REPAS,a summary rating scale for resistance to passive movement: Item selection,reliability and validity

Purpose.?To establish: (i) item characteristics and item selection for the REPAS; (ii) internal consistency, inter-rater and test-retest reliability of the final REPAS version and its subtests; (iii) the association between the REPAS and selected other clinical scales of impairment and activity limitation.

Method.?Thirty-three neurological patients with central paresis. Two REPAS assessments with a one-week interval by two independent raters. Concurrent assessment of the Motricity Index, Box-and-Block test, Functional Ambulation Category, Timed walking, Barthel Index, Disability Rating Scale, Carer Burden Scale, and Hygiene Score.

Results.?Twenty-six of 52 REPAS items fulfilled the item selection criteria. The final test version showed a high internal consistency, inter-rater and test-retest reliability (correlation coefficients: 0.87 – 0.97, no significant difference between raters or with test repetition). Reliability of the arm and leg subtests was substantial (correlation coefficients: arm subtest 0.63 – 0.98, leg subtest 0.56 – 0.96). REPAS scores were moderately associated with basic ADL competence and a carer's burden with arm or leg adductor spasticity. The REPAS, arm subtest scores, degree of arm paresis and gross manual dexterity showed a moderately high association.

Conclusions.?The Ashworth scale-based guidelines assured comparability of test administration and scoring. The REPAS is a reliable and valid summary rating scale for resistance to passive movement.     

Assessment of arm/hand functioning in children with a congenital transverse or longitudinal reduction deficiency of the upper limb

Purpose. Selection of appropriate functional tests and questionnaires to assess capacity (tests) and performance (questionnaires) of arm/hand functioning in children with congenital transverse or longitudinal (radius dysplasia) reduction deficiencies of the upper limb.

Method. A PubMed Medline search was performed. Tests and questionnaires were evaluated according to three criteria: (1) items represent bimanual daily activities, (2a) quality of movement is scored (tests) or (2b) difficulty in performing a task (questionnaires), (3) instrument is attractive for children aged 4 - 12.

Results. We found 14 functional tests and nine questionnaires to measure arm/hand functioning. Three tests, the Assisting Hand Assessment (AHA), Unilateral Below Elbow Test (UBET) and University of New Brunswick Test of prosthetic function (UNB Test) and two questionnaires, the Prosthetic Upper limb Functional Index (PUFI) and the children's version of the ABILHAND (ABILHAND-Kids) met the criteria.

Conclusions. Two functional tests (AHA and UBET) and two questionnaires (ABILHAND-Kids and PUFI) were considered appropriate to assess arm/hand functioning in children with congenital reduction deficiencies of the upper limb, but require further study on psychometric properties for these patient groups.     

Can the results 6 months after anterior cervical decompression and fusion identify patients who will have remaining deficit at long-term?

Purpose. There is no knowledge if short-term outcome in patients after anterior cervical decompression and fusion (ACDF) can be used to identify which patients have remaining deficit in long term. This study investigates if 6-month outcome with a broad assessment after ACDF with a cervical intervertebral fusion cage can be a guide for the 3-years outcome.

Method. A prospective study. Questions about background data, pain, numbness, neck specific disability, distress, sick leave, health, symptom satisfaction and effect of and satisfaction with surgery were asked 28 patients 3 years after ACDF. Measurements have earlier been obtained before and 6 and 12 months after ACDF.

Results. Compared with the results before surgery patients had improved in pain intensity (p = 0.001), neck pain (0.001), numbness (p = 0.02) and were more 'satisfied' with having their neck problems (p = 0.01). Except for a worsening in expectations of surgery fulfilled (p = 0.04) there were no significant differences between 6-month and 3-year outcome. Three years after ACDF about two-thirds of the patients had remaining deficit with regard to pain intensity, Neck Disability Index, Distress and Risk Assessment Method and general health. According to the parameters studied 50 - 78% of those who at the 6-month follow-up were without deficit were still healthy at the 3-year follow-up. For patients with deficit at 6-month follow-up, still 83 - 100% had deficit 3 years after surgery.

