Jeffrey W. Jutai

Issues for selection of outcome measures in stroke rehabilitation: ICF Participation

Purpose. To evaluate the psychometric and administrative properties of outcome measures in the ICF Participation category, which are used in stroke rehabilitation research and reported in the published literature. Method. Critical review and synthesis of measurement properties for six commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature. Results. Validity has been well reported for at least half of the measures reviewed. However, methods for reporting specific measurement qualities of outcome instruments were inconsistent. Responsiveness of measures has not been well documented. Of the three ICF categories, Participation seems to be most problematic with respect to: (a) lack of consensus on the range of domains required for measurement in stroke; (b) much greater emphasis on health-related quality of life, relative to subjective quality of life in general; (c) the inclusion of a mixture of measurements from all three ICF categories. Conclusions. The reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved participation associated with stroke rehabilitation. There is no consensus regarding the most important indicators of successful involvement in a life situation and which ones best represent the societal perspective of functioning. In particular, quality of life outcomes lack adequate conceptual frameworks to guide the process of development and validation of measures.

Adolescents with physical disabilities: some psychosocial aspects of health.

PURPOSE To examine the psychosocial issues related to growing up with a physical disability. METHODS Adolescents with physical disabilities aged 11-16 years were compared with a Canadian national sample of adolescents using the Health Behaviours in School-Aged Children (HBSC), a World Health Organization Cross-National Study survey. RESULTS Adolescents with physical disabilities reported good self-esteem, strong family relationships, and as many close friends as adolescents in the national sample. However, adolescents with physical disabilities participated in fewer social activities and had less intimate relationships with their friends. They had more positive attitudes toward school, teachers, and their fellow classmates than the national sample, but fewer had plans for postsecondary education. The majority of adolescents with physical disabilities reported that they had not received information on parenthood, birth control, and sexually transmitted diseases. CONCLUSIONS There are a number of critical areas of risk for adolescents with physical disabilities to which health promotion efforts should be directed. These include lower levels of peer integration, heightened adult orientation, low educational aspirations, and poor knowledge of sexuality.

Impact of early vs delayed admission to rehabilitation on functional outcomes in persons with stroke.

OBJECTIVE Delayed admission to rehabilitation may result in poorer outcomes by reducing exposure to therapeutic interventions at a time when the brain is primed for neurological recovery. The present study examined the effects of early vs delayed admission on functional outcome and length of stay in patients admitted to a rehabilitation unit for first-ever unilateral stroke. DESIGN Retrospective chart review. METHODS Differences in length of rehabilitation stay and functional outcome variables among 435 patients, grouped by interval from stroke event to rehabilitation admission (=30 days vs 31-150 days and 5 additional subgroups) were examined using a multivariate technique. RESULTS Admission and discharge FIM scores, FIM change and FIM efficiency were significantly higher among early admission patients (p<0.01), while length of stay was significantly longer among delayed admission patients (p<0.01). A significant association was identified between age and admission (p<0.01) and discharge FIM (p<0.01) scores as well as FIM change scores (p=0.017). Subgroup analyses revealed significant differences in FIM scores, FIM change and length of stay between groups of patients admitted 0-15 and 16-30 days (p<0.01) and between patients admitted 16-30 days and 31-60 days post-stroke (p<0.01). No significant differences were noted between patients admitted from 31-60 and 61-90 or 61-90 and 91-150 days. CONCLUSION Patients admitted to stroke rehabilitation within 30 days of first-ever, unilateral stroke experienced greater functional gains and shorter lengths of stay than those whose admission to rehabilitation was delayed beyond 30 days.

Systematic Review of Hip Fracture Rehabilitation Practices in the Elderly

OBJECTIVE To address the need for a research synthesis on the effectiveness of the full range of hip fracture rehabilitation interventions for older adults and make evidence based conclusions. DATA SOURCES Medline, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2007 for studies published in English. The terms rehabilitation and hip fracture were exploded in order to obtain related search terms and categories. STUDY SELECTION In the initial search of the databases, a combined total of 1031 articles was identified. Studies that did not focus on hip fracture rehabilitation, did not include persons over the age of 50 years, and/or did not include measures of physical outcome were excluded. DATA EXTRACTION Only studies with an Oxford Center for Evidence-Based Medicine Levels of Evidence level of I (randomized controlled trial, RCT) or II (cohort) were reviewed. The methodologic quality of both types of studies was assessed using a modified version of the Downs and Black checklist. DATA SYNTHESIS There were 55 studies that met our selection criteria: 30 RCTs and 25 nonrandomized trials. They were distributed across 6 categories for rehabilitation intervention (care pathways, early rehabilitation, interdisciplinary care, occupational and physical therapy, exercise, intervention not specified) and 3 settings (acute care hospital, postacute care/rehabilitation, postrehabilitation). CONCLUSIONS When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability. Eleven intervention categories across 3 settings were associated with improved ambulatory outcomes. Seven intervention approaches were related to improved functional recovery, while 6 intervention approaches were related to improved strength and balance recovery. Decreased length of stay and increased falls self-efficacy were associated with 2 interventions, while 1 intervention had a positive effect on lower-extremity power generation.

