Emerging technologies and their potential for generating new assistive technologies

Limited access to assistive technology (AT) is a well-recognized global challenge. Emerging technologies have potential to develop new assistive products and bridge some of the gaps in access to AT. However, limited analyses exist on the potential of these technologies in the AT field. This paper describes a study that aimed to provide an overview of emerging technological developments and their potential for the AT field. It involved conducting a gray literature review and patent analysis to create an overview of the emerging enabling technologies that may foster the development of new AT products and services and identify emerging AT applications. The analysis identified seven enabling technologies that are relevant to the AT field. These are artificial intelligence, emerging human-computer interfaces, sensor technology, robotics, advances in connectivity and computing, additive manufacturing and new materials. Whilst there are over 3.7 million patents related to these enabling technologies, only a fraction of them - 11,000 patents were identified in the analysis specifically related to AT (0.3%). The paper presents some of the promising examples. Overall, the results indicate that there is an enormous potential for new AT solutions that capitalize on emerging technological advances.

High seroprevalence of COVID-19 infection in a large slum in South India; what does it tell us about managing a pandemic and beyond?

People living in urban slums or informal settlements are among the most vulnerable communities, highly susceptible to coronavirus disease 2019 (COVID-19) infection and vulnerable to the consequences of the measures taken to control the spread of the virus. Fear and stigma related to infection, mistrust between officials and the population, the often-asymptomatic nature of the disease is likely to lead to under-reporting. We conducted a cross-sectional study to determine the seroprevalence of COVID-19 infection in a large slum in South India 3 months after the index case and recruited 499 adults (age >18 years). The majority (74.3%) were females and about one-third of the population reported comorbidities. The overall seroprevalence of IgG antibody for COVID-19 was 57.9% (95% CI 53.4-62.3). Age, education, occupation and the presence of reported comorbidities were not associated with seroprevalence (P-value >0.05). Case-to-undetected-infections ratio was 1:195 and infection fatality rate was calculated as 2.94 per 10 000 infections. We estimated seroprevalence of COVID-19 was very high in our study population. The focus in this slum should shift from infection prevention to managing the indirect consequences of the pandemic. We recommend seroprevalence studies in such settings before vaccination to identify the vulnerability of COVID-19 infection to optimise the use of insufficient resources. It is a wake-up call to societies and nations, to dedicate paramount attention to slums into recovery and beyond - to build, restore and maintain health equity for the 'Health and wellbeing of all'.

Effectiveness of provision of outdoor mobility services and devices in the Netherlands

Objective: To answer the following questions: What are the problems encountered by people with outdoor mobility disabilities? What solutions are being offered to them in the Netherlands? How effective are these solutions? How responsive is the IPPA instrument (Individually Prioritized Problem Assessment)?

Design: Analysing the results of a follow-up study using the IPPA instrument.

Setting: The Dutch Service for the Disabled Act (SDA, in Dutch: WVG) provision system. This act is responsible for the provision of mobility aids and home adaptations.

Subjects: Fifty-nine people with outdoor mobility disabilities.

Interventions: The provision of outdoor mobility service and devices.

Main outcome measures: Effectiveness of provisions as measured using IPPA (i.e., the degree to which activities have become less difficult to perform), effect size of IPPA with this intervention.

Results: Problems identified by clients are very diverse and specific but can be classified fairly well on the basis of the International Classification of Functioning, Disability and Health (ICF); in the main, the solutions they are provided with are very similar and generic. Effectiveness is excellent at a group level, but insufficient for some at an individual level. The IPPA instrument is highly responsive in this setting. Most mobility problems respondents identified, although very individual and specific, were related to shopping, social visits or leisure activities. These specific sets of problems were solved using ‘standard’, generic solutions.

Conclusions: The Dutch provision system should be more ‘demand oriented’ and less ‘supply oriented’. IPPA turns out to be a useful, structured and individualoriented method to evaluate service delivery.

Post-discharge nursing problems of spinal cord injured patients: on which ” elds can nurses contribute to rehabilitation?

Objective: To identify nursing problems of spinal cord injured (SCI) patients after discharge from clinical rehabilitation and to identify gaps in the nursing care regarding the prevention of these problems.

Design: The study had an exploratory character and was divided into three phases. Phase 1 had a qualitative nature. Eight patients were interviewed to obtain insight into experienced problems after discharge. In phase 2, a panel of experts regarding nursing care for SCI patients selected nursing problems out of all problems mentioned. Phase 3 consisted of a mailed questionnaire including the nursing problem areas identified in phase 2, which was sent to all patients that were discharged during the last 18 months before the study.