Conclusions. Despite a rather small study obtained the stability of 6-month and 3-year results indicates that short-term results might be sufficient for evaluating effects of the treatment. Since the patients in this study clearly demonstrate broad problems array of development of more structured multi-professional rehabilitation models including exercises which improve neck muscle strength, endurance and proprioception need to be introduced.     

Reliability and validity of The Awareness of Social Inference Test (TASIT): a clinical test of social perception

Purpose. The Awareness of Social Inference Test (TASIT) is an audiovisual tool designed for the clinical assessment of social perception with alternate forms for re-testing. Part 1 assesses emotion recognition, Parts 2 and 3 assess the ability to interpret conversational remarks meant literally (i.e., sincere remarks and lies) or non-literally (i.e., sarcasm) as well as the ability to make judgments about the thoughts, intentions and feelings of speakers. This paper aims to examine TASIT's reliability and validity.

Method. Some 32 adults with severe, chronic brain injuries were administered Form A twice, one week apart. 38 adults with brain injuries were readministered alternate forms over a period of 5 - 26 weeks. Construct validity was examined in subsets of a sample of 116 adults with brain injuries by relating TASIT performance to standard tests of neuropsychological function and specific social perception measures.

Results. Test-retest reliability ranged from 0.74 - 0.88. Alternate forms reliability ranged from 0.62 - 0.83. TASIT performance was associated with face perception, information processing speed and working memory. Socially relevant new learning and executive tasks were significantly associated with TASIT performance whereas non-social tasks showed little association. Social perception tasks such as Ekman photos and theory of mind stories were also associated.

Conclusions. TASIT has adequate psychometric properties as a clinical test of social perception. It is not overly prone to practice effects and is reliable for repeat administrations. Performance on TASIT is affected by information processing speed, working memory, new learning and executive functioning, but the uniquely social material that comprises the stimuli for TASIT will provide useful insights into the particular difficulties people with clinical conditions experience when interpreting complex social phenomena.     

Characteristics of the Frenchay Activities Index one year after a stroke: a population-based study

Purpose. To further describe the properties of Frenchay Activities Index (FAI) with special emphasis on relationships with stroke severity and cognition.

Methods. Survivors from a population-based first-ever stroke cohort (n = 246) were assessed with FAI one year post-stroke. At the same time patients were asked about their status pre-stroke. Stroke severity was assessed at baseline with the NIH stroke scale (NIHSS). Cognition was assessed at one year with the Mini Mental State Examination (MMSE).

Results. Pre-stroke and post-stroke FAI averaged at 40.1 and 32.4, respectively. There was a floor effect post-stroke, where 17% had the lowest possible score. The sum score was related to age, but not to gender. Individual items, however, were gender-related. NIHSS was clearly related to the difference FAI pre-stroke - post-stroke, but individual variations were large. Individual NIHSS items differed regarding their impact on post-stroke FAI. MMSE post-stroke also has a clear relationship with FAI, but there are large individual variations.

Conclusions. This study establishes a population-based standard for FAI scores one year after a stroke. The effects of stroke severity and cognition have been demonstrated. FAI gives useful information that is not obtained from basic ADL scales, such as the Barthel Index.     

Clinical significance of specific spinal mobilization for patients with ankylosing spondylitis evaluated by quantitative assessments and patient interviews

Purpose. To assess individual responses to specific spinal mobilization (SSM) in terms of spinal mobility, perceived stiffness, pain and activities of daily living (ADL) in patients with Ankylosis Spondylitis (AS), and whether and how interviews supported or supplemented the quantitative results.

Methods. Spinal mobility was recorded by the fingertip-to-floor distance, the Modified Schober Test, myerinometer, and the chest expansion test. The measures corresponding to sites targeted by SSM was used as effect variables, and the other as control variables. Visual analogue scales assessed pain and stiffness. The Bath Ankylosing Spondylitis Functional Index assessed ADL. A single subject experimental design was applied. The patients' experiences were investigated by semi-structured qualitative interviews.

