Harmen van der Linde

Clinimetric Properties of Instruments to Assess Activities in Patients With Hand Injury: A Systematic Review of the Literature

OBJECTIVE To perform a systematic review of the literature to assess the clinimetric properties of instruments measuring limitations of activity. DATA SOURCES The Medline, Cochrane Library, Picarta, Occupational Therapy-seeker, and CINAHL databases were searched for English or Dutch language articles published between 2001 and 2006. STUDY SELECTION Two reviewers independently reviewed the identified publications for eligibility (based on the title and abstract), methodologic criteria, and clinimetric properties. To evaluate the available information of the clinimetric properties, the quality criteria for instrument properties were used. DATA EXTRACTION All the clinimetric properties of the 23 instruments were described based on the publications that were included. DATA SYNTHESIS In total, 103 publications were retrieved, 79 of which were eligible for inclusion. Of these, 54 met the methodologic quality criteria. Twenty-three instruments were reviewed, divided into (1) pegboard tests measuring fine hand use only; (2) instruments measuring fine hand use only, by picking up, manipulating, and placing different objects; (3) instruments measuring single tasks (and fine hand use) by scoring task performance; and (4) questionnaires. The reliability, validity, and responsiveness of only 5 instruments were adequately described in the literature; the description of the clinimetric properties of the other instruments was inadequate. CONCLUSIONS None of the instruments had a positive rating for all the clinimetric properties.

Evidence for bilaterally delayed and decreased obstacle avoidance responses while walking with a lower limb prosthesis

OBJECTIVE To examine whether the increased failure rates in obstacle avoidance of patients with lower limb amputation can be understood on the basis of increased delay and/or decreased amplitudes of obstacle avoidance responses. METHODS Subjects performed obstacle avoidance on a treadmill while EMG recordings were made of several major muscles of the leg. RESULTS It was found that subjects with a lower limb amputation have delayed responses (e.g. delays of 20 ms for the Biceps Femoris) and have decreased response amplitudes (36-41% smaller). Furthermore, such changes were observed not only on the prosthetic side, but also on the sound side. The decreased amplitudes were associated with increased failure rates in the obstacle avoidance task. CONCLUSIONS It is concluded that the bilaterally delayed and reduced responses in persons with a lower limb prosthesis reflect a basic reorganization within the central nervous system aimed at providing synchronized activity in both lower limbs, even though the peripheral deficit involves only one limb. SIGNIFICANCE The present results on obstacle avoidance responses can be used to evaluate future prosthetic training involving obstacle crossings for amputee rehabilitation.

From satisfaction to expectation: the patient's perspective in lower limb prosthetic care.

Purpose. To obtain information about the wishes and experiences of patients with a lower limb amputation with regard to prosthetic prescription and their exchange of information with the healthcare providers. Method. Design: Cross-sectional questionnaire. Setting: Outpatient clinic of a Rehabilitation Centre. Study participants: A random sample of patients with a lower limb amputation (n = 81). Main outcome measures: In analogy with the QUOTE questionnaire a focus group technique was used. Prosthetic users formulated 24 specific items, which were of importance according to them. The items were divided into 4 categories: (i) service demand, (ii) prosthetic prescription, (iii) information, (iv) insurance aspects. The questionnaire consisted of two sets (A and B) of 24 items rating importance of items and experience in everyday practice. To identify different dimensions within the 24 items, a factor analysis in SPSS was performed for lists A and B followed by a varimax rotation. Impact factors were calculated by multiplying the mean score of importance on an item with the percentage of patients that experienced this item as negative. Results. A total of 113 questionnaires were sent by e-mail with a response of 73%. The outcomes of the questionnaires resulted in 2 sets of information: One concerning the importance of several items in the process of prosthetic prescription, the other the experience of the prosthetic user about those items. By multiplying the scores on importance by the percentage of negative experience per item (impact score) points of improvement for clinical practice were formulated. Conclusions. A discrepancy between the needs of patients and what they experience in their contacts with clinical professionals as the most important dimension was noticed. A questionnaire with specific items for a homogeneous target group is a good method to formulate points of improvement for clinical practice in healthcare.

