is a result of altered behaviour reflecting attitudes towards low back pain in society, and information and advice given in primary healthcare.

Cross-cultural validity of functional independence measure items in stroke: A study using Rasch analysis

Abstract: Objective: To analyse cross-cultural validity of the Functional Independence Measure (FIM) in patients with stroke using the Rasch model. Settings: Thirty-one rehabilitation facilities within 6 different countries in Europe. Participants: A total of 2546 in-patients at admission, median age 63 years. Methods: Data from the FIM were evaluated with the Rasch model, using the Rasch analysis package RUMM2020. A detailed analysis of scoring functions of the 7 categories of the FIM items was undertaken prior to testing fit to the model. Categories were re-scored where necessary. Analysis of Differential Item Functioning was undertaken in pooled data for each of the FIM motor and social-cognitive scales, respectively. Results: Disordered thresholds were found on most items when using 7 categories. Fit to the Rasch model varied between countries. Differential Item Functioning was found by country for most items. Adequate fit to the Rasch model was achieved when items were treated as unique for each country and after a few country-specific items were removed. Conclusion: Clinical collected data from FIM for patients with stroke cannot be pooled in its raw form, or compared across countries. Comparisons can be made after adjusting for country-specific Differential Item Functioning, though the adjustments for Differential Item Functioning and rating scales may not generalize to other samples.

Development of the home and community environment (HACE) instrument.

Abstract: Objective To develop and pilot test the Home and Community Environment instrument (HACE), a self-report measure designed to characterize factors in a person's home and community environment that may influence level of participation. Design A cross-sectional survey. Subjects Sixty-two adults recruited from community organizations and an outpatient rehabilitation center. Methods Six environmental domains were assessed: (i) home mobility; (ii) community mobility; (iii) basic mobility devices; (iv) communication devices; (v) transportation factors; and (vi) attitudes. Descriptive statistics, Kappa statistics and Kruskal-Wallis tests were used to ascertain whether persons were capable of assessing characteristics of their environment, could do so reliably and whether the distribution of environmental factors differed by type of living situation. Results Participants were capable of characterizing their home environment and most aspects of their community with acceptable reliability. The median percent agreement of the 6 environmental domains ranged from 75% to 100% (median Kappa values ranged from 0.47 to 1.0). Percent agreement for individual HACE items ranged from 58% to 100%. The lowest reliability values were observed in the community mobility domain. As hypothesized, individuals who lived in private homes characterized home and community mobility factors differently from those who lived in multi-unit complexes; evidence of HACE's validity. Conclusion HACE is a promising self-report instrument for assessing characteristics of an individual's home and community environments. Additional research is needed to assess its utility for rehabilitation research.

Evaluating the reliability of multi-item scales: a non-parametric approach to the ordered categorical structure of data collected with the Swedish version of the Tampa Scale for Kinesiophobia and the Self-Efficacy Scale.

Abstract: Objective: To compare the ability of a rank-invariant nonparametric method with that of kappa statistics to evaluate the reliability of the Swedish version of the Tampa Scale for Kinesiophobia and the Self-Efficacy Scale by identifying systematic and random disagreement. The aim was, further, to compare 2 different statistical approaches to obtain a global value from multi-item scales. Design: A test-retest study. Subjects: A total of 46 patients with whiplash-associated disorders were enrolled and 39 (85%) completed the testretest assessment. Methods: Data from the multi-item scales were summarized using both sum and median scores. Paired data were evaluated with a rank-invariant statistical method to identify systematic and random disagreement. Data were also evaluated with kappa statistics. Results: The non-parametric approach demonstrated that the Swedish version of the Tampa Scale for Kinesiophobia and the Self-Efficacy Scale are reliable for patients with whiplash-associated disorders. In contrast to the rankinvariant method, kappa statistics provided no information on disagreement between the 2 test occasions. Median scoring improved reliability due to lack of disagreement while the sum scores method was characterized by random individual disagreement. Conclusion: This study has increased understanding of the advantages and limitations of 2 non-parametric statistical methods and, it is hoped, will contribute to the development of reliable measurements.

Clinimetrics in rehabilitation medicine: current issues in developing and applying measurement instruments 1

Abstract: Clinimetrics in rehabilitation medicine, i.e. the field of developing, evaluating and applying measurement instruments, has undergone considerable progress. Despite this progress, however, several issues remain. These include: (i) selection of an instrument out of the wide range available; (ii) using an instrument in a variety of diagnostic groups; (iii) using an instrument in individual patients, as opposed to a group of patients; and (iv) the use of instruments in clinical practice. This paper reviews these issues, as well as current attempts at resolving them. Illustrative examples are given. It is concluded that solutions seem to be available, but considerable research effort is required to make these a reality. Clinimetrics in rehabilitation medicine remains a field with challenging opportunities for research.

Coping strategy use: does it predict adjustment to chronic back pain after controlling for catastrophic thinking and self-efficacy for pain control?

Abstract: Objective: To explore whether coping strategy use predicted levels of adjustment in chronic low back pain after controlling for the influence of catastrophic thinking and selfefficacy for pain control. Methods: Eighty-four patients with chronic low back pain completed the Coping Strategies Questionnaire, a pain VAS and the Roland Disability Questionnaire. To derive composite measures of coping, the Coping Strategies Questionnaire subscales, excluding the Catastrophizing subscale and 2 single-item scales, were entered into a principal components analysis. The extent to which scores on the coping measures predicted levels of adjustment after controlling for catastrophic thinking (Catastrophizing subscale) and self-efficacy for pain control (2 single-item scales) was explored using sequential multiple regression analysis. Results: Two coping dimensions emerged from the principal components analysis, which were labelled Distraction and Praying or Hoping, and Denial of Pain and Persistence. Scores obtained on these coping measures explained an additional 5% and 13% of the variance in pain intensity and disability, respectively. Interestingly, however, the scores on the coping measures did not predict pain intensity or disability after controlling for the influence of catastrophic thinking and self-efficacy for pain control. Conclusion: Coping strategy use might only be related to levels of adjustment via the effect it has on catastrophic thinking and self-efficacy for pain control.

Cost-effectiveness of botulinum toxin type a in the treatment of post-stroke spasticity

Abstract: Objective: Treatment strategies for post-stroke spasticity include oral anti-spastic drugs, surgery, physiotherapy and botulinum toxin type A injection. The objective of this study was to compare the cost-effectiveness and outcomes of oral therapy vs. botulinum toxin type A treatment strategies in patients with flexed wrist/clenched fist spasticity. Methods: Treatment outcome and resource use data were collected from an expert panel experienced in the treatment of post-stroke spasticity. A decision tree model was developed to analyse the data. Results: Thirty-five percent of patients receiving oral therapy showed an improvement in pre-treatment functional targets which would warrant continuation of therapy, compared with 73% and 68% of patients treated with botulinum toxin type A first- and second-line therapy, respectively. Botulinum toxin type A treatment was also more cost-effective than oral therapy with the “cost-persuccessfully-treated month” being £942, £1387 and £1697 for botulinum toxin type A first-line, botulinum toxin type A second-line and oral therapy, respectively. Conclusion: In conclusion, botulinum toxin type A is a costeffective treatment for post-stroke spasticity.

Children's adjustment to a parent's stroke: determinants of health status and psychological problems, and the role of support from the rehabilitation team.

Abstract: Objective: To investigate the support given to young children of patients with stroke by rehabilitation teams and to identify characteristics of the patients, spouses and children that relate to children’s adjustment 2 months after the patient’s discharge. Subjects and methods: Seventy-seven children (18 years of age) of patients with stroke consecutively admitted to inpatient rehabilitation were included. Adjustment was measured with the Child Behaviour Check List, Child Depression Inventory and Functional Status II. Multilevel regression analyses were conducted to identify determinants of adjustment. Results: Half of the children received some form of support from a rehabilitation team. Receiving more support was related to more severe disability of the parent with stroke, but not to the child’s health or behavioural problems at the start of the stroke victim’s inpatient stay. At the start of rehabilitation, 54% of the children had subclinical or clinical problems. Children’s adjustment 2 months after their parent’s discharge was related to the strain on spouses and not to the patients’ characteristics or those of the support. Conclusion: The children’s adjustment was related to the strain perceived by the healthy parent. There is a need for support that focuses on the experience of children of patients with stroke, regardless of stroke severity.

ABility to rise independently from a chair during 6-month follow-up after unilateral and bilateral total knee replacement.

Abstract: Objective: The purpose of this study was to compare extensor mechanism function using a sit-to-stand test in patients undergoing uni- and bilateral total knee replacement, with a 6-month follow-up. Design: Prospective controlled study. Patients: The series included 72 patients with total knee replacement (unilateral 32 patients, bilateral 40 patients). Methods: All patients were evaluated pre-operatively by the physiotherapist and then at 2-weekly intervals during the postoperative 6 months using Hospital for Special Surgery knee score, and range of motion. Extensor mechanism function was evaluated at the same time points using a sit-tostand test. Results: At the end of study, there was no difference between the groups in their knee range of motion and Hospital for Special Surgery scores ( p > 0.05). There was a significant difference between the groups in their chair rising ability ( p < 0.05). At 2 weeks, 22% of patients in the group with unilateral total knee replacement and 20% of patients in the group with bilateral total knee replacement could rise independently. However, there was significant difference in favour of unilateral total knee replacement at 4, 6, 8 and 10 weeks. At 10 weeks, all patients in the group with unilateral total knee replacement and at 6 months all patients in the group with bilateral total knee replacement could rise independently. Conclusion: We conclude that patients with unilateral total knee replacement gain independence earlier than patients with bilateral total knee replacement. However, for patients with bilateral total knee replacement eventually to gain independence, they should be prepared for a longer rehabilitation programme.

Ice and pulsed electromagnetic field to reduce pain and swelling after distal radius fractures.

Abstract: Objective: To examine the relative effectiveness of ice therapy and/or pulsed electromagnetic field in reducing pain and swelling after the immobilization period following a distal radius fracture. Methods: A total of 83 subjects were randomly allocated to receive 30 minutes of either ice plus pulsed electromagnetic field (group A); ice plus sham pulsed electromagnetic field (group B); pulsed electromagnetic field alone (group C), or sham pulsed electromagnetic field treatment for 5 consecutive days (group D). All subjects received a standard home exercise programme. A visual analogue scale was used for recording pain; volumetric displacement for measuring the swelling of the forearm; and a hand-held goniometer for measuring the range of wrist motions before treatment on days 1, 3 and 5. Results: At day 5, a significantly greater cumulative reduction in the visual analogue scores as well as ulnar deviation range of motion was found in group A than the other 3 groups. For volumetric measurement and pronation, participants in group A performed better than subjects in group D but not those in group B. Conclusion: The addition of pulsed electromagnetic field to ice therapy produces better overall treatment outcomes than ice alone, or pulsed electromagnetic field alone in pain reduction and range of joint motion in ulnar deviation and flexion for a distal radius fracture after an immobilization period of 6 weeks.

Differential item functioning of the Functional Independence Measure in higher performing neurological patients.

Abstract: Objective: When comparing outcomes of the Functional Independence Measure (FIM™) between patient groups, item characteristics of the FIM™ should be consistent across groups. The purpose of this study was to compare item difficulty of the FIM™ in 3 patient groups with neurological disorders. Subjects: Patients with stroke (n = 295), multiple sclerosis (n = 150), and traumatic brain injury (n = 88). Methods: FIM™ scores were administered in each group. The FIM™ consists of a motor domain (13 items) and a cognitive domain (5 items). Rasch rating scale analysis was performed to investigate differences in item difficulty (differential item functioning) between groups. Results: Answering categories of the FIM™ items were reduced to 3 (from the original 7) because of disordered thresholds and low answering frequencies. Two items of the motor domain ("bladder" and "bowel") did not fit the Rasch model. For 7 out of the 11 fitting motor items, item difficulties were different between groups (i.e. showed differential item functioning). All cognitive items fitted the Rasch model, and 4 out of 5 cognitive items showed differential item functioning. Conclusion: Differential item functioning is present in several items of both the motor and cognitive domain of the FIM™. Adjustments for differential item functioning may be required when FIM™ data will be compared between groups or will be used in a pooled data analysis.

Effectiveness of intensive training for children with cerebral palsy--a comparison between child and youth rehabilitation and conductive education.

Abstract: Objectives: To compare the short-term effectiveness of 1 intensive training period in child and youth rehabilitation with Move&Walk conductive education and describe the effects of 1 intensive ...