Results. Six patients completed 12 sessions of SSM. In five patients spinal mobility improved by 6-38%, and perceived stiffness reduced by 6 - 82%. Further improvements were found after three months. Improvements were not seen in the control variables. The interviews revealed that to become less stiff had various meanings for the patients, the SSM helped to get control of motion, and the conversations with the therapists enabled them to cope with the situation.

Conclusions. The findings suggest that SSM can diminish spinal stiffness, but this had different meanings for the patients. What were important were what they experienced and learnt during the therapy process.     

Gait in the early days after total knee and hip arthroplasty: a comparison

Purpose. To evaluate whether gait after Total Knee Arthroplasty (TKA) is different from gait after Total Hip Arthroplasty (THA) in the early days following surgical intervention.

Method. The gait was studied in water, thus exploiting its buoyancy force. Twenty consecutive patients underwent TKA and twenty consecutive patients underwent THA. The mean age was 70.2 years (SD 6.9). Twenty age-matched volunteers were the control group.

Results. At the beginning TKA and THA patients had the same speed and the same step length. At day 15 there was a speed difference in favour of THA patients (t = - 2.245, df 38, p = 0.031). Likewise, the step length was longer in THA patients (t = -2.293 df 38, p = 0.027). In contrast to TKA patients, THA patients were unbalanced, having a longer stance phase on the non-operated leg and a longer swing on the contralateral one.

Conclusions. Gait strategies were completely different after TKA and THA interventions. TKA patients were balanced over their feet and they appeared more cautious and more concerned about gait quality than moving quickly. By contrast, THA patients were unbalanced, having a longer stance phase on the non-operated leg and a longer swing on the contralateral one. However, their speed gain was higher.     

Reliability and construct validity of the client-centred rehabilitation questionnaire

Purpose. A key component in assessing the performance of rehabilitation services is the client's perspective. The purpose of this paper is to report on the development of a publicly available measure of client-centred rehabilitation (CCRQ) that can be used for discriminative and evaluative purposes.

Method. Mixed qualitatative and quantitative methods were used. Phase 1: Identification of seven domains of client-centred rehabilitation based on a literature review, focus groups with clients, and review by content experts. Phase 2: Item generation for the seven conceptually derived subscales and cognitive interviews with inpatient rehabilitation patients. Phase 3: Psychometric testing for internal reliability, test-retest reliability and discriminative construct validity using data from a mailed, self-administered survey to 1568 patients discharged from two large inpatient rehabilitation facilities.

Results. The seven conceptually derived subscales all have strong internal (0.72 - 0.87) and test-retest reliability (0.74 - 0.85). Discriminative construct validity is demonstrated by the ability of subscales to identify significant differences between programs within two rehabilitation facilities.

Conclusions. The results for the reliability and validity of this measure support its value for use in clinical and quality improvement work as well as research.     

Can children with developmental coordination disorder adapt to task constraints when catching two-handed?

Purpose. To compare the nature and extent of inter and intralimb coupling during two-handed catching and the effect of manipulating task constraints in children with Developmental Coordination Disorder (DCD) and their typically developing peers (AMC).

Method. Twenty children aged 7 - 10 years, ten with DCD and 10 AMC attempted to catch a ball ten times in condition 1 (C1), ball to the midline; condition 2 (C2), ball to the left shoulder and condition 3 (C3), ball to the right shoulder. Both 3D kinematic data and video data were collected.

Results. Children with DCD caught fewer balls than the AMC children, regardless of age or condition (p ≤ 0.001). Children with DCD demonstrated a higher degree of linkage between limbs in C1 and a lower degree of between limb coupling in C2 and C3 when compared to the AMC (p ≤ 0.05). Differences between the AMC7 - 8 and AMC9 - 10 group were found with respect to interlimb coupling.

Conclusions. The influence of manipulating task constraints and the individual nature of children with DCD must be considered by those involved in rehabilitation. By doing so, children with DCD may search for appropriate motor solutions to many functional movement tasks required for everyday life.     

Young women with fibromyalgia in the United States and Sweden: perceived difficulties during the first year after diagnosis

Purpose. The major symptoms of fibromyalgia (FM) - pain, tiredness, disrupted sleep, and muscle weakness - severely impact everyday activities, including the paid work role of women who have had FM for a long time. There are no prospective studies on young and newly diagnosed women with FM. The aim of the present study was to describe and compare difficulties young and newly diagnosed women in Sweden and the United States experienced during their first year after diagnosis.

