Measuring enfranchisement: importance of and control over participation by people with disabilities

Evaluating the Usability and Equivalence of Electronic Patient-Reported Outcome Measures for Individuals with a Lower-Limb Amputation

Introduction

Electronic versions of patient-reported outcome measures (PROMs) seem to have a clear administrative logging advantage to traditional paper versions. However, most of them have not been formally evaluated for their suitability to replace paper outcome measures for assessment of individuals with lower-limb amputations. The aim of this study is to examine the usability and equivalence of electronic to paper versions of PROMs suitable for use in prosthetic clinical care and research for persons with lower-limb loss.

Methods

In this cross-sectional study, 10 participants remotely completed the following PROMs online and then on paper: Orthotic and Prosthetic User Survey (OPUS), Modified Falls Efficacy Scale (MFES), Prosthetic Evaluation Questionnaire (PEQ), Patient Health Questionnaire–9 (PHQ-9), and Community Participation Indicators (CPI). Participants also answered open-ended and standardized questions regarding the usability of the electronic surveys. Wilcoxon signed rank tests, comparisons to minimum detectable change, intraclass correlation coefficients, and Bland-Altman plots were used to evaluate differences between the two survey versions, meaningful changes in scores, reliability, and systematic biases, respectively.

Results

Electronic surveys had fewer missing or ambiguous responses than paper surveys; however, the PEQ Social Burdens subscale could not be evaluated due to error in the creation of the electronic survey. No significant differences were found between scores of the two versions for any of the measures, but multiple participants had meaningful changes in the Appearance and Sounds PEQ subscales. All measures demonstrated acceptable reliability between versions, except the Appearance, Perceived Response, and Sounds subscales of the PEQ. No systematic biases in scores or usability concerns were found for any measures.

Conclusions

This study analysis showed that most of the electronic PROMs studied are easily used and demonstrate equivalence to the paper versions. However, the PEQ Appearance, Perceived Response, Sounds, and Social Burden subscales require further evaluation.

Clinical Relevance

Except for the PEQ, electronic versions of the PROMs in this study can likely be used interchangeably with paper versions among individuals with lower-limb loss.

Developing multidimensional participation profiles after traumatic brain injury: a TBI model systems study

Purpose. To characterize societal participation profiles after moderate-severe traumatic brain injury (TBI) along objective (Frequency) and subjective (Satisfaction, Importance, Enfranchisement) dimensions.Materials and Methods. We conducted secondary analyses of a TBI Model Systems sub-study (N = 408). Multiaxial assessment of participation included the Participation Assessment with Recombined Tools-Objective and -Subjective questionnaires (Participation Frequency and Importance/Satisfaction, respectively) and the Enfranchisement Scale. Participants provided responses via telephone interview 1-15 years post-injury. Multidimensional participation profiles (classes) were extracted using latent profile analysis.Results. A 4-class solution was identified as providing maximal statistical separation between profiles and being clinically meaningful based on profile demographic features. One profile group (48.5% of the sample) exhibited the "best" participation profile (High Frequency, Satisfaction, Importance, and Enfranchisement) and was also the most advantaged according to socioeconomic indicators. Other profile groups showed appreciable heterogeneity across participation dimensions. Age, race/ethnicity, education level, ability to drive, and urbanicity were features that varied between profiles.Conclusions. Societal participation is a critical, but inherently complex, TBI outcome that may not be adequately captured by a single index. Our data underscore the importance of a multidimensional approach to participation assessment and interpretation using profiles. The use of participation profiles may promote precision health interventions for community integration.Implications for RehabilitationOur study found unidimensional measures of societal participation in traumatic brain injury (TBI) populations that focus exclusively on frequency indicators may be overly simplistic and miss key subjective components of participationTaking a multidimensional perspective, we documented four meaningfully distinct participation subgroups (including both objective and subjective dimensions of societal participation) within the TBI rehabilitation populationMultidimensional profiles of participation may be used to group individuals with TBI into target groups for intervention (e.g., deeper goal assessment for individuals who do not rate standard participation activities as important, but also do not participate and do not feel enfranchised).

Predictors of Multidimensional Profiles of Participation After Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To identify personal, clinical, and environmental factors associated with 4 previously identified distinct multidimensional participation profiles of individuals following traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Participants (n = 408) enrolled in the TBI Model Systems (TBIMS) Participation Module, all 1 year or more postinjury.

DESIGN

Secondary data analysis of cross-sectional data from participants in a multicenter TBIMS module study on participation conducted between May 2006 and September 2007. Participants provided responses to questionnaires via a telephone interview at their study follow-up (1, 2, 5, 10, or 15 years postinjury).

MAIN MEASURES

Participants provided responses to personal (eg, demographic), clinical (eg, function), environmental (eg, neighborhood type), and participation measures to create multidimensional participation profiles. Data from measures collected at the time of injury (preinjury questionnaire, injury characteristics) were also included. The primary outcome was assignment to one of 4 multidimensional participation profile groups based on participation frequency, importance, satisfaction, and enfranchisement. The measures used to develop the profiles were: Participation Assessment with Recombined Tools-Objective, Importance, and Satisfaction scores, each across 3 domains (Productivity, Social Relationships, Out and About in the Community) and the Enfranchisement Scale (contributing to one's community, feeling valued by the community, choice and control).

RESULTS

Results of the multinomial regression analysis, with 4 distinct participation profile groups as the outcome, indicated that education, current employment, current illicit drug use, current driving status, community type, and Functional Independence Measure Cognitive at follow-up significantly distinguished participation profile groups. Findings suggest a trend toward differences in participation profile groups by race/Hispanic ethnicity.

CONCLUSIONS

Understanding personal, clinical, and environmental factors associated with distinct participation outcome profiles following TBI may provide more personalized and nuanced guidance to inform rehabilitation intervention planning and/or ongoing clinical monitoring.

The differences in demographics, fear of falling, transfer quality and participation enfranchisement between manual and power wheelchair users with multiple sclerosis and spinal cord injury

PURPOSE

To examine the differences in demographics, fear of falling (FOF), transfer quality and participation enfranchisement between manual and power wheelchair users with multiple sclerosis (MS) and spinal cord injury (SCI).

MATERIALS AND METHODS

Secondary data analysis including 126 manual or power wheelchair users with MS and SCI (median age, 53.00 years, IQR = 24.00). Demographic information including age, gender, height, weight and disability duration was collected. Body mass index (BMI) was calculated for all participants. Participation enfranchisement was examined using both subscales (Importance and Control) of the enfranchisement scale of the Community Participation Indicator (CPI). FOF was assessed using the Spinal Cord Injury-Falls Concern Scale (SCI-FCS) and transfer quality was assessed using the Transfer Assessment Instrument (TAI) 3.0 and 4.0. Mann-Whitney's U-tests or independent samples t-tests and chi-square were used to analyse the differences between continuous variables and categorical variables, respectively.

RESULTS

Fifty-seven percent of participants were manual wheelchair users. There were significant differences in most demographic information except for weight and disability duration. Significant differences were also found for BMI (t = 1.06, p = 0.04), CPI-Importance (U = 1282.50, p < 0.01), CPI-Control (U = 1165.50, p < 0.01) and SCI-FCS (t = 4.08, p < 0.01). Manual wheelchair users outperformed power wheelchair users in all outcomes analysed except the TAI (p = 0.18).

CONCLUSIONS

Power wheelchairs users presented with a higher BMI, reported lower participation enfranchisement, and reported higher levels of FOF compared to manual wheelchair users. The findings may help clinicians to develop targeted rehabilitation goals specific for power and manual wheelchair users with MS and SCI.