Setting: Specialist rehabilitation centre, the Netherlands.

Subjects: Eight patients participated in phase 1 (100% response rate), 35 nurses participated in phase 2 (87.5% response rate) and 35 patients participated in phase 3 (62.5% response rate).

Results: The most important nursing problems in the response group appeared to be: limitations to activities of daily living, having difficulties in asking for help (assertiveness), pain, coping with the disability, dependency on personal help and problems with changed bladder regulation. The respondents made several suggestions for improving nursing care, involving both clinical care and care after discharge.

Conclusions: SCI patients experience serious problems after discharge from clinical rehabilitation. Nurses can give input on a wide variety of these problems.

[The psychometric properties of three self-report screening instruments for identifying frail older people in the community]

BACKGROUND

Frailty can lead towards serious adverse consequences, such as disability. With regard to prevention valid screening instruments are needed to identify frail older people. The aim was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added.

METHODS

A questionnaire was sent to 687 older people (> or = 70 years). (1) Agreement between instruments, (2) internal consistency, (3) cumulative scalability according to Mokken scale analysis and (4) construct validity were evaluated.

RESULTS

The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, TFI and SPQ was 0.73, 0.79 and 0.26, respectively. The scalability of the three instruments was inadequate (Loevinger's H: 0.28, 0.30 and 0.09 for GFI, TFI and SPQ, respectively). Frailty scores correlated significantly with each other and with the GARS scores.

CONCLUSION

Especially the GFI and TFI seem to be useful to identify frail older people. Further research regarding their predictive validity is still needed.

Community participation of people with an intellectual disability: a review of empirical findings

STUDY DESIGN

A systematic review of the literature.

OBJECTIVES

To investigate community participation of persons with an intellectual disability (ID) as reported in empirical research studies.

METHOD

A systematic literature search was conducted for the period of 1996-2006 on PubMed, CINAHL and PSYCINFO. Search terms were derived from the International Classification of Functioning, Disability and Health. Three investigators assessed the relevance of the initially identified studies using predefined content and methodological selection criteria. Included domains of community participation were: (1) domestic life; (2) interpersonal interactions and relationships; (3) major life areas; and (4) community, civic and social life.

RESULTS

Of 2936 initial hits, 23 quantitative studies eventually met the selection criteria and were included in the study. Only two studies are based on a theoretical framework. Research instruments were various and were most often ad hoc and not validated. The average number of persons in the social network of people with ID appears to be 3.1, one of them usually being a professional service staff member. People with ID are 3-4 times less employed than non-disabled peers; they are less likely to be employed competitively and are more likely to work in sheltered workshops or in segregated settings than those with other disabilities. People with ID are less likely to be involved in community groups, and leisure activities are mostly solitary and passive in nature. Most of the people with ID had been accompanied in an activity by training/therapeutic staff.

CONCLUSION

It can be concluded that on the basis of empirical evidence, within the time frame of this literature search, little is known about community participation of people with ID. Many researchers did not clearly define community participation and were concerned with limited areas of community participation; research is seldom based on a theoretical framework. Most studies focus on people with mild ID, and there are few reports of the subjects' sample. However, one conclusion can consistently be drawn from the review: people with ID living in community settings participate more than people living in a segregated setting, but their participation level is still much lower than non-disabled and other disability groups.

Impact of environmental factors on community participation of persons with an intellectual disability: a systematic review

STUDY DESIGN

A systematic review of the literature.

OBJECTIVES

To describe which environmental factors have an impact on community participation of persons with an intellectual disability.

METHODS

A systematic literature search was conducted for the period of 1996-2006 in Pubmed, CINAHL and PSYCINFO. Search terms were derived from the International Classification of Functioning, Disability and Health. Three investigators assessed the relevance of the studies identified using predefined selection criteria. Aspects of community participation included were: domestic life; interpersonal interactions and relationships; major life areas; community, civic and social life. Environmental factors included were: products and technology; natural environment and human-made changes to environment; support and relationships; attitudes; services, systems and policies.

RESULTS

Out of 236 initial hits, 9 quantitative studies and 2 qualitative studies met the predefined selection criteria and were included in the study. Various research instruments were used in the studies and only one study used a conceptual framework. The review allowed the identification of a number of environmental factors positively affecting participation: opportunities to make choices; variety and stimulation of the environment of facilities; opportunities for resident involvement in policy making; small residential facilities; opportunities for autonomy; vocational services; social support; family involvement; assistive technology; and positive staff attitudes. A number of identified environmental factors negatively affecting participation are: lack of transport and not feeling accepted.

