Access to the environment and life satisfaction after spinal cord injury

OBJECTIVE: To determine the potential relation between satisfaction with life after spinal cord injury and access to the environment as measured by selected items from the Craig Handicap Assessment and Reporting Technique (CHART). DESIGN: Prospective, correlational/predictive study using cross-sectional and longitudinal data from 18 Model Spinal Cord Injury Systems of Care. SUBJECTS: Adult persons with traumatic-onset spinal cord injury (n = 650) evaluated at 1 or 2 years postinjury. OUTCOME MEASURE: Satisfaction With Life Scale (SWLS). PREDICTOR VARIABLES: Demographic characteristics, impairment and disability classifications. medical complications, rehabilitation insurance status, occupational status as measured by the CHART Occupation Scale, self-perceived health (from SF-36), and access to the environment as measured by items from the CHART Mobility Scale. RESULTS: Access to the environment was positively and linearly associated with satisfaction with life, demonstrated both positive and negative change over time, and was positively associated with subject's neurologic status. Access to the environment added to the explanatory model to predict life satisfaction even after all other independent measures were accounted for. CONCLUSION: Access to the environment (an "outside the person" factor) is important in predicting satisfaction with life for persons with spinal cord injury. The measure of access to the environment developed here is promising and worthy of further exploration and expansion.     

The use of proxies in community integration research

OBJECTIVE: To assess the level of agreement between persons with various disabilities and their proxies in reporting community integration outcomes using the Craig Handicap Assessment and Reporting Technique (CHART). DESIGN: Reliability study. SETTING: Participants living in the community for a minimum of 6 months after onset of disability or completion of inpatient rehabilitation. PARTICIPANTS: Persons (n = 983) with disability resulting from amputation, burn, multiple sclerosis, spinal cord injury (SCI), stroke, or traumatic brain injury and their self-selected proxies. INTERVENTIONS: Telephone interview of subjects (FIM instrument, CHART); proxies (CHART). FIM instrument assesses the degree of assistance with physical and cognitive subscales; CHART measures community integration in 6 subscales: physical, cognitive, and economic independence, and mobility, social integration, and occupation. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs) were used to assess participant-proxy agreement, and stepwise multiple regressions were used to identify patterns of difference in agreement based on disability type and demographic variables. RESULTS: Thirty-seven of the 38 items examined for the entire sample yielded moderate to strong ICCs. Multiple regression analyses indicated that proxies overrated participants with severe functional cognitive disabilities on the mobility subscale (p < .001), overrated participants with less than a high school education on the total CHART score (p < .01), and underrated participants with SCIs on the occupation subscale (p < .01). Differences in all cases, however, were less than 6 points out of a possible score of 100 per subscale. CONCLUSIONS: Participant-proxy agreement across the 6 disability groups provided evidence in support of the inclusion of proxy data for persons with various types of disabilities in community integration research.     

Reliability and validity of the Craig Handicap Assessment and Reporting Technique for Japanese individuals with spinal cord injury

It is necessary and important to quantify the handicap sustained by individuals with spinal cord injury (SCI); however, few instruments are available to measure the level of the disability. One of the best developed and most often used measures is the Craig Handicap Assessment and Reporting Technique (CHART). Nevertheless, a Japanese version has not yet been developed and tested for SCI individuals. The purpose of this study was to develop a Japanese version of the CHART (CHART-J) and to investigate its test-retest reliability and discriminant validity in SCI in Japan. Fifty-four individuals with SCI participated in the test-retest reliability study and 293 participated in the discriminant validity analysis. We have shown that the test-retest reliability coefficients of the CHART-J range from 0.57 to 1.00. In addition, its discriminant validity is acceptable for individuals with SCI in Japan. Therefore, the CHART-J is useful as a measure of disability for Japanese individuals with SCI.     