Preferences for Participation Measurement Among Individuals Diagnosed With Cancer: A Qualitative Content Analysis

Individuals with cancer experience occupational participation restrictions, but there is no consensus on how to measure this construct. The objective of this study is to describe the perspectives and preferences of individuals with cancer regarding participation measurement. Forty individuals with brain, breast, colorectal, and lung cancer provided feedback on three participation measures in semi-structured interviews. Through an iterative, team-based content analysis approach, interview text was coded using the study codebook and organized into themes. Core themes included (a) participation measures highlighted occupational priorities, (b) measuring participation can identify supportive care needs, (c) measures must balance thoroughness with speed of completion, (d) measurement timeframe varies by treatment phase, and (e) evaluating community engagement is not a priority for some individuals with cancer. Integrating participation measures into cancer care can support referrals to occupational therapy and supportive services. It is essential to consider time since cancer diagnosis and client priorities when selecting participation measures.

Consistency of participation over time among persons aging with physical disability as measured by a tool designed for use among community-based organizations

BACKGROUND

Community participation measures for persons aging with disability were developed and evaluated to support community-based organizations (CBOs) with efficient assessment of change in participation and need for supports/services to facilitate participation.

OBJECTIVE

To evaluate a set of nine activity domain measures to broadly assess community participation and change in participation over time.

METHODS

A community-based sample (N = 323) of persons ages 45-65 responded to a survey with repeated measures three times annually (T1, T2, T3) between 2019 and 2022. Nine activity domain measures were developed based on extant research and evaluated with assistance from community-based support service providers. Statistical analyses employed T-tests and chi-square tests to assess change in participation over time, perceptions of participation satisfaction, and assistance needed to facilitate participation. Participants were asked if they thought changes were attributable to aging, the COVID-19 pandemic, or other factors.

RESULTS

Findings showed varying levels of participation across the nine activity domains, with the lowest participation rate for employment and the highest participation rates for personal leisure and managing medications across T1, T2, and T3. Change in participation over the three-year period was limited; most change was reported as activity reduction. In general, respondents indicated that reduction was due to their aging or the COVID-19 pandemic. Personal assistance, transportation, environmental modifications, and improved health were identified as factors needed to help increase participation levels.

CONCLUSION

The activity domain measures demonstrated efficiency in identifying participation rates and change. CBOs may deem them useful for assessing support and service needs to facilitate participation.

Participation and Its Association With Health Among Community-Dwelling Adults With Chronic Stroke

IMPORTANCE

Little is known about the severity of participation restrictions among people living in the community with chronic stroke. Even less is known about the association between participation and health in this population.

OBJECTIVE

To describe participation among people with chronic stroke and examine the association between participation and physical and mental health.

DESIGN

Secondary analysis of baseline data from an intervention study.

SETTING

The parent multisite intervention study was conducted in the community, and assessments were administered in participants' homes.

PARTICIPANTS

Thirty-one community-dwelling adults with chronic stroke.

OUTCOMES AND MEASURES

Participation was measured with the Activity Card Sort (percentage of prestroke activities retained) and the Enfranchisement Scale of the Community Participation Indicators. Health was measured with the PROMIS®-29 Physical Health and Mental Health subscales. We calculated descriptive statistics for participation measures and Spearman's ρ correlations between participation and health outcomes.

RESULTS

Participation scores were poor on all measures of participation. Most striking, 94.9% of participants retained less than 80% of their prestroke activities. All measures of participation were modestly correlated with physical health (ρ = .28-.46) and were moderately correlated with mental health (ρ = .42-.63).

CONCLUSIONS AND RELEVANCE

Participation restrictions are prevalent among adults with chronic stroke, with potential implications for mental health. Stronger community-based rehabilitation and support services to enhance participation of this high-risk population are warranted. What This Article Adds: This report highlights the severity of participation restrictions among people with chronic stroke. Moreover, this report shows that people with stroke feel a lack of inclusion in the community and that participation is associated with mental and physical health.

Footwear limitations in women prosthesis users relate to more than preference

BACKGROUND

The option to wear desired footwear may be an important part of community reintegration after lower-limb amputation.

OBJECTIVES

This study explored outcomes related to footwear, health, and participation in women Veterans with lower-limb amputation.

METHODS

A cross-sectional questionnaire was mailed to all women Veterans age 18-82 years with major lower-limb amputation(s) who had received prosthetics services in the US Department of Veterans Affairs (N = 538). The questionnaire assessed Perceived Challenges (including clothing limitations, prosthetic foot limitations [width, height, and shape], and shoe avoidance for safety concerns), type of footwear used and preference, and included subscales from the Patient-Reported Outcome Measurement Information System, Amputee Body Image Scale Prosthetic Limb Users' Survey of Mobility, Community Participation Index, Activities-Specific Balance Confidence Scale, and Prosthesis Evaluation Questionnaire. Bivariate correlations examined relationships between a composite measure of Perceived Challenges and patient-reported outcomes.

RESULTS

One hundred questionnaires were returned (18.6% response rate; 3 excluded for limited prosthesis use). The Perceived Challenges score was significantly correlated with scores for the Amputee Body Image Scale-Revised (r = 0.24, p = 0.019), Patient-Reported Outcome Measurement Information System (ability to participate: r = -0.25, p = 0.014), Prosthesis Evaluation Questionnaire (utility: r = -0.32, p = 0.001, appearance: r = -0.48, p < 0.001), Activities-Specific Balance Confidence Scale (r = -0.20, p = 0.046), and Prosthetic Limb Users' Survey of Mobility (r = -0.21, p = 0.036), but not depression or anxiety.

CONCLUSIONS

Women who have greater issues with how their prosthesis affects the shoes and clothing they can wear also have poorer body image, reduced functional capabilities, and lower reported participation in activities. Improved prosthetic foot design may help to improve social participation and other important outcomes for women prosthesis users.

Predictors of participation enfranchisement of wheelchair users with spinal cord injury in the United States

CONTEXT/OBJECTIVE

To investigate predictors of participation enfranchisement of individuals living with spinal cord injury (SCI) who use a wheelchair full-time.

DESIGN

Secondary data analysis of a cross-sectional study.

SETTING

Community, United States.

PARTICIPANTS

Participants were 59 wheelchair users (median age of 52.5 years, IQR = 21) with chronic SCI (>1 year after injury).

INTERVENTIONS

No intervention.

MAIN OUTCOME MEASURES

Participation enfranchisement was measured using the enfranchisement scale of the Community Participation Indicators (CPI). Dependent variables included importance of participation (CPI-Importance) and control over participation (CPI-Control) subscales of the CPI. Independent variables included demographics and clinical characteristics (age, sex, time since injury, level of injury), wheelchair skills, mobility level, symptoms of depression, and environmental barriers. Backward multivariable linear regression analyses were carried-out to identify predictors of CPI-Importance and CPI-Control.

RESULTS

Five predictors including mobility level, wheelchair skills, sex, level of injury, and symptoms of depression explained 57% (F = 14; P < 0.01) of the variance in CPI-Importance. Three predictors including mobility level, symptoms of depression, and environmental barriers explained 60% (F = 27; P < 0.01) of the variance in CPI-Control.

CONCLUSION

This study provides evidence of potential modifiable factors such as mobility, wheelchair skills, environmental barriers, and symptoms of depression that can influence importance of participation and control over participation of wheelchair users with SCI. The models presented in this study can serve as a conceptual framework to design effective interventions to improve participation enfranchisement of wheelchair users with SCI.

