Methods: Initial items on the PMTT were developed based on a literature review and in consultation with therapists experienced in the use of power mobility. Items were trialled in clinical settings, reviewed, and refined. Items were then operationalized and an administration manual detailing scoring for each item was created. Qualitative and quantitative methods were used to establish content validity via a 15 member, international expert panel. The content validity ratio (CVR) was determined for each possible item.
Results: Of the 19 original items, 10 achieved minimum required CVR values and were included in the final version of the PMTT. Items related to manoeuvring a power mobility device were merged and an item related to the number of switches used concurrently to operate a power mobility device were added to the PMTT.
Conclusions: The PMTT may assist therapists in developing training programs that facilitate the acquisition of beginning power mobility skills in children who have multiple, severe impairments.
- Implications for Rehabilitation
The Power Mobility Training Tool (PMTT) was developed to help guide the development of power mobility intervention programs for children who have multiple, severe impairments.
The PMTT can be used with children who access a power mobility device using either a joystick or a switch.
Therapists who have limited experience with power mobility may find the PMTT to be helpful in setting up and conducting power mobility training interventions as a feasible aspect of a plan of care for children who have multiple, severe impairments.
Method: A systematic literature search was conducted in MEDLINE, Cochrane, EMBASE, CINAHL and Web of Science. Included studies compared QoL, function, activity and/or participation level in patients with bone-anchored or socket prostheses. A best-evidence synthesis was performed.
Results: Out of 226 studies, five cohort and two cross-sectional studies were eligible for inclusion, all had methodological shortcomings. These studies used 10 different measurement instruments and two separate questions to assess outcome. Bone-anchored prostheses were associated with better condition-specific QoL and better outcomes on several of the physical QoL subscales, outcomes on the physical bodily pain subscale were inconclusive. Outcomes on function and activity level increased, no change was found at participation level. The level of evidence was limited.
Conclusions: There is a need for a standard set of instruments. There was limited evidence that bone-anchored prostheses resulted in higher QoL, function and activity levels than socket prostheses, in patients with socket-related problems.
- Implications for Rehabilitation
Use of bone-anchored prostheses in combination with intensive outpatient rehabilitation may improve QoL, function and activity level compared with socket prosthesis use in patients with a transfemoral amputation and socket-related problems.
All clinicians and researchers involved with bone-anchored prostheses should use and publish data on QoL, function, activity and participation level.
There needs to be an agreement on a standard set of instruments so that interventions for patients with a lower extremity amputation are assessed consistently.
Methods: In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline.
Results: A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments.
Conclusions: The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients.
- Implications for Rehabilitation
The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation.
The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients’ needs and the degree of priority of the affected ICF category.
Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: ‘Training on the job’ and ‘peer assessment in clinical situations’.
Methods: This study presents the interim results of the Korean Stroke Cohort for Functioning and Rehabilitation. On day 7, stroke evaluation was performed using the functional assessment battery including the National Institute of Health Stroke Scale (NIHSS). At 6 months after stroke, functional outcomes using the face-to-face functional assessment battery including Functional Independence Measure (FIM) were analyzed in the patients who had a score of 0 on the NIHSS at 7 days after stroke onset.
Results: In the very mild stroke group, 455 patients were followed up at 6 months. Out of these patients, 11.0% had impairments in cognitive function, 14.1% had motor impairment, and 2.1% had impairments in their mobility measured by the functional assessment battery. At 6 months after onset, 3.3% of stroke survivors without recurrence showed dependency according to the FIM.
Conclusions: Many acute stroke patients with mild stroke severity as assessed by the NIHSS had impairments in various functional domains, and could have been easily overlooked for intensive rehabilitation therapy. Candidates for comprehensive rehabilitation therapy might be better identified by the functional assessment battery.
- Implications for rehabilitation
Many acute stroke patients with mild stroke severity assessed by NIHSS could be easily overlooked for intensive rehabilitation therapy.
Candidates for comprehensive rehabilitation therapy should be evaluated using a functional assessment battery rather than the NIHSS.
Method: We provide a summary of models of psychological adjustment to chronic disease. We also evaluate various options for incorporating categories of psychological adjustment into the ICF.