Reliability and validity of a self-report FIM (FIM-SR) in persons with amputation or spinal cord injury and chronic pain

OBJECTIVE: To evaluate the reliability and validity of a self-report FIM (FIM-SR) in two samples of adults with disabilities. DESIGN: Participants in a clinical trial of amitriptyline for pain (n = 84 with spinal cord injury [SCI], n = 38 with amputation) provided responses to the study measures via telephone interview. Reliability was estimated using Cronbach's alpha and test-retest correlation coefficients, and validity was examined by comparing FIM-SR scores with the Craig Handicap Assessment and Reporting Technique (CHART) by comparing the CHART scores between the participants with SCI and amputation, and by comparing CHART scores between subjects with different levels of SCI. RESULTS: In the SCI sample, the FIM-SR demonstrated adequate reliability, and correlational analyses supported the validity of the FIM-SR motor scales. In addition, the FIM-SR motor scales discriminated subjects with different diagnoses (SCI vs. amputation) and injury levels (paraplegia vs. tetraplegia). The psychometric properties of the entire FIM-SR in the amputation sample and of the FIM-SR cognitive scales in the SCI sample were difficult to determine due to a ceiling effect in which these scale scores were skewed toward the top end of the range. CONCLUSIONS: The FIM-SR motor scales and total FIM-SR score are reliable and valid measures of perceived functional independence in individuals with SCI. However, all of the FIM-SR scales in the amputation sample, and the FIM-SR cognitive scales in the SCI sample, seem to be less useful measures of functioning due to subjects reporting high levels of independence. The FIM-SR should be retested in amputation samples with more variable levels of functioning.     

The relation of shoulder pain and range-of-motion problems to functional limitations, disability, and perceived health of men with spinal cord injury: a multifaceted longitudinal study

OBJECTIVES: To determine if shoulder pain and range-of-motion (ROM) problems can be predicted by demographic, injury-related, body weight, and radiographic data over 3 years and to determine the relationships among these shoulder problems and functional limitations, disability, and perceived health. DESIGN: A longitudinal, 2-panel study in which data were collected at 2 points in time, 3 years apart. SETTING: The community. PARTICIPANTS: Eighty-nine adult men with traumatic spinal cord injury (SCI) in the Houston-Galveston, TX, area. MAIN OUTCOME MEASURES: The acromioclavicular (AC) and the glenohumeral (GH) joints were x-rayed on plain film in standard anteroposterior position. Functional limitations were determined with the FIM instrument; disability was measured with the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS: Thirty percent had shoulder pain and 22% had shoulder ROM problems. Men with shoulder pain had lived longer with SCI, were more likely to report shoulder ROM problems, had lower CHART mobility scores, and were more likely to rate their health as fair than those without shoulder pain. Shoulder ROM problems were more common among men who were older, had AC joint narrowing, had lower FIM scores, and reported poorer health. CONCLUSION: Shoulder pain and ROM problems were relatively prevalent. Demographic, injury-related, and radiographic variables were identified that were predictive of these problems over a period of at least 3 years. The shoulder problems were related to functional limitations, disability, and perceived health.     

Development of a framework for the evidence-based choice of outcome measures in neurological physiotherapy

BACKGROUND: Neurological physiotherapists recognize the need to include standardized outcome measures (OMs) in clinical practice but lack of information about the OMs available hampers utilization. This paper reports on the first stage of a project to identify the most robust OMs for use in neurological physiotherapy. OBJECTIVE: To identify what physiotherapists perceive that they need to measure during a neurological assessment. METHODS: Three separate workshops were held using patient vignettes to represent the acute, rehabilitation and community settings. Thirty senior neurological physiotherapists participated and were asked: 'What would you observe, test or measure if assessing this patient?' Data were analysed using thematic content analysis performed independently by each of the authors. Internal and external member checking ensured validity. In addition, the authors produced definitions of the items and domains identified in the data collection and subsequent content analysis. RESULTS: Items from the data collection were classified into 16 domains that physiotherapists need to measure: Weakness; range of movement/contracture; pain; muscle tone/spasticity; sensation; ataxia/co-ordination; personal fatigue; oedema; subluxation; postural and balance impairment; walking impairment; upper limb; balance disability; walking disability; mobility disability and falls. CONCLUSIONS: The domains that physiotherapists need to measure during clinical assessment were identified. In the second stage of the project these domains will inform systematic reviews to identify the most robust outcome measures for use in clinical practice.     

