Empowerment in measurement: “muscle,” “voice,” and subjective quality of life as a gold standard 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

[Perspectives of patients with Duchenne muscular dystrophy: A focal group to improve healthcare quality]

INTRODUCTION

Duchenne muscular dystrophy is a complex disease that requires a multidisciplinary and coordinated approach. Given that therapeutic efforts are centred on improving the quality of life of the patient, the aim of this study is to find out the views of young people and adolescents with Duchenne muscular dystrophy, their families, and health professionals as regards the healthcare provided by the hospital in order to improve their quality of life.

METHODS

A qualitative study was conducted using 3 focal groups consisting of patients, families, and healthcare professionals. A thematic guide was prepared, and the information from the interviews was gathered using a sound recorder. In order to analyse the information, the transcriptions were coded and the significant data of each interview were extracted and grouped into various topics.

RESULTS/CONCLUSIONS

The main worries of the 3 groups were along the same line. On the one hand, the importance of a coordinated multidisciplinary team in the same unit that provides the integral care. On the other hand, sport as a common interest in these adolescents, and the consideration of a positive relationship between leisure and quality of life, finding that their participation in physiotherapy groups of great use. To achieve this objective, it is necessary to improve the coordination between the hospital and the different groups. The parents also demanded better cover in the social and psychological care offered by the hospital. Lastly, the importance of humanising the care was mentioned (privacy, adapting of structures, transmission of information, sexuality…).

Relationship between late objective and subjective outcomes of holistic neurorehabilitation in patients with traumatic brain injury

OBJECTIVE

To explore the relation between objectively measured outcomes of neurorehabilitation and subjective self-appraisal of those outcomes in patients with traumatic brain injury (TBI).

METHODS

Forty-five adults (34 men; age at injury, mean ± SD, 30.1 ± 10.3 years) with chronic moderate-to-severe TBI (9.7 ± 5.5 years from injury; post-traumatic amnesia, 80% over one week) from two rehabilitation centres, in two countries. The subjects have had to resume working at various levels of competence following post-acute comprehensive neuropsychologically oriented neurorehabilitation, and experienced no functionally incapacitating, medical or psychological problems, for a minimum of six months after discharge. Objective outcome measure was the level of work competence attained post-rehabilitation transposed from the descriptions of the types of work attained by each subject into a number along a 10-point scale. Subjective outcome measure was the personal evaluations by ratings in six consequences of rehabilitation (effort during rehabilitation, meaning in life, productivity, acceptance, social life and intimate relationships) along a 10-point scale.

RESULTS

The attained work competence was statistically significantly related to the subjective self-appraisal of the ability to establish intimate relationships [odds ratio (OR), 1.79; 95% confidence interval (CI), 1.20-2.68; P = .005]. Otherwise, no association between subjective ratings and the levels of work was found. Of the patients, 67% attained competitive, 22% subsidized, and 11% volunteer or sheltered work. The subjective self-rated outcomes of the patients were relatively good [median, lower quartile (Q1) - upper quartile (Q3): 8 to 9, 7 to 8 - 8 to 9 out of 10]. The lowest ratings were observed for the ability to establish intimate relationships (8, 7-8 out of 10).

CONCLUSIONS

The results support the need to evaluate rehabilitation outcomes involving both objective measures and subjective appraisals of them. The findings suggest that community functioning and satisfaction with that are distinct aspects of the subjects´ experience that must be considered in the evaluation of rehabilitation. It seems that comprehensive neurorehabilitation improve outcome, and patients with TBI with tailored placements were largely satisfied with the areas of wellness in their life. Additional larger controlled studies are needed to clarify how composition of neurorehabilitation and individualization in outcomes assessment might enhance the outcome of TBI rehabilitation.