Results: Acute and ongoing illness stressors; emotional, cognitive and behavioral responses; personal background; and social and environmental background are major categories in the adjustment process. These categories could, in principle, be integrated with various components of the ICF. Any future revision of the ICF should explicitly incorporate psychological adjustment and its (sub)categories.
Conclusion: The ICF could incorporate categories of psychological adjustment to chronic disease, although several adaptations and clarifications will be required.
- Implications for Rehabilitation
In the context of an ageing society and large numbers of people living with chronic diseases, it is essential to understand psychological adjustment to chronic disease.
However, the classification of psychological adjustment to chronic disease is unclear in the current version of the International Classification of Functioning, Disability and Health (ICF).
We demonstrate that the ICF could incorporate categories of psychological adjustment to chronic disease, although several adaptations and clarifications would first be required.
We suggest that these adaptations and clarifications should be considered in any future revision of the ICF.
Materials and methods: Cross-cultural adaptation of the original English version of the ABILOCO to the Brazilian–Portuguese language followed standardized procedures. The adapted version was administered to 136 stroke subjects and its measurement properties were assessed using Rash analysis. Cross-cultural validity was based on cultural invariance analyses.
Results: Goodness-of-fit analysis revealed one misfitting item. The principal component analysis of the residuals showed that the first dimension explained 45% of the variance in locomotion ability; however, the eigenvalue was 1.92. The ABILOCO-Brazil divided the sample into two levels of ability and the items into about seven levels of difficulty. The item-person map showed some ceiling effect. Cultural invariance analyses revealed that although there were differences in the item calibrations between the ABILOCO-original and ABILOCO-Brazil, they did not impact the measures of locomotion ability.
Conclusions: The ABILOCO-Brazil demonstrated satisfactory measurement properties to be used within both clinical and research contexts in Brazil, as well cross-cultural validity to be used in international/multicentric studies. However, the presence of ceiling effect suggests that it may not be appropriate for the assessment of individuals with high levels of locomotion ability.
- Implications for rehabilitation
Self-report measures of locomotion ability are clinically important, since they describe the abilities of the individuals within real life contexts.
The ABILOCO questionnaire, specific for stroke survivors, demonstrated satisfactory measurement properties, but may not be most appropriate to assess individuals with high levels of locomotion ability
The results of the cross-cultural validity showed that the ABILOCO-Original and the ABILOCO-Brazil calibrations may be used interchangeable.
Method: One hundred and sixty-six subjects with mild to moderate stroke were recruited and interviewed using the PS-SES. The principal axis factoring analysis was run to examine the factor structure, and internal consistency was assessed by computing Cronbach’s alpha coefficient.
Results: The final measure is a 35-item scale with six subscales: (1) managing home participation, (2) staying organized, (3) planning and managing community participation, (4) managing work/productivity, (5) managing communication, and (6) advocating for resources. The instrument demonstrated high internal consistency.
Conclusion: The PS-SES is a reliable measure offering unique information regarding self-efficacy in managing participation.
- Implications for Rehabilitation
Post-stroke participation requires complex management of resources, information, and strategies.
There is a gap in instruments that can assess self-efficacy in managing participation following a stroke.
The PS-SES is a valid tool measuring self-efficacy in using participation strategies in home, work, and community contexts.
Design: Secondary analysis of cross-sectional data from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults.
Setting: 11 western countries.
Subjects: Community-dwelling adults, aged 55 or older.
Main outcome measure: Assessment of goals and priorities.
Results: The final sample size consisted of 17,222 respondents, 54% of whom reported an assessment of their goals and priorities (AGP) by healthcare professionals. In logistic regression model 1, which was used to analyse the entire population, the determinants found to have moderate to large effects on the likelihood of AGP were information exchange on stress, diet or exercise, or both. Country (living in Sweden) and continuity of care (no regular professional or organisation) had moderate to large negative effects on the likelihood of AGP. In model 2, which focussed on respondents who experienced continuity of care, country and information exchange on stress and lifestyle were the main determinants of AGP, with comparable odds ratios to model 1. Furthermore, a professional asking questions also increased the likelihood of AGP.
Conclusions: Continuity of care and information exchange is associated with a higher probability of AGP, while people living in Sweden are less likely to experience these assessments. Further study is required to determine whether increasing information exchange and professionals asking more questions may improve goal setting with older patients.