儿童功能独立检查在脑瘫残疾组测量的效度研究

目的探讨修订的儿童功能独立检查表及方法的有效性。方法在脑瘫（ｃｅｒｅｂｒａｌｐａｌｓｙ,ＣＰ）残疾组３４例儿童中进行儿童功能独立检查的结构效度和实证效度检验。结果儿童功能独立检查表与适应商数（ａｄａｐｔｉｖｅｄｅｖｅｌｏｐｍｅｎｔｑｕｏｔｉｅｎｔ,ＡＤＱ）、神经肌肉系统缺陷程度、美国脑瘫学会（Ａｍｅｒｉｃａｎａｓｓｏｃｉａｔｉｏｎｏｆｃｅｒｅｂｒａｌｐａｌｓｙ,ＡＡＣＰ）障碍分类和治疗性分级的等级相关分析显示,大多数参数的相关系数在统计学上有显著意义。结论儿童功能独立检查是一种有较好效度指标的医疗康复儿童残疾测量工具。     

The relationship of lumbar flexion to disability in patients with low back pain

BACKGROUND AND PURPOSE: Physical therapists routinely assess spinal active range of motion (AROM) in patients with low back pain (LBP). The purpose of this study was to use 2 approaches to examine the relationship between impairment of lumbar spine flexion AROM and disability. One approach relied on the use of normative data to determine when an impairment in flexion AROM was present. The other approach required therapists to make judgments of whether the flexion AROM impairment was relevant to the patient's disability. SUBJECTS: Fifteen physical therapists and 81 patients with LBP completed in the study. METHODS: Patients completed the Roland-Morris Back Pain Questionnaire (RMQ), and the therapists assessed lumbar spine flexion AROM using a dual-inclinometer technique at the initial visit and again at discharge. RESULTS: Correlations between the lumbar flexion AROM measure and disability were low and did not vary appreciably for the 2 approaches tested. CONCLUSION AND DISCUSSION: Measures of lumbar flexion AROM should not be used as surrogate measures of disability. Lumbar spine flexion AROM and disability are weakly correlated, suggesting that flexion AROM measures should not be used as treatment goals.     

Employment after spinal cord injury: an analysis of cases from the Model Spinal Cord Injury Systems

OBJECTIVE: To describe the relationship of multiple biographic, injury-related, and educational factors with employment outcomes after spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Data were collected through 18 model SCI systems, a nationwide network of hospitals that treat approximately 14% of all SCIs in the United States. PARTICIPANTS: A total of 3,756 persons with traumatic SCI who completed the Form II data collection during their annual follow-up at years 1, 2, 5, 10, 15, 20, or 25 years (the most recent Form II was accepted). MAIN OUTCOME MEASURES: The Model Systems Forms I and II were used to identify biographic, injury-related status, employment at injury, and productivity status upon follow-up (Form I is used to elicit basic demographic and discharge information, whereas Form II is used to track multiple outcomes during annual follow-ups). The Craig Handicap Assessment Reporting Technique (CHART) was used to assess hours spent in gainful employment and other productive activities. RESULTS: CHART data revealed only a modestly higher Employment rate (24.8%) than that of the traditional single Form II item (22%). Being Caucasian, younger at injury, having lived more years with SCI, having a less severe injury, and having more years of education were all predictive of being employed. Violence at injury was associated with lower employment rates (only 12.9% employed), especially among Caucasians (only 24% employed). Being employed at injury was associated with a greater probability of postinjury employment, but only in the first few years after injury. Among employed participants, women and those who had been injured fewer years averaged fewer hours spent at work. CONCLUSIONS: Findings were consistent with those in previous studies. Interventions to improve employability should focus on education and the needs of individuals from minority backgrounds.     

