Kwang Hwa Chang

Implementing disability evaluation and welfare services based on the framework of the international classification of functioning, disability and health: experiences in Taiwan

BackgroundBefore 2007, the disability evaluation was based on the medical model in Taiwan. According to the People with Disabilities Rights Protection Act, from 2012 the assessment of a person’s eligibility for disability benefits has to be determined based on the International Classification of Functioning, Disability, and Health (ICF) framework nationwide. The purposes of this study were to: 1) design the evaluation tools for disability eligibility system based on the ICF/ICF-Children and Youth; 2) compare the differences of grades of disability between the old and new evaluation systems; 3) analyse the outcome of the new disability evaluation system.MethodsTo develop evaluation tools and procedure for disability determination, we formed an implementation taskforce, including 199 professional experts, and conducted a small-scale field trial to examine the feasibility of evaluation tools in Phase I. To refine the evaluation tools and process and to compare the difference of the grades of disability between new and old systems, 7,329 persons with disabilities were randomly recruited in a national population-based study in Phase II. To implement the new system smoothly and understand the impact of the new system, the collaboration mechanism was established and data of 168,052 persons who applied for the disability benefits was extracted from the information system and analysed in Phase III.ResultsThe measures of the 43 categories for body function/structure components, the Functioning Scale of Disability Evaluation System for activities/participation components, and the needs assessment have been developed and used in the field after several revisions. In Phase II, there was 49.7% agreement of disability grades between the old and new systems. In Phase III, 110,667 persons with a disability received their welfare services through the new system. Among them, 77% received basic social welfare support, 89% financial support, 24% allowance for assistive technology, 7% caregiver support, 8% nursing care and rehabilitation services at home, and 47% were issued parking permits for persons with disability.ConclusionThis study demonstrated that disability evaluation system based on the ICF could provide a common language between disability assessment, needs assessment and welfare services. However, the proposed assessment protocol and tools require additional testing and validation.

The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: A systemic review and meta-analysis

Objective: In this study, we intended to evaluate whether swallow treatment with neuromuscular electrical stimulation is superior to that without neuromuscular electrical stimulation, and whether neuromuscular electrical stimulation alone is superior to swallow therapy. Methods: We searched the PubMed and Scopus databases from their earliest record to 31 December 2014 for randomized and quasi-randomized controlled trials that used neuromuscular electrical stimulation to treat post-stroke dysphagia. The Jadad scale was used to assess the quality of the included studies. We extracted the mean differences and standard deviation (SD) between baseline and posttreatment or posttreatment mean and SD for selected outcomes measured in the experimental and control groups for subsequent meta-analyses. Results: Eight studies were identified. For the comparison “swallow treatment with neuromuscular electrical stimulation vs. swallow treatment without neuromuscular electrical stimulation,” we found a significant standardized mean difference (SMD) of 1.27 (95% confidence interval (CI) = 0.51–2.02, P = 0.001) with significant heterogeneity (I2 = 85%). The meta-analysis for the comparison of neuromuscular electrical stimulation alone and swallow therapy demonstrated a non-significant SMD of 0.25 (95% CI = –0.16–0.65, P = 0.23) without significant heterogeneity (I2 = 16%). Conclusion: Swallow treatment with neuromuscular electrical stimulation seems to be more effective than that without neuromuscular electrical stimulation for post-stroke dysphagia in the short term considering the limited number of studies available. Evidence was insufficient to indicate that neuromuscular electrical stimulation alone was superior to swallow therapy.

The probability of spontaneous regression of lumbar herniated disc: a systematic review:

Objective: To determine the probability of spontaneous disc regression among each type of lumbar herniated disc, using a systematic review. Data sources: Medline, Cochrane Library, CINAHL, and Web of Science were searched using key words for relevant original articles published before March 2014. Articles were limited to those published in English and human studies. Review methods: Articles had to: (1) include patients with lumbar disc herniation treated conservatively; (2) have at least two imaging evaluations of the lumbar spine; and (3) exclude patients with prior lumbar surgery, spinal infections, tumors, spondylolisthesis, or spinal stenosis. Two reviewers independently extracted study details and findings. Thirty-one studies met the inclusion criteria. Furthermore, if the classification of herniation matched the recommended classification of the combined Task Forces, the data were used for combined analysis of the probability of disc regression of each type. Nine studies were applicable for probability calculation. Results: The rate of spontaneous regression was found to be 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and 13% for disc bulging. The rate of complete resolution of disc herniation was 43% for sequestrated discs and 15% for extruded discs. Conclusions: Spontaneous regression of herniated disc tissue can occur, and can completely resolve after conservative treatment. Patients with disc extrusion and sequestration had a significantly higher possibility of having spontaneous regression than did those with bulging or protruding discs. Disc sequestration had a significantly higher rate of complete regression than did disc extrusion.