Development of a scale to measure the psychosocial impact of assistive devices: lessons learned and the road ahead

Purpose : In this paper the history of the development and validation of the PIADS is reviewed. Assistive devices (ADs) are extremely prevalent forms of health care intervention for persons who have a disability. There is a consensus that the AD field needs a reliable and valid measure of how users perceive the impact of ADs on their quality of life (QoL) and sense of well-being. The Psychosocial Impact of Assistive Devices Scale (PIADS) is a 26 item self-rating scale designed to fill this measurement gap. The challenges that we encountered are described in attempting to adequately conceptualize QOL impact, and operationalize it in a measure suitable for use with virtually all forms of AD. Current efforts to extend the validation of the PIADS are summarized. Conclusions : The study concludes by suggesting directions for future research and development of the scale. They include a richer examination of its conceptual relationships to other health care and rehabilitation outcome measures, and further investigation of its clinical utility. The PIADS is a reliable and valid tool that appears to have very significant power to predict AD abandonment and retention. It can and should be used both deductively and inductively to build, discover and test theory about the psychosocial impact of assistive technology.

Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions

Purpose: To evaluate the psychometric and administrative properties of outcome measures assigned to the ICF Body Functions category, and commonly used in stroke rehabilitation research. Method: Critical review and synthesis of measurement properties for five commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature. Results: The reporting of specific measurement qualities for outcome instruments was relatively consistent across measures located within the same general ICF category. Far less information was available on the responsiveness of measures, compared with reliability and validity. The best available instruments were associated with the following body functions: cognitive impairment, depression and motor recovery. Conclusions: The reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved body functions in stroke rehabilitation since there is significant diversity. However there appears to be good consensus about what are the most important indicators of successful rehabilitation outcome in each domain of body function.

A systematic review of the rehabilitation of moderate to severe acquired brain injuries

Objective: To conduct a systematic review of the rehabilitation literature of moderate to severe acquired brain injuries (ABI) from traumatic and non-traumatic causes. Methods: A review of the literature was conducted for studies looking at interventions in ABI rehabilitation. The methodological quality of each study was determined using the Downs and Black scale for randomized controlled trials (RCTs) and non-RCTs as well as the Physiotherapy Evidence Database (PEDro) scale for RCTs only. Results: Almost 14 000 references were screened from which 1312 abstracts were selected. A total of 303 articles were chosen for careful review of which 275 were found to be interventional studies but only 76 of these interventional studies were RCTs. From this, 5 levels of evidence were determined with 177 conclusions drawn; however of the 177 conclusions only 7 were supported by two or more RCTs and 41 were supported by one RCT. Conclusion: Only 28% of the interventional studies were RCTs. Over half of the 275 interventional studies were single group interventions, pointing to the need for studies of improved methodological quality into ABI rehabilitation.

Age-related macular degeneration and low-vision rehabilitation: a systematic review

BACKGROUND Because of the prevalence and devastating consequences of age-related macular degeneration (AMD), a systematic review devoted to low-vision rehabilitation and AMD seems timely and appropriate. METHODS Several electronic databases were searched for studies from 1980 to 2006 involving individuals with low vision or visual impairment and rehabilitation interventions. Studies were assessed for quality and level of evidence. RESULTS The findings indicate that standard low-vision rehabilitation programs, conventional in-clinic assessments, and optical devices are effective ways of managing and living with vision loss. Areas of unmet need include determining which types of orientation and mobility programs and devices are most effective and developing methods of matching assistive technologies with the individuals visual and environmental requirements. INTERPRETATION Additional randomized controlled trials with similar intervention comparisons and outcome measures are needed to form stronger conclusions for the most effective low-vision rehabilitation interventions for individuals with AMD.

Psychopathy and cerebral asymmetry in semantic processing

Abstract A divided visual field (DVF) procedure was used to investigate the cerebral organization of language processes in psychopaths. The subjects consisted of four groups of 13 right-handed males: noncriminals (NC), and criminals with high (H), medium (M), and low (L) scores on the Psychopathy Checklist (Hare, 1980). The subject had to decide if a concrete noun, tachistoscopically presented in either the left (LVF) or the right visual hemifield (RVF), matched a pretrial work (SR task), or was an exemplar of a specific category (SC task) or an abstract category (AC task). There were no group differences in reaction time. As predicted, group differences in errors were confined to the AC task; Groups L and NC made fewer RVF than LVF errors (thus showing the sort of RVF advantage expected with semantic categorization), whereas the opposite was true of Group H. The results, along with those obtained in a recent dichotic listening study, lead us to speculate that psychopathy may be associated with weak or unusual lateralization of language function, and that psychopaths may have fewer left hemisphere resources for processing language than do normal individuals.

Psychopathy and Event-Related Brain Potentials (ERPs) associated with attention to speech stimuli☆

Abstract Event-related brain potentials (ERPs) were used to determine whether low left-hemisphere arousal or unusual cortical responses to speech stimuli might be associated with anomalies in language function that reportedly occur when psychopaths perform lateralized information-processing tasks. ERPs to phonemic stimuli were recorded while 11 psychopathic (P) and 13 nonpsychopathic (NP) male prison inmates performed a Single-Task and a Dual-Task. In the Single-Task, a speech discrimination ‘oddball’ paradigm, the subject was required to respond whenever a target stimulus (the less frequent of two phonemes) occured. In the Dual-Task, he had to respond to target stimuli while simultaneously performing a perceptual-motor (distractor) task. There were no group differences in ERP measures of central arousal (N100) during performance of the Single- and Dual-Tasks. For both groups, the P300 component of the ERP to the target stimulus was smaller and had longer latency during the Dual-Task than during the Single-Task, indicating that in the Dual-Task phonemic discrimination and the perceptual-motor task completed for similar perceptual resources. Overlapping Group Ps P300 responses to the target stimulus during the Dual-Task was a vertex and asymmetric (left-hemisphere) positive slow wave (SW), suggesting unusual speech processing in psychopaths under conditions of distraction, perhaps related to reduced sensitivity to the sequential probabilities associated with events presented in an auditory channel. The results were consistent with the hypothesis that psychopaths have limited left-hemisphere resources for processing linguistic stimuli.