Validity and community utility of the Canadian Occupational Performance Measure

Assessment tools and classification systems used for the upper extremity in children with cerebral palsy

BACKGROUND

Clinicians interested in assessment and outcome measurement of upper extremity (UE) function and performance in children with cerebral palsy (CP) must choose from a wide range of tools.

QUESTIONS/PURPOSES

We systematically reviewed the literature for UE assessment and classification tools for children with CP to compare instrument content, methodology, and clinical use.

METHODS

We searched Health and Psychosocial Instruments (HaPI), US National Library of Medicine (PubMed), and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) databases (1937 to the present) to identify UE assessment and outcomes tools. We identified 21 tools for further analysis and searched HaPI, PubMed, CINAHL Plus, and Google Scholar ( http://scholar.google.com/schhp?tab=ws ) databases to identify all validity and reliability studies, systematic reviews, and original references for each of the 21 tools.

RESULTS

The tools identified covered ages birth to adulthood. International Classification of Functioning, Disability and Health domains addressed by these tools included body function, body structure, activities and participation, and environmental factors. Eleven of the tools were patient or family report, seven were clinician-based observations, and three tools could be used in either fashion. All of the tools had published evidence of validity. Nine of the tools were specifically designed for use in subjects with CP. Two of the tools required formal certification before use. Ten of the tools were provided free of charge by the investigators or institution who developed them.

CONCLUSIONS

Familiarity with the psychometric and clinometric properties of assessment and classification tools for the UE in children with CP greatly enhances a clinician's ability to select and use these tools in daily clinical practice for both clinical decision-making and assessment of outcome.

Navigating patient-centered goal setting in inpatient stroke rehabilitation: how clinicians control the process to meet perceived professional responsibilities

OBJECTIVE

Patient-centered goal setting, while central to contemporary rehabilitation, has been associated with growing uncertainty regarding its application in clinical practice. We aimed to examine the application of goal setting in inpatient stroke rehabilitation.

METHODS

Data collected from 44 participants (nine patients, seven family members, 28 health professionals), using multiple data sources (interviews, recorded clinical sessions, team meetings, participant-observation, and clinical documentation), were analyzed using constant comparative methods.

RESULTS

Certain goals (characterized by short timeframes, conservative estimation of outcomes, and physical function) were privileged over others. Involvement of patients and family in goal setting resulted in interactional dilemmas when their objectives, skills and perceived capacity did not align with privileged goals. When alignment did occur, greater patient involvement still did not appear to influence clinical reasoning.

CONCLUSION

This study raises questions about how 'patient-centered' current goal setting practices are and whether a 'patient-centered' approach is even possible in inpatient stroke rehabilitation when considering predominant funding and health system models.

PRACTICE IMPLICATIONS

For 'patient-centered' goal setting to be more than rhetorical, clinicians need to examine the values they attribute to certain types of goals, the influence of organizational drivers on goal selection, and how goals are actually used to influence clinical practice.

Utilization of the iPad application: Aid for Decision-making in Occupation Choice

The purpose of the study was to develop and evaluate an iPad (Apple) application, Aid for Decision-making in Occupation Choice (ADOC), so as to promote shared decision-making in an occupation-based goal setting. This application involves the client choosing from 94 illustrations describing daily activities related to the category of "activities and participation". One hundred occupational therapy clients evaluated the ADOC for goal setting; the clients and 37 occupational therapists underwent a survey to determine their perceptions of decision-making in the goal setting. More than 90% of the clients felt that they could give their opinions using the ADOC regarding goal setting. The majority of the occupational therapists (>90%) felt that ADOC would be useful in their clinical practice for setting client goals. The results indicated that ADOC is a useful and acceptable tool for both clients and occupational therapists in shared decision-making in occupation-based goal setting.

Chedoke Arm and Hand Activity Inventory-9 (CAHAI-9): perceived clinical utility within 14 days of stroke

PURPOSE

The Chedoke Arm and Hand Activity Inventory-9 (CAHAI-9) is an activity-based assessment developed to include relevant functional tasks and to be sensitive to clinically important changes in upper limb function. The aim of this study was to explore both therapists' and clients' views on the clinical utility of CAHAI-9 within 14 days of stroke.

METHOD

Twenty-one occupational therapists actively working in stroke settings were recruited by convenience sampling from 8 hospitals and participated in semistructured focus groups. Five clients within 14 days of stroke were recruited by consecutive sampling from 1 metropolitan hospital and participated in structured individual interviews. The transcripts were analyzed thematically.

RESULTS

Six themes emerged from the focus groups and interviews: collecting information, decisions regarding client suitability, administration and scoring, organizational demands, raising awareness, and clients' perceptions of CAHAI-9 utility. All therapists agreed CAHAI-9 was suited for the stroke population and assisted identification of client abilities or difficulties within functional contexts. Opinions varied as to whether CAHAI-9 should be routinely administered with clients who had mild and severe upper limb deficits, but therapists agreed it was appropriate for clients with moderate deficits. Therapists made suggestions regarding refinement of the scoring and training to increase utility. All clients with stroke felt that the assessment provided reassurance regarding their recovery.

CONCLUSION

The findings indicate that CAHAI-9 shows promise as an upper limb ability assessment for clients within 14 days of stroke.

