Catherine L. Backman

Case studies, single-subject research, and N of 1 randomized trials : Comparisons and contrasts

Case studies, single-subject research designs, and N of 1 randomized clinical trials are methods of scientific inquiry applied to an individual or small group of individuals. A case study is a form of descriptive research that seeks to identify explanatory patterns for phenomena and generates hypotheses for future research. Single-subject research designs provide a quasi-experimental approach to investigating causal relationships between independent and dependent variables. They are characterized by repeated measures of an observable and clinically relevant target behavior throughout at least one pretreatment (baseline) and intervention phase. The N of 1 clinical trial is similar to the single-subject research design through its use of repeated measures over time but also borrows principles from the conduct of large, randomized controlled trials. Typically, the N of 1 trial compares a therapeutic procedure with placebo or compares two treatments by administering the two conditions in a predetermined random order. Neither the subject nor the clinician is aware of the treatment condition in any given period of time. All three approaches are relatively easy to integrate into clinical practice and are useful for documenting individualized outcomes and providing evidence in support of rehabilitation interventions.

Occupational balance: Exploring the relationships among daily occupations and their influence on well-being

In this lecture, I have reviewed theoretical discussions and definitions of occupational balance, findings from selected studies, and highlighted some methods for measuring aspects of occupational balance. Are any of these ideas directly applicable to occupational therapy practice, education and research? Consider the hassles of everyday life, and add the complicating factors of illness, injury, disability, and limited income. Life, and the pursuit of necessary, desirable and obligatory occupations, can become overwhelming. Given that occupational therapists aim to enable individuals, regardless of ability, to successfully engage in a range of occupations, the answer to the question is yes. Furthering our understanding of occupational balance can improve our ability to serve individual clients and society. In 2001, Fearing stated in her Muriel Driver Memorial Lecture: We will not only recognize and value the skill of maintaining balance, our own and that of our clients, but we will live it. Balance will not be viewed as a set of scales that has equal parts such as work on one side and play on the other but rather the kind of balance that comes from being centred so that we act from a stable base. From that stable base, we will gain a keen sensitivity to rhythm--knowing when to move and when to let go. (Fearing, 2001 pp. 214-215) Perhaps these reflections have added a little coherence to the study of occupational balance. Occupational balance is a relative state, recognizable by a happy or pleasant integration of life activities and demands. There are indicators of imbalance, more so than tangible ways to measure it, and once recognized occupational therapists have the strategies to help restore a sense of occupational balance. Given our collective history and skill in client-centred practice, occupational therapists are capable of both advancing this line of inquiry and attaining occupational balance for ourselves and our clients.

Employment and work disability in rheumatoid arthritis.

Purpose of reviewThe cost of work disability due to rheumatoid arthritis is substantial to both individuals and society. Approximately one third of people with rheumatoid arthritis will leave employment prematurely. Several studies over the past two decades have identified risk factors for work disability, and recent literature suggests increasing interest in ways to assess work limitations and offer interventions to prevent work loss. Recent findingsWork disability results from a complex interaction of characteristics of individuals, the nature of their work, and their environment, including the physical workplace, policies related to work accommodation, and interpersonal relationships. Practitioners need tools to help identify patients experiencing limitations in the workplace and at risk for permanent work disability. Two new tools show promise in this area. Although there is general agreement that vocational assessment and intervention should occur early in the course of rheumatoid arthritis, evidence for vocational rehabilitation is sadly lacking. A recent systematic review identified only six studies, all uncontrolled, but suggestive of beneficial effects. SummaryAssessment of possible work limitations and potential for vocational rehabilitation should be considered in the evaluation of employed patients and those wishing to work. Further development and evaluation of work retention and return-to-work programs for people with rheumatoid arthritis is required.

Assessment of Hand Function: The Relationship between Pegboard Dexterity and Applied Dexterity

The relationship between pegboard dexterity and applied dexterity was investigated by examining performance on the Nine-Hole Pegboard Test and on functional tasks from the Applied Dexterity section of the Arthritis Hand Function Test. Subjects were 395 adult volunteers aged 20–79 years, stratified by age and gender. Significant correlation coefficients were obtained for pegboard dexterity and applied dexterity at p < .01 for the sample as a whole. However, when the sample was examined by age groups, no significant relationships were found for the 20–29 years group. Pegboard tests are quick and inexpensive assessment tools, but if they have no relationship to the functional use of the hands they may be of questionable value. The results of this study suggest that the Nine-Hole Pegboard Test may be a useful screening device for detecting hand dysfunction related to dexterity.