- Key points
A patient goal-oriented approach can be beneficial for older patients with chronic conditions or multimorbidity; however, discussing goals with these patients is not a common practice.
The likelihood of discussing goals varies by country, occurring most commonly in the USA, and least often in Sweden.
Country-level differences in continuity of care and questions asked by a regularly visited professional affect the goal discussion probability.
Patient characteristics, including age, have less impact than expected on the likelihood of sharing goals.
Method: Focus group discussions including 34 German patients (age 8–18 years) and 21 parents were conducted and qualitatively analyzed. To identify relevant concepts, statements were coded according to the International Classification of Functioning, Disability and Health: Children & Youth version (ICF-CY). Upon condensation, relevant statements were reformulated as items.
Results: 1950 statements related to 125 ICF-CY categories were identified. After condensation and prioritization, 59 items were retained. These were generated based on the ICF-CY domains environmental factors (27 items), activities and participation (18 items), body functions (9 items), and body structures (5 items).
Conclusions: A new instrument, the Achondroplasia Personal Life Experience Scale (APLES) to assess burden of disease and functioning from the patients perspective of children and adolescents with achondroplasia has been developed in its pilot version based on the classification of the ICF-CY. Psychometric performance of the APLES is currently being examined.
- Implications for Rehabilitation
Using the ICF-CY within the development of a disease-specific instrument to assess burden of disease and functioning provides guidance for clinicians and researchers in the selection of appropriate instruments complying with ICF categories.
Qualitative research based on focus group interviews is an effective method to elicit experiences, beliefs, points of view, understandings, perceptions, impressions, needs and concerns as well as attitudes from the perspective of the individuals on a specific topic such as functioning.
Direct assessment of the patient perspective is necessary to thoroughly understand a patient’s experience of disease and treatment, the impact on their functioning and relevant health-care needs.
Including the perspective of the patient and its family is an important component in the provision of health-care services.
Patient-reported outcomes are not only important for the development of interventions and the use in clinical trials but can also be used in medical decision-making processes.
Method: Six focus groups (n= 30) with individuals with spinal cord injury were conducted. Two independent coders thematically analyzed the transcribed data.
Results: Twenty environmental factors were identified, all of which were classified into eight categories: built environment; natural environment; assistive technology; transportation; information and technology access; economics; social support and social attitudes; and systems, services and policies. While all factors had direct impacts on individuals’ participation outcomes, factors within the categories of societal attitudes, policies and economics also affected participation through affecting other environmental factors. Some factors together also showed cumulative or countering effects on participation. Accordingly, a conceptual model of the relationships between environmental factors and participation was constructed.
Conclusions: This study highlighted key environmental factors and their impacts on participation of people with spinal cord injury. The findings support previous research findings but also suggest that different factors may have different levels of impact on participation. Based on our findings, rehabilitation practitioners and policymakers can prioritize intervention plans to optimize the environment for people with spinal cord injury and improve their societal participation.
- Implications for rehabilitation
Environmental factors are critical contributors to participation among people with spinal cord injury (SCI) and need to be addressed in rehabilitation programs.
Factors with broader impacts on participation, such as societal attitudes and policies, should be treated as priorities in intervention plans aimed at improving participation among people with SCI.
Rehabilitation practitioners should not only consider how the community supports people with SCI but also consider how rehabilitation programs change the community.
Method: Two independent expert teams analyzed medical records on 299 consecutive patients admitted for CSS or DSS rehabilitation. One team provided a golden standard for the patient referrals, and the other team provided RCS-E scores. Models for predicting referrals from RCS-E scores were developed on data for 149 patients and tested on the remaining 150 patients.
Results: The optimal RCS-E sum score threshold for referral prediction was 11, predicting the golden standard for patient referral with sensitivity 88%, specificity 78% and correct classification rate 81%. Improved referral prediction performance was achieved by using RCS-E item-wise score thresholds (sensitivity 81%, specificity 89%, correct classification rate 87%). The RCS-E sum score range for patients referred CSS and DSS by the item-wise model was, respectively, 0–12 and 2–22 suggesting strong non-linear interaction of the RCS-E items.
Conclusions: We found excellent referral decision support in the RCS-E and the item specific threshold model, when patients with acquired brain injury are to be referred to CSS or DSS as their primary rehabilitation.