Characteristics and consequences of falls among people with multiple sclerosis who use wheelchairs or scooters: Differences between injurious and non-injurious falls

BACKGROUND

Falls are common among people living with multiple sclerosis (MS) who use wheelchairs or scooters. Falls may lead to severe consequences including physical injuries. However, very little is known about the circumstances associated with injurious falls in this population. Therefore, we aimed to explore the differences in fall-related characteristics between injurious and non-injurious falls among people with MS who use wheelchairs or scooters.

METHODS

A convenience sample of 48 people with MS (age = 62.0 [13.0] years, gender = 81.3% female, primary mobility aid = power wheelchair) completed a fall-history survey that examined the characteristics and consequences of their most recent fall. Participants also completed standard questionnaires on quality of life, community participation, and fear of falling.

RESULTS

Most falls (85.4%) reported by participants occurred inside the house. Twelve (25.0%) participants reported experiencing fall-related injuries such as bruises, cuts, muscle strains, and fractures. People who reported being injured after a fall had a higher proportion of falls that occurred during transfers compared to those who were not injured (n = 10, 83.3% vs n = 17, 47.2%). Most participants (45.8%) did not receive any information from healthcare professionals on how to manage their fall-risk after their fall experience. No differences between injurious and non-injurious fallers in quality of life, community participation, and fear of falling were observed.

CONCLUSIONS

This cross-sectional investigation provides compelling evidence that people with MS who use wheelchairs or scooters are at high risk of fall-related injuries. The study findings underscore the importance of increasing health care providers' awareness about the frequency and consequences of falls. Further, it demonstrates the critical need for evidence-based interventions specifically designed to minimize fall-related injuries in this vulnerable population.

Online Delivery of the Individualized Reduction of Falls Intervention for Persons With Multiple Sclerosis Who Use a Wheelchair or Scooter Full-time: A Pilot Study

BACKGROUND

People with multiple sclerosis (MS) who use a wheelchair or scooter full-time fall frequently; however, fall prevention programming that meets the unique needs of this population is limited. This study examined the preliminary efficacy of a group-based online fall prevention and management intervention designed specifically for people with MS.

METHODS

This pre/post intervention, mixed-methods study included people with MS who used a wheelchair or scooter full-time, experienced at least 1 fall within the past year, and transferred independently or with minimal or moderate assistance. Participants engaged in a 6-week, online, individualized, multicomponent fall prevention and management intervention: Individualized Reduction of Falls-Online (iROLL-O).

RESULTS

No statistically significant change in fall incidence occurred after iROLL-O. However, fear of falling significantly decreased (P < .01) and knowledge related to fall management (P = .04) and fall prevention and management (P = .03) significantly improved. Qualitative results indicated that participants valued the opportunity for peer learning and iROLL-O's attention to diverse influences on fall risk.

CONCLUSIONS

This study is the first to examine the preliminary efficacy of an online fall prevention and management intervention for people with MS who use a wheelchair or scooter full-time. iROLL-O has promise, and participants found it valuable. Further efforts are needed to retain iROLL-O participants with lower confidence and functional mobility, and more research is needed to investigate the impact of the intervention on key outcomes over time.

Comparison of Informational and Educational Resource Provision for Individuals Living With Traumatic Brain Injury Based on Language, Nativity, and Neighborhood

OBJECTIVE

To examine a resource provision program for individuals living with moderate-to-severe traumatic brain injury (TBI), using a comparison of the resources provided across social differences of language, nativity, and neighborhood.

SETTING

The Rusk Rehabilitation TBI Model System (RRTBIMS) collects data longitudinally on individuals from their associated private and public hospitals, located in New York City.

PARTICIPANTS

A total of 143 individuals with TBI or their family members.

DESIGN

An observational study of relative frequency of resource provision across variables of language, nativity, and neighborhood, using related-samples nonparametric analyses via Cochran's Q test.

MAIN MEASURES

Variables examined were language, place of birth, residence classification as medically underserved area/population (MUA), and resource categories.

RESULTS

Results indicate that US-born persons with TBI and those living in medically underserved communities are provided more resources than those who are born outside the United States or reside in communities identified as adequately medically served. Language was not found to be a factor.

CONCLUSION

Lessons learned from this research support the development of this resource provision program, as well as guide future programs addressing the gaps in health information resources for groups negatively impacted by social determinants of health (SDoH). An approach with immigrant participants should take steps to elicit questions and requests, or offer resources explicitly. We recommend research looking at what interpreter strategies are most effective and research on SDoH in relation to the dynamic interaction of variables in the neighborhood setting.

Cut points and sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in adults with traumatic brain injury

BACKGROUND

Community participation is an important outcome of rehabilitation following traumatic brain injury. Yet, few measures assess inclusion and belonging (enfranchisement) as a dimension of community participation. The Enfranchisement scale of the Community Participation Indicators addresses this need. However, research on its psychometric properties is lacking.

OBJECTIVE

To examine cut points and sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in adults with traumatic brain injury.

DESIGN

This was a repeated measures study with assessments administered twice (3 months apart).

SETTING

Assessments were administered either over the phone, virtually (Zoom), or in person at the participant's home.

PARTICIPANTS

A total of 44 participants from community settings who had either experienced a traumatic brain injury within the previous year or were receiving rehabilitation interventions were recruited.

MAIN OUTCOME MEASURE

The Enfranchisement scale has two subscales: the Control subscale (range: 13-65) and the Importance subscale (range: 14-70). On both subscales, lower scores indicate better enfranchisement.

METHODS

The software SAS PROC Logistic and the macro %ROCPlot were used to examine cut points at varying levels of sensitivity and specificity. The area under the receiver operating characteristics curve was calculated to determine overall classification accuracy. Minimum detectable change and minimal clinically important difference were also calculated.

RESULTS

For the Control subscale, a cut point of 44 (area under the curve = .75), a minimum detectable change of 8, and a minimal clinically important difference of 5 were found. For the Importance subscale, a cut point of 39 (area under the curve = .81), a minimum detectable change of 8, and a minimal clinically important difference of 5 were found.

CONCLUSIONS

The cut points resulted in good classification accuracy, providing support for their reliability. The results provided evidence that both subscales are sensitive to change in adults with brain injury.

Characterizing fatigue phenotypes with other symptoms and clinically relevant outcomes among people with multiple sclerosis

PURPOSE

Fatigue is a common symptom of multiple sclerosis (MS) and can adversely affect all aspect of quality of life. The etiology of fatigue remains unclear, and its treatments are suboptimal. Characterizing the phenotypes of fatigued persons with MS may help advance research on fatigue's etiology and identify ways to personalize fatigue interventions to improve quality of life. The purpose of this study was to identify fatigue phenotypes; examine phenotype stability overtime; and characterize phenotypes by health and function, social and environmental determinants, psychosocial factors, and engagement in healthy behaviors.

METHODS

We conducted a longitudinal study over a 3-month period with 289 fatigued participants with MS. To identify fatigue phenotypes and determine transition probabilities, we used latent profile and transition analyses with valid self-report measures of mental and physical fatigue severity, the mental and physical impact of fatigue, depression, anxiety, and sleep quality. We used ANOVAs and effect sizes to characterize differences among phenotypes.

RESULTS

The best fitting model included six subgroups of participants: Mild Phenotype, Mild-to-Moderate Phenotype, Moderate-to-Severe Phenotype, Severe Phenotype, Fatigue-dominant Phenotype, and Mental Health-dominant Phenotype. The transition analysis indicated that phenotypic membership was highly stable. Variables with a large eta squared effect size included environmental barriers, self-efficacy, and fatigue catastrophizing.