Assessment of disability in spinal cord injury

PURPOSE: Spinal cord injury (SCI) implies a drastic change in the quality of life of an individual, and this fact must be considered by the physiatrist. The aim of this study was to assess the degree of disability shown by patients with spinal cord injury at 5 years post-SCI. For this purpose we used the Craig Handicap Assessment and Reporting Technique (CHART) scale which included the evaluation of occupation, physical independence, mobility, social integration and economic self-sufficiency. METHOD: A questionnaire was mailed to 243 patients who were admitted over a one-year period to the Hospital Nacional de Parapléjicos in Toledo, Spain. From these, we received 90 answers. No significant differences were observed when they were compared to the 90 patients who answered the questionnaire. RESULTS: 30% of the patients had less than 333 points on the scale, meaning that they could be considered severely disabled, while a score higher than 438 points was seen in 46.7% of the patients: most of these individuals were younger than 18 and had less severe neurologic injuries. CONCLUSIONS: Despite the enormous impact of SCI, according to the scale used most patients have scores above the disability level.     

Nursing home residence: quality of life among individuals with spinal cord injury

OBJECTIVE: To examine the quality of life among individuals with spinal cord injury currently living in a nursing home vs. community residence. DESIGN: A case-control design matched nursing home and community residents on numerous demographic and medical characteristics. Two groups of 37 individuals (nursing home vs. community residents) were matched case-for-case on age (i.e., within 10 yr), education, gender, race, marital status, and impairment level. Etiology of spinal cord injury, American Spinal Injury Association Impairment Index at the time of rehabilitation discharge, and injury duration, although not specifically matched, were not significantly different between groups (P > 0.05). Outcome measures included the Satisfaction With Life Scale, and the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS: Results indicated that overall self-reported quality of life was significantly lower among nursing home residents compared with matched community-dwelling residents (mean = 18 and 14, respectively). Similarly, self-reported handicap was significantly higher among the nursing home residents compared with community residents (mean = 337 and 181, respectively), particularly in the areas of physical independence, mobility, occupational functioning, and economic self-sufficiency (P < 0.05). In contrast, the score on the CHART social integration subscale was similar across groups (P > 0.05). CONCLUSION: Despite matching numerous variables, the nursing home residents demonstrated significantly lower quality of life across multiple domains as compared with their community-dwelling counterparts. Additional research is needed to examine the specific mechanisms associated with these differences.     

Disability evaluation of extremity fractures

Most fractures heal with restoration of bone and joint function. Disability is generally temporary in these instances, and there is no permanent impairment to be rated in the majority of cases. However, multiple complications can occur that can lead to loss of skeletal function, restricted range of motion, and associated soft tissue injuries, and neurovascular damage can dramatically and severely compromise function and performance. Clearly, not all fractures heal within the timeframes as outlined in Table 2, and determination of the point of maximum medical improvement, which must be achieved in order to declare an impairment as permanent, can be challenging in these cases. Some individuals with fractures that demonstrate bone union radiologically may develop long-term disability; nearly 30% of individuals with a unilateral lower extremity fracture will not return to work within 12 months of injury. In the absence of a complicating soft tissue injury, the explanation for this discrepancy between impairment and disability can be elusive. During the past 10 years, improved systems of trauma care have reduced mortality rates in the United States. As greater numbers of persons survive motor vehicle accidents and other major trauma, the possibility exists that increasing numbers of fractures leading to impairment or disability may be seen. Recognition of how and when fractures heal, possible complications that may arise, risk factors for long-term disability, and the correlation of vocational and avocational physical demands with the resultant outcome will enable the clinician to appropriately and accurately assess disability status, design a rehabilitation program, and assign an impairment rating.     