- Implications for Rehabilitation
Efficient rehabilitation after acquired brain injury requires rehabilitation settings that meet patient needs.
Validated tools for referral decision support make the process more transparent.
Patient rehabilitation complexity can be stratified by the RCS-E with high sensitivity, specificity and predictive value of positive test.
RCS-E is an excellent tool for referral decision support.
Methods: Participants in MMR from an outpatient rehabilitation unit in primary care in Sweden were recruited for interviews about any kind of change they experienced that they thought were related to their participation in the MMR. Systematic text condensation according to Malterud was used to analyze the data.
Results: A total of 14 participants were interviewed. The interview analysis resulted in four categories in which the participants described their experience of change related to the MMR: a new desire for participation, increased embodied knowledge, a stronger sense of feeling empowered and regained hope. The categories interacted and from these categories, one theme emerged: a sense of increased living space.
Conclusion: According to these results, it is important to have various entrances to enhance change and to be aware of how these changes interact and can reinforce each other in order to facilitate the participants’ empowerment processes toward a sense of increased living space.
- Implications for rehabilitation
The efforts in MMR should be coordinated to be mutually reinforcing as changes in one area could facilitate in others and thus facilitate the participants’ empowerment processes.
Participants experience change after MMR in areas that standardized assessment questionnaires do not capture and consequently it would be useful to let the participants answer an open question about perceived changes together with standardized questionnaires.
Method: A systematic literature search for papers evaluating multimodal rehabilitation was conducted. The PubMed and EBSCO databases were searched from 1995 to 2015. Two or three researchers independently read each paper, performed a quality assessment and coded meanings of gender using qualitative content analysis.
Results: Twenty-seven papers were included in the review. Gender was used very differently in the MMR studies investigated but primarily it referred to factual differences between men and women. Only one paper provided a definition of the concept of gender and how it had been used in that study. In the content analysis, the meaning of gender formed three categories: “Gender as a factual difference”, “The man is the ideal” and “Gender as a result of social role expectations”.
Conclusions: The meaning of the concept of gender in multimodal rehabilitation is undefined and needs to be developed further. The way the concept is used should be defined in the design and evaluation of multimodal rehabilitation in future studies.
- Implications for rehabilitation
Healthcare professionals should reflect on gender relations in encounters with patients, selection of patients into rehabilitation programs and design of programs.
In rehabilitation for chronic pain the patients’ social circumstances and cultural context should be given the same consideration as biological sex and pain symptoms.
Methods: We conducted retrospective cognitive interviews with 13 participants in an out-patient heart center. Interviews were transcribed and analyzed based on the framework approach to qualitative analysis. The four stages from Tourangeau’s cognitive model were used as a framework to index the data from each item.
Results: There was variation in comprehension of questions leading to variation in responses. Comprehension issues were due to terms perceived by participants to be vague and the use of English terms uncommon in Singapore. Cultural influences impacted decision processes and problems with response processes of the self-rating Likert scale surfaced.
Conclusions: This study reinforces the need to culturally adapt the tool, even when language translation is not necessary. Providing Likert scales with a larger number of may widen the relevance of PAM-13 in Singapore.
- Implications for rehabilitation
Need to culturally adapt assessment tool, even when language translation is not necessary.
Consider using Likert scales with a larger number of categories when using in Asian countries such as Singapore.
Caution must be taken when using PAM-13 levels to decide interventions for each individual.
Methods: Each meaningful concept included in the BMS assessments was linked to the International Classification of Functioning, Disability and Health (ICF) in order to classify and describe the content of each measure. The linking was completed by two experienced coders. The perspective of each assessment was also determined.
Results: The body function component was most frequently addressed overall followed by the activities and participation component. The component body structures and environmental factors are not extensively covered in the BMS assessments. ICF chapter and category distribution varied greatly between assessments. The assessments were of the health status perspective.
Conclusion: This study suggests a need to revisit the item composition of the BMS assessments to more evenly distribute ICF topics and subtopics that are pertinent to burn injury which will ensure a broader but more precise understanding of burn injury recovery.
- Implications for Rehabilitation
A better understanding of the data collected through the Burn Model Systems (BMS) project may contribute to improve data collection tools and ultimately lead to clinical practice innovations and improvements.