CONCLUSION

These results indicate that the magnitude of fatigue experienced may be more important to consider than the type of fatigue when characterizing fatigue phenotypes. Future research should explore whether tailoring interventions to environmental barriers, self-efficacy, and fatigue catastrophizing reduce the likelihood of transitioning to a more severe phenotype.

Measuring subjective aspects of participation in adults with disabilities: A systematic review of the coverage, content validity and internal structure of standardised instruments

OBJECTIVE

To systematically review evidence on the coverage, content validity and internal structure of self-report measures capturing subjective aspects of participation for adults with disabilities.

DATA SOURCES

EMBASE, MEDLINE and reference lists were searched until July 10^th, 2022 for articles on measurement properties of instruments measuring participation as defined in the International Classification of Functioning, Disability and Health, from a subjective perspective.

METHOD

Each instrument was assessed for its coverage of subjective aspects of participation. The Consensus-based Standards for the Selection of Health Measurement Instruments were used to assess the quality of each study. Content validity and internal structure (structural validity, internal consistency and cross-cultural validity) were rated against published standards and qualified by the adapted Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Thirty-eight studies regarding 10 instruments were analysed. Most instruments mix activity and participation items. Only the Measure of Experiential Aspects of Participation (with high-quality evidence of sufficient structural validity and generally sufficient internal consistency), the Participation Enfranchisement and the Community Integration Measure showed adequate coverage. For all instruments, evidence of content validity is of low- to very low quality. There is high-quality evidence that the Participation Scale is not unidimensional.

CONCLUSION

In general, the coverage and the evidence for content validity and internal structure of measures capturing experiential aspects of participation are limited. The Measure of Experiential Aspects of Participation has the best level of evidence in support of its use. The score of the Participation Scale cannot be considered an adequate reflection of participation.

Conceptualization of Participation: A Qualitative Synthesis of Brain Injury Stakeholder Perspectives

Background

The return to participation in meaningful life roles for persons with acquired brain injury (pwABI) is a goal shared by pwABI, their families, clinicians, and researchers. Synthesizing how pwABI define participation will help to identify the aspects of participation important to pwABI and can inform a person-centered approach to participation outcome assessment. To-date, the qualitative synthesis approach has been used to explore facilitators and barriers of participation post-stroke, and views about participation among individuals with stroke in the UK.

Objectives

This paper's objectives are to (1) conduct a scoping review of qualitative literature that defines and characterizes participation from the perspective of pwABI of any type, (2) synthesize how pwABI define and categorize participation, and (3) link the themes identified in the qualitative synthesis to the International Classification of Functioning, Disability, and Health (ICF) using standardized linking rules to enhance the comparability of our findings to other types of health information, including standardized outcome measures.

Methods

We completed a scoping review of qualitative literature. Our search included PubMed, APA PsychInfo, CINAHL, and Embase databases and included articles that (1) had qualitative methodology, (2) had a sample ≥50% pwABI, (3) had aims or research questions related to the meaning, definition, perception, or broader experience of participation, and (4) were in English. Qualitative findings were synthesized using Thomas and Harden's methodology and resultant themes were linked to ICF codes.

Results

The search identified 2,670 articles with 2,580 articles excluded during initial screening. The remaining 90 article abstracts were screened, and 6 articles met the full inclusion criteria for the qualitative synthesis. Four analytical themes emerged: (1) Essential Elements of Participation (2) How pwABI Approach Participation, (3) Where pwABI Participate, and (4) Outcomes of Participation. Each overarching theme included multiple descriptive themes.

Conclusion

In this paper, we identified themes that illustrate key components of participation to pwABI. Our results provide insight into the complex perspectives about participation among pwABI and illustrate aspects of participation that should hold elevated importance for clinicians and researchers supporting participation of pwABI.

Frailty among people with multiple sclerosis who are wheelchair users

Background

Frailty is a biological syndrome arising from cumulative declines across multiple physiologic systems. Although recent reports have described elevated frailty levels in people with multiple sclerosis (MS) with minimal to moderate disability, very little is known about frailty in individuals with severe disability. The objective of the current investigation was to evaluate frailty through the deficit accumulation model and to explore the relationship of frailty with MS clinical subtypes, disease duration and fall-history in wheelchair users living with MS.

Materials and methods

Standard validated procedures were used to calculate a frailty index in 45 wheelchair and scooter users living with MS (median age = 60.0[16.0] years, 82.2% female, patient determined disease steps score = 7.0). Information on demographics, MS clinical subtypes, disease duration, and six-month fall-history were collected as part of a standardized medical survey.

Results

The mean frailty index score was 0.54 (standard deviation = 0.13). Overall, 91.1% and 8.9% of participants met objective diagnostic criteria for severe and moderate frailty, respectively. A one-way ANOVA revealed no significant differences (F = 0.054, p = 0.948) in the frailty index among participants with relapsing-remitting MS, primary progressive, and secondary progressive MS. No relationship between frailty and disease duration (r = -0.058, p = 0.706) was found. A univariable negative binomial regression analysis revealed a significant association between frailty index scores and the number of falls experienced in the previous six months (IRR = 1.75, 95% CI [1.06–2.91], p = 0.030).

Conclusion

The current study suggests that individuals with MS with advanced disability also live with coexisting frailty and that the frailty index may be a valuable tool in evaluating fall-risk in wheelchair users living with MS. The significant overlap observed between severe disability and severe frailty highlights the emerging need to untangle this bi-directional relationship to identify appropriate therapeutic pathways in the MS population living with advanced disability.

Amputation-specific and generic correlates of participation among Veterans with lower limb amputation

Participation in valued interpersonal and community activities is a key component of rehabilitation for Veterans with amputation. The purpose of this study was to identify specific factors that promote or inhibit participation to inform development of interventions that may facilitate participation in desired life activities. A convenience sample of 408 Veterans with at least one lower limb amputation and who had received outpatient care from the Regional Amputation Center (RAC) completed a mailed survey. Participation was measured using the Community Participation Indicators (CPI) Importance, Control, and Frequency scales and the Patient Reported Outcome Measurement Information System (PROMIS) Ability to Participate in Social Roles and Satisfaction with Social Participation scales. Multiple imputation procedures were used to address missing data. Correlates of participation were examined through multiple linear regression. A total of 235 participants completed the survey, a response rate of 58%. Levels of participation, measured with the PROMIS instruments, were 43.2 (SD = 8.1) for Ability and 46.4 (SD = 8.6) for Satisfaction. Regression analyses found robust amputation-specific correlates for participation, including body image and balance confidence. Generic (non-amputation specific) correlates for participation included depression and pain interference. Development of treatment approaches and devices that can address body image, balance confidence, pain, and mental health concerns such as depression have the potential to enhance the participation and rehabilitation of Veterans with lower limb amputation.

Long-term effects of spasticity treatment, including selective dorsal rhizotomy, for individuals with cerebral palsy

AIM

To understand the long-term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy.

METHOD

This was a pre-registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes-SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No-SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long-term assessment (age ≥21y, follow-up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life.

RESULTS

Spasticity was effectively reduced at long-term assessment in the Yes-SDR group and was unchanged in the No-SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes-SDR + 11 vs No-SDR + 5) and walking speed (Yes-SDR unchanged, No-SDR declined 25%). The Yes-SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design).

INTERPRETATION

Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life.