Effects of elastic-band exercise on lower-extremity function among female patients with osteoarthritis of the knee

Objective: To investigate a new style of resistance exercise using elastic bands and explore its therapeutic effect on the lower-extremity function of female patients with osteoarthritis (OA) of the knee. Design: A randomized, controlled clinical trial. Setting: University-affiliated medical center. Participants: Forty-one women with mild-to-moderate knee OA were randomly assigned to one of two groups, an exercise group (n = 24; age: 65.0 ± 8.4 years), and a control group (n = 17; age: 70.8 ± 8.4 years). Interventions: The exercise group performed supervised exercise with elastic bands in addition to conventional modality treatments two to three times a week for 8 weeks. The control group received only the conventional modality treatments over the same period. Main outcome measures: The distance of the functional forward-reach, 30 s chair stand repetitions, walking function (time of a 10 m walk, timed up-and-go, and going up-and-down 13-stair tests), and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index scores. Results: Statistically significant improvements in all measures were observed in the exercise group after 8 weeks (p < 0.001). Except for the outcomes on the functional forward-reach (p = 0.108) and going up-and-down 13-stair test (p = 0.278), there were significant differences in the extent of improvement between the two groups. Positive changes in the 30 s chair stand test, 10 m walk test, and timed up-and-go test were 2.5 ± 1.4 repetitions, 1.4 ± 1.2 s, and 1.6 ± 1.1 s in the exercise group, which were significant better than those in the control group (0.6 ± 0.9 repetitions, 0.5 ± 1.1 s, and 0.3 ± 1.1 s, respectively) (p ≤ 0.001). The lower scores of all three subscales of the WOMAC index were significant after 8 weeks (p ≤ 0.05), especially for pain (−2.3 ± 1.3) and physical function (−10.7 ± 5.9) (both p ≤ 0.01), and the improvements were all significant better than those of the control group (p ≤ 0.05). Conclusions: A new style of resistance exercise using elastic bands with four color combinations (yellow-red, red-red, red-green, and green-green) over a period of 8 weeks can significantly improve lower-extremity function among females with mild-to-moderate knee OA. Implications for Rehabilitation Resistance exercise is an effective means of improving the lower extremity function for people with knee osteoarthritis (OA). A new model for using elastic bands combinations based on leg-press exercise and the principles of progressive resistance training leads to improved lower extremity function in female patients with knee OA after an 8-week period.

Contribution of Ischemic Stroke to Hip Fracture Risk and the Influence of Gender Difference

OBJECTIVES To clarify the contribution of stroke to the risk of hip fracture (HF) and the influence of gender difference on HF, and to estimate the incidence rate of poststroke HF. DESIGN A prospective, probability-sampling, 10-year, population-based cohort study. SETTING A National Health Insurance Research Database consisting of 200,432 randomly selected enrollees. PARTICIPANTS Subjects with acute ischemic stroke (N=1951; mean age ± SD, 65.6 ± 9.8y; 56.5% men) were identified. For each stroke subject, 2 age- and gender-matched controls were recruited. Control subjects did not have any brain disease. Those subjects younger than 45 years were excluded. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The incidence rate and the adjusted hazard ratio of sustaining an HF were estimated. The cumulative HF-free probability was plotted. RESULTS Stroke subjects had a higher incidence rate of HF than their controls (women: 11.3 vs 4.4/1000 person-years, P<.001; men: 5.6 vs 2.9/1000 person-years, P<.001). The risk of HF was higher among stroke subjects, yielding an adjusted hazard ratio (95% confidence interval) of 2.33 (1.62-3.34) for women and 1.73 (1.12-2.68) for men. Compared with men with stroke, women with stroke had an adjusted hazard ratio of 1.83 (1.18-2.85). Stroke subjects had a lower cumulative HF-free probability throughout the 10-year duration than did the control subjects (women, P<.001; men, P=.005). Half of the poststroke HFs occurred within 2.5 years of the onset of stroke. CONCLUSIONS Ischemic stroke is a risk factor for HF, which is at work over and beyond age and gender. Being a woman with stroke increases this fracture risk. An active program for fracture prevention might prove effective for stroke subjects, and this may be especially true for women.

Functioning and Disability Analysis of Patients with Traumatic Brain Injury and Spinal Cord Injury by Using the World Health Organization Disability Assessment Schedule 2.0

The purpose of this study is to compare traumatic brain injuries (TBI) and spinal cord injuries (SCI) patients’ function and disability by using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0); and to clarify the factors that contribute to disability. We analyzed data available between September 2012 and August 2013 from Taiwan’s national disability registry which is based on the International Classification of Functioning, Disability, and Health (ICF) framework. Of the 2664 cases selected for the study, 1316 pertained to TBI and 1348 to SCI. A larger percentage of patients with TBI compared with those with SCI exhibited poor cognition, self-care, relationships, life activities, and participation in society (all p < 0.001). Age, sex, injury type, socioeconomic status, place of residence, and severity of impairment were determined as factors that independently contribute to disability (all p < 0.05). The WHODAS 2.0 is a generic assessment instrument which is appropriate for assessing the complex and multifaceted disability associated with TBI and SCI. Further studies are needed to validate the WHODAS 2.0 for TBI and SCI from a multidisciplinary perspective.

