Toward a cognitive-affective model of goal-setting in rehabilitation: is self-regulation theory a key step?

Purpose: The aim of this article is to argue that self-regulation theory might offer a useful model for clinical practice, theory-building and empirical research on goal-setting in rehabilitation.

Method: Relevant literature on goal-setting and motivation in rehabilitation is considered and some problematic issues for current practice and future research are highlighted. Carver and Scheier's self-regulation theory and its application to rehabilitation research is examined.

Results: It is argued that self-regulation theory offers a robust theoretical framework for goal-setting and one in which the salient concepts of motivation and emotion are prominent.

Conclusions: Self-regulation theory offers a potentially useful heuristic framework for rehabilitation research.     

Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature

Purpose: The objective of our study was to identify prognostic social factors in the subacute phase after stroke for the discharge destination from the hospital stroke-unit.

Methods: A systematic literature search was performed, designed in accordance with the Cochrane Collaboration criteria. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria.

Results: Characteristics of the social situation that proved to be important for prediction of the discharge destination are marital status and social support. Quantity and methodological quality of the research studies were insufficient, and the number of possible social prognostic factors investigated was limited by the absence of a conceptual framework of social subdomains in the studies, including an unambiguous definition of the prognostic social factors within these subdomains.

Conclusions: A great need exists for research into the prognostic qualities of the following social factors: the ability to provide support, presence, and readiness of the homefront; the availability of professional care, personal financial means, membership of societies and clubs, frequency of contacts with close relatives and friends; the quality of the patient's residence with regard to the adaptation to the needs and abilities of the patient. A commitment about the aforementioned conceptual framework is mandatory.     

Long-term outcomes after moderate to severe traumatic brain injury

Objective: This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI).

Design: Retrospective cohort study.

Setting and subjects: We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury.

Main outcome measures: Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services.

Results: Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living.

Conclusion: Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.     

A comparison of consumer-directed and agency-directed personal assistance services programmes

Purpose: To compare a consumer-directed personal assistance services (PAS) programme with an agency-directed PAS programme.

Method: A convenience sample was used for this cross-sectional study with one data collection point. Outcomes were compared for consumer-directed and agency-directed PAS. Hierarchical regressions were also used to determine the predictors of outcomes across PAS programmes. In-home interviews were conducted by a trained data collector from April 2000 to December 2001.

Results: Participants in the consumer-directed programme reported more choices over PAS and satisfaction with PAS. Self-reported outcomes were primarily predicted by the following variables: service arrangement, type of provider, importance of directing PAS, health status, number of personal assistants used in past 12 months, sufficient PAS hours received, and social support.

Conclusions: Consumer-directed PAS enhances outcomes for many persons with disabilities. Self-reported outcomes are affected by many factors that could be addressed in PAS programme development.     

Agricultural workers' return to work following spinal cord injury: a comparison with other industry workers

Purpose: To investigate the impact of spinal cord injury on employment outcomes as experienced by agricultural workers in comparison with persons employed in other industries. Because of the challenges associated with working in many of the agricultural industries, it was anticipated that agricultural workers would achieve inferior return-to-work outcomes.

Method: Survey of all employed persons who experienced a traumatic spinal cord injury in southeastern Australia between 1990 and 1996 (inclusive).

Results: Contrary to expectation, agricultural workers had a significantly higher rate of return to work (61.7% vs. 41.1%). However, an investigation into the hours spent working and agricultural workers' satisfaction with their employment activities, indicated that most were underemployed and had the potential to achieve even better outcomes.

Conclusion: Results indicate that more can be done to help injured agricultural workers achieve their employment potential.     

Reliability and validity of the Dutch version of QUEST 2.0 with users of various types of assistive devices

Purpose : In this paper, the Dutch version of the Quebec User Evaluation of Satisfaction with assistive Technology (D-QUEST) is validated in users of a large variety of assistive devices ( n =2002).

Method : D-QUEST consists of a written questionnaire. The respondent rates his or her satisfaction with respect to 12 aspects on a five-point scale. Users of 10 different types of assistive devices participated. Analyses were performed for each type of assistive device. Reliability is tested by analysing internal consistency. Content validity is tested by analysing applicability of the 12 aspects. The non-applicability option for answering questions is studied. Construct validity is tested by analysing correlations with problem solving and with general satisfaction.

Results : Reliability proves to be good for all types of assistive devices. Including the non-applicability option improves the feasibility of the instrument without affecting content validity. Correlations between D-QUEST scores on the one hand and problem solving and general satisfaction questions on the other are as expected, supporting validity.