Understanding the participation outcomes for persons with disability when partnered with assistance dogs: A scoping review

Introduction

Assistance dogs are trained to support persons living with disability and mitigate limitations that hinder their participation in everyday activities. Despite participation being a frequent challenge for people with disabilities, evidence linking assistance dog provision to improved participation outcomes is underdeveloped. This scoping review aimed to improve understanding by mapping the participation outcomes claimed in research on assistance dogs using the International Classification of Functioning (ICF), Disability and Health framework.

Methods

Using the Arksey and O′Malley's six‐step framework, this scoping review searched six databases. Data were collected, mapped and summarised in accordance with the domains outlined in the ICF.

Results

In total, 38 studies across 41 papers met the inclusion criteria. Included studies investigated assistance dogs who were partnered with people living with physical disabilities, mental illness, autism and chronic conditions that require alerting (e.g., epilepsy and diabetes). Mapping of participation outcomes suggested that assistance dogs can have a positive impact on participation in many areas of daily life.

Conclusion

Findings can assist practitioners, funders and policymakers to recognise the value of assistance dogs as a support for people with disability. However, further research is needed to address limitations regarding study designs, for example, the outcome measures used.

Risk factors associated with falls and fall-related injuries among wheelchair users with spinal cord injury

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Shorter time since injury and higher mobility levels as well as poor physical health are associated with higher risk of falls and fall-related injuries, respectively in wheelchair users with spinal cord injury.

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The findings indicate good discriminant ability and clinical utility of the factors presented to identify wheelchair users who are at risk of falls and fall-related injuries.

Objective

To identify risk factors for falls and fall-related injuries for wheelchair users with spinal cord injury (SCI).

Design

Cross-sectional study.

Setting

Community setting.

Participants

Fifty-nine community dwelling wheelchair users (N=59), 47.5% male, median age of 52.5 years (IQR, 21 years) with chronic SCI, median time since injury of 16.6 years (IQR, 27.3 years).

Interventions

No intervention.

Main Outcome Measures

Outcomes were incidence of falls and fall-related injuries. Participants reported on falls and fall-related injuries experienced in the previous 6 months. Independent variables were self-reported and performance-based measures. Self-reported measures included demographics, characteristics of SCI, fear of falling, psychological measures, functional independence, wheelchair skills, environmental barriers, quality of life, and community participation. Performance-based measures included transfer quality and sitting balance assessments. Logistic regression analyses were conducted to identify factors influencing falls and fall-related injuries.

Results

In total, 152 falls and 30 fall-related injuries were reported from a total of 37 fallers. After logistic regression analysis, the model with the greatest levels of clinical utility and discriminative ability for falls (sensitivity 81%; specificity 55%; area under the receiving operating characteristic curve [AUC] statistics=0.73; 95% CI, 0.60-0.86) included the variables of shorter time since SCI, high mobility level, and having received education on fall prevention. The model for fall-related injuries (sensitivity 79%; specificity 75%; AUC statistics=0.77; 95% CI, 0.59-0.96) included the variables of older male individual, lower physical health score, and having received education on fall prevention.

Conclusions

The regression models presented may be used to identify wheelchair users with SCI at greater risk of falls and fall-related injuries. The findings may help to refer those in need to tailored fall and fall-related injury prevention programs. The findings presented in this study were based on a relatively small sample convenience; therefore, further prospective studies with a larger sample size are warranted.

Detecting change in community participation with the Enfranchisement scale of the community participation indicators

OBJECTIVE

This study determined the sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in people with stroke.

DATA SOURCES

We analyzed data from two studies of participants with stroke: an intervention study and an observational study.

MAIN MEASURES

The Enfranchisement Scale contains two subscales: the Importance subscale (feeling valued by and contributing to the community; range: 14-70) and the Control subscale (choice and control: range: 13-64).

DATA ANALYSIS

Assessments were administered 6 months apart. We calculated minimum detectable change and minimal clinically important difference.

RESULTS

The Control subscale analysis included 121 participants with a mean age of 61.2 and mild-moderate disability (Functional Independence Measure, mean = 97.9, SD = 24.7). On the Control subscale, participants had a mean baseline score of 51.4 (SD = 10.4), and little mean change (1.3) but with large variation in change scores (SD = 11.5). We found a minimum detectable change of 9 and a minimum clinically important difference of 6. The Importance subscale analysis included 116 participants with a mean age of 60.7 and mild-moderate disability (Functional Independence Measure, mean = 98.9, SD = 24.5). On the Importance subscale, participants had a mean baseline score of 44.1 (SD = 12.7), and again demonstrated little mean change (1.08) but with large variation in change scores (SD = 12.6). We found a minimum detectable change of 11 and a minimum clinically important difference 7.

CONCLUSIONS

The Control subscale required 9 points of change, and the Importance subscale required 11 points of change, to achieve statistically and clinically meaningful changes, suggesting adequate sensitivity to change.

Community Participation by People with Chronic Obstructive Pulmonary Disease

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV₁: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all r_s = 0.30, p < 0.05). Older age and more moderate-to-vigorous physical activity independently predicted greater community participation measured by CPI. Higher levels of depression symptoms were associated with less formal and informal community participation on ESS (r_s = -0.25). More formal community participation on ESS was weakly (r_s = 0.2-0.3) associated with older age, better lung function, exercise capacity and self-efficacy, and less breathlessness. Self-efficacy, exercise capacity, and age independently predicted formal community participation in individuals with COPD. Strategies to optimize self-efficacy and improve exercise capacity may be useful to enhance community participation in people with COPD.

Construct validity of the enfranchisement scale of the community participation indicators

OBJECTIVE

This study examined the construct validity of the Enfranchisement scale of the Community Participation Indicators.

DESIGN

We conducted a secondary analysis of data collected in a cross-sectional study of rehabilitation outcomes.

SUBJECTS

The parent study included 604 community-dwelling adults with chronic traumatic brain injury, stroke, or spinal cord injury. The sample had a mean age of 64.1 years, was two-thirds male, and included a high proportion of racial minorities (n = 250, 41.4%).

MAIN MEASURES

The Enfranchisement scale contains two subscales: the Control subscale and the Importance subscale. We examined correlations between each Enfranchisement subscale and measures of participation, environment, and impairments. The current analyses included cases with at least 80% of items completed on each subscale (Control subscale: n = 391; Importance subscale: n = 219). Missing values were imputed using multiple imputation.

RESULTS

The sample demonstrated high scores, indicating poor enfranchisement (Control subscale: M = 51.7; Importance subscale: M = 43.0). Both subscales were most strongly associated with measures of participation (Control subscale: r = 0.56; Importance subscale: r = 0.52), and least strongly associated with measures of cognition (Control subscale: r = 0.03; Importance subscale: r = 0.03). The Importance subscale was closely associated with depression (r = 0.54), and systems, services, and policies (r = 0.50). Both subscales were associated with social attitudes (Control subscale: r = 0.44; Importance subscale: r = 0.44) and social support (Control subscale: r = 0.49; Importance subscale: r = 0.41).

CONCLUSIONS

We found evidence of convergent validity between the Enfranchisement scale and measures of participation, and discriminant validity between the Enfranchisement scale and measures of disability-related impairments. The analyses also revealed the importance of the environment to enfranchisement outcomes.

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

Fear of Falling, Community Participation, and Quality of Life Among Community-Dwelling People Who Use Wheelchairs Full Time

OBJECTIVES

To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF).

DESIGN

Cross-sectional study design.

SETTING

University research laboratory.

PARTICIPANTS

Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

To quantify FOF, participants responded (yes/no) to the question: "Are you worried or concerned that you might fall?" Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF.