Systematic review of ICF core set from 2001 to 2012

Abstract Purpose: This study systemically reviewed the published literature on the ICF core set. Method: A computer search of the MEDLINE, PubMed and SCOPUS databases was conducted between 2001 and December 2012. Articles reporting on the development of a set or sets of ICF categories for specific disease or health conditions were selected for a systematic review. Results: The analysis included 116 articles from 36 journals, with the majority of papers having been published in 2011 and 2012. In these studies, spinal cord injury was the most frequently reported disease. The majority of the experts involved in the consensus process were physicians and physical therapists. Conclusion: This systematic review of studies on ICF core sets provided background information on the current developmental status of ICF core sets. Our findings also highlight possible directions for future research. Implications for Rehabilitation The aim to develop ICF core sets is to provide a practical way to address a specific patient population in daily practice. This review showed the development of ICF core set in last decade and provide directions for future research. Development of ICF core set is still limited in area outside Europe and incomplete in number of major diseases.

Association between muscle power impairment and WHODAS 2.0 in older adults with physical disability in Taiwan.

Abstract Purpose: To explore the association between muscle power impairment and each World Health Organization Disability Assessment Schedule second edition (WHODAS 2.0) domain score among subjects with physical disability. Methods: Subjects (≥60 years) with physical disability related to neurological diseases, including 730 subjects with brain disease (BD) and 126 subjects with non-BD, were enrolled from a data bank of persons with disabilities from 1 July 2011 to 29 February 2012. Standardized WHODAS 2.0 scores ranging from 0 (least difficulty) to 100 (greatest difficulty) points were calculated for each domain. Results: More than 50% of subjects with physical disability had the greatest difficulty in household activities and mobility. Muscle power impairment (adjusted odds ratios range among domains, 2.75–376.42, p < 0.001), age (1.38–4.81, p < 0.05), and speech impairment (1.94–5.80, p < 0.05) were associated with BD subjects experiencing the greatest difficulty in most WHODAS 2.0 domains. But a few associated factors were identified for the non-BD group in the study. Conclusions: Although the patterns of difficulty in most daily activities were similar between the BD and non-BD groups, factors associated with the difficulties differed between those two groups. Muscle power impairment, age and speech impairment were important factors associated with difficulties in subjects with BD-related physical disability. Implications for Rehabilitation Older adults with physical disability often experience difficulties in household activities and mobility. Muscle power impairment is associated with difficulties in daily life in subjects with physical disability related to brain disease. Those subjects with brain disease who had older age, a greater degree of muscle power impairment, and the presence of speech impairment were at higher risk of experiencing difficulties in most daily activities.

Body Composition Assessment in Taiwanese Individuals With Poliomyelitis

OBJECTIVES To measure the changes in the total and regional body fat mass, and assess the clinical usefulness of the body mass index (BMI) in detecting overweight subjects with sequelae of poliomyelitis. DESIGN Prospective, cross-sectional study. SETTING General community. PARTICIPANTS Subjects with poliomyelitis (n=17; age range, 42-57y; mean, 47y; 12 men, 5 women) and able-bodied people (n=17) matched by sex, age, body weight, and body height participated in the study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Total and regional body composition was measured with dual-energy x-ray absorptiometry. Clinical characteristics such as blood pressure, serum biochemical studies, and habitual behaviors (daily cigarette smoking, alcohol consumption, and exercise regimen) of all participants were evaluated. RESULTS Compared with able-bodied controls, subjects with poliomyelitis had a 50% greater total body fat mass, significant increases in the regional fat mass in every part of the body, and had the greatest increase of fat mass in the thorax. Nearly all the subjects (94%) with poliomyelitis were obese according to standards of body composition. However, one third of them had a BMI value of less than 25.0kg/m(2). CONCLUSIONS People with poliomyelitis have a higher prevalence of obesity and a significant increase in total and regional fat mass. Current BMI underestimates the total body fat mass percentage compared with the control; therefore, a population-specific BMI should be used to address the prevalence of obesity in postpolio survivors.

Measuring Disability and Its Predicting Factors in a Large Database in Taiwan Using the World Health Organization Disability Assessment Schedule 2.0

The definition of disability had been unclear until the International Classification of Functioning, Disability, and Health was promulgated in 2001 by the World Health Organization (WHO). Disability is a critical but relatively neglected public-health concern. We conducted this study to measure disabilities by using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) and identify the factors that contribute to disabilities. We obtained and analyzed the data on people who applied to Taiwan’s disability registration system between September 2012 and August 2013. A total of 158,174 cases were selected for this study. Among the people included in this study, 53% were male, and the females were on average 3 years older than the males. More males than females were of a low socioeconomic status, but the rate of employment was higher among the males than among the females. Age, sex, place of residence, and types and severity of impairment were all determined to be factors that independently contributed to disability. This study has demonstrated that disability can be measured and compared using WHODAS 2.0. Increasing the public-health attention devoted to disability and identifying the factors associated with disability can promote independence and social participation in people with disabilities.