Method. Three interviews, 6 months apart, were conducted, with 49 Swedish and 45 US women between the ages of 18 and 39. Five open-ended questions were asked concerning physical, psychological and social difficulties and limitations, and factors that increased or decreased their difficulties and limitations. At interviews 2 and 3 the women were also asked about ways of preventing their difficulties. The answers were written down and analysed by a content analysis approach.

Results. Consistent categories of difficulties were reported: symptoms, movements, activities, moods, social network, external factors and coping strategies. More US women were working outside their homes than were their Swedish counterparts and they expressed more difficulties compared with the Swedish women.

Conclusions. In general, difficulties decreased and coping strategies increased over the 1-year period in both groups of newly diagnosed, young women.     

Prevalence and impact of disability in north-western Ethiopia

Purpose. To assess the prevalence and impact of disability in one urban and three rural areas in north-western Ethiopia.

Methods. The study design is cross-sectional and quantitative. Data was collected by using pretested and standardized structured questionnaires containing socio-demographic characteristics, type of disability, functional, and social dysfunction.

Results. A total of 932 individuals with disability were found out of a total of 24,453 individuals giving the overall crude disability rate for the three towns as 3.8%. Disability in the lower locomotor was the most frequently reported type - 442 (47.0%) - followed by blindness 269 (28.6%), upper motor 152 (16.1%), mental retardation 97 (10.3%) and hearing loss 78 (8.3%) respectively. The major self-care problem experienced by the disabled is toileting in 292 (31.1%) cases, bathing in 248 (26.4%) and dressing 157 (16.7%). Other problems experienced by the respondents are parents' negative attitudes towards the disabled, evidenced by hiding them. This was observed in 340 (36.2%) cases. No care was provided by caregivers in 221 (23.6%) cases.

Conclusion. The majority of disabled people have problems with activities of daily life especially toileting, bathing and dressing. Interventions to alleviate the problems of the disabled should be designed and implemented.     

Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring

Purpose. To examine the support required by family carers for stroke survivors.

Methods. Forty-two family carers were recruited for surveys of needs, knowledge, satisfaction, and competence in caring before and 4 - 6 weeks after discharge from an Acute Stroke Unit (ASU).

Results. Information deficits about dealing with psychological, emotional, and behavioural problems and local service information were priorities before and after discharge. Younger female carers (under 56 years) were least satisfied with communication with ASU staff. Face to face contact was valued. After discharge younger female carers, particularly of non-White ethnic groups, reported lower levels of competence in caring and higher burden. Knowledge of stroke risk factors was low in all groups. High satisfaction with treatment and therapy in the ASU, was not transferred to the community. Carers reported feeling alone and described uncoordinated services.

Conclusions. Carers are able to anticipate and prioritise their needs, value communication with staff and involvement with discharge-planning, but particular difficulties were experienced by younger female carers and those from non-White ethnic groups. This requires particular attention when developing targeted interventions for family carers from a mixed ethnic community. In-depth and longitudinal studies are needed to detail psychosocial needs and guide practice particularly amongst non-White family carers.     

Reduction of disability after stroke is a more informative predictor of long-time survival than initial disability status

Purpose. Few studies have evaluated the roles of reducing disability after stroke in predicting survival. This study aimed to investigate the effects of improvement in the Barthel Index (BI) and other prognostic factors on survival in patients with first-time noncardioembolic ischemic stroke.

Method. BI effectiveness was defined as the improvement of BI between initial stroke (within 3 days) and 2 months after stroke. Cox regression analysis and Kaplan-Meier methods were used to evaluate the predictive roles of various prognostic factors.