German validation of Quality of Life after Brain Injury (QOLIBRI) assessment and associated factors

The consequences of traumatic brain injury (TBI) for health-related quality of life (HRQoL) are still poorly understood, and no TBI-specific instrument has hitherto been available. This paper describes in detail the psychometrics and validity of the German version of an internationally developed, self-rated HRQoL tool after TBI-the QOLIBRI (Quality of Life after Brain Injury). Factors associated with HRQoL, such as the impact of cognitive status and awareness, are specifically reported. One-hundred seventy-two participants after TBI were recruited from the records of acute clinics, most of whom having a Glasgow Coma Scale (GCS) 24-hour worst score and a Glasgow Outcome Scale (GOSE) score. Participants had severe (24%), moderate (11%) and mild (56%) injuries as assessed on the GCS, 3 months to 15 years post-injury. The QOLIBRI uses 37 items to measure "satisfaction" in the areas of "Cognition", "Self", "Daily Life and Autonomy", and "Social Relationships", and "feeling bothered" by "Emotions"and "Physical Problems". The scales meet standard psychometric criteria (α = .84 to .96; intra-class correlation-ICC = .72 to .91). ICCs (0.68 to 0.90) and αs (.83 to .96) were also good in a subgroup of participants with lower cognitive performance. The six-subscale structure of the international sample was reproduced for the German version using confirmatory factor analyses and Rasch analysis. Scale validity was supported by systematic relationships observed between the QOLIBRI and the GOSE, Patient Competency Rating Scale for Neurorehabilitation (PCRS-NR), Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Short Form 36 (SF-36), and Satisfaction with Life Scale (SWLS). The German QOLIBRI contains novel information not provided by other currently available measures and has good psychometric criteria. It is potentially useful for clinicians and researchers, in post-acute and rehabilitation studies, on a group and individual level.

Multidisciplinary care for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care, but the evidence base for its effectiveness is unclear.

OBJECTIVES

To assess the effectiveness of multidisciplinary care in adults with Guillain-Barré syndrome, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), AMED (1985 to May 2010), PEDro (1982 to May 2010) and LILACS (1982 to May 2010). We checked the bibliographies of papers identified and contacted their authors and known experts in the field seeking published and unpublished trials.

SELECTION CRITERIA

Randomised and controlled clinical trials that compared multidisciplinary care in Guillain-Barré syndrome with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary care in different settings or at different levels of intensity.Studies of 'other designs' (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis.

DATA COLLECTION AND ANALYSIS

We performed a 'best evidence' synthesis based on methodological quality.

MAIN RESULTS

No randomised controlled trials or controlled clinical trials were identified. We summarised the results of three observational studies in the Discussion section of this review.

AUTHORS' CONCLUSIONS

In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date comes from three 'very low quality' observational studies. These provide some support for improved disability in the short term (less than 6 months) with high intensity inpatient multidisciplinary rehabilitation; and for improved quality of life, as measured by a reduction in handicap (participation). These conclusions are tentative and the gap in current research should not be interpreted as proof that multidisciplinary care is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of multidisciplinary care in the Guillain-Barré syndrome population.

Individualized measurement of quality of life in older adults: development and pilot testing of a new tool

We describe theoretical background, development, and piloting of a measure for quality of life in older adults that specifically takes into account the subjective perspective. Although quality of life is usually subjectively assessed, normative thresholds for "the good life" are most often set by a third party. The new tool FLQM asks for respondents to name, rate, and weight those domains in life that are most important for their life-satisfaction solely from their own point of view. Construct validity was pilot-tested in two samples of elders (N₁ = 44; N₂ = 90). Correlations were in the medium range in both studies and support the questionnaire's validity. There were no age or gender differences on total score. However, in Study 1 as well as in Study 2 older subjects named significantly fewer domains than did younger participants. Further, in Study 1 the overall number of distinct domains generated by the participants diminished with age-the "interindividual pool of domains" shrank. Implications of this age-associated narrowing of domainscope are discussed on a background of adaptation theories. Concluding, the new questionnaire seems apt to assess older peoples' quality of life even in a physically very ill population, but needs further testing, especially regarding its reliability. This is currently being undertaken in a larger longitudinal sample to assure psychometric properties.

