Hugh G Dickson

ICF Core Sets for stroke.

OBJECTIVE To report on the results of the consensus process integrating evidence from preliminary studies to develop the first version of the Comprehensive ICF Core Set and the Brief ICF Core Set for stroke. METHODS A formal decision-making and consensus process integrating evidence gathered from preliminary studies was followed. Preliminary studies included a Delphi exercise, a systematic review, and an empirical data collection. After training in the ICF and based on these preliminary studies relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS The preliminary studies identified a set of 448 ICF categories at the second, third and fourth ICF levels with 193 categories on body functions, 26 on body structures, 165 on activities and participation, and 64 on environmental factors. Thirty-nine experts from 12 different countries attended the consensus conference on stroke. Altogether 130 second-level categories were included in the Comprehensive ICF Core Set with 41 categories from the component body functions, 5 from body structures, 51 from activities and participation, and 33 from environmental factors. The Brief ICF Core Set included a total of 18 second-level categories (6 on body functions, 2 on body structures, 7 on activities and participation, and 3 on environmental factors). CONCLUSION A formal consensus process integrating evidence and expert opinion based on the ICF framework and classification led to the definition of ICF Core Sets for stroke. Both the Comprehensive ICF Core Set and the Brief ICF Core Set were defined.

Task-dependent changes in the responses to low-threshold cutaneous afferent volleys in the human lower limb

1. In seven human subjects who were standing without support the sural nerves were stimulated electrically using trains of non‐painful stimuli (five pulses at 300 Hz), designed to activate afferents from cutaneous mechanoreceptors. The reflex effects of the stimulus train on different muscles of the ipsilateral and contralateral legs were sought in post‐stimulus averages of rectified EMG. Changes in the pattern of reflex influence were investigated when the subjects maintained different postures. 2. Clear reflex responses were seen in ipsilateral tibialis anterior, soleus, biceps femoris and vastus lateralis, but only when the muscles were actively contracting. In each muscle, inhibition was the dominant reflex response within the first 100 ms. In four of the seven subjects, reflex changes were detectable in the contralateral tibialis anterior and soleus, the peak‐to‐peak modulation within the first 200 ms being 25‐50% of that for the homologous ipsilateral muscle. 3. When subjects attempted to stand on a tilted platform, an unstable platform or on one leg with the other flexed, different combinations of muscles were active, involving both flexors and extensors or predominantly flexors or predominantly extensors. In each posture the reflex effects were demonstrable only in the active muscles. 4. With ipsilateral tibialis anterior, there were task‐dependent changes in the short‐latency components of the EMG response, approximately 60 ms and 80 ms after the stimulus. When seated performing voluntary contractions these components were difficult to define, and when standing on a platform tilted toe‐up they were small. When the ipsilateral leg was flexed or when standing on an unstable base, these early components were more prominent in each subject. With contralateral tibialis anterior, the dominant reflex pattern was inhibition when seated and contracting voluntarily, and facilitation during bipedal stance tilted toe‐up. These changes in reflex pattern could not be explained by different levels of background contraction. 5. It is concluded that cutaneous mechanoreceptors of the foot have widespread reflex actions on muscles throughout both limbs, particularly the ipsilateral limb, and that the reflex pattern in different muscles and within a single muscle may change dependent on the task that the subject is undertaking. These task‐dependent changes indicate plasticity in the expression of cutaneous reflex activity, affecting both short‐latency spinal as well as long‐latency pathways.

The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale.

OBJECTIVE To develop and validate a simple method for detecting dementia that is valid across cultures, portable and easily administered by primary health care clinicians. DESIGN Culture and Health Advisory Groups were used in Stage 1 to develop culturally fair cognitive items. In Stage 2, clinical testing of 42 items was conducted in a multicultural sample of consecutive new referrals to the geriatric medicine outpatient clinic at Liverpool Hospital, Sydney, Australia (n = 166). In Stage 3, the predictive accuracy of items was assessed in a random sample of community-dwelling elderly persons stratified by language background and cognitive diagnosis and matched for sex and age (n = 90). MEASUREMENTS A research psychologist administered all cognitive items, using interpreters when needed. Each patient was comprehensively assessed by one of three geriatricians, who ordered relevant investigations, and implemented a standardized assessment of cognitive domains. The geriatricians also collected demographic information, and administered other functional and cognitive measures. DSM-IV criteria were used to assign cognitive diagnoses. Item validity and weights were assessed using frequency and logistic regression analyses. Receiver-operating characteristic (ROC) curve analysis was used to determine overall predictive accuracy of the RUDAS and the best cut-point for detecting cognitive impairment. RESULTS The 6-item RUDAS assesses multiple cognitive domains including memory, praxis, language, judgement, drawing and body orientation. It appears not to be affected by gender, years of education, differential performance factors and preferred language. The area under the ROC curve for the RUDAS was 0.94 (95% CI 0.87-0.98). At a cut-point of 23 (maximum score of 30), sensitivity and specificity were 89% and 98%, respectively. Inter-rater (0.99) and test-retest (0.98) reliabilities were very high. CONCLUSIONS The 6-item RUDAS is portable and tests multiple cognitive domains. It is easily interpreted to other languages, and appears to be culturally fair. However, further validation is needed in other settings, and in longitudinal studies to determine its sensitivity to change in cognitive function over time.