The Canadian Occupational Performance Measure's semi-structured interview: its applicability to lumbar spinal fusion patients. A prospective randomized clinical study

BACKGROUND

Although lumbar spinal fusion has been performed for more than 70 years, few studies have examined rehabilitation strategies for spinal fusion patients, and there is only sparse information about the patient's activity level after surgery. The Canadian Occupational Performance Measure (COPM) is a standardized semi-structured interview, developed to identify patients' problems in relation to activities of daily living (ADL). The COPM has neither been examined in a randomised clinical study nor employed in relation to lumbar spinal fusion patients. We aimed to examine whether or not the use of the semi-structured interview COPM during in-hospital rehabilitation could: (1) identify more ADL-related problems of importance to the patients after discharge from the hospital, (2) enhance the patients' ADL performance after discharge from hospital

METHOD

Eighty-seven patients undergoing a lumbar spinal fusion caused by degenerative diseases were randomly assigned to either use of the COPM or to standard treatment.

RESULTS AND CONCLUSION

Use of the COPM during hospitalization helped in identifying more ADL problems encountered by patients during the first 3 months post-discharge period as COPM served to identify more treatment goals and plans of action. Use of the COPM had no impact on the patients' ADL performance, and the difference is so small that COPM may be of little clinical consequence.

Modified Constraint-Induced Movement Therapy for Elderly Clients With Subacute Stroke

A growing body of research, including evidence from numerous randomized controlled trials, suggests that constraint-induced movement therapy (CIMT) reduces impairment. The mean age of participants in most studies has been <65 yr, even though most stroke survivors are older than that. We investigated the efficacy of a modified CIMT protocol on participation, activity, and impairment in a population of older adults experiencing subacute stroke. Using an interrupted time series design, 4 older adults (mean age = 82) were assessed before and after intervention. Although none of the participants adhered to the 6-hr per day self-practice aspect of the CIMT protocol, considerable improvements were noted in participation, as measured using the Canadian Occupational Performance Measure. Some improvements were also noted at the level of impairment and activity. This work accords with previous literature on CIMT and has important implications for the evolution of stroke rehabilitation in elderly people.

Accelerometer-triggered electrical stimulation for reach and grasp in chronic stroke patients: a pilot study

BACKGROUND

Electrical stimulation of the upper extremity may reduce impairment in patients following stroke. Stimulation triggered on demand combined with task practice may be an effective means of promoting recovery of function.

OBJECTIVE

The authors investigated the feasibility of using accelerometer-controlled electrical stimulation for the elbow, wrist, and finger extensors to enable functional task practice in patients with chronic hemiparesis.

METHODS

Following a 4-week baseline, participants received 2 weeks of cyclic stimulation exercise to elbow and forearm extensor muscles, followed by 10 weeks of triggered stimulation to practice functional reaching. Participants were reassessed 12 weeks later as well. Outcome measures were the Action Research Arm Test (ARAT), Modified Ashworth Scale (MAS), Canadian Occupational Performance Measure (COPM), Psychosocial Impact of Assistive Devices Scale (PIADS), and Use of Device Questionnaire (UDQ).

RESULTS

Fifteen volunteers who had at least 45° of forward shoulder flexion and could initiate elbow extension and grasp completed the study. The ARAT score improved from 19 to 32 (P = .002); the MAS score for elbow, wrist, and finger flexor spasticity was reduced from 2 each to 1, 0, and 1 (P < .05); the COPM performance and satisfaction scores improved (P = .001); and the PIADS became positive for competence (P = .005), adaptability (P = .008), and self-esteem (P = .008). Gains were maintained 12 weeks later.

CONCLUSIONS

Accelerometer-triggered electrical stimulation to augment task training for the hemiplegic arm is feasible and may improve functional ability and quality of life which may be maintained 12 weeks after treatment. A randomized trial design is required to evaluate efficacy and cost benefit.

Chedoke Arm and Hand Activity Inventory-9 (CAHAI-9): a multi-centre investigation of clinical utility

Aims:

Assessment of upper limb ability is a common focus of the occupational therapist in acute stroke. Chedoke Arm and Hand Activity Inventory - 9 (CAHAI-9) is an activity based assessment developed to include relevant functional tasks and to be sensitive to clinically important changes in upper limb function. The aim of this study was to investigate the clinical utility of CAHAI-9 in an acute stroke setting.

Methods:

Thirty-two occupational therapist participants from eight hospitals completed 100 CAHAI-9 assessments, on 92 patients with stroke, over six months. Occupational therapists completed questionnaires regarding the clinical utility of CAHAI-9.

Findings:

The mean patient age was 69 years and mean CAHAI-9 score was 39/63. The mean administration time was 16 minutes. Eighty-three percent of therapists indicated they would use CAHAI-9 again. Eight-seven percent agreed CAHAI-9 was useful for patients with mild and moderate (91%) upper limb deficits however only 25% agreed for severe deficits.

Conclusions:

The findings indicate that CAHAI-9 shows promise as an upper limb ability assessment in acute stroke, with therapists indicating they would use CAHAI-9 again. However, further investigation of the scoring issues may be warranted before CAHAI-9 is ready for clinical use in Australian acute care settings.