DISCUSSION

It can be concluded that little has been published about the impact of environmental factors on community participation. Many studies do not clearly define the concept of community participation. Research on the impact of environmental factors on community participation so far seems not to be based on a theoretical framework. Most studies focused on the impact of services on community participation in general.

The implementation of an Electronic Nursing Record in a general hospital in the Netherlands: lessons to learn

This article describes the implementation of an Electronic Nursing Record (ENR) in Maasland Hospital (Orbis Medical and Healthcare group) in Sittard, the Netherlands. Through analysis of documents, structured interviews and participatory observation, a study was made of the plans prior to the introduction of the ENR, how the process proceeded, which enhancing and constraining factors influenced the process and how the nursing staff experienced the introduction of the ENR. The implementation of the system took place in 2006 and 2007. The selection and design of the system was carried out first, followed by a pilot phase. After thorough review and adjustment, the introduction of the ENR in the other wards of the hospital followed according to plan. The implementation process was carried out by several nurses in different roles (project management, project group members, key-users and teachers). The introduction of the system had two objectives: saving time by promoting efficiency and quality improvement by the introduction of standardization in documentation and the use of nursing care plans. The study indicates, however, that no time-efficiency was achieved by using the ENR so far. This had an adverse effect on the acceptance of the system by the nurses. The nurses were positive about the set-up of the implementation process, especially the contribution of the project group, the key-users on the ward and the resources which were made available (the staffing, external expertise and training).

Health behaviour of persons with spinal cord injury

STUDY DESIGN

Postal survey.

OBJECTIVE

To describe the health behaviour of persons with spinal cord injury (SCI) living in the community and the relationships between health behaviour, respondent/injury characteristics, and health-related variables: the presence and number of secondary impairments, readmissions in rehabilitation centre and hospital, and perceived health.

SETTING

Members of the Dutch Association of Patients with SCI.

METHODS

The frequency of health behaviours, that delay or prevent secondary impairments, was assessed by means of a 22-item, self-report questionnaire. The questionnaire was also focused on 13 secondary impairments.

RESULTS

The frequency of engaging in health behaviour varied considerably between the respondents. Variance was observed between and within the health behaviours measured. The respondents did not frequently engage in pressure relief methods when sitting/driving in their wheelchair. Almost no statistical differences were observed between health behaviour of subgroups of respondents based on respondent/injury characteristics. However, the total health behaviour scores increased significantly with increasing age and pressure sore prevention was significantly more applied in persons with a complete lesion. Health behaviour was significantly more applied in respondents who had one or more secondary impairments.

CONCLUSION

As secondary impairments are prevalent among persons with SCI and education on a healthy lifestyle is a core component of every rehabilitation programme, it is of great importance to rigorously test the efficacy of health behaviours promoted during rehabilitation. Therefore, longitudinal research is recommended.

Burden of support for partners of persons with spinal cord injuries

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

(1) To describe the support given to persons with spinal cord injuries (SCI) by their partners, (2) to describe the perceived burden of support by partners and (3) to examine predictors of perceived burden of support.

SETTING

The Netherlands.

METHODS

All members of the Dutch patients organisation DON (N = 1004) and their caregivers, if applicable, were invited. Physical disability of the person with SCI was measured using the Barthel Index (BI). A number of secondary conditions, other practical problems and psychosocial problems were recorded. Partner support was described using a list of ADL-support, other practical support and emotional support. Burden of support was measured by a six-item measure (Cronbach's alpha 0.92), Nonparametric descriptive statistics and correlations were used. Linear regression was used to identify predictors of caregiver burden.

RESULTS

Responses were obtained from 461 persons with SCI. Of 265 couples, patient as well as partner data were available. Mean age of the partners was 49.4 years (SD 12.2) and 69.8% were women. Mean BI of the persons with SCI was 12.3 (SD 4.7) on a 0-20 scale and 60.4% were seriously disabled (BI < 15). Most partners provided various kinds of support. ADL-support and other practical support were given much more often by partners of persons with serious disability, but less difference was seen regarding emotional support. Professional (paid) support was obtained by 45.3% of all couples. Perceived burden of support was high in 24.8% of partners of persons with serious disabilities against 3.9% of partners of persons with minor disabilities. Significant predictors of caregiver burden were (in order of importance) the amount of ADL support given, psychological problems of the patient, partner age, partner gender, BI score and time after injury (total explained variance 47%).