Anxiety and depression over the first year of spinal cord injury: a longitudinal study.

The literature concerning the psychological consequences following spinal cord injury (SCI) indicates a discordance between clinical impressions and empirical research. Although many studies report that psychological morbidity is not an inevitable consequence of SCI, much of this research is characterised by methodological inadequacies and the conclusions are therefore tenuous. The present study assessed 41 persons with SCI for depression and anxiety using objective psychological measures on three occasions over the first year of SCI and compared them with 41 able bodied controls matched for age, sex, education and, as far as possible, occupation. Results demonstrated significant differences between the two groups, with the SCI group being more anxious and depressed. However, psychological morbidity was not an inevitable consequence of SCI, with group means reflecting mild levels of depression and anxiety. No significant differences were found across time and no interactions between groups and time were detected. Implications for the treatment of SCI are discussed.

Long-term psychological outcomes in spinal cord injured persons: Results of a controlled trial using cognitive behavior therapy

OBJECTIVE Although there are many anecdotal reports that psychological intervention is effective in enhancing adjustment to spinal cord injury (SCI), there are little data to support this assertion. To date, reports of few longitudinal-based controlled trials that assessed psychological outcomes for SCI persons have been published. This study was conducted to determine long-term efficacy of cognitive behavior therapy during rehabilitation. DESIGN The study employed a nonrandomized controlled trial, and measures were taken on three occasions: before, immediately after, and 12 months after treatment. SETTING, OUTCOME MEASURES, AND INTERVENTION: Anxiety, depressive mood, and self-esteem were assessed in 28 SCI persons consecutively selected on admission to hospital, who participated in specialized group cognitive behavior therapy (CBT) during rehabilitation. CONTROLS The intervention groups responses on the measures were compared with a control group of 41 SCI persons who only received traditional rehabilitation services during their hospitalization. RESULTS There were no overall group differences on anxiety, depressive mood, and self-esteem, although there was a trend for the treatment group to have greater levels of improvement in depression scores across time in comparison to the control group. However, those in the treatment group who reported high levels of depressive mood before the CBT treatment were significantly less depressed 1 year after injury, compared to similar persons in the control group. CONCLUSIONS While it appears not everyone who experiences SCI needs CBT, at least in the hospital phase of their rehabilitation, those who report high levels of depressive mood benefited greatly from CBT.

The effectiveness of group psychological intervention in enhancing perceptions of control following spinal cord injury

Objective: This research investigated the effects of a structured psychological intervention, delivered during hospital rehabilitation, on the perceptions of control in people with spinal cord injury (SCI). Method: A longitudinal study was designed to assess perceptions of control (using an objective measure of locus of control) in SCI persons who participated in specialised group cognitive-behavioural therapy (CBT) during hospital rehabilitation. The treatment SCI groups responses on locus of control were compared with a control group of SCI persons who only received traditional rehabilitation services during their hospitalisation. Results and Conclusions: Mean locus of control scores were not high (i.e. external) for both groups and there were no overall group differences on locus of control responses across time in comparison to the control group. However, subjects in both groups who initially perceived life as externally controlled were extracted to form subgroups. The members of the subgroup who received CBT were significantly more likely to feel in control of themselves 2 years post injury compared to similar persons in the control group. Furthermore, an external locus of control was significantly but mildly associated with depressive mood 2 years after the injury. This research suggests that the provision of a structured psychological program in the rehabilitation stage will be beneficial for many SCI persons who feel that they have little control over their lives.

Improving the long-term adjustment of spinal cord injured persons.