A patient-prioritized ability assessment in haemophilia: the Canadian Occupational Performance Measure

Assessment of musculoskeletal function in individuals with haemophilia has been attempted with clinimetric instruments, which use predetermined domains for assessing the same. This study introduces the application of an instrument, the Canadian Occupational Performance Measure (COPM), which is an open-ended questionnaire that allows patients to prioritize their needs and rate their performance in different tasks of daily living as well as their satisfaction in performing them. To study the utility of COPM in evaluating the musculoskeletal functional status of patients with haemophilia and to assess its effectiveness in planning individualized management plans for them. COPM was administered to 67 individuals with haemophilia aged 10-55 years and the data were compared with functional deficits identified through FISH (Functional Independence Score for Haemophilia). A total of 31 performance difficulties in the areas of self-care (62%), productivity (21%) and leisure (17%) were identified by COPM. All eight domains of FISH were identified in COPM as problems in self-care. In addition to these, COPM identified problems in the areas of productivity and leisure. In 78% of the responses on COPM, there was concordance between the performance and satisfaction scores. However, there was discordance between the two in the remaining 22% of responses. COPM is a useful tool for assessment of musculoskeletal dysfunction in haemophilia. It provides a greater insight into the needs of each patient and helps in planning individualized intervention strategies.

Routine administration of the Canadian Occupational Performance Measure: effect on functional outcome

BACKGROUND/AIM

Routinely using outcome measures as an integral component of practice has been encouraged for decades yet has not been widely adopted. There are many reasons to measure outcomes yet any positive effect of measurement on our programs or clients has not been substantiated. If the time-consuming nature of outcome measurement is to be encouraged, we need to begin addressing larger questions of the value of outcome measurement on care and outcomes. This cohort study evaluated the impact of routinely administering the Canadian Occupational Performance Measure on client outcomes on a geriatric rehabilitation unit.

METHODS

Changes in Functional Independence Measure™ scores between an experimental group (n = 45) that received the routine use of the Canadian Occupational Performance Measure for evaluation/planning versus a historical comparison group (n = 58) that received 'usual' care were analysed using generalised linear modeling.

RESULTS

Both groups had significant changes in Functional Independence Measure™ scores over time. Results for differences between groups were inconclusive with a significantly underpowered analysis; however, results suggest that a medium to large effect of this intervention cannot be expected.

CONCLUSIONS

Results are significant for the field of routine outcome measurement, suggesting that when adding the Canadian Occupational Performance Measure to routine assessment within an inpatient rehabilitation setting, substantially improved Functional Independence Measure™ score outcomes should not be expected. The value of routine outcome measurement on client outcomes remains largely unexplored. Routinely, using outcome measures requires additional research to determine the specific benefits to our programs and client outcomes.

Biceps-to-triceps transfer for elbow extension in persons with tetraplegia

PURPOSE

Restoration of elbow extension via tendon transfer is an integral part of upper extremity surgical reconstruction in persons with tetraplegia. The purpose of this investigation was to assess patient satisfaction and elbow extension strength after biceps-to-triceps transfers.

METHODS

This is a retrospective chart review of biceps-to-triceps transfers in patients with spinal cord injury. Forty-five patients (77 arms) with spinal cord injury underwent biceps-to-triceps transfer. A total of 40 patients (68 arms) were available for follow-up. The average age at surgery was 17.3 years (range, 6.4-21.7 y).The biceps tendon was transferred around the medial aspect of the arm. The preoperative elbow extension strength was 0/5 (54 arms), 1/5 (10 arms), or 2/5 (4 arms). We also used the Canadian Occupational Performance Measure to measure patient-perceived outcome in a subset of 8 subjects.

RESULTS

Stringent manual muscle testing (MMT) for elbow extension revealed a statistically significant increase in muscle strength after surgery (p < .001). Forty-two arms were able to extend completely against gravity (MMT 3/5 or greater). Nine arms had a mild extension lag against gravity (MMT of 3/5). Therefore, 75% (51/68) of arms were able to function overhead. Seventeen arms had MMT scores less than 3/5. The top 5 goals of the 8 patients with completed preoperative and postoperative Canadian Occupational Performance Measure results were analyzed. After transfer, all 8 patients reported improved performance of and/or satisfaction with at least one goal. Performance and satisfaction were greatly improved (at least 4 points) for activities of living such as dressing, grooming, reaching for objects, recreational activities, wheelchair propulsion, and transfers.

CONCLUSIONS

Based on these results, we believe the biceps-to-triceps transfer is a reliable technique for restoration of elbow extension in persons with tetraplegia. Overhead function is obtainable in most cases with careful surgical technique and meticulous postoperative therapy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Relief of chronic or resistant depression (Re-ChORD): a pragmatic, randomized, open-treatment trial of an integrative program intervention for chronic depression

BACKGROUND

Chronic depression is a particularly disabling mood disorder and treatment outcomes are poor with either psychotherapy or pharmacotherapy alone. There is growing evidence that an integrative treatment approach may be optimal. A novel multi-modal, multi-disciplinary treatment program, Re-ChORD, was developed at the University of British Columbia and evaluated in this pilot study.