RESULTS

A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F_2,82=4.714; P=.012; Wilks' λ=0.897) and WHOQOL-BREF (F_4,63=3.32; P=.016; Wilks' λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF.

CONCLUSIONS

FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users' community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL.

A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT

BACKGROUND

Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility.

OBJECTIVE

This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial.

DESIGN

Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework.

SETTING

Four sites across the UK.

PARTICIPANTS

Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months.

INTERVENTIONS

Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone.

MAIN OUTCOME MEASURES

Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data.

RESULTS

A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted.

CONCLUSIONS

The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries.

FUTURE WORK

Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13587999.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.

A brief fall prevention intervention for manual wheelchair users with spinal cord injuries: A pilot study

Objective: To conduct a pilot study of an intervention to decrease fall incidence and concerns about falling among individuals living with Spinal Cord Injury who use manual wheelchairs full-time. Design: Pre/post. After a baseline assessment, a structured intervention was implemented. The assessment protocol was repeated 12 weeks after the baseline assessment. Setting: Research laboratory and community. Participants: 18 individuals living with SCI who use a manual wheelchair full-time with an average age of 35.78 ± 13.89 years, lived with SCI for 17.06 ± 14.6 years; 61.1% were female. Intervention: A 1:1, 45 minute, in-person intervention focused on factors associated with falls and concerns about falling: transfers skills and seated postural control. Outcome measures: Participants reported fall incidence and completed the Spinal Cord Injury Fall Concerns Scale, Community Participation Indicators and the World Health Organization Quality of Life - short version (WHOQOL-BREF). Transfer quality was assessed with the Transfer Assessment Instrument (TAI) and seated postural control with the Function In Seating Test (FIST). Results: Recruitment, assessment and delivery of the intervention were successfully completed. After exposure to the intervention, fall incidence significantly decreased, (P = 0.047, d_z= 0.507) and FIST scores improved (P = 0.035, d_z = 0.54). Significant improvements were also found in the WHOQOL-BREF Physical (P = 0.05, d_z= 1.566) and Psychological (P = 0.040, d_z= 0.760) domains. Conclusion: The feasibility of the structured intervention was established and the intervention has the potential to reduce fall incidence and improve quality of life among individuals living with SCI who use a wheelchair. Appropriately powered randomized controlled trials of the program are warranted.

REFRESH protocol: a non-inferiority randomised clinical trial comparing internet and teleconference to in-person 'Managing Fatigue' interventions on the impact of fatigue among persons with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. It is considered a major cause of non-traumatic disability in young adults. One of the most common and disabling symptoms of MS is fatigue. MS fatigue can impact all aspects of quality of life, including physical, mental and social function. Fortunately, fatigue self-management interventions, such as 'Managing Fatigue: A 6 week energy conservation course', can decrease the impact of fatigue and improve health-related quality of life. The purpose of this study is to compare three modes of delivering the Managing Fatigue intervention-two remote delivery formats (teleconference and internet) and one in-person format-on perceptions of fatigue and its impact on physical, mental and social function.

METHODS AND ANALYSIS

A non-inferiority randomised clinical trial is being conducted to compare the three delivery formats (1:1:1 allocation ratio) among 582 participants with MS living in the Midwestern and Northeastern United States. The hypothesis is that teleconference and internet versions of the intervention are non-inferior to the traditional mode of clinical service delivery (ie, one to one, in person) in terms of the primary outcome of self-reported fatigue impact (ie, Fatigue Impact Scale) and the secondary outcome of health-related quality of life (ie, Multiple Sclerosis Impact Scale). Outcomes are being measured at baseline, 2 months, 3 months and 6 months. The primary analysis tool will be linear mixed effects model. The prespecified inferiority margin for the primary outcome is 10 points. We will also examine whether baseline characteristics (eg, sociodemographic) moderate outcomes of the Managing Fatigue intervention and whether changes in self-efficacy and fatigue self-management behaviours mediate changes in outcomes.

ETHICS AND DISSEMINATION

The protocol is approved centrally by the institutional review board at Case Western Reserve University. Eligible participants give consent before being enrolled and randomised into the study. The study results will be disseminated through relevant advocacy organisations, newsletters to participants, publication in peer-reviewed journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03550170; Pre-results.

"Starting to Live a Life": Understanding Full Participation for People With Disabilities After Institutionalization

IMPORTANCE

A key objective of the Americans With Disabilities Act of 1990 (ADA) is community integration; yet, nearly 30 yr later, little is known about the participation of people with disabilities who transition from institutions to the community.

OBJECTIVE

To understand how people with disabilities describe full participation after transitioning from an institution to the community and to identify environmental barriers and facilitators to participation during and after this transition.

DESIGN

The ADA-Participatory Action Research Consortium (ADA-PARC), a collaboration among researchers, people with disabilities, and community organizations, is implementing a multimethod, participatory action research study of participation among people with disabilities posttransition. This article presents qualitative findings from semistructured interviews collected as part of the larger ADA-PARC project.

SETTING

ADA-PARC community partners across the United States.

PARTICIPANTS

One hundred fifty-three adults with disabilities.

OUTCOMES AND MEASURES

We used a semistructured interview guide to ask participants about their experiences during and after transition to the community.

RESULTS

We identified four themes: (1) the process of transition as ongoing rather than a single event, (2) access to everyday occupations as full participation and what fully represents "living a life," (3) environmental barriers to participation, and (4) social identity as participation as the transformative process of moving from the disempowering isolation of the institution to being integrated into the community.

CONCLUSIONS AND RELEVANCE

As people with disabilities transition into community settings, they require ongoing supports to facilitate their full, long-term participation.

WHAT THIS ARTICLE ADDS

People with disabilities reported that transitioning from institutions to the community was itself not enough to support their full community participation; rather, they viewed transition as an ongoing process, and they needed services and supports to fully participate. Occupational therapy practitioners working in institutional and community settings can partner with local disability advocacy communities to support their clients' sense of identity and self-confidence during and after transition to the community.

Referral Prioritization in Home Care Occupational Therapy: A Matter of Perspective

Background.

Prioritizing referrals for home care occupational therapy is somewhat subjective, and public and patient perspectives on waiting list priorities are unknown.

Purpose.

To explore the views of home care occupational therapists (OTs), older persons (OPs) and adults with disabilities on waiting list priorities, as well as issues and challenges underlying these priorities.

Method.

We conducted in-depth interviews with 11 OTs, 10 OPs and 9 adults with disabilities. Participants were asked to prioritize referral scenarios while explaining their choices. Directed and conventional content analysis allowed the identification of themes for each group of participants.

Findings.

OTs experienced conflicts of values but mainly prioritized referrals based on client safety. OPs sought to maximize client’s independence, and persons with disabilities aimed to improve clients’ social participation.

Implications.

OTs should seek the perspectives of their target clientele on referral prioritization criteria and strive to adjust prioritization practices accordingly.

Domains and dimensions of community participation following traumatic brain injury

PRIMARY OBJECTIVE

To examine patterns of community participation, as well as the relationship among community participation outcomes and time since injury, impairments, environmental factors, and enfranchisement in adults with traumatic brain injury (TBI).

RESEARCH DESIGN

Cross-sectional study of a sample of 61 adults with TBI.

METHODS AND PROCEDURES

We administered the Participation Measure- 3 Domains 4 Dimensions to examine community participation in the three domains (productivity, community activities, and social participation) using four dimensions (diversity of activities, frequency, difficulty, and desire for change).