CONCLUSION

A substantial proportion of partners of persons with SCI suffer from serious burden of support. Prevention of caregiver burnout should be part of the lifelong care for persons with SCI.

[Falls in nursing homes: on average almost two per bed per year, resulting in a fracture in 1.3%]

OBJECTIVE

To determine how many falls occur annually in Dutch nursing homes and how many fractures are the result of falls.

DESIGN

Written questionnaire study.

METHOD

All 371 Dutch nursing homes received a questionnaire requesting information on the number of somatic and psychogeriatric beds and the number of falls and fractures as a result of falls in 2000 and 2001.

RESULTS

Of the 371 questionnaires, 202 (54%) were returned. These were distributed as follows over the three types of nursing homes: combined: 151 (75%), somatic: 15 (7%), psychogeriatric: 36 (18%). The average capacity of the participating nursing homes was 180 beds. There was an average of more than 300 reported falls per nursing home: 336 in 2000 (SD: 180; median 314) and 311 in 2001 (SD: 165, median 294). On average, there were almost 2 falls per bed per year. The number of falls per bed in the psychogeriatric group was higher than in the somatic group. There was an average of about 4 fractures per year per nursing home as a result of falls: 4.3 in 2000 (SD: 3.7; median 4.0) and 3.6 in 2oo1 (SD: 2.8; median 3.0). The average number of annual fractures due to a fall was about 23 per 1ooo beds. An average of 1.3% of the falls resulted in a fracture. There were no clear differences here between somatic and psychogeriatric patients.

CONCLUSION

The reported number of falls per nursing-home bed averaged almost 2 per year, and an average of 1.3% of these falls resulted in a fracture.

Follow-up care for persons with spinal cord injury living in the community: a systematic review of interventions and their evaluation

STUDY DESIGN

Systematic review.

OBJECTIVES

(1) To describe and compare follow-up care programmes, performed by rehabilitation centres, for persons with spinal cord injury (SCI) and (2) to describe the effects of these programmes regarding the occurrence of secondary impairments, well-being, the quality and costs of care.

METHODS

A systematic literature search was conducted in MEDLINE (1972-2003) and CINAHL (1982-2003). Publications were selected about medical and/or nursing follow-up care to SCI patients living in the community performed by or with rehabilitation facilities for SCI patients. The aim of the follow-up care should be a decrease of secondary impairments, an improvement of well-being, an improvement of the quality and/or a decrease of the costs of care.

RESULTS

The search resulted in 24 papers. The descriptions of the programmes in these papers were sometimes rather scattered, vague or brief. The most important methods were telemedicine (six programmes; of which five were performed in the same rehabilitation centre), outpatient consulting hours (six programmes), home visits (three programmes, and case management (one programme). Eight other programmes combined several methods (ie outpatient consulting hours, home visits, peer teaching and support, outings, ongoing support, therapy from several care disciplines, SCI education, providing SCI expertise and support to community health-care providers, coordination of care with community nursing agencies). In all, 16 programmes have been evaluated to some degree. In general the quality of the studies was low. Most evaluations were pre-experimental in design. Only three were quasi-experimental, and two programmes were experimental in design. Although several studies claimed positive effects, it was not possible to draw conclusions on the effect of follow-up care on the occurrence of secondary impairments, well-being, the quality and costs of care.

CONCLUSION

There is a need for the development, the publication and the well-designed evaluation of follow-up care programmes for persons with SCI.

Transmural care in the rehabilitation sector: implementation experiences with a transmural care model for people with spinal cord injury

PURPOSES

The purpose of this article is first to describe the development and content of a transmural care model in the rehabilitation sector, which aims to reduce the number and severity of health problems of people with spinal cord injury (SCI) and improve the continuity of care. Second, the purpose is to describe the applicability and implementation experiences of a transmural care model in the rehabilitation sector.

METHODS

The transmural care model was developed in cooperation with the Dutch Association of Spinal Cord Injured Patients, community nurses, general practitioners, rehabilitation nurses, rehabilitation managers, physiatrists and researchers. The core component of the care model consists of a transmural nurse, who 'liaises' between people with SCI living in the community, professional primary care professionals and the rehabilitation centre. The transmural care model provides a job description containing activities to support people with SCI and their family/partners and activities to promote continuity of care. The transmural care model was implemented in two Dutch rehabilitation centres. The following three aspects, as experienced by the transmural nurses, were evaluated: the extent to which the care model was implemented; enabling factors and barriers for implementation; strength and weakness of the care model.