METHODS

Re-ChORD consisted of guidelines-based medication management, and group-based interpersonal psychotherapy and occupational therapy. A randomized, parallel-groups, open-treatment trial was conducted comparing Re-ChORD to treatment as usual (TAU). Inclusion criteria were current depression (17-item Ham-D > or = 15) and a diagnosis of a chronic depressive disorder. The primary outcome variable was clinical remission (17-item Ham-D < or = 7) at 4 month assessment.

RESULTS

A total of 64 patients were randomised to Re-ChORD (N=34) and TAU (N=30). Under both intention to treat (ITT) and completer analyses, the remission rate was significantly higher in the Re-ChORD than TAU groups. Treatment effect size for remission was of medium magnitude (22.2% and 29.6% over TAU under ITT and completer analyses).

LIMITATIONS

We did not collect sufficient follow-up data to investigate maintenance of gains. Re-ChORD shares elements with other combined treatments, and the present positive findings cannot be interpreted as being specific to the Re-ChORD program.

CONCLUSIONS

Consistent with growing evidence that integrative treatments are necessary for chronic depressive disorders, Re-ChORD was demonstrated in this pilot study to produce significantly greater rates of remission than treatment as usual. A larger-scale trial is warranted.

Clinical efficacy of the vertebral wedge osteotomy for the fusionless treatment of paralytic scoliosis

STUDY DESIGN

Pre-post intervention study using outcome measure design.

OBJECTIVE

To evaluate the clinical efficacy and functional impact of a fusionless treatment for paralytic scoliosis at 2-year follow-up.

SUMMARY OF BACKGROUND DATA

It has been shown that 67% of pediatric patients with progressive paralytic scoliosis require spinal fusion to correct the curve. However, maintenance of spinal flexibility, motion, and potential growth is desirable.

METHODS

Fourteen patients with scoliosis secondary to spinal cord injury or myelodysplasia underwent a fusionless vertebral wedge osteotomy. Thirteen patients were available for minimum 2-year follow-up, using standard scoliosis radiographs. The functional impact of the procedure was evaluated using the Pediatric Outcomes Data Collection Instrument (PODCI), the Functional Independence Measure (FIM), and the Canadian Occupational Performance Measure (COPM).

RESULTS

At a minimum 2-year follow-up, 10 patients of 13 (77%) had improvement of greater than 5 degrees in their coronal Cobb angle. Two (15%) patients' curves measured the same (+/-5 degrees). One patient's curve had worsened by 12 degrees as compared to the preoperative Cobb angle. The overall average correction of the 13 patients was 56.1%. Two patients required fusion with an average delay to fusion of 30 months. At current follow-up, range of motion across the treated levels averaged 43 degrees (range 8 degrees to 103 degrees). The FIM showed no changes pre to post, and the PODCI scores showed some increases at 2-year follow-up. Clinical and statistical improvement in performance and satisfaction scores was seen pre to post on the Canadian Occupational Performance Measure.

CONCLUSION

Vertebral wedge osteotomy is potentially an effective treatment option for paralytic scoliosis. At 2-year follow-up, there was no loss of function as measured by the PODCI and FIM, and there was improvement in the COPM. Cobb angle measurements were either improved or maintained in 12 of 13 patients. Although 2 patients required fusion, they had an average of 2.5 years of subsequent growth before surgery.

Feasibility of the Canadian Occupational Performance Measure for Routine Use

Purpose:

Despite encouragement, routine outcome measurement is not standard practice in occupational therapy. This applies across most practice areas and outcome measures, including occupational therapy measures such as the Canadian Occupational Performance Measure. Barriers to using outcome measures have been proposed, but are gathered from therapists not measuring outcomes routinely. This study gathered therapists' perceptions on outcome measurement following a period of routine outcome measure use. A secondary aim was to propose a therapist-driven template for summarising outcome data routinely.

Procedures:

Using a process evaluation, a short answer survey was used with three occupational therapists following 5 months of Canadian Occupational Performance Measure use in older people's rehabilitation. The data were summarised descriptively, using a proposed template based on therapist feedback.

Findings:

The therapists perceived that the measure facilitated treatment for both therapists and clients but they experienced challenges related to client cognition and sustaining use. Template creation indicated that the therapists placed more importance on individual than group level data.

Conclusion:

The therapists perceived benefit in routine Canadian Occupational Performance Measure use. The instrument appears feasible for meaningful and routine use but not necessarily for sustained use. Increasing outcome measure use is complex, requiring more knowledge on barriers, expectations of value and methods of data utilisation.

INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia

BACKGROUND

Congenital hemiplegia is the most common form of cerebral palsy (CP) accounting for 1 in 1300 live births. These children have limitations in capacity to use the impaired upper limb and bimanual coordination deficits which impact on daily activities and participation in home, school and community life. There are currently two diverse intensive therapy approaches. Traditional therapy has adopted a bimanual approach (BIM training) and recently, constraint induced movement therapy (CIMT) has emerged as a promising unimanual approach. Uncertainty remains about the efficacy of these interventions and characteristics of best responders. This study aims to compare the efficacy of CIMT to BIM training to improve outcomes across the ICF for school children with congenital hemiplegia.