Multidisciplinary care for adults with amyotrophic lateral sclerosis or motor neuron disease

BACKGROUND

Multidisciplinary care (MDC) is increasingly thought to be an important means of symptomatic and supportive management for motor neuron disease (MND) but the evidence base for its effectiveness is unclear.

OBJECTIVES

To assess the effectiveness of MDC in adults with MND, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected.

SEARCH STRATEGY

We searched The Cochrane Neuromuscular Disease Group Specialized Register (11 May 2009), and The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHLPlus (1937 to April 2009), AMED (1985 to April 2009) and LILACS (1982 to April 2009).

SELECTION CRITERIA

Randomised and controlled clinical trials that compared MDC in MND with either routinely available local services or lower levels of intervention; or studies that compared MDC in different settings or at different levels of intensity.Studies of 'other designs' (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis.

DATA COLLECTION AND ANALYSIS

We performed a 'best evidence' synthesis based on methodological quality. We grouped studies in terms of setting and intensity (high or low) of therapy.

MAIN RESULTS

No randomised controlled trials or controlled clinical trials were identified. We summarised the results of five observational studies (including one with two reports) in the Discussion section of this review.

AUTHORS' CONCLUSIONS

In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date is based on three 'low' and two 'very low quality' observational studies. These suggest 'very low quality evidence' for an advantage for mental health domains (only) of quality of life without increasing healthcare costs, and 'low level quality' evidence for reduced hospitalisation for MDC in low-intensity outpatient settings; and 'very low quality' evidence for improved disability in high-intensity settings. The evidence for survival is conflicting. These conclusions are tentative and the gap in current research should not be interpreted as proof that MDC is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of MDC in the MND population. Future research should focus on observational designs to assess care and outcomes in 'real-life' settings. The interface between neurology, rehabilitation and palliative care should be explored to provide long-term support for MND.

Domains of a TBI minimal data set: Community reintegration phase

Efforts to establish a minimal data set for the period of community integration after traumatic brain injury (TBI) have been the focus of a working group of leading researchers, clinicians and advocates attending the Galveston Brain Injury Symposium in 2001 and 2002. The purpose of the data set is to increase the consistency and interpretability of TBI research and programme evaluation by providing a common set of measures to document key aspects of community integration. It is intended to be sensitive to intervention, comprehensive, reflect satisfaction and outcome and promote future treatment/therapy. In deciding on the components of a minimal data set, the tri-partite model of outcomes was adopted (initially employed in psychotherapy, adapted to TBI) which focuses on the needs of the individual, society and the health provider. Scales are recommended for the respective components of the model.

Disability meanings according to patients and clinicians: imagined recovery choice pathways

OBJECTIVE

The purpose of this study was to explore how the meaning of disability varies between patients with acute-onset activity limitations and clinicians, and between males and females.

METHODS

Seventy-nine patients undergoing inpatient rehabilitation and 93 practicing rehabilitation clinicians in the USA developed personal recovery choice pathways through recovery preference exploration (RPE). Imagining complete dependence in 18 activities as diverse as eating and expression, each individual determined an optimal sequence of recovery. This sequence was used to determine the relative value of each activity compared with the other 17. Three comparisons were made by calculating the mean absolute difference (MAD) in median utilities, including patients versus clinicians, male versus female patients, and male versus female clinicians. The MAD shows the relative magnitude of disparity between each pair.

RESULTS

The MAD value between patients and clinicians was 3.4 times larger and 4.8 times larger than the MAD values between male and female patients and male and female clinicians, respectively.

CONCLUSIONS

The much larger difference in recovery preferences between patients and clinicians compared with differences between genders suggests that life contexts of being a patient with disabilities versus a clinician are more potent determinants of activity limitation perspectives than being a man or woman.