Study Design: The study involved the long-term assessment of persons with spinal cord injury (SCI) who previously participated in a nonrandomized longitudinal controlled trial.Objectives: The objective was to report on the effectiveness of early psychological intervention in improving some aspects of adjustment to SCI 2 years post injury.Setting: The study was conducted in Sydney, Australia.Methods: Twenty-eight SCI persons who had participated in group Cognitive Behaviour Therapy (CBT) during hospital rehabilitation were assessed for drug usage, hospital re-admissions, relationships, perceived adjustment and social discrimination 2 years after treatment. The intervention groups responses on the measures were compared with a control group of 31 SCI persons who only received traditional rehabilitation services during their hospitalization.Results: Subjects in the treatment group experienced less hospital re-admissions, used less drugs and reported higher levels of adjustment compared to the control group. Relationships were stable for both groups and there were no suicides in either group up to 2 years. There were no differences in perceived social discrimination between the two groups.Conclusion: The study suggests the long-term adjustment for SCI persons is encouraging for the majority. However, the provision of group CBT for SCI persons appears to improve significantly some aspects of adjustment to the injury in the long-term.

What do non-English-speaking patients value in acute care? Cultural competency from the patient's perspective: a qualitative study

Objective. The purpose of this research was to locate cultural competence within the experiential domain of the non-English-speaking patient. Design. Seven language-specific focus groups were held with 59 hospital patients and carers of patients with limited English to better understand their experience and to identify critical factors leading to their constructions of care. Grounded theory analysis within a constructivist perspective was undertaken. Results. While the majority of patients were positive about their hospital experience, the theme of powerlessness appeared central to many patient experiences. Language facilitation was the most common issue. Inattention to specific cultural mores and racism in some instances contributed to negative experiences. Patients primarily valued positive engagement, information and involvement, compassionate, kind and respectful treatment, and the negotiated involvement of their family. Conclusion. Because of the specific nature of each patient–provider interaction within its particular social and political environment, culturally competent behaviour in one context may be culturally incompetent in another. We propose a model of cultural empowerment that reflects the phenomenological basis of cultural competence in that cultural competence must be consistently renegotiated with any particular patient in a particular healthcare context. Similarly, ongoing community consultations are needed for health services and organisations to retain cultural competence.

Immunizing against depression and anxiety after spinal cord injury

OBJECTIVE To further report on the effectiveness of early psychological intervention in reducing anxiety and depressive mood in persons with spinal cord injury 2 years after injury. DESIGN A nonrandomized, longitudinal, controlled trial. SETTING, OUTCOME MEASURES, AND INTERVENTION: Twenty-eight spinal cord injured persons participated in group cognitive behavior therapy during hospital rehabilitation. They were assessed for depressive mood and anxiety before, immediately after, and 12 and 24 months after treatment. The intervention groups responses on the measures were compared with a control group of 31 spinal cord injured persons who only received traditional rehabilitation services during their hospitalization. RESULTS Subjects in the treatment group with high depression and anxiety scores before treatment were significantly less depressed and reduced their anxiety to a greater extent 2 years after the injury in comparison with similar persons in the control group. CONCLUSIONS Group cognitive behavior therapy for spinal cord injured persons who are abnormally depressed and anxious appears to reduce depressive mood and anxiety in the short and long term.

“The Happy Migrant Effect”: perceptions of negative experiences of healthcare by patients with little or no English: a qualitative study across seven language groups

Background: The subjective experiences of patients with little or no English who either attended the Emergency Department or were admitted to the wards of a tertiary referral hospital were explored. Setting and methods: The reports of experiences from 49 patients of a tertiary referral hospital were analysed using grounded theory methods applied to translated transcriptions from focus groups held with discharged patients in seven languages. Results: Inability to communicate in English, poor patient and family involvement with staff, a lack of control or powerlessness, staff shortages, staff negligence or incompetence, and treatment delays were reported by some patients. Others tended to discount or minimise the significance of similar experiences, suggesting a construct, “The Happy Migrant Effect,” in which there is reluctance to assert healthcare rights. Patients appear “happy” and satisfied, despite problems with their hospital care. Explanatory factors for the construct include extreme powerlessness related to being unable to communicate, a positive comparison of healthcare in the new country compared with the old, patriotism for the new country, cultural norms that proscribe acceptance, politeness or social desirability, self-denigration for not having learnt English and, for a few, a fear of reprisals if they spoke out in complaint. Conclusions: Some immigrant patients with poor language skills might not report serious problems with healthcare delivery. In all patients in this study where problems with healthcare were reported, the events were considered to be largely preventable by appropriate language facilitation, patient and family involvement, and provider respect and compassion.