METHODS/DESIGN

A matched pairs randomised comparison design will be used with children matched by age, gender, side of hemiplegia and level of upper limb function. Based on power calculations a sample size of 52 children (26 matched pairs) will be recruited. Children will be randomised within pairs to receive either CIMT or BIM training. Both interventions will use an intensive activity based day camp model, with groups receiving the same dosage of intervention delivered in the same environment (total 60 hours over 10 days). A novel circus theme will be used to enhance motivation. Groups will be compared at baseline, then at 3, 26 and 52 weeks following intervention. Severity of congenital hemiplegia will be classified according to brain structure (MRI and white matter fibre tracking), cortical excitability using Transcranial Magnetic Stimulation (TMS), functional use of the hand in everyday tasks (Manual Ability Classification System) and Gross Motor Function Classification System (GMFCS). Outcomes will address neurovascular changes (functional MRI, functional connectivity), and brain (re)organisation (TMS), body structure and function (range of motion, spasticity, strength and sensation), activity limitations (upper limb unimanual capacity and bimanual motor coordination), participation restrictions (in home, school and recreation), environmental (barriers and facilitators to participation) and quality of life.

DISCUSSION

This paper outlines the theoretical basis, study hypotheses and outcome measures for a matched pairs randomised trial comparing CIMT and BIM training to improve outcomes across the ICF.

TRIAL REGISTRATION

ACTRN12609000912280.

Is There a Role for Occupational Therapy within a Specialist Child and Adolescent Mental Health Eating Disorder Service?

In Northern Ireland, only two occupational therapists work within the specialist field of child and adolescent mental health (CAMH). This is despite recommendations made by the Bamford Review of Mental Health and Learning Disability (Northern Ireland) that occupational therapy should be a core element of CAMH provision. The College of Occupational Therapists has urged practitioners to challenge inequalities in health and social care provision and to use occupational language to reinforce the relationship between occupation, recovery and wellbeing. This opinion piece highlights occupational therapy core skills and occupational therapy frames of reference or modalities, underlining the application of both to eating disorders. The treatment models discussed are the Model of Human Occupation, the Canadian Model of Occupational Performance and sensory integration. Evidence reinforces that the models discussed are applicable, appropriate and valuable when treating children and adolescents with an eating disorder.

It is argued that the valuable and unique role of occupational therapy must be recognised by health and social care commissioners and CAMH providers and be vocalised by occupational therapists. CAMH teams are advised to embrace the unique skills that occupational therapists have to offer children and adolescents with eating disorders in order to ensure that clients receive truly multidisciplinary and client-centred evidence-based services.

Perspectives on outcome: what disability insiders and outsiders each bring to the assessment table

In selecting which effects of an intervention are assessed and defined as outcomes, the researcher draws on his or her perspective, which, because it differs from that of the insider (ie, the person with a disability/the treatment recipient), will lead to selection of 1 or more outcome variables that are possibly at variance with or irrelevant to the insider's values/goals. This is not to say that one perspective on outcomes is better than another and is to be preferred, but instead that the perspectives are likely to complement each other. Acknowledging and respecting the insider's perspective on outcome can be accomplished by including in the measurement plan both the outcome variables of interest to the researcher and measures that are shaped to tap into the insider's values. General principles for incorporating the insider's perspective into assessment of outcomes are discussed, with a focus on shaping subjective measures to incorporate fully what is salient and important to the disability insider, as well as adopting metrics that are compatible with the insider's values. Also included is a description of a specific tool (Participation Objective, Participation Subjective) for assessing participation that draws on both the insider's and the outsider's views.

Development of items designed to evaluate activity performance and participation in children and adolescents with spinal cord injury

Background/Objective. Outcomes-based data, whether used clinically or for research, are difficult to collect in the pediatric spinal cord injury (SCI) population due to a lack of appropriate assessment measures. The purpose of this paper is twofold: to describe the process by which two item pools were developed to evaluate activity performance and participation among children with SCI and to introduce the resultant items specific to pediatric SCI. Methods. The process of item development, including construct development, review of related assessment tools, chart review, item writing and refinement using focus groups, cognitive interviews, and further refinement, was used to create the items pools for activity and participation for children and adolescents with SCI. Results. A total of 347 items were written for the activity performance construct and 61 items were written for the participation construct. Several domains were established within each construct and items were written for both child and parent respondents. Conclusion. The process of detailed item development is the first step in the process of developing an outcomes instrument for children and adolescents with SCI to assess activity performance and participation. The items are representative of pediatric SCI because they address areas specific to children and adolescents with SCI such as wheeled mobility, upper extremity function with adaptive equipment, role performance, and socialization. After testing these items in calibration studies, we will determine if these items can be developed into effective computer-adaptive testing applications.

Goal achievement as a patient-generated outcome measure for stress urinary incontinence

OBJECTIVES

To explore women's goals and goal attainment for the conservative and surgical treatment of stress urinary incontinence (SUI), and to examine the feasibility of Goal Attainment Scaling (GAS) as an outcome measure in this population.

BACKGROUND

Despite the range of treatments for SUI, little is known about the outcomes patients consider important. Current instruments measure the impact of SUI on the ability to live a 'normal' life without addressing what normal looks like for the patient. Patient-generated measures that address what a patient aims to achieve may fill this gap.

DESIGN

A mixed-methods exploratory design combined semi-structured interviews with validated questionnaires and individualized rating of goal achievement. SETTING AND PARTICIPANTS PARTICIPANTS: with SUI (n = 18) were interviewed in their homes prior to initiation of treatment and 3-6 months afterwards.