RESULTS

The transmural care model was not implemented in all its details, with a clear difference between the two rehabilitation centres. Enabling factors and barriers for implementation were found at three levels: 1. the level of the individual professional (e.g. competencies, attitude and motivation), 2. the organisational and financing level (e.g. availability of facilities and finances), and 3. the social context (the opinion of colleagues, managers and other professionals involved with the care). The most important weakness experienced was that there was not enough time to put all the activities into practice. The strength of the care model lies in the combination of support of patients after discharge, support of and cooperation with primary care professionals, and feedback of experiences to the clinical rehabilitation teams.

CONCLUSION

We recommend further improving and implementing the care model and encourage other care professionals and researchers to share their implementation experiences of follow-up care innovations for people with SCI.

Quality of regional individual needs assessment agencies regulating access to long term-care services: a client perspective

PURPOSE

To determine if and how the outcome quality from a client perspective is related to process characteristics and structure of Regional Individual Needs Assessment Agencies (RIOs) regulating access to long-term care services in The Netherlands.

THEORY

Because of decentralised responsibilities, ultimo 1999 85 RIOs were set up. RIOs differ in their structural and process characteristics. This could lead to differences in client quality. Insight into factors relating to client quality (e.g. client satisfaction) can improve the needs assessment process.

METHODS

Eighteen RIOs participated in this study. These RIOs each selected 120 clients, filled in forms about their needs assessment procedures and sent them a questionnaire assessing judgements, experiences and satisfaction with the RIO.

RESULTS

We received 1916 RIO-forms and 1062 client questionnaires. Eighty-two percent of the clients were satisfied with the RIO, the percentages not satisfied clients varied from 10 to 29% among items and working procedures. Satisfaction is mostly related to what is actually done for the client. Information aspects and providing choices are important determinants of client quality with the RIO.

CONCLUSION

In improving quality seen from a client perspective, one should focus on what is actually done for the client, rather than looking at the RIOs structure.

Stroke service in The Netherlands: an exploratory study on effectiveness, patient satisfaction and utilisation of healthcare

Objective

To assess whether shared care for stroke patients results in better patient outcome, higher patient satisfaction and different use of healthcare services.

Design

Prospective, comparative cohort study.

Setting

Two regions in the Netherlands with different healthcare models for stroke patients: a shared care model (stroke service) and a usual care setting.

Patients

Stroke patients with a survival rate of more than six months, who initially were admitted to the Stroke Service of the University Hospital Maastricht (experimental group) in the second half of 1997 and to a middle sized hospital in the western part of the Netherlands between March 1997 and March 1999 (control group).

Main outcome measures

Functional health status according to the SIP-68, EuroQol, Barthel Index and Rankin Scale, patient satisfaction and use of healthcare services.

Results

In total 103 patients were included in this study: 58 in the experimental group and 45 in the control group. Six months after stroke, 64% of the surviving patients in the experimental group had returned home, compared to 42% in the control group (p<0.05). This difference could not be explained by differences in health status, which was comparable at that time. Patients in the shared care model scored higher on patient satisfaction, whereas patients in the usual care group received a higher volume of home care.

Conclusions

The Stroke Service Maastricht resulted in a higher number of patients who returned home after stroke, but not in a better health status. Since patients in the usual care group received a higher volume of healthcare in the period of rehabilitation, the Stroke Service Maastricht might be more efficient.

[Initiating insulin therapy in patients with diabetes mellitus type 2: in a transmural setting is at least as effective as in an outpatient setting; a retrospective study with a 4-year follow-up]

OBJECTIVE

Assessing whether the initiation of insulin therapy in patients with diabetes mellitus type 2 can be delivered as effectively in a structured transmural care model as in the more usual outpatients structure.

DESIGN

Retrospective comparative cohort study.

METHOD

In 1997 data were collected from 52 patients with diabetes mellitus type 2 all of whom were above 40 years of age and transferred to insulin therapy in 1993: 25 in a transmural care setting and 27 in an outpatients setting, both in Amsterdam, the Netherlands. Both groups were treated according to one protocol concerning the initiation and monitoring of insulin therapy, treatment goals and follow-up. Outcome measures were: percentage of glycated haemoglobin (HbA1c), health status, self-care behaviour and patient satisfaction. In 1993 the mean age was (transmural/outpatients setting): 67.5/65.3 years; percentage of men: 32%/48%; mean duration of diabetes: 7.3/10.6 years; HbA1c: 9.1%/9.3%; mean body mass index: 27.4/29.1 kg/m2.