MAIN RESULTS AND OUTCOMES

All dimensions of community participation seem to be impaired following TBI, as evidenced by scores in the lower half of the available range. Most impaired was social participation (frequency: M = 10.0, SD = 3.4, possible range 0-24; difficulty: M=  11.3, SD = 3.2, possible range 4-16). Correlational analyses revealed that depression (r = 0.51), environmental factors (r = 0.51), and enfranchisement (r = 0.42), seem to play an important role in community participation outcomes, and may be potential targets for intervention. Results did not vary based on time since injury.

CONCLUSION

Our results suggest that depression, environmental factors, and enfranchisement may be important considerations for future interventions aiming to promote management of identified barriers.

An exploration of linear and curvilinear relationships between community participation and neurocognition among those with serious mental illnesses

OBJECTIVE

Longitudinal research supports an effect of participation in aspects of community life (e.g., leisure activity, employment) on neurocognition in the general population. This study examined the extent and nature of the relationship between community participation and neurocognition among people with serious mental illnesses.

METHOD

Participants included 168 adults with schizophrenia spectrum or affective disorder diagnoses who completed the Temple University Community Participation Measure and Brief Assessment of Cognition in Schizophrenia. Hierarchical multiple regression analyses explored linear and curvilinear effects of the amount and breadth of community participation on neurocognition.

RESULTS

Significant linear relationships existed between amount of community participation and overall neurocognitive functioning, motor speed, verbal fluency, and attention/processing speed, and between breadth of participation and verbal fluency. Significant curvilinear effects were noted between amount of community participation and verbal memory, and between breadth of community participation and overall neurocognitive functioning and motor speed.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings suggest that enhanced community participation may contribute to improved neurocognitive functioning, further supporting the importance of this rehabilitation target. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The association between volition and participation in adults with acquired disabilities: A scoping review

Background/objective

Physical, cognitive and psychological factors such as self-efficacy and motivation affect participation in populations with acquired disabilities. Volition is defined as a person's motivation for participating in occupation. The concept of ‘volition’ expands similar concepts and theories, which focus mostly on cognitive processes that influence motivation. Although volition seems to affect participation, the association between these two concepts has not been examined in populations with acquired disabilities. This scoping review explored this association.

Methods

The literature review used a structured five-stage framework, according to predefined inclusion and exclusion criteria. Seven electronic databases (CINAHL, PsycINFO, PubMed, Web of Science, SCOPUS, The Cochrane Library-Wiley, OTseeker) and Google Scholar were searched for relevant articles, published in English from January 2001 to May 2018.

Results

A total of 18 articles, relating to populations with various diagnoses were included. Two directly examined volition and participation and showed a positive association between them. Other articles discussed the effect of participants’ chronic condition on their volition and participation, the effect of volition on participation, or the effect on participation of an intervention addressing volition.

Conclusions

An acquired disability affects both volition and participation, and volition seems to affect participation among people with acquired disabilities. Few articles showed positive effects of interventions that addressed clients' volition, on participation. Further research should include additional health conditions and types of literature, to better understand the association between these concepts. This understanding will contribute to the development of occupational therapy interventions that emphasise volition, in order to improve participation outcomes.

Development and Psychometric Characteristics of the TBI-QOL Independence Item Bank and Short Form and the TBI-QOL Asking for Help Scale

OBJECTIVE

To develop an item response theory (IRT)-calibrated, patient-reported outcome measure of subjective independence for individuals with traumatic brain injury (TBI).

DESIGN

Large-scale item calibration field testing; confirmatory factor analysis (CFA) and graded response model IRT analyses.

SETTING

Five TBI Model System centers across the United States.

PARTICIPANTS

Adults with complicated mild, moderate, or severe TBI (N=556).

OUTCOME MEASURES

Traumatic Brain Injury-Quality of Life (TBI-QOL) Independence item bank and the TBI-QOL Asking for Help scale.

RESULTS

A total of 556 individuals completed 44 items in the Independence item pool. Initial factor analyses indicated that items related to the idea of "asking for help" were measuring a different construct from other items in the pool. These 9 items were set aside. Twenty-two other items were removed because of bimodal distributions and/or low item-total correlations. CFA supported unidimensionality of the remaining Independence items. Graded response model IRT analysis was used to estimate slopes and thresholds for the final 13 Independence items. An 8-item fixed-length short form was also developed. The 9 Asking for Help items were analyzed separately. One misfitting item was deleted, and the final 8 items became a fixed-length IRT-calibrated scale. Reliability was high for both measures.

CONCLUSIONS

The IRT-calibrated TBI-QOL Independence item bank and short form and TBI-QOL Asking for Help scale may be used to measure important issues for individuals with TBI in research and clinical applications.

Perceptions of Fall Circumstances, Recovery Methods, and Community Participation in Manual Wheelchair Users

OBJECTIVE

The aim of the study was to examine the circumstances surrounding the worst fall experienced by full-time manual wheelchair users in the past 12 mos, the recovery process, and influence on community participation.

DESIGN

A mixed-method research study was conducted. Semistructured interviews were conducted to understand the circumstances of the worst fall experienced and the recovery process. A quantitative fear of falling assessment and the community participation indicators were used to further evaluate the influence of the fall.

RESULTS

There were 20 manual wheelchair users (mean ± SD, 47 ± 13 yrs, 55% male). Falls most commonly occurred outside during wheelchair propulsion. Falls were attributed to both intrinsic and extrinsic factors. Seventy percent of participants reported a fear of falling and 80% required assistance to recovery. No significant correlations were found between fall frequency and community participation indicator scores. Participants who needed assistance to recover (56.70 ± 17.66) had lower community participation indicator importance scores compared with participants able to recover independently (88.93 ± 22.13), P = 0.05.

CONCLUSIONS

Falls are complex and most manual wheelchair users need assistance to recover. Comprehensive programs including education on prevention and postfall management are needed. Results may increase understanding of the circumstances associated with falls and inform the development of evidenced-based clinical practice guidelines.

Initial psychometric evaluation of the Community Participation Activation Scale

Background.

Current assessments do not capture the dynamic and complex process of managing different individual and environmental factors influencing community participation post-stroke.

Purpose.

The purpose of this study was to examine the psychometric properties of the Community Participation Activation Scale (CPAS) in persons with stroke.

Method.

Rating scale structure, unidimensionality, reliability and precision, construct validity, and differential item functioning of the CPAS were examined with 93 community-dwelling people with stroke.

Findings.

The CPAS consists of 15 action items and 10 attitude items. Person separation reliabilities of the action and attitude domains were .75 and .72, respectively, and internal consistency reliabilities were good (>.80). The CPAS showed low to moderate correlation with community integration and enfranchisement constructs.

Implications.

The CPAS may be used as an assessment to better understand an individual’s level of activation and to inform individually designed, participation-focused interventions, although it needs further improvement to be used as a clinical measure.

Scoping Review: The Trajectory of Recovery of Participation Outcomes following Stroke

Participation is a central concept in health and well-being and healthcare, yet operationalizing this concept has been difficult. Its definition, uses in healthcare, and impacts on recovery require ongoing research. Our review question goes like this: from the longitudinal evidence investigating participation among stroke survivors, what are the patterns of participation recovery in stroke survivors over time, and what interventions are used to improve participation? To fully understand these questions, we also ask, how is participation defined in the stroke literature, and what are the measures of participation used in the stroke literature? A systematic scoping review was undertaken using the search terms "stroke," "longitudinal," "participation," and "outcome" in seven databases. Articles included were published until April 2017, written in English, and had at least two longitudinal assessments of participation. Fifty-nine articles met the inclusion criteria. The International Classification of Functioning, Disability and Health was the most frequent definition of participation used (34%). There were 22 different measures of participation. Eight of ten studies demonstrated significant improvements in participation up to 12 months poststroke. Efficacy of interventions and their impact on participation varied. The various definitions, measures, and intervention efficacies of participation highlight the need for further research worldwide into achieving meaningful participation and quality of life among stroke survivors. Future practice should include participation as a main outcome measure.