MAIN VARIABLES

Participants reported individualized goals pre-treatment and rated goal attainment after surgical and conservative therapy. Quality of life impact and change were measured using short forms of the Incontinence Impact Questionnaire and Urinary Distress Inventory.

RESULTS

Women expressed a median of four highly individualized treatment-related goals but goal achievement following conservative treatment was poor. GAS was not feasible as an outcome measure; women readily identified personal goals but could not independently identify graded levels of attainment for each goal.

CONCLUSIONS

Although further work is needed to examine the most feasible, valid, and reliable method of measuring goal achievement in research, asking patients with UI to identify pre-treatment goals may provide useful information to guide treatment-related decision making.

Participation in community-based activities of daily living: comparison of a pushrim-activated, power-assisted wheelchair and a power wheelchair

PURPOSE

The purpose of this study was to evaluate pushrim-activated, power-assisted wheelchair (PPW) performance among dual-users in their natural environment to determine whether the PPW would serve as a satisfactory alternative to a power wheelchair for community-based activities.

METHODS

A concurrent mixed methods research design using a cross-over trial was used. The outcome measures used were number of hours reported using the different wheelchairs, Quebec User Evaluation of Satisfaction with assistive Technology (QUEST), Functioning Everyday with a Wheelchair (FEW), Psychosocial Impact of Assistive Devices Scale (PIADS) and Canadian Occupational Performance Measure (COPM).

RESULTS

The number of hours spent participating in self-identified activities was not significantly different. Only the Self-Esteem subscale of the PIADS identified a statistically significant difference between the PPW and power wheelchair conditions (p = 0.016). A clinically important difference for Performance and Satisfaction was suggested by the COPM, in favour of the power wheelchair.

CONCLUSIONS

Additional knowledge was gained about the benefits of PPW technology. Participants were able to continue participating independently in their self-identified community activities using the PPW, and identified comparable ratings of satisfaction and performance with the PPW and the power wheelchair. For some individuals requiring power mobility, the PPW may provide an alternative to the power wheelchair.

Effectiveness and expectations of intensive training: A comparison between child and youth rehabilitation and conductive education

OBJECTIVE

To compare the effectiveness of two intensive training-programmes from a professional and parent perspective. To describe and compare the type of expectations of the two intensive training programmes with the self-reported individualized goals.

DESIGN

Quasi-experimental with two groups.

SETTING AND INTERVENTION

Traditional health care and conductive education. PATIENTS AND THEIR PARENTS: Fifty-four children with cerebral palsy, 3-16 years old.

METHODS

Data included a self-reported individualized goal measure (SRIGM), before and after the ITP. Individualized goals were classified according to the International Classification of Functioning (ICF). Clinical measures (CM) included repeated measures with Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory-Functional Skills (PEDI-FS).

RESULTS

Twenty-eight parents out of 54 perceived a clinically significant improvement on the SRIGM with no significant difference between the training programmes. Most individualized goals were formulated in the domain of Mobility (115 out of 248) and Neuromusculoskeletal and movement-related functions (64 out of 248 goals) of ICF in both training programmes. There was no difference in the proportion of improvement measured with SRIGM compared to the CM, if an improvement in any dimension in GMFM or domain in PEDI FS was counted.

CONCLUSION

There were no major differences in outcome and expectations between the training programmes. Parents' expectations were mainly directed towards improvement in prerequisites of motor function and mobility skills. The SRIGM confirmed the outcome on the CM.

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.

Activities and impairments in the early stage of rehabilitation after Colles' fracture

PURPOSE

The purpose of this study was to investigate problems in performing activities after Colles' fracture, and to correlate activity limitations with impairments in the early stage of rehabilitation.

METHOD

Assessments were performed 1 and 5 weeks after removing plaster casts. A client-specific instrument, The Canadian Occupational Performance Measure, and a disease-specific dichotomous scale of 10 activities of daily living were used. Range of motion, grip strength, pain and dexterity were also assessed according to standardized methods.

RESULTS

Thirty-three women, aged 51-87 years, with Colles' fracture treated with closed reduction and a plaster cast participated. Highly significant statistical and clinical improvements were found in the capacity, number and performance of activities. Problems were mainly classified as self-care activities at 1 week, and as productivity activities at 5 weeks, while problems in leisure activities were practically the same. However, one-third of the patients were not able to perform all basic activities of daily living at 5 weeks. Improvements in pain frequency, range of motion, grip strength and dexterity did not correlate very well with improvements in performance or the patients' satisfaction with the performance of their activities.

CONCLUSIONS

The importance of assessing both impairments and activities in patients with Colles' fracture must be stressed.

Measures and time points relevant for post-surgical follow-up in patients with inflammatory arthritis: a pilot study

Background

Rheumatic diseases commonly affect joints and other structures in the hand. Surgery is a traditional way to treat hand problems in inflammatory rheumatic diseases with the purposes of pain relief, restore function and prevent progression. There are numerous measures to choose from, and a combination of outcome measures is recommended. This study evaluated if instruments commonly used in rheumatologic clinical practice are suitable to measure outcome of hand surgery and to identify time points relevant for follow-up.