Clinicians interested in using BMS data for research purposes can better understand what topics are included and excluded in the collection and what perspectives are addressed.
This study highlights the need for burn clinicians around the world to lend their expertise to the WHO for the development of a much needed burn injury International Classification of Functioning, Disability and Health Core Set.
Design Data were collected during a three-month prospective, non-randomized follow-up study (Effective Health Centre) using questionnaires and an electronic health record.
Setting Three primary health care practices in Pirkanmaa, Finland.
Subjects Altogether 622 patients were recruited during a one-week period. Inclusion criteria: the patient had a doctor’s or nurse’s appointment on the recruiting day and agreed to participate. Exclusion criteria: patients visiting a specialized health guidance clinic for pregnant women, children, and mothers.
Main outcome measures Patient characteristics, resource use, and costs based on the ICPC-2 EOC classification.
Results On average, the patients had 1.22 EOCs during the three months. Patient characteristics and resource use differed between the EOC chapters. Chapter L, “Musculoskeletal”, had the most episodes (17%). The most common (8%) single EOC was “upper respiratory infection”. The mean cost of an episode (COE) was €389.56 (standard error 61.11) and the median COE was €165.00 (interquartile range €118.46–288.56) during the three-month follow-up. The most expensive chapter was K, “Circulatory”, with a mean COE of €909.85. The most expensive single COE was in chapter K, €32 545.56. The most expensive 1% of the COEs summed up covered 36% of the total COEs.
Conclusion Patient characteristics, resource use, and costs differed between the ICPC-2 chapters, which could be taken into account in service planning and pricing. Future studies should incorporate more specific diagnoses, larger data sets, and longer follow-up times.
- Key points
The most common episodes were under the ICPC-2 “Musculoskeletal” chapter, but the highest mean and single-episode costs were related to the “Circulatory” chapter.
The mean (median) cost of episodes that started in primary care was €390 (€165) during the three-month follow-up.
Patient characteristics, resource use, and costs differed significantly between the ICPC-2 chapters. The most expensive 1% of the episodes covered 36% of the total costs of all the episodes.
Method: Fifty-two participants were recruited from six rehabilitation centers in Norway. Goals were formulated by the participants during semi-structured goal-setting conversations with health professionals trained in motivational interviewing. An inductive qualitative content analysis was conducted to classify and quantify the expressed goals. Changes in goal content from admission to discharge were calculated as percentage differences. Goal content was explored across demographic and contextual characteristics.
Results: A total of 779 rehabilitation goals were classified into 35 categories, within nine overarching dimensions. These goals varied and covered a wide range of topics. Most common at admission were goals concerning healthy lifestyle, followed by goals concerning symptoms, managing everyday life, adaptation, disease management, social life, and knowledge. At discharge, goals about knowledge and symptoms decreased considerably, and goals about healthy lifestyle and adaptation increased. The health profession involved and patient gender influenced goal content.
Conclusions: The rehabilitation goals of the patients with rheumatic diseases were found to be wide-ranging, with healthy lifestyle as the most prominent focus. Goal content changed between admission to, and discharge from, rehabilitation stays.
- Implications for rehabilitation
Rehabilitation goals set by patients with rheumatic diseases most frequently concern healthy lifestyle changes, yet span a wide range of topics.
Patient goals vary by gender and are influenced by the profession of the health care worker involved in the goal-setting process.
To meet the diversity of patient needs, health professionals need to be aware of their potential influence on the actual goal-setting task, which may limit the range of topics patients present when they are asked to set rehabilitation goals.
The proposed framework for classifying goal content has the capacity to detect changes in goals occurring during the rehabilitation process, and may be used as a clinical tool during goal-setting conversations for this patient group.
Design: Qualitative study. Focus group discussion and analysis through Systematic Text Condensation.
Setting: Primary Health Care, Region Västra Götaland, Sweden.
Subjects: Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations.
Main Outcome measure: Patients’ experiences and perceptions of the use of MADRS-S in primary care.
Results: Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression.
Conclusion: Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides.
- Key Points
Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to
Confirmation: MADRS-S shows that I have depression and how serious it is.
Centeredness: The most important thing is for the GP to listen to and take me seriously.
Clarification: MADRS-S helps me understand why I need treatment for depression.