Results. A total of 111 patients were enrolled. Mean age at the time of stroke was 68 (±11.2) years. Median follow-up time was 77.4 months. Mean initial BI was 36.1 (±28.5) and mean BI effectiveness was 46.9 ± 29.0. Overall, 55 deaths (49.5%) of the cohort were ascertained. The BI effectiveness had significant effects on long-time survival while initial BI was not a significant predictor. Higher BI effectiveness led to lower risk of mortality (hazard ratio = 0.44, 95% CI 0.24 - 0.80, p = 0.007). Elder age was correlated with poor survival (overall p = 0.006). Subjects in the eldest age group (≧70 years) showed a significant elevated risk for death (hazard ratio = 3.42, 95% CI 1.18 - 9.92). There was a trend indicating that the smaller the lesion size, the more favourable the prognosis (overall p = 0.057).

Conclusions. BI effectiveness in the first 2 months after first-time noncardioembolic stroke was more informative than initial disability status for predicting long-time mortality. It highlights the potential benefit in maximizing functional performance in patients with stroke.     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose. To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods. A community-based longitudinal study. All inhabitants aged 22 - 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to 'localized LBP' and to 'LBP with additional sites of BP'. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results. Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported 'localized LBP' and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported 'Generalized BP' comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported 'localized LBP'. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions. Subjects with 'localized LBP' presented healthier lifestyle than subjects with 'Generalized BP'. The latter experienced higher degree of pain measures. It seems that 'Generalized BP' is not a different entity than 'localized LBP' but rather a more severe one.     

The social experience of aging with a chronic illness: perspectives of older adults with multiple sclerosis

Purpose. The purpose of this study was to explore the social experiences of older adults with multiple sclerosis (MS) in order to recognize the changes in social experience and social needs that may occur with aging with a chronic illness.

Method. Analysis of qualitative data from an exploratory study utilizing a phenomenological approach with 27 older adults with MS, aged 55 - 81.

Results. In-depth interviews revealed that the social experience was influenced by groups of factors including the person's social needs, experience of MS, values and expectations, characteristics of the social support system, the response of the support providers, and the accessibility of the social environment. The participants discussed concerns about the future adequacy of support. A process of negotiation was also described and was seen as an opportunity to change the social experience and social support received.

Conclusion. This study provides an insider's view of the social changes that older adults living with MS experience. This study also identifies barriers to the acquisition of support and addresses the importance of appropriately responding to the changing needs of this population.     

Reduced community integration in persons following traumatic brain injury, as measured on the Community Integration Measure: an exploratory analysis

Purpose. To explore the community integration of individuals who had suffered a Traumatic Brain Injury (TBI) and compare this to members of the general public.

Method. An independent groups design explored differences in three groups' levels of community integration. These groups consisted of ten survivors of TBI, ten male and ten female controls and were measured using The Community Integration Measure (CIM). All participants were resident in Northern Ireland (NI). The brain injured participants were drawn from a Belfast-based social skills programme.

Results. Mann-Whitney U tests showed a statistically significant difference between female controls and brain-injured individuals (U = 26.50, N₁ = 10, N₂ = 10, p = 0.037, one-tailed).

Conclusion. Females were more integrated into their communities than males, who were, in turn, more integrated than brain injured individuals. It would appear that brain injury survivors are doubly disadvantaged. Their gender (mainly male), and the injury itself, conspire to reduce their integration within the wider community.     

The demand for rehabilitation therapists in Beijing health organizations over the next five years

Purpose. To estimate the demand for rehabilitation therapists in Beijing health organizations over the next 5 years.

Methods. A literature search was carried out to confirm the distribution of rehabilitation therapists in Beijing health organizations in the past and to predict the demand for rehabilitation therapists in Beijing hospitals over the next 5 years by linear regression and logistic curve fitting.

Results. The total demand for rehabilitation therapists in Beijing in 2007 and 2010 will be 1480 - 1620 and 2240 - 2530, respectively.

Conclusions. The allocation and training of manpower specialized in rehabilitation therapeutics for the rehabilitation departments of polyclinics in Beijing should be improved.     

Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial

Background. The Canadian Occupational Performance Measure (COPM) is a commonly used outcome measure in rehabilitation. In this study it was adapted for very young children by deleting paid/unpaid work and household management categories and having parents act as proxies to rate child performance and their own satisfaction.

Purpose. To assess the internal consistency reliability, content and construct validity, responsiveness, and impact of half scores (20 not 10-point scale) of the adapted COPM.

Method. Parent proxies of subjects aged 2 - 8 (mean 3.9) years with spastic hemiplegic cerebral palsy (n = 41) participating in a clinical trial. There was a total of 214 occupational performance problems for analysis and an additional 56 which had used half score ratings. Internal consistency reliability and construct validity were evaluated using Cronbach alpha statistic. Proxy views explored content validity. Responsiveness was evaluated using pre-post intervention scores and a comparison with Goal Attainment Scaling scores which were assumed to be a suitable benchmark measure. The effect of half scores was assessed by two-sample t-tests.

Results. The COPM adaptations did not have a negative impact on internal consistency reliability as this was acceptable for performance (0.73) and satisfaction (0.83). The high Cronbach alpha scores indicated good construct validity. Content of occupations and rating approach was considered valid by proxies. Use of half scores did not result in significantly different performance ratings, but mean satisfaction ratings were significantly higher when half scores were used (p = 0.0001). This suggests that half scores may provide more precise proxy satisfaction ratings, but at the cost of rigour as internal consistency with satisfaction half scores was lower (0.63 vs. 0.82). Responsiveness to change in clinical status was demonstrated by significant pre-post scores and moderate correlations with goal attainment scores.

Conclusion. The adapted COPM is a psychometrically robust tool and the use of half scores is not recommended.     

Long-term outcome of superficialis-to-profundus tendon transfer in patients with clenched fist due to spastic hemiplegia

Background. Spastic hemiplegia is a common feature after stroke, which can result in a clenched fist deformity with secondary hygienic problems and pain. Operative treatment can improve these problems, although literature about its long-term effects is lacking.

Purpose. To determine whether Superficialis-to-Profundus tendon (StP-) transfer procedure leads to permanent improvement of hygiene and reduction of pain in patients with clenched fist due to spastic hemiplegia following stroke.

Method. Patients who underwent a StP-transfer in 2003 - 2005 were evaluated on skin condition, upper extremity joint mobility, resting position and muscle tone and with VAS scores on hygiene maintenance and pain in the hand.

Results. Six patients (mean age 54 years; duration after stroke 10 years) were included. Indications to operate were hygienic problems only (3) or combined with pain (3). The average follow-up period was 19 months. After 6 weeks of post-operative splinting, no standard follow-up was applied. Serious post-operative complications were not reported. At follow-up no hygienic problems were present and pain was decreased in all except one patient. All hands could passively be fully opened. In resting position, flexion was seen in the MCP-joints (60 - 90°). Muscle tone was raised in flexors of the wrist and fingers and m. adductor pollicis (Ashworth 1 - 2). Given the same pre- and post-operative circumstances, all patients would agree to have the surgery over again.

Conclusion. Even 19 months after the StP-transfer for clenched fist, all operated hands could still be fully opened and there was a permanent improvement of hygiene and pain reduction.     

Pattern of disability among patients attending Taif Rehabilitation Center, Saudi Arabia

Purpose. Despite the growing awareness of the community about the economic, psychological and medical impact of disability, limited research has been carried out to determine the pattern of disabilities in Saudi Arabia.

Methods. This is a cross-sectional study of hospital records of patients who were admitted to Armed Forces Rehabilitation Center, Taif, Saudi Arabia, during the period from 1999 - 2005. A total of 850 patient records were reviewed. Data were collected on age, sex, nationality, data of admission and discharge and type of disability. Univariate and multivariate logistic regression analyses were performed to determine predictors of long stay at the hospital.

Results. Trauma as an etiology of disability was more common than non-traumatic incidents among male and middle age patients (16 - 45 years). Traumatic accidents mostly result in quadriplegia (72.8%). Male, single, less than 45 years old, patients with traumatic accidents and patients with paralytic types of disability were significantly more likely to stay longer at the hospital (≥6 months).

Conclusions. The home care program should be expanded to minimize duration of stay at the rehabilitation centers with lower cost as well as health education of the public would help in encouraging disabled patients to adapt to daily life activities.