RESULTS

In the period 1993-1997 the mean HbA1c decreased from 9.1% to 7.2% in the transmural care group and from 9.3% to 7.6% in the outpatients care group (both: p = 0.000). The percentage of patients with poor glycaemic control (HbA1c > 8%) decreased from 60 to 8 in the transmural care group and from 59 to 15 in the outpatients care group. The percentage of patients with good glycaemic control (HbA1c < 7%) increased from 4 to 52 in the transmural care group and from 11 to 30 in the outpatients care group. No statistically significant differences were found between the patient groups with respect to health status, self-care behaviour and patient satisfaction.

CONCLUSION

The transfer of patients with diabetes mellitus type 2 insulin therapy in a shared care setting was at least as effective as in an outpatients setting.

Risk factors for burn-out in caregivers of stroke patients, and possibilities for intervention

OBJECTIVE

To identify which caregivers of stroke patients living at home experience the highest levels of strain and are at risk of burn-out, and to investigate how support for caregivers of stroke patients could best be organized, and when this support should be offered.

DESIGN AND SETTING

Caregivers of stroke patients were recruited in four regions of the Netherlands. A total of 212 caregivers were interviewed. Multiple stepwise regression analysis was performed to determine the effects of patient and caregiver characteristics, resources, coping strategies and duration of the caregiver role on caregiver strain, mental well-being and vitality.

SUBJECTS

The majority of the caregivers were female spouses. Their mean age was 64 years, and their socioeconomic status middle class. Stroke had occurred about 3.5 years ago on average.

MAIN OUTCOME MEASURES

The following main outcome measures were used: the Caregiver Strain Index, and two scales of the Short Form-36 to measure caregivers' mental well-being and vitality.

RESULTS

Severe cognitive, behavioural and emotional changes in the patient constitute the main risk factors for caregiver burn-out. Women, younger caregivers and caregivers in poor physical health were also identified as risk groups. Caregivers with high perceived self-efficacy, satisfied with social support, and frequently using the coping strategy confronting, experience less strain, higher mental well-being and greater vitality. Duration of the caregiver role does not influence caregivers' strain, mental well-being or vitality.

CONCLUSIONS

Women, younger caregivers, caregivers in poor physical health, and caregivers of patients with severe changes are at risk of burn-out. Support programmes should focus on self-efficacy, social support, and the coping strategy confronting. No specific moment could be identified at which support programmes should be offered.

Development, content, and process evaluation of a coping intervention for patients with rheumatic diseases

Rheumatic diseases, like many other chronic diseases, represent an important public health problem. To reduce the impact of rheumatic and other chronic diseases, the appropriate management of these conditions should be encouraged through the use of established educational programs. This article describes the development and content of a coping intervention for groups of patients with rheumatic diseases aimed at increasing social support and quality of life. Patients' and supervisors' perceptions of the coping intervention as the results of a process evaluation will also be discussed. The purpose of this paper is to provide information for health educators who want to use the coping intervention with patients with rheumatic diseases or who want to develop a similar intervention for other target populations. Results of the process evaluation show that the intervention was well received by the patients as well as the supervisors.

Effects of a coping intervention on patients with rheumatic diseases: results of a randomized controlled trial

OBJECTIVE

To test the effects (on coping, social interactions, loneliness, functional health status, and life satisfaction) of an intervention aimed at teaching people with rheumatic diseases to cope actively with their problems.

METHODS

A total of 168 patients with chronic rheumatic disorders affecting the joints were randomly assigned to a coping intervention group, a mutual support control group, or a waiting list control group. Measurements were by self-report questionnaires.

RESULTS

Post-intervention measurements showed that the coping intervention increased action-directed coping and functional health status, but these effects did not persist up to 6-months followup. In patients who attended at least half of the 10 sessions, the coping intervention contributed to decreased loneliness at post-intervention and to improvements in social interactions and life satisfaction at 6-months followup.

CONCLUSION

Teaching patients with rheumatic diseases to cope actively with their problems had positive impacts. Consequently it is recommended that the coping intervention be incorporated into regular care. Maintenance sessions are advisable.

The construction of a patient record-based risk model for recurrent falls among elderly people living in the community

BACKGROUND

Predictive models of fall risk in the elderly living in the community may contribute to the identification of elderly at risk for recurrent falling.