Enhanced life-role participation in response to comprehensive gait training in chronic-stroke survivors

Purpose: Intensive gait training can produce improvements in gait and function (>6 months after stroke); however, findings are mixed for enhanced life-role participation. Therefore, it is unclear if improved gait and function translate into life-role participation gain. Our objective was to evaluate whether intensive gait therapy can produce improvements in life-role participation for chronic-stroke survivors, according to a comprehensive measure dedicated to life-role participation. Methods: In conjunction with a clinical gait-training trial, we conducted a secondary analysis for a 44-member cohort with stroke (>6 months). Gait-training interventions included functional neuromuscular stimulation, body-weight supported treadmill training, over-ground gait training and exercise for 1.5 hours/day, 4 days/week for 12 weeks. Study measures included Tinetti Gait (gait impairment), Functional Independence Measure (FIM, function), Stroke Impact Scale subscale of life-role participation (SIS part) and Craig Handicap Assessment and Reporting Technique (CHART, life-role participation). Analysis included Wilcoxon signed rank test and polytomous universal regression model. Results: Gait interventions produced significant improvement in CHART (p = 0.020), SIS part (p = 0.011), FIM (p < 0.0001), and Tinetti Gait (p < 0.0001). Age, gender and time since stroke did not predict response to treatment. Conclusions: Intensive gait therapy resulted in significant gain in life-role participation, according to a comprehensive measure, so dedicated. [Box: see text].     

Continuous passive motion improves shoulder joint integrity following stroke

OBJECTIVE: In a pilot study of patients with a first stroke and hemiparesis, we sought to determine whether treatment of the upper limb with continuous passive motion (CPM) that was device delivered would alter impairment, disability or the associated adverse symptoms of shoulder joint instability, pain and tone. DESIGN: Patients were randomly assigned to receive daily CPM treatments or participate in self-range of motion groups under the supervision of an occupational therapist. All patients received standard daily poststroke therapy for 3.5 h per day. A blinded evaluator at admission and discharge assessed patients using standardized scales of impairment, disability and adverse symptoms. SETTING: Specialized stroke unit of an acute rehabilitation hospital. SUBJECTS: Two hundred and eighty consecutive patients were screened and 35 of these with a first unilateral stroke, 13 +/- 6 days following the acute event, provided informed consent and were randomly assigned to CPM treatment or supervised group self-range exercise. MAIN MEASURES: Thirty-two completed the study and were evaluated using standardized measures for motor impairment (Fugl-Meyer, Motor Status Scale and Medical Research Council Motor Power), adverse symptoms (gleno-humeral stability, pain and tone), and disability (Functional Independence Measure). RESULTS: CPM-treated patients demonstrated positive trends towards improved shoulder joint stability (p = 0.06, confidence interval -0.03, 2.3) when compared with patients performing therapist-supervised self-range of motion. There were no significant differences in motor impairment, disability, pain or tone. CONCLUSIONS: Device-delivered continuous passive range of motion may offer an enhanced benefit for some adverse symptom reduction in the hemiplegic arm after stroke over traditional self-range of motion exercise.     

Prognostic factors of long-term functioning and productivity after traumatic brain injury: a systematic review of prospective cohort studies

OBJECTIVE: To systematically review prospective cohort studies that investigated prognostic factors associated with long-term activity limitations or participation restrictions and productivity after a traumatic brain injury. DATA SOURCES: PubMed and Psychinfo were searched from 1995 to April 2005, and references were checked. REVIEW METHODS: Publications were selected if the study assessed prognostic factors for activity limitations or participation restrictions at least one year post injury; outcome was measured with another or additional measure besides the Glasgow Outcome Scale; the design was a prospective cohort study of adult traumatic brain injury patients; the article was a full-text article written in English, French, German or Dutch. Two reviewers independently assessed methodological quality. A study was considered as 'high quality' if it satisfied at least half of the maximum available quality score. RESULTS: Thirty-five articles reporting on 14 cohorts were included. Due to heterogeneity in prognostic factors and outcome measures, a best-evidence synthesis was performed. All cohorts were of high quality. Strong evidence for predicting disability was found for older age, pre-injury unemployment, pre-injury substance abuse, and more disability at rehabilitation discharge. Strong prognostic factors for being non-productive were pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission, and pre-injury substance abuse. CONCLUSION: Older age, pre-injury unemployment, pre-injury substance abuse and more disability at rehabilitation discharge are important predictors of long-term disability. Pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission and pre-injury substance abuse are important predictors of being non-productive.     