Traumatic brain injury research priorities: the Conemaugh International Brain Injury Symposium

In 2005, an international symposium was convened with over 100 neuroscientists from 13 countries and major research centers to review current research in traumatic brain injury (TBI) and develop a consensus document on research issues and priorities. Four levels of TBI research were the focus of the discussion: basic science, acute care, post-acute neurorehabilitation, and improving quality of life (QOL). Each working group or committee was charged with reviewing current research, discussion and prioritizing future research directions, identifying critical issues that impede research in brain injury, and establishing a research agenda that will drive research over the next five years, leading to significantly improved outcomes and QOL for individuals suffering brain injuries. This symposium was organized at the request of the Congressional Brain Injury Task Force, to follow up on the National Institutes of Health Consensus Conference on TBI as mandated by the TBI ACT of 1996. The goal was to review what progress had been made since the National Institutes of Health (NIH) Consensus Conference, and also to follow up on the 1990's Decade of the Brain Project. The major purpose of the symposium was to provide recommendations to the U.S. Congress on a priority basis for research, treatment, and training in TBI over the next five years.

Recovery from disablement: what functional abilities do rehabilitation professionals value the most?

OBJECTIVE

To determine whether rehabilitation clinicians representing different therapeutic disciplines would choose to recover from profound disability differently.

DESIGN

Applying recovery preference exploration as a data-collection tool, clinicians imagined recovery from complete disability in each of the 18 activities assessed on the FIM instrument. We hypothesized that recovery-choice pathways would vary among the disciplines because of differences in training and practice focus. We compared each clinician's preference for imagined recovery of the ability to perform each FIM activity relative to the other 17. Item-level preferences were explored by discipline. The mean absolute difference (MAD) in the medians of the 18 FIM recovery preference values between each of the disciplines was used to quantify overall differences.

SETTING

Inpatient rehabilitation unit within a larger tertiary care urban hospital of an academic medical center.

PARTICIPANTS

Ninety-three clinicians actively providing care to patients in an inpatient rehabilitation setting classified into 5 groups anticipated to have similar types of practices: physicians and medical students (physician group), nurses, occupational and recreational therapists (occupational therapy [OT] group), physical therapists (physical therapy [PT] group), and neuropsychologists and social workers (psychology group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Relative recovery preferences in 18 FIM activities.

RESULTS

The MAD value between the 2 groups with the least similar recovery values (physician and psychology groups) was 1.78 times larger than the MAD value between the 2 groups with the most similar recovery values (PT and OT groups).

CONCLUSIONS

There were subtle differences in recovery choice pathways that may logically relate to differences in the cognitive processes used in clinical decision making among the therapeutic discipline groups.

Multidisciplinary rehabilitation for adults with multiple sclerosis

BACKGROUND

Multidisciplinary rehabilitation (MD) is an important component of symptomatic and supportive treatment for Multiple sclerosis (MS), but evidence base for its effectiveness is yet to be established.

OBJECTIVES

To assess the effectiveness of organized MD rehabilitation in adults with MS. To explore rehabilitation approaches that are effective in different settings and the outcomes that are affected.

SEARCH STRATEGY

The sources used included: Cochrane Central Register of Controlled Trials "CENTRAL", MEDLINE (1966- 2005), CINAHL (1982- 2005), PEDro (1990- 2005), EMBASE (1988- 2005), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register (NRR).

SELECTION CRITERIA

Randomized and controlled clinical trials that compared MD rehabilitation with routinely available local services or lower levels of intervention; or trials comparing interventions in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis based on methodological quality was performed. Trials were grouped in terms of setting and type of rehabilitation and duration of patient follow up.