Contextualizing disability: a cross-sectional analysis of the association between the built environment and functioning among people living with spinal cord injury in the United States

STUDY DESIGN

Secondary analysis of cross-sectional data from a multisite cohort study.

OBJECTIVES

To analyze the association between the built environment and physical functioning reported by adults living with chronic spinal cord injury (SCI).

SETTING

Four US Spinal Cord Injury Model Systems centers in New Jersey, Colorado, Illinois, and Michigan.

METHODS

Participants were from the Spinal Cord Injury-Functional Index/Capacity (SCI-FI/C) development study. Survey data from N = 402 participants were geocoded for analysis. Geographic Information Systems (GIS) analysis was used to define five- and half-mile buffer areas around participants' residential addresses to represent the community and neighborhood environments, respectively, and to create measures of land use, residential density, destination density, and park space. The relationships between these built environment features and four domains of physical functioning-basic mobility, wheelchair mobility, self-care, and fine motor function-were modeled using ordinary least squares (OLS) regression.

RESULTS

People with paraplegia living in neighborhoods with more destinations and a nearby park reported higher levels of self-care functioning. For people with tetraplegia, living in a community with more destinations was associated with better wheelchair mobility and fine motor functioning, and living in a neighborhood with high land use mix was associated with higher fine motor functioning scores.

CONCLUSIONS

The association between the built environment and functioning after SCI is supported and in need of further investigation. Understanding the environmental context of disability may lead to community-based interventions and effective public policy that will attenuate the experience of limitations and promote accessibility on a larger scale.

Quality of life among individuals with rugby-related spinal cord injuries in South Africa: a descriptive cross-sectional study

OBJECTIVES

Rugby-related spinal cord injuries (SCIs) are rare but life altering and traumatic events. Little is known about the long-term consequences and outcomes of players who have sustained these injuries. This study investigated current quality of life (QoL) and factors associated with QoL, among individuals with rugby-related SCI in South Africa, by using the International Classification of Functioning, Disability and Health (ICF) framework.

DESIGN

Descriptive cross-sectional study.

SETTING

Rugby-related SCI population of South Africa, as captured in the BokSmart/Chris Burger Petro Jackson Players' Fund database.

PARTICIPANTS

Ninety (n=90) of the 102 eligible players on the database agreed to participate in the study.

MAIN OUTCOME MEASURE

The relationship between QoL, as measured with the WHO Quality of Life questionnaire (WHOQOL-BREF) and specific independent variables (demographic information, level of independence and participation in various activities and life roles) was investigated. Variables that were significantly associated with QoL in bivariate analyses were included in multiple linear regression analyses.

RESULTS

The mean score and SD of the WHOQOL-BREF was 15.1±2.3 arbitrary units. Participation (an ICF framework construct) and income were significantly associated with overall QoL (p<0.001). Participation was the only variable significantly associated with all QoL subdomains (p<0.001). Additionally, number of health concerns, type of healthcare (public vs private) and level of education were significantly associated with various QoL domains (p<0.001).

CONCLUSIONS

On average, these individuals with rugby-related SCI presented with higher QoL scores than other comparable SCI studies. However, lower levels of participation and income, certain levels of education, increased health concerns and use of public healthcare were associated with lower levels of QoL. Sporting bodies have a responsibility to optimise player welfare, by acting on the modifiable factors associated with QoL.

Mobility Device Quality Affects Participation Outcomes for People With Disabilities: A Structural Equation Modeling Analysis

OBJECTIVE

To test the effect that indicators of mobility device quality have on participation outcomes in community-dwelling adults with spinal cord injury, traumatic brain injury, and stroke by using structural equation modeling.

DESIGN

Survey, cross-sectional study, and model testing.

SETTING

Clinical research space at 2 academic medical centers and 1 free-standing rehabilitation hospital.

PARTICIPANTS

Community-dwelling adults (N=250; mean age, 48±14.3y) with spinal cord injury, traumatic brain injury, and stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

The Mobility Device Impact Scale, Patient-Reported Outcomes Measurement Information System Social Function (version 2.0) scale, including Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities, and the 2 Community Participation Indicators' enfranchisement scales. Details about device quality (reparability, reliability, ease of maintenance) and device type were also collected.

RESULTS

Respondents used ambulation aids (30%), manual (34%), and power wheelchairs (30%). Indicators of device quality had a moderating effect on participation outcomes, with 3 device quality variables (repairability, ease of maintenance, device reliability) accounting for 20% of the variance in participation. Wheelchair users reported lower participation enfranchisement than did ambulation aid users.

CONCLUSIONS

Mobility device quality plays an important role in participation outcomes. It is critical that people have access to mobility devices and that these devices be reliable.

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial

BACKGROUND

Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed 'Balance Right in MS' (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial.

METHODS/DESIGN

This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience).

DISCUSSION

The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial.

TRIAL REGISTRATION

ISRCTN13587999.

Self-management program participation and social support in Parkinson's disease: Mixed methods evaluation

Aims

To explore the potential influence of the Stanford Chronic Disease Self-Management Program (CDSMP) on social support in Parkinson disease (PD).

Methods

This was a quasi-experimental mixed methods design. Volunteers with PD (n=27) and care partners (n=6) completed the CDSMP, questionnaires of social support and self-management outcomes, and an interview about social support in relation to CDSMP participation. PD participants (n=19) who did not participate in the CDSMP completed the questionnaires for quantitative comparison purposes.

Results

Regarding the quantitative data, there were no significant effects of CDSMP participation on social support questionnaire scores; however, there were some positive correlations between changes in social support and changes in self-management outcomes from pre- to post-CDSMP participation. Three qualitative themes emerged from the interviews: lack of perceived change in amount and quality of social support, positive impact on existing social networks, and benefit from participating in a supportive PD community.

Conclusions

Although participants did not acknowledge major changes in social support, there were some social support-related benefits of CDSMP participation for PD participants and care partners. These findings provide a starting point for more in-depth studies of social support and self-management in this population.

Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/OMERACT recommendations

Although pain reduction is commonly the primary outcome in chronic pain clinical trials, physical functioning is also important. A challenge in designing chronic pain trials to determine efficacy and effectiveness of therapies is obtaining appropriate information about the impact of an intervention on physical function. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) and Outcome Measures in Rheumatology (OMERACT) convened a meeting to consider assessment of physical functioning and participation in research on chronic pain. The primary purpose of this article is to synthesize evidence on the scope of physical functioning to inform work on refining physical function outcome measurement. We address issues in assessing this broad construct and provide examples of frequently used measures of relevant concepts. Investigators can assess physical functioning using patient-reported outcome (PRO), performance-based, and objective measures of activity. This article aims to provide support for the use of these measures, covering broad aspects of functioning, including work participation, social participation, and caregiver burden, which researchers should consider when designing chronic pain clinical trials. Investigators should consider the inclusion of both PROs and performance-based measures as they provide different but also important complementary information. The development and use of reliable and valid PROs and performance-based measures of physical functioning may expedite development of treatments, and standardization of these measures has the potential to facilitate comparison across studies. We provide recommendations regarding important domains to stimulate research to develop tools that are more robust, address consistency and standardization, and engage patients early in tool development.