Methods

Thirty-one patients (median age 56 years, median disease duration 15 years) with inflammatory rheumatic disease and need for post-surgical occupational therapy intervention formed this pilot study group.

Hand function was assessed regarding grip strength (Grippit), pain (VAS), range of motion (ROM) (Signals of Functional Impairment (SOFI)) and grip ability (Grip Ability Test (GAT)). Activities of daily life (ADL) were assessed by means of Disabilities of the Arm, Shoulder and Hand Outcome (DASH) and Canadian Occupational Performance Measure (COPM). The instruments were evaluated by responsiveness and feasibility; follow-up points were 0, 3, 6 and 12 months.

Results

All instruments showed significant change at one or more follow-up points. Satisfaction with activities (COPM) showed the best responsiveness (SMR>0.8), while ROM measured with SOFI had low responsiveness at most follow-up time points. The responsiveness of the instruments was stable between 6 and 12 month follow-up which imply that 6 month is an appropriate time for evaluating short-term effect of hand surgery in rheumatic diseases.

Conclusion

We suggest a core set of instruments measuring pain, grip strength, grip ability, perceived symptoms and self-defined daily activities. This study has shown that VAS pain, the Grippit instrument, GAT, DASH symptom scale and COPM are suitable outcome instruments for hand surgery, while SOFI may be a more insensitive test. However, the feasibility of this protocol in clinical practice awaits prospective studies.

Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients involving dedicated early rehabilitation intervention programs: design of a prospective, multi-centre, non-randomised clinical trial

Background

In conventional multi-trauma care service (CTCS), patients are admitted to hospital via the accident & emergency room. After surgery they are transferred to the IC-unit followed by the general surgery ward. Ensuing treatment takes place in a hospital's outpatient clinic, a rehabilitation centre, a nursing home or the community. Typically, each of the CTCS partners may have its own more or less autonomous treatment perspective. Clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('Supported Fast-track multi-Trauma Rehabilitation Service': SFTRS), featuring: 1) earlier transfer to a specialised trauma rehabilitation unit; 2) earlier start of 'non-weight-bearing' training and multidisciplinary treatment; 3) well-documented treatment protocols; 4) early individual goal-setting; 5) co-ordination of treatment between trauma surgeon and physiatrist, and 6) shorter lengths-of-stay, may be more (cost-)effective.

This paper describes the design of a prospective cohort study evaluating the (cost-) effectiveness of SFTRS relative to CTCS.

Methods/design

The study population includes multi-trauma patients, admitted to one of the participating hospitals, with an Injury Severity Scale score > = 16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. In a prospective cohort study CTCS and SFTRS will be contrasted. The inclusion period is 19 months. The duration of follow-up is 12 months, with measurements taken at baseline, and at 3,6,9 and 12 months post-injury.

Primary outcome measures are 'quality of life' (SF-36) and 'functional health status' (Functional Independence Measure). Secondary outcome measures are the Hospital Anxiety & Depression Scale, the Mini-Mental State Examination as an indicator of cognitive functioning, and the Canadian Occupational Performance Measure measuring the extent to which individual ADL treatment goals are met. Costs will be assessed using the PROductivity and DISease Questionnaire and a cost questionnaire.

Discussion

The study will yield results on the efficiency of an adapted care service for multi-trauma patients (SFTRS) featuring earlier (and condensed) involvement of specialised rehabilitation treatment. Results will show whether improved SFTRS logistics, combined with shorter stays in hospital and rehabilitation clinic and specialised early rehabilitation training modules are more (cost-) effective, relative to CTCS.

Trial registration

Current Controlled Trials register (ISRCTN68246661) and Netherlands Trial Register (NTR139).

Continuity, transition and participation: preparing clients for life in the community post-stroke

AIMS

To examine issues of continuity and transition facing clients as they return to life in the community following stroke and the role of rehabilitation in this process.

KEY FINDINGS AND IMPLICATIONS

The sudden onset of disability following a stroke represents a major disruption to the continuity of a person's life experience. Rehabilitation has an important role in the transition from the non-disabled to the disabled state however current rehabilitation services and outcomes post-stroke focus on functional recovery rather than on a return to meaningful roles and activities and pay little attention to the transition from the non-disabled to the disabled self. Although some current rehabilitation models address the importance of involvement in a life situation, they do not adequately address issues of the role of the environment, the nature of community, the importance of meaning and choice when thinking about life situations, and change in abilities across the life course.

CONCLUSIONS

Models of rehabilitation service delivery need to move to a chronic disease management model that incorporates outcomes that are meaningful to clients, and not the assumed needs or outcomes as defined by rehabilitation professionals.

Validity and Utility of the Canadian Occupational Performance Measure as an Outcome Measure in a Craniofacial Pain Center

Temporomandibular disorders and orofacial pain may cause impairment and functional limitations in activities involving the face, especially the mouth. The impact of chronic pain on occupational performance in this population has not been studied. The validity and utility of the Canadian Occupational Performance Measure (COPM) as an outcome measure in an orofacial pain setting was assessed, including specific occupational performance problems reported by individuals with temporomandibular disorder, orofacial pain, or both. Participants were patients ( N = 29) referred for treatment of chronic orofacial pain at a tertiary, university-based pain center. Assessments occurred prior to standard occlusal splint therapy and 8 weeks after the initial evaluation. Measures included the COPM, the Pain Disability Index, and numerical pain rating scales. The COPM scores showed significant correlations with other measures. Study participants identified a diverse range of occupational performance problems. The COPM may have utility as an outcome measure for use in orofacial pain. It provides the treatment team with data related to occupational performance and patient satisfaction.