OBJECTIVES

Our aim was to investigate occurrence, determinants and health consequences of falls in a community-dwelling elderly population and the contribution of data from patient records to a risk model of recurrent falls.

METHODS

A population survey was carried out using a postal questionnaire. The questionnaire on occurrence, determinants and health consequences of falls was sent to 2744 elderly persons of 70 years and over, registered in four general practices (n = 27 000). Data were analysed by bivariate techniques and logistic regression.

RESULTS

A total of 1660 (60%) responded. Falls (> or =1 fall) in the previous year were reported by 44%: one-off falls by 25% and recurrent falls (> or =2 falls) by 19%. Women had significantly more falls than men. Major injury was reported by 8% of the fallers; minor injury by 49%. Treatment of injuries was by the GP in 67% of cases. From logistic regression, a risk model for recurrent falls, consisting of the risk factors female gender, age 80 years or over, presence of a chronic neurological disorder, use of antidepressants, problems of balance and sense organs and complaints of muscles and joints was developed. The model predicted recurrent falls with a sensitivity of 64%, a specificity of 71%, a positive predictive value of 42% and a negative predictive value of 86%.

CONCLUSION

A risk model consisting of six variables usually known to the GP from the patient records may be a useful tool in the identification of elderly people living in the community at risk for recurrent falls.

Preventing falls and mobility problems in community-dwelling elders: the process of creating a new intervention

Mobility impairments and the consequences of falls can have a considerable impact on community-dwelling elders' autonomy and quality of life. This article describes the development and implementation of a falls and mobility intervention that features preventive home visits by public health nurses; the study accompanying the intervention also is presented. This article offers practical guidelines to health professionals who are considering, developing, implementing, and testing new interventions aimed at the prevention of falls and mobility problems in this population.

Can shared care deliver better outcomes for patients undergoing total hip replacement? A prospective assessment of patient outcomes and associated service use

OBJECTIVES

To assess whether shared care for patients undergoing total hip replacement delivers better outcomes compared to care as usual.

DESIGN

Prospective, observational cohort study.

SETTING

Two regions in The Netherlands where different organisational health care models have been implemented: a shared care setting (experimental group) and a care as usual setting (control group).

PATIENTS

One hundred and fifteen patients undergoing total hip replacement: 56 in the experimental group and 59 in the control group.

MAIN MEASURES

Functional health status according to the sickness impact profile, hip function, patient satisfaction and use of health care services.

RESULTS

Two weeks before hip replacement both groups were comparable concerning patient characteristics, hip function and health status. The mean improvement of the total sickness impact profile score between two weeks before hip replacement and six months after was -1.92 in the shared care group, compared to -5.11 in care as usual group, a difference in favour of the control group (p=0.02). The mean length of hospital stay was comparable in both settings: 12.8 days in the shared care group and 13.2 days in the care as usual group. After hip replacement, compared to care as usual, patients in the shared care group received more homecare, with a higher frequency, and for a longer period of time. No differences in patient satisfaction between the two groups were found.

CONCLUSIONS

Six months after hip replacement, the health status of patients in the care as usual group, using significantly less home care, was better than the status of patients in the shared care group.

DISCUSSION

The utilisation of home care after hip replacement should be critically appraised in view of the need to stimulate patients' independence.

Effects of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: randomised controlled trial

OBJECTIVE

To evaluate whether a programme of multifactorial home visits reduces falls and impairments in mobility in elderly people living in the community.

DESIGN

Randomised controlled trial with 18 months of follow up.

SETTING

Six general practices in Hoensbroek, the Netherlands.

PARTICIPANTS

316 people aged 70 and over living in the community, with moderate impairments in mobility or a history of recent falls.

INTERVENTION

Five home visits by a community nurse over a period of one year. Visits consisted of screening for medical, environmental, and behavioural factors causing falls and impairments in mobility, followed by specific advice, referrals, and other actions aimed at dealing with the observed hazards.

MAIN OUTCOME MEASURES

Falls and impairments in mobility.

RESULTS

No differences were found in falls and mobility outcomes between the intervention and usual care groups.

CONCLUSION

Multifactorial home visits had no effects on falls and impairments in mobility in elderly people at risk who were living in the community. Because falls and impairments in mobility remain a serious problem among elderly people, alternative strategies should be developed and evaluated.