Conclusions : D-QUEST (and therefore also QUEST) proves itself to be a highly applicable, reliable and valid instrument to assess user-satisfaction of users of all kinds of assistive device provisions.     

Designing effective written health education materials: considerations for health professionals

Purpose: Written health education materials can only be effective if they can be read, understood, and remembered by patients. The purpose of this article was to review the literature about features that should be incorporated into written health education materials to maximize their effectiveness, identify where there is consensus and debate about which features should be incorporated, and develop recommendations that health professionals can use when reviewing their existing materials and designing new materials.

Method: Literature review of published research and education articles.

Results: There is a large number of features that need to be considered when designing written health education materials so that they are suitable for the target audience and effective. Although there is consensus about the majority of features that should be included, further research is needed to explore the contribution of certain features, such as illustrations, to the effectiveness of written materials and the effect of well-designed written materials on patient outcomes.

Conclusions: Health professionals need to provide their patients with written health education materials that are patient-orientated and designed according to the best practice principles in written health education material design.     

Measuring fatigue in people with multiple sclerosis

Objective: To compare methods of assessing fatigue.

Design: Cross sectional.

Setting: Community.

Subjects: Forty Multile Sclerosis (MS) patients and 20 healthy controls.

Main outcome measures: Fatigue questionnaires, SDSA dot cancellation test, finger tapping test, TEA Lottery.

Results: The MS patients had significantly higher levels of fatigue than the controls on the Task Induced Fatigue Scale, Fatigue Severity Scale and Fatigue Impact Scale. The Task Induced Fatigue Scale completed whilst imagining oneself driving and the Fatigue Assessment Instrument did not differentiate between MS patients and controls. Finger tapping differentiated between MS patients and controls but there was no significant difference between MS patients and controls on visual and auditory concentration tests. A factor analysis indicated that questionnaire measures of fatigue were inter-related but independent of objective test performance.

Conclusions: Questionnaire measures can be used to assess fatigue in people with MS. The FSS differentiated MS patients from controls and is relatively short. It was therefore recommended for clinical use.     

Long-term outcome of equestrian injuries in children

Purpose: To investigate the possible development of long-term disabilities arising from paediatric equestrian injuries.

Method: All patients, aged 17 years or younger, treated in a hospital setting because of an equestrian injury during a five-year period received a questionnaire. A reference population and healthy friends served as controls.

Results: Four years post-injury, 41 of the 100 respondents still experienced disabilities following the injury. The median Injury Severity Score was 4. Absenteeism from school lasted 2 weeks, and from horse riding, 4 months. Compared to the reference population, the results of the Child Health Questionnaire were poorer considering most of its subscales. In comparison with the friends, the patients only scored lower on 'physical functioning'. The risk factors concerning poor long-term outcomes were being an advanced rider, sustaining injuries other than fractures of the extremities or sustaining subsequent injuries following the riding accident.

Conclusions: Although equestrian injuries in children are minor to moderate in their severity, these injuries are significant considering that a large proportion of patients experience long-term disabilities.     

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

Purpose: The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

Method: The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa = 0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

Results: The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

Conclusions: A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.     

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

Methods: Design: A prospective observational cohort study and a cross-sectional study.

Setting: University hospital in the Netherlands.

Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.     

The bath environment, the bathing task, and the older adult: a review and future directions for bathing disability research

Purpose. To review existing research studies to identify optimal intervention strategies for remediation and prevention of bathing disability and future directions for bathing disability research.

Method. Bathing disability, defined as problems in the interaction between the person and the environment during bathing performance, is examined through a comprehensive, narrative literature review.

Results. Most studies focus on the relationship between the person and the environment (such as assistive device use and environmental hazards) while fewer studies focus on analysis of the bathing task or the interaction of the person, environment, and bathing task. Of intervention studies, most do not focus solely on remediation of bathing disability and outcomes vary widely.

Conclusions. In order to help remediate and prevent bathing disability, it will be necessary to better understand and measure the person-environment-occupation interaction involved in bathing as it relates to specific groups of older adults.     

Mirror treatment of lower limb phantom pain: A case study

Purpose: Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that 'mirror treatment' can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic 'mirror treatment' for lower-limb phantom pain.

Method: We present the first case study of the use of 'mirror treatment' in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results: During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion: This case study, conducted in a conventional clinical setting, supports the potential of 'mirror treatment' for PLP in people with a lower limb amputation.     

A new design approach of user-centered design on a personal assistive bathing device for hemiplegia

Purpose. To move closer to the goal of independent living for stroke patients with hemiplegia, this study is to design an assistive bathing device approached from a User-Centred Design (UCD).