Predicting prosthetic use in elderly patients after major lower limb amputation

Background: The main determinants of prosthetic use known from literature apply to the younger patient with lower limb amputation. Studies aimed at identifying determinants of outcome of lower limb amputation in elderly patients with multimorbidity that rehabilitate in skilled nursing facilities (SNFs) are scarce. Objectives: To predict prosthetic use and physical mobility in geriatric patients admitted to SNFs for rehabilitation after lower limb amputation and the impact of multimorbidity. Study Design: Prospective design. Methods: Univariate and multivariate logistic and linear regression analyses were used to identify determinants that were independently related to prosthetic use and the timed-up-and-go test (TUG test). Results: Of 55 eligible patients, 38 had complete assessments on admission and at discharge. Fifty per cent was provided with a prosthesis. Multimorbidity was present in 53% of the patients. Being able to ambulate independently, and having a transtibial amputation (rather than a higher level of amputation), without phantom pain determined prosthetic use (R2=56%), while cognitive abilities, low amputation level, and pre-operative functional abilities were independently associated with the TUG test (R2=82%). Conclusions: Elderly patients referred to an SNF for prosthetic training have a high probability of using a prosthesis when having an independent ambulation after transtibial amputation, without phantom pain. These patients should be considered for prosthetic training. Clinical relevance This study gives more insight into the outcomes of geriatric patients with lower limb amputation after rehabilitation in skilled nursing facilities. This is the first study that focuses on determinants of prosthetic use in these elderly patients, often with multimorbidity.

Residual Complaints After Neuralgic Amyotrophy

OBJECTIVE To develop recommendations regarding outcome measures and topics to be addressed in rehabilitation for persons with neuralgic amyotrophy (NA), this study explored which functions and activities are related to persisting pain in NA and which questionnaires best capture these factors. DESIGN A questionnaire-based survey from 2 cross-sectional cohorts, one of patients visiting the neurology outpatient clinic and a cohort seen at a multidisciplinary plexus clinic. SETTING Two tertiary referral clinics based in the Department of Neurology and Rehabilitation from a university medical center provided the data. PARTICIPANTS A referred sample of patients (N=248) with either idiopathic or hereditary NA who fulfilled the criteria for this disorder, in whom the last episode of NA had been at least 6 months ago and included brachial plexus involvement. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Two custom clinical screening questionnaires were used as well as the Shoulder Rating Questionnaire-Dutch Language Version, the Shoulder Pain and Disability Index (SPADI), the Shoulder Disability Questionnaire (SDQ), and Overall Disability Sum Score. RESULTS The survey confirms the high prevalence of persisting pain and impairments. More than half of the patients were restricted by pain, while in those without pain 60% experienced residual paresis. Correlations show an intimate relation between pain, scapular instability, problems with overhead activities, and increased fatigability. A standard physical therapy approach was ineffective or aggravated symptoms in more than 50%. CONCLUSIONS Pain and fatigue are strongly correlated to persisting scapular instability and increased fatigability of the affected muscles in NA. Our results suggest that an integrated rehabilitation approach is needed in which all of these factors are addressed. We further recommend using the SPADI and SDQ in future studies to evaluate the natural course and treatment effects in NA.

Geriatric rehabilitation of lower limb amputees: a multicenter study.

Purpose: The aim of this study was to determine factors independently associated with successful rehabilitation of patients with lower limb amputation in skilled nursing facilities (SNFs). Methods: All patients admitted to one of the 11 participating SNFs were eligible. Multidisciplinary teams collected the data. Successful rehabilitation was defined as discharge to an independent living situation within 1 year after admission. Functional status at discharge, as measured with the Barthel index (BI), was a secondary outcome. Multivariate regression analyses were used to assess the independent contribution of each determinant to the two outcome measures. Results: Of 55 eligible patients, 48 were included. Mean age was 75 years. Sixty-five percent rehabilitated successfully. Multivariate analyses showed that presence of diabetes mellitus (DM) (OR 23.87, CI 2.26–252.47) and premorbid BI (OR 1.37, CI 1.10-1.70) were the most important determinants of successful rehabilitation, whereas 78% of the variance of discharge BI was explained by premorbid BI, BI on admission, and 1-leg balance. Conclusion: The presence of DM and high premorbid BI were associated with discharge to an independent living situation within 1 year after admission. Premorbid BI, admission BI, and 1-leg balance were independently associated to discharge BI. Implications for Rehabilitation Geriatric patients with amputation in SNFs have a fair prognosis of being discharged to an independent living situation after rehabilitation. Pre-operative functional abilities of geriatric amputees are important in predicting rehabilitation outcome. Improving physical condition before amputation could lead to better rehabilitation outcome.