Effects of transmural care on coordination and continuity of care

Although health care in The Netherlands is of a high quality with strong emphasis on primary care and high accessibility to hospital care, care deficits may arise in patients with chronic complex health problems who need the attention of several caregivers. Because no regular coordinating centre or person exists, coordination of care may be deficient leading to a poor continuity of care. This may be particularly true for those patients being cared for by both primary and hospital care teams, as is the case for most terminal cancer patients. Therefore, a transmural home care intervention programme for terminal cancer patients was introduced which intended to optimize coordination of care and thereby improve continuity of care. This quasi-experimental study investigated the effects of this intervention (intervention group 79 patients) on indicators of coordination and continuity of care. When compared to standard care (control group 37 patients) moderate positive effects (mainly for the nursing disciplines) on the various indicators of coordination and continuity of care by the transmural home care intervention programme were found. Future prospective studies are needed to further elucidate the effects of transmural care on these aspects of care.

Short-term effects of a group support program and an individual support program for caregivers of stroke patients

Caregivers of stroke patients who live at home experience many problems. There is evidence from the literature that caregivers' situations can be improved by teaching them active coping strategies and by offering them information about the disease. This study investigated the short-term effects of two different interventions both with the same contents, and both aimed at enhancing caregivers' confidence in knowledge, active coping strategies, mental well-being, vitality, social support, assertiveness, and at reducing strain. In addition, we investigated which type of support, i.e. a group program or home visits, had the most positive effects. Caregivers of stroke patients from four regions of the Netherlands were assigned in blocks to a control group or one of the intervention programs. To the group program 130 caregivers were assigned, to the home visits 78 caregivers, and to the control group 49 caregivers. Caregivers were interviewed before entering the program and after completion of the program. Multiple stepwise regression analysis was used to determine the effects of the interventions. In the short-term, both interventions (group program and home visits together) contributed significantly to an increase in confidence in knowledge about patient care, and the use of the active coping strategies 'confronting' and 'seeking social support'. The group program achieved a small increase in seeking social support. When only taking into account those caregivers that followed a substantial part of the program (per protocol group) also a medium effect was found from both interventions on perceived self efficacy. When comparing the group program and the home visits, no significant differences in effects were found. The results of the program are considered encouraging. We recommend implementation of more intervention programs that focus on coping and providing information.

Effects of preventive home visits to elderly people living in the community: systematic review

OBJECTIVE

To assess the effects of preventive home visits to elderly people living in the community.

DESIGN

Systematic review.

SETTING

15 trials retrieved from Medline, Embase, and the Cochrane controlled trial register.

MAIN OUTCOME MEASURES

Physical function, psychosocial function, falls, admissions to institutions, and mortality.

RESULTS

Considerable differences in the methodological quality of the 15 trials were found, but in general the quality was considered adequate. Favourable effects of the home visits were observed in 5 out of 12 trials measuring physical functioning, 1 out of 8 measuring psychosocial function, 2 out of 6 measuring falls, 2 out of 7 measuring admissions to institutions, and 3 of 13 measuring mortality. None of the trials reported negative effects.

CONCLUSIONS

No clear evidence was found in favour of the effectiveness of preventive home visits to elderly people living in the community. It seems essential that the effectiveness of such visits is improved, but if this cannot be achieved consideration should be given to discontinuing these visits.

Social support, coping and subjective well-being in patients with rheumatic diseases

The purpose of this cross-sectional study is to examine the relationship between social support, coping, and subjective well-being by testing three hypotheses: (1) social support influences subjective well-being via coping; (2) coping influences subjective well-being via social support; (3) there is a reciprocal relationship between social support and coping, and both concepts influence subjective well-being. Data were analyzed from 628 patients with one or more chronic rheumatic disorder(s) affecting the joints, in some patients combined with another rheumatic disease (no fibromyalgia). Although causal inferences are not possible, the results present a plausible causal sequence in supporting the second hypothesis. This is only true, however, for coping by awaiting/avoidance: coping by awaiting/avoidance led to less social support and this decrease in social support influenced subjective well-being negatively.

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research

OBJECTIVE

The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of re evant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made.

METHOD

Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH.

RESULTS

Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived hea th as the subjective part of the person level and domain-specific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal mode is intended to serve as a framework in which different outcomes can be positioned in relation to each other.

CONCLUSION

Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

Impact of gait problems and falls on functioning in independent living persons of 55 years and over: a community survey

In a cross-sectional, population-based study among community-dwelling persons of 55 years and over the incidence of falls, risk indicators for falls, specifically age, and the impact of gait problems, falls and other risk factors on functioning was determined. A randomly age-stratified sample (n = 655) was taken from all independent living persons of 55 years and over (n = