Anita Beelen

Validity of the Canadian Occupational Performance Measure: a client-centred outcome measurement

Objective: To study the convergent and divergent validity of the Canadian Occupational Performance Measure (COPM). Design: Cross-sectional study. Setting: The occupational therapy departments of two university hospitals in Amsterdam. Subjects: One hundred and five consecutive outpatients. Outcome measures: The COPM is a measure of a clients self-perception of occupational performance in the areas of self-care, productivity and leisure. Outcome measures of the COPM are: the clients most important problems in occupational performance and a total score for performance and a total score for satisfaction for these problems. Problems reported in the COPM were compared with the Sickness Impact Profile (SIP68), the Disability and Impact Profile (DIP) and an open-ended question. Results: Complete data were obtained for 99 clients. The identification of occupational performance problems with the COPM surpassed the items reported in the SIP68, the DIP and the open-ended question, which confirms the surplus value of the COPM. Divergent validity was further demonstrated by the low correlation coefficients between the total SIP68 scores and the COPM. Seventy-four per cent of the occupational performance problems reported in the COPM had a corresponding item in the DIP and 49% had a corresponding item in the SIP68. Convergent validity was supported by the fact that 63% of the corresponding problems in the DIP were reported to be a disruption of quality of life and 74% of the corresponding problems in the SIP68 were identified as a disability. Conclusion: The results of this study provide supportive evidence for the convergent and divergent validity of the COPM. The data support the assumption that the COPM provides information that cannot be obtained with current standardized instruments to measure health.

Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments.

This study reviews the instruments used for the clinical assessment of spasticity in children with cerebral palsy, and evaluates their compliance with the concept of spasticity, defined as a velocity‐dependent increase in muscle tone to passive stretch. Searches were performed in Medline, Embase, and Cinahl, including the keywords ‘spasticity’, ‘child’, and‘cerebral palsy’, to identify articles in which a clinical method to measure spasticity was reported. Thirteen clinical spasticity assessment instruments were identified and evaluated using predetermined criteria. This review consists of reports on the standardization applied for assessment at different velocities, testing posture, and quantification of spasticity. Results show that most instruments do not comply with the concept of spasticity; standardization of assessment method is often lacking, and scoring systems of most instruments are ambiguous. Only the Tardieu Scale complies with the concept of spasticity, but this instrument has a comprehensive and time–consuming clinical scoring system.

Disability and functional assessment in former polio patients with and without postpolio syndrome

OBJECTIVES To compare perceived health problems and disability in former polio subjects with postpolio syndrome (PPS) and those without postpolio syndrome (non-PPS), and to evaluate perceived health problems, disability, physical performance, and muscle strength. DESIGN Cross-sectional survey; partially blinded data collection. SUBJECTS One hundred three former polio subjects, aged 32 to 60yrs. This volunteer sample came from referrals and patient contacts. Criterion for PPS: new muscle weakness among symptoms. MAIN OUTCOME MEASURES Nottingham Health Profile (NHP), adapted D-code of the International Classification of Impairments, Disabilities and Handicaps, performance test, and muscle strength assessment. RESULTS PPS subjects (n = 76) showed higher scores (p < .001) than non-PPS subjects (n = 27) within the NHP categories of physical mobility, energy, and pain. On a 16-item Polio Problems List, 78% of PPS subjects selected fatigue as their major problem, followed by walking outdoors (46%) and climbing stairs (41%). The disabilities of PPS subjects were mainly seen in physical and social functioning. No differences in manually tested strength were found between patient groups. PPS subjects needed significantly more time for the performance test than non-PPS subjects and their perceived exertion was higher. Perceived health problems (NHP-PhysMobility) correlated significantly with physical disability (r = .66), performance-time (r = .54), and muscle strength (r = .38). With linear regression analysis, 54% of the NHP-PhysMobility score could be explained by the performance test (time and exertion), presence of PPS, and muscle strength, whereas strength itself explained only 14% of the NHP-PhysMobility score. CONCLUSIONS PPS subjects are more prone to fatigue and have more physical mobility problems than non-PPS subjects. In former polio patients, measurements of perceived health problems and performance tests are the most appropriate instruments for functional evaluation.

Neurobehavioral and developmental profile of very low birthweight preterm infants in early infancy

Aim: To describe the neurobehavioral and developmental profile of very low birthweight (VLBW) preterm infants in early infancy. Methods: Twenty VLBW infants and 10 term control infants were assessed at term, 3 and 6 mo of age. Neurobehavioral assessments included the Neonatal Behavioral Assessment Scale (NBAS) at term; the Infant Behavioral Assessment at term, 3 and 6 mo of age and the Behavioral Rating Scale of the Bayley Scales of Infant Development—II (BSID‐II) at 3 and 6 mo of age. Development was evaluated with the Bayley Motor and Mental Scale at 3 and 6 mo. Results: At term age VLBW infants differed from term infants on all the clusters and supplementary items of the NBAS. VLBW infants also showed more stress and less approach behavior at term and 6 mo of age and more problems with self‐regulation in all subsystems at 6 mo of age. Moreover, VLBW infants performed lower on the Bayley Motor, Mental and Behavioral Rating Scale: 12 VLBW infants scored questionable or non‐optimal on the Psychomotor Development Index and 18 questionable or non‐optimal on the Behavioral Rating Scale. These results support the need for neurobehavioral intervention of VLBW infants in the first 6 mo of life.

Shoulder contracture and osseous deformity in obstetrical brachial plexus injuries

Background: The purposes of this study were to determine the prevalence of and the association between shoulder contracture and osseous deformity in a cohort of children with an obstetrical brachial plexus injury and to identify the risk factors for these complications.Methods: In a retrospective cohort study, all children with an obstetrical brachial plexus injury who had been born between January 1991 and January 1998 at one academic medical center and all those with the same diagnosis who had been born elsewhere during the same period and were referred to the medical center within six weeks after delivery were evaluated at fixed time-intervals by one examiner. The patients underwent a final orthopaedic, neurological, and radiographic examination at a mean age of 3.7 years (range, one to seven years). Shoulder contracture was defined as a decrease in the passive range of motion in one or more directions compared with the range on the unaffected side. Osseous deformity was defined as a nonspherical humeral head or an abnormal glenoid.Results: The prevalence of a shoulder contracture of >10° was 56% (twenty-nine of fifty-two patients), and the prevalence of an osseous deformity was 33% (sixteen of forty-eight patients with complete radiographic follow-up). In the children in whom complete neurological recovery was delayed (i.e., recovery was more than three weeks after birth), the prevalence of shoulder contracture was 54% (thirteen of twenty-four patients) and the prevalence of osseous deformity was 26% (six of twenty-three patients). A strong association was noted between shoulder contracture and osseous deformity (p = 0.004). Directly after birth, the presence of a clavicular fracture was the only factor that was associated (p = 0.016) with the development of an osseous deformity (but not with a shoulder contracture). At a later stage, speed and extent of neurological recovery were related to shoulder contracture and osseous deformity. An asymmetric appearance was noticed in children who had a contracture, including those who had complete neurological recovery.Conclusions: The prevalence of shoulder contracture and osseous deformity in children with obstetrical brachial plexus injury was high, even in those with complete neurological recovery. These complications were strongly associated with one another. No symptom that appeared immediately after birth was identified as a factor that would predict the development of future shoulder contracture. A clavicular fracture was found to be significantly associated with the development of an osseous deformity at a later stage.Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Poor functional status immediately after discharge from an intensive care unit

Purpose. To evaluate the functional status of patients within the first week of discharge from an intensive care unit (ICU), and to identify predictors and explanatory factors of functional status. Methods. A prospective, observational, cohort study was conducted with consecutive ICU patients who had stayed in a mixed, closed-format, university-level ICU for longer than 48 h. Results. Between 3 and 7 days of discharge from the ICU, functional status (as primary outcome), walking ability, muscle strength, and sensory and cognitive functioning were assessed in 69 survivors. The overall functional status was poor (median Barthel Index 6). In their ability to perform basic activities of daily living, 67% percent were severely dependent, 15% were moderately dependent, and 9% were slightly dependent on other people. Independent walking was impossible for 73% of participants, grip strength was reduced for 50%, and 30% had cognitive impairments. Duration of ventilation was associated with functional status after ICU discharge. Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU. Conclusion. In the first week after discharge from the ICU, the majority of the patients had substantial functional disabilities in activities of daily living. These disabilities were more severe in patients who experienced ventilation for a longer period of time. There is a need for prospective studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge.

FUNCTIONAL STATUS AFTER INTENSIVE CARE: A CHALLENGE FOR REHABILITATION PROFESSIONALS TO IMPROVE OUTCOME

OBJECTIVE To examine restrictions in daily functioning from a rehabilitation perspective in patients one year after discharge from the intensive care unit, and to identify prognostic factors for functional status. DESIGN Cross-sectional design. PATIENTS Consecutive patients who were admitted to the intensive care unit for more than 48 h (n = 255). METHODS One year after intensive care, functional status (Sickness Impact Profile) as primary outcome, and Quality of Life (SF-36), anxiety and depression (Hospital Anxiety Depression Scale), and post-traumatic stress disorder (Impact of Events Scale) were evaluated. RESULTS Fifty-four percent of the patients had restrictions in daily functioning. Walking and social activities were most frequently restricted (30-60% of the patients). Quality of life was lower than the general Dutch population. Symptoms of anxiety and depression were found in 14%, and post-traumatic stress disorder in 18%. Severity of illness at admission and length of stay in the intensive care unit were identified as prognostic factors, although they explained only 10% of functional status. CONCLUSION The high prevalence of long-lasting restrictions in physical, social and psychological functioning among patients who stayed in the intensive care unit for at least 2 days implies that these patients are a potential target population for rehabilitation medicine. Multidisciplinary therapies need to be developed and evaluated in order to improve outcome.

POOR FUNCTIONAL RECOVERY AFTER A CRITICAL ILLNESS: A LONGITUDINAL STUDY

OBJECTIVE To determine the time course of functional health status, and to inventory impairments in body functions, limitations in activities, and restrictions in participation after critical illness. DESIGN Prospective observational cohort study. SETTING Mixed medical and surgical closed format; intensive care unit of an academic medical hospital. PATIENTS Consecutive patients over a period of 3 months who were ventilated in the intensive care unit for more than 48 h (n = 116). METHODS Functional health status was assessed 3, 6 and 12 months after discharge from the intensive care unit using the Sickness Impact Profile 68. Impairments in function, limitations in activities, and restrictions in participation, classified according to the International Classification of Functioning, Disability, and Health (ICF), were evaluated after 3 and 12 months. RESULTS Due to a high mortality rate (48%) and poor health conditions, data could not be obtained from all participants at all measurement points. Physical functioning and social behaviour improved predominantly within the first 6 months, while impaired psychological functioning remained unchanged within one year after discharge from the intensive care unit. After one year, 69% of patients were still restricted in performing daily activities and only 50% had resumed work. CONCLUSION The extent and severity of lasting intensive care unit-related disability necessitates the development of multidisciplinary after-care to improve health status, functional independence and return to work.

Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial.

Objective To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy. Design Randomised controlled trial. Setting Neurology outpatient clinics in three Dutch hospitals. Participants 205 patients with symptoms and signs of cervical radiculopathy of less than one month’s duration Interventions Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group). Main outcome measures Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks. Results In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale (β=−3.1 mm, 95% confidence interval −4.0 to −2.2 mm) and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction (collar: β=−1.9 mm, −3.3 to −0.5 mm; physiotherapy: β=−1.9, −3.3 to −0.8), resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks (β=−0.9 mm, −2.0 to 0.3). Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm (−4.2 to −1.3), amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm (−3.9 to −0.8) resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest (β=−0.9 mm, −1.6 to −0.1) and a non-significant effect with physiotherapy and home exercises. Conclusion A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy. Trial registration Clinical trials NCT00129714.

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset. Methods: Design: A prospective observational cohort study and a cross-sectional study. Setting: University hospital in the Netherlands. Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study. Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life. Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients. Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.