Method. Based on User-Centred Design methodology, a design process is adopted for this study. Observation and evaluation results from a Usability Context Analysis (UCA) are employed to improve the strengths, weaknesses, opportunities and threats (SWOT) and the matrix for matching the environmental threats and opportunities with company's weaknesses and especially it's strengths (TOWS), resulting in two assistive device (AD) design methods named AD-SWOT and AD-TOWS. Therefore, a new assistive device design process (AD-Design process) is proposed. A case study of stroke patients is conducted to practically apply the AD-Design process to the design of assistive bathing devices for stroke patients.

Results. By using the AD-Design process, three design concept orientations (AD-SO, AD-ST, AD-WO) were found for design concept generating from AD-TOWS. Four concepts for AD were decided and designed by the viewpoint of UCD. Finally, three ADs for bathing were tested by user-based assessment. And results showed the devices can help individuals clean case's body parts, such as case's backs and armpits that they were previously unable to clean independently.

Conclusions. AD-design process could help a product designer to generate suitable design approaching from UCD. In this study, three ADs (Back Cleaning Board, Feet Cleaning and Single-Sided Elastic Bathing Belt) were designed for a stroke patient's individual bathing.     

Disability prevention and communication among workers, physicians, employers, and insurers--current models and opportunities for improvement

Purpose: To review prevailing models of disability management and prevention with respect to communication, and to suggest alternative approaches.

Method: Review of selected articles.

Results: Effective disability management and return to work strategies have been the focus of an increasing number of intervention programmes and associated research studies, spanning a variety of worker populations and provider and business perspectives. Although primary and secondary disability prevention approaches have addressed theoretical basis, methods and costs, few identify communication as a key factor influencing disability outcomes. Four prevailing models of disability management and prevention (medical model, physical rehabilitation model, job-match model, and managed care model) are identified. The medical model emphasizes the physician's role to define functional limitations and job restrictions. In the physical rehabilitation model, rehabilitation professionals communicate the importance of exercise and muscle reconditioning for resuming normal work activities. The job-match model relies on the ability of employers to accurately communicate physical job requirements. The managed care model focuses on dissemination of acceptable standards for medical treatment and duration of work absence, and interventions by case managers when these standards are exceeded. Despite contrary evidence for many health impairments, these models share a common assumption that medical disability outcomes are highly predictable and unaffected by either individual or contextual factors. As a result, communication is often authoritative and unidirectional, with workers and employers in a passive role.

Conclusion: Improvements in communication may be responsible for successes across a variety of new interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost-effective; however, controlled trials are needed.     

Success in the workplace following traumatic brain injury: are we evaluating what is most important?

Purpose: Vocational outcome, and in particular full-time paid work, is considered an important indicator of successful rehabilitation following traumatic brain injury (TBI). However it has not been established that these outcomes adequately or accurately represent the values of the people with TBI. This paper describes a study exploring the experiences of individuals who attempted returning to work following TBI, with emphasis on factors that related to perceptions of 'success' or 'failure'.

Method: A phenomenological study, interviewing seven people with moderate to severe TBI was conducted. The interview data were analysed for themes relating to experiences of success or failure in the workplace. Community consultation provided additional perspectives in the interpretation and validation of results.

Results: The results of this study support in part the assumption that paid employment is indicative of success following TBI. Equally prevalent were findings that challenged this assumption, including situations where: (1) return to employment contributed to catastrophic personal events, (2) feelings of success were achieved even though paid employment was not, and (3) success in the workplace was associated with factors other than hours worked or pay earned.

Conclusions: This research suggests that the use of work placement as a measure of successful rehabilitation might misrepresent the perspective of individuals with TBI. A multi-factorial approach to evaluating vocational rehabilitation is recommended, which incorporates the subjective experience of work.     

Behavioural cues of personality in Parkinson's disease

Purpose: To determine if there were observable cues of personality to be found in the appearance and expressive behaviour of six men and six women with Parkinson's disease.

Method: Participants completed a personality measure and engaged in an individual, videotaped interview. Four trained raters measured the expressive behaviour demonstrated in the videotapes. A correlational design was used to explore associations between self-reported personality and measures of expressive behaviour.

Results: In this sample, more eyebrow furrowing indicated significantly higher levels of Neuroticism and less formal dress indicated significantly higher levels of Openness to Experience. These associations remained large and significant after controlling for the effect of disease severity.

Conclusions: Whereas previous research has focused on the detrimental effect of Parkinson's disease symptoms on first impressions, this study explored the potential for accurate first impressions of personality by identifying observable cues of personality. Findings suggest that in early stages of Parkinson's disease there may be plausible and intuitive cues of personality present in expressive behaviour.