Motor learning and the use of videotape feedback after stroke

BACKGROUND

Efforts have been made to apply motor learning theories to the rehabilitation of individuals following stroke. Motor learning poststroke has not been well investigated in the literature. This research attempted to fill the gap regarding motor learning applied to practice.

PURPOSE

This two-group research study attempted to determine the effectiveness of an experimental therapy combining videotape feedback with occupational therapy compared to only occupational therapy in learning the motor skill of donning socks and shoes after stroke.

METHOD

Ten participants were randomly assigned to one of the two groups and all participants were videotaped during pretest and up to 10 treatment sessions aimed at donning socks and shoes. Only one group viewed their videotape replay. The acquisition of donning socks and shoes was measured using the socks and shoes subtests of the Klein-Bell Activities of Daily Living Scale and their scores on the Canadian Occupational Performance Measure.

RESULTS

There was no significant difference between the two groups and both groups improved. However, the group that received videotape feedback thought they performed better and were more satisfied with their ability to don shoes, lending support for the use of videotape feedback poststroke to improve satisfaction with performance.

Validity and reliability of the instrument Performance and Satisfaction in Activities of Daily Living (PS-ADL) and its clinical applicability to adults with rheumatoid arthritis

AIM

This study set out to evaluate the validity and reliability of the instrument Performance and Satisfaction of Activities of Daily Living (PS-ADL) in patients with rheumatoid arthritis (RA). The PS-ADL is a questionnaire including 39 actions divided into 12 activities measuring the degree of difficulty and satisfaction with activity performance.

METHOD

Construct validity was examined by factor analysis. For convergent and discriminant validity evaluation, the Performance and the Satisfaction scales were correlated to the Health Assessment Questionnaire (HAQ), the Rheumatoid Arthritis Self-Conception (RASC), pain, fatigue, and mobility. Internal consistency was tested and repeated measurements were taken to establish the Percentage Agreement (PA) and correlation coefficients for test-retest reliability.

RESULTS

The factor analysis revealed the PS-ADL scale to be unidimensional. Significant correlations were seen between the Performance and Satisfaction scales and the HAQ (r(s) 0.78, 0.67), and between the RASC and Satisfaction scale (r(s) 0.45). Cronbach's alpha level ranged from 0.41 to 0.92 for the Performance scale and 0.66 to 0.94 for the Satisfaction scale. The percentage agreement (PA) at action level ranged from 68% to 91% for the Performance scale and from 59% to 91% for the Satisfaction scale.

CONCLUSION

The PS-ADL is a valid instrument with satisfactory reliability. It is easy to handle and can be recommended for use in RA patients.

Measuring wheelchair intervention outcomes: development of the wheelchair outcome measure

PURPOSE

Provision of a wheelchair has immediate intuitive benefits; however, it can be difficult to evaluate which wheelchair and seating components best meet an individual's needs. As well, funding agencies now prefer evidence of outcomes; and therefore measurement upon prescription of a wheelchair or its components is essential to demonstrate the efficacy of intervention. As no existing tool can provide individualized goal-oriented measure of outcome after wheelchair prescription, a research project was undertaken to create the Wheelchair Outcome Measure (WhOM).

METHOD

A mixed methods research design was employed to develop the instrument, which used in-depth interviews of prescribers, individuals who use wheelchairs and their associates, supplemented by additional questions in which participant preferences in key areas of the measure were quantified.

RESULTS

The WhOM is a client-specific wheelchair intervention measurement tool that is based on the World Health Organization's International Classification of Function, Disability, and Health. It identifies desired outcomes at a participation level and also acknowledges concerns about body structure and function.

CONCLUSION

The new outcome instrument will allow clients to identify and evaluate the outcomes they wish to achieve with their wheelchairs and seating and provide clinicians a way to quantify outcomes of their interventions in a way that is meaningful to the client and potential funding sources.

Clinimetric properties of participation measures for 5- to 13-year-old children with cerebral palsy: a systematic review

This study systematically reviewed the validity, reliability, sensitivity to change, and clinical utility of measurements of participation for children with cerebral palsy. Sixteen measures were identified and seven met the inclusion criteria of having 30% content measuring participation, for use with children aged 5 to 13 years with physical disability, and were condition specific. The Children's Assessment of Participation and Enjoyment (CAPE) assessed participation in leisure and recreation, while the School Function Assessment (SFA) and School Outcome Measure addressed participation in the school environment. The Assessment of Life Habits for Children (LIFE-H) measured participation in home, school, and community life, and the Children Helping Out: Responsibilities and Expectations assessed children's participation in household duties. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were individualized tools used to evaluate goal achievement. Results showed most instruments had adequate reliability and validity. The COPM and GAS were the only measures that reported adequate responsiveness to detect clinically significant change. Limited data are currently available to determine the responsiveness of the CAPE, LIFE-H, and SFA. A combination of assessments is required to capture participation of children in home, school, and community environments.