MAIN RESULTS

Eight trials (7 RCTs; 1 CCT) (747 participants and 73 caregivers) were identified. Seven RCTs scored well and one CCT scored poorly on the methodological quality assessment. There was 'strong evidence' that despite no change in the level of impairment, inpatient MD rehabilitation can produce short-term gains at the levels of activity (disability) and participation for patients with MS. For outpatient and home-based rehabilitation programmes there was 'limited evidence' for short-term improvements in symptoms and disability with high intensity programmes, which translated into improvement in participation and quality of life. For low intensity programmes conducted over a longer period there was strong evidence for longer-term gains in quality of life; and also limited evidence for benefits to carers. Although some studies reported potential for cost-savings, there is no convincing evidence regarding the long-term cost-effectiveness of these programmes. It was not possible to suggest best 'dose' of therapy or supremacy of one therapy over another. This review highlights the limitations of RCTs in rehabilitation settings and need for better designed randomized and multiple centre trials.

AUTHORS' CONCLUSIONS

MD rehabilitation programmes do not change the level of impairment, but can improve the experience of people with MS in terms of activity and participation. Regular evaluation and assessment of these persons for rehabilitation is recommended. Further research into appropriate outcome measures, optimal intensity, frequency, cost and effectiveness of rehabilitation therapy over a longer time period is needed. Future research in rehabilitation should focus on improving methodological and scientific rigour of clinical trials.

Spasticity experience domains in persons with spinal cord injury

OBJECTIVE

To understand the everyday life experiences of persons who have spasticity associated with spinal cord injury (SCI).

DESIGN

Applied ethnographic design.

SETTING

Patients' homes and rehabilitation clinics.

PARTICIPANTS

Twenty-four people with SCI who experience spasticity.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Domains identified through qualitative analysis of in-depth open-ended interviews.

RESULTS

Domain analysis revealed 7 domains: physical, activity, emotional, economic, interpersonal, management, and cognitive. Descriptive subcategories within each domain were identified. Patients personalized the meaning of spasticity and expressed their understandings of the condition in ways that may not be consistent with clinical definitions. Some patients suggested that being able to control spasticity was preferable to total suppression.

CONCLUSIONS

Spasticity-related interventions need to be aimed at what matters most to the patient. It is critical for clinicians to understand patients' experiences to make accurate assessments, effectively evaluate treatment interventions, and select appropriate management strategies. When providers reconfigure patients' descriptions to fit neatly with a biomedical understanding of spasticity without carefully assessing the descriptions in terms of what matters most to patients, a potential risk for misappropriating interventions may arise.

Appraising evidence on community integration following brain injury: a systematic review

A systematic review of the community integration (CI) literature for persons with traumatic brain injury was undertaken to evaluate: (1) How do we best measure CI? (2) Can we predict CI following rehabilitation? (3) Does social and activity participation have an effect on CI? (4) Does CI have an effect on quality of life/life satisfaction? Seventy-two articles were analysed. The results demonstrated: (1) strong evidence supporting the use of the Community Integration Questionnaire (CIQ), (2) mixed evidence supporting the ability to predict CI, with the prominent predictive variables being severity of injury, age, gender, education, prior work, living environment, cognition, emotional status, functional performance and disability. The literature search was restricted to articles published in English and the heterogeneity in the outcomes, methods, participants and other characteristics not reported. Further research is needed to examine the complex relationship of person, environment and CI.

Pushing the frames of reference in traumatic brain injury rehabilitation

Cognitive rehabilitation is an empirically based field driven by multiple sources of activities and knowledge bases. Drawing on frames of reference provided by rehabilitation, neuropsychology, and rehabilitation psychology, cognitive rehabilitation has evolved to a point where studies have been generated to qualify for consideration in tables of evidence. At the center of cognitive rehabilitation is the effort to teach people to overcome or adapt to limitations. While rehabilitation has traditionally been focused on activity, a recent trend in the literature is to incorporate the individuals experience into a frame of reference for rehabilitation. Emphasizing the experience of the person in the situation fits into cognitive rehabilitation and raises the bar for rehabilitation not only in viewing rehabilitation as an activity to relieve burdens but also in terms of how rehabilitants come to grips with limitations. Dealing with limitations is an important indicator of mental health.