Standardized outcome assessment in brain injury rehabilitation for younger adults

Purpose: To explore possible candidates for a common outcome measure for brain injury rehabilitation in younger adults. Method: Patients recovering from brain injury pass through several different stages of rehabilitation, illustrated by the 'Slinky model'. Outcome measures used to assess progress must not only meet scientific criteria for validity and reliability - they must be practical to use in a clinical setting and relevant to the rehabilitation goals at each stage. Within most major rehabilitation settings, the commonest goals focus on reducing disability or dependency. Among the most widely used measures in the UK are the Barthel Index, the Functional Independence Measure (FIM) and the extended Functional Assessment Measure (FIM+FAM). The relationship between these instruments is discussed. Conclusion: No single outcome measure is suitable for all brain injury rehabilitation, but by taking these most widely used measures and understanding the relationship between them, we already have a potential common language in disability measurement between the majority of rehabilitation centres in the UK and beyond. These instruments, however, have clear floor and ceiling effects and further work is needed to agree common measures for rehabilitation intervention that falls outside the sensitivity range of these three scales.     

Measuring disability with parsimony: evidence for the utility of a single item

PURPOSE: To provide evidence for the utility of a single item measure designed to quantify disability in the past 30 days. METHOD: Australian data from studies comprising a community-dwelling elderly sample (N = 328) and a sample of chronic osteoarthritis (OA) patients (N = 119) are reported. Degree of disability was classified as 0-30 days, 0 vs. 1 or more days, and 0-9 vs. 10 or more days. Associations between disability and a range of demographic, health-related, and psychological variables were assessed. RESULTS: Participants with OA reported a significantly higher level of disability than participants from the community sample regardless of how disability was classified. Modest levels of association were noted between the number of disability days (0-30) and both health and psychological indices in both samples. The three alternative classifications of disability made little difference to the significance of associations. On balance, the comparison of 0-9 vs. 10 or more days appeared the more predictive classification of disability. CONCLUSIONS: The performance of the single item measure of disability was generally very satisfactory. Future investigations into the clinical application of the item across a range of patient groups are encouraged.     

Health-related quality of life and disability in survivors of multiple trauma one year after intensive care unit discharge

OBJECTIVE: To evaluate health-related quality of life and disability in multiple-trauma patients requiring intensive care unit management. DESIGN: A total of 87 survivors of multiple trauma, with a median age of 31 yrs and a median Injury Severity Score of 22, were enrolled in the present study. The Nottingham Health Profile, Glasgow Outcome Scale, and Rosser Disability Scale were used to assess the functional consequences of trauma 1 yr after intensive care unit discharge. RESULTS: A total of 64 of 87 patients had a problem in at least one of the six domains related to subjective health status. The most prevalent complaint was related to somatic subdimensions, but emotional functioning was also affected. Nottingham Health Profile part 2 showed that 63 of the survivors experienced problems in at least one of the daily activities. Of particular importance, inability to work was reported by 47% of the patients. Fifty-nine percent experienced moderate-to-severe disability as evaluated by Glasgow Outcome Scale and Rosser Disability Scale. High aggregate injury severity score along with severe head trauma were independent predictors of poor health-related quality of life and disability. CONCLUSIONS: The majority of survivors of major trauma exhibit considerable levels of disability and impairment in health-related quality of life. Global injury severity score and degree of brain trauma determine functional limitations. This information may help in organizing long-term rehabilitation of multiple-trauma patients.