Effects of aerobic exercise therapy and cognitive behavioural therapy on functioning and quality of life in amyotrophic lateral sclerosis: protocol of the FACTS-2-ALS trial

BackgroundAmyotrophic lateral sclerosis (ALS) is a fatal progressive neurodegenerative disorder affecting motor neurons in the spinal cord, brainstem and motor cortex, leading to muscle weakness. Muscle weakness may result in the avoidance of physical activity, which exacerbates disuse weakness and cardiovascular deconditioning. The impact of the grave prognosis may result in depressive symptoms and hopelessness. Since there is no cure for ALS, optimal treatment is based on symptom management and preservation of quality of life (QoL), provided in a multidisciplinary setting. Two distinctly different therapeutic interventions may be effective to improve or preserve daily functioning and QoL at the highest achievable level: aerobic exercise therapy (AET) to maintain or enhance functional capacity and cognitive behavioural therapy (CBT) to improve coping style and cognitions in patients with ALS. However, evidence to support either approach is still insufficient, and the underlying mechanisms of the approaches remain poorly understood. The primary aim of the FACTS-2-ALS trial is to study the effects of AET and CBT, in addition to usual care, compared to usual care alone, on functioning and QoL in patients with ALS.Methods / DesignA multicentre, single-blinded, randomized controlled trial with a postponed information model will be conducted. A sample of 120 patients with ALS (1 month post diagnosis) will be recruited from 3 university hospitals and 1 rehabilitation centre. Patients will be randomized to one of three groups i.e. (1) AET + usual care, (2) CBT + usual care, (3) Usual care. AET consists of a 16-week aerobic exercise programme, on 3 days a week. CBT consists of individual psychological support of patients in 5 to 10 sessions over a 16-week period. QoL, functioning and secondary outcome measures will be assessed at baseline, immediately post intervention and at 3- and 6-months follow-up.DiscussionThe FACTS-2-ALS study is the first theory-based randomized controlled trial to evaluate the effects, and the maintenance of effects, of AET and CBT on functioning and QoL in patients with ALS. The results of this study are expected to generate new evidence for the effect of multidisciplinary care of persons with ALS.Trial registrationDutch Trial Register NTR1616.

Assessment of activities in patients with hand injury: A review of instruments in use.

Physical impairments are not necessarily coupled with functional limitations. For this reason, it is important to assess not only body functions and structures, but also activities and/or participation to decide which intervention is indicated and to evaluate the effect of the intervention in a valid way. The purpose of this review was to examine available instruments for assessing the limitations in activity and their application within the clinical reasoning process in patients with hand injuries. A literature search identified instruments that met four selection criteria: quality of information, target population, percentage items related to hand function, and a focus on activities. The selected instruments were categorised according to three items: the specific components, the aspects of activity that could be assessed with it and how activity was assessed (questionnaire or otherwise). Seventy two instruments were identified, of which 23 met the selection criteria. These selected instruments showed important differences in the constructs they assessed and in the manner of assessment. Instruments to assess limitations of activity as a result of hand injury should be evaluated further in terms of reliability and validity, before their use within the clinical reasoning process can be standardised.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Rehabilitation process and prosthetics. Part 2

Background: A structured, multidisciplinary approach in the rehabilitation process after amputation is needed that includes a greater focus on the involvement of both (para)medics and prosthetists. There is considerable variation in prosthetic prescription concerning the moment of initial prosthesis fitting and the use of replacement parts. Objectives: To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 2 focuses on rehabilitation process and prosthetics. Study design: Systematic literature design. Methods: Literature search in five databases and quality assessment on the basis of evidence-based guideline development. Results: An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. Conclusion: The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for treatment and reintegration of patients undergoing amputation of a lower extremity and can be used to provide patient information. Clinical relevance This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Amputation surgery and postoperative management. Part 1

Background: Surgeons still use a range of criteria to determine whether amputation is indicated. In addition, there is considerable debate regarding immediate postoperative management, especially concerning the use of ‘immediate/delayed fitting’ versus conservative elastic bandaging. Objectives: To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 1 focuses on amputation surgery and postoperative management. Study design: Systematic literature design. Methods: Literature search in five databases. Quality assessment on the basis of evidence-based guideline development. Results: An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. Conclusion: The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for diagnosis, referral, assessment, and undergoing amputation of a lower extremity and can be used to provide patient information. Clinical relevance This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.