Arthritis Hand Function Test: Development of a Standardized Assessment Tool

The Arthritis Hand Function Test (AHFT) is being developed for use with adults who have rheumatoid arthritis. It consists of 11 items designed to measure pure and applied strength and dexterity. The AHFT was administered twice to a sample of 20 subjects with a diagnosis of rheumatoid arthritis, to examine inter-rater and test-retest reliability. Subjects were also tested with the Jebsen Hand Function Test (JHFT) and completed the Arthritis Impact Measurement Scales (AIMS) questionnaire so occupational therapists could examine concurrent validity with these two established instruments. Data analysis resulted in correlation coefficients of .89 to 1.00 for inter-rater and .53 to .95 for test-retest reliability of the AHFT. The AHFT correlated well (r=.63) with the JHFT for the right hand, but poorly (r=.08) for the left hand. The AHFT correlated well (r=.71) with the dexterity scale on the AIMS, but showed little relationship with other AIMS scales. These preliminary data suggest that the AHFT is a promising instrument for evaluating hand function in people who have arthritis.

Association Between Mobility, Participation, and Wheelchair-Related Factors in Long-Term Care Residents Who Use Wheelchairs as Their Primary Means of Mobility

To explore how wheelchair‐related factors, mobility, and participation are associated in a sample of long‐term care residents who use wheelchairs as their primary means of mobility.

Expert Consensus on Best Practices for Post–Acute Rehabilitation After Total Hip and Knee Arthroplasty: A Canada and United States Delphi Study

To synthesize professional and patient expertise with available evidence to recommend best practices for post–acute rehabilitation following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA).

The Single-Case Reporting Guideline In BEhavioural Interventions (SCRIBE) 2016 Statement

Reporting guidelines, such as the Consolidated Standards of Reporting Trials (CONSORT) Statement, improve the reporting of research in the medical literature (Turner et al., 2012). Many such guidelines exist, and the CONSORT Extension to Nonpharmacological Trials (Boutron et al., 2008) provides suitable guidance for reporting between-groups intervention studies in the behavioral sciences. The CONSORT Extension for N-of-1 Trials (CENT 2015) was developed for multiple crossover trials with single individuals in the medical sciences (Shamseer et al., 2015; Vohra et al., 2015), but there is no reporting guideline in the CONSORT tradition for single-case research used in the behavioral sciences. We developed the Single-Case Reporting guideline In Behavioral interventions (SCRIBE) 2016 to meet this need. This Statement article describes the methodology of the development of the SCRIBE 2016, along with the outcome of 2 Delphi surveys and a consensus meeting of experts. We present the resulting 26-item SCRIBE 2016 checklist. The article complements the more detailed SCRIBE 2016 Explanation and Elaboration article (Tate et al., 2016) that provides a rationale for each of the items and examples of adequate reporting from the literature. Both these resources will assist authors to prepare reports of single-case research with clarity, completeness, accuracy, and transparency. They will also provide journal reviewers and editors with a practical checklist against which such reports may be critically evaluated.

Exploring Occupational Balance in Adults with Rheumatoid Arthritis

Chronic illness disrupts participation in daily living. The objective of this study was to identify factors associated with three indicators of occupational balance: perceived satisfaction with performance of ones primary occupation, the balance of time spent on occupations, and daily achievements. One hundred sixty-nine adults (78% women) with rheumatoid arthritis completed the Occupational Questionnaire and a survey of health and functional status. Using multiple linear regression, general health status was a significant predictor of all three indicators of occupational balance. Self-efficacy with respect to arthritis symptoms, work limitations, and self-care ability were additional predictors of satisfaction with achievements; social function, pain, and work ability were additional predictors of satisfaction with performance; and the proportion of time spent in occupations deemed as enjoyable was an additional predictor of satisfaction with balance of time spent across occupations. Study results provide support for emerging models of occupational balance as a multidimensional concept.

Tension at the borders: perceptions of role overload, conflict, strain and facilitation in work, family and health roles among employed individuals with arthritis

Objective. To examine inter-relationships among arthritis (A), work (W) and personal life (P) roles and their reciprocal influences, especially experiences of role balance/imbalance among individuals with inflammatory arthritis (IA) and OA. Methods. Eight focus groups were conducted with 24 women and 16 men (aged 29–72 years). A purposive sample was recruited from community advertising. Eligibility included current employment or having been employed within the previous year. Participants were asked about ways arthritis, work and personal life roles intersected and their impact. A standardized questionnaire collected demographic, symptom and employment data for descriptive purposes. Results. Participants noted that having arthritis affected their identity and intersected with work and personal roles, creating role overload, role conflict, role strain and role facilitation. Role overload highlighted that arthritis both affected and was impacted by work and personal life (A → W; A → P; W → A; P → A). Role conflict focused on A → W and A → P difficulties, whereas role facilitation emphasized the positive impact of work and personal life roles on arthritis (W → A; P → A). Role strain was pervasive and arose from numerous sources. Personal strategies (e.g. positive framing) and contextual factors (e.g. support) were important in contributing to or ameliorating role balance/imbalance. Conclusions. By comprehensively examining multiple types of role balance/imbalance and the context within which it occurs, this study identifies gaps in patient-oriented measurement of the impact of arthritis and areas of need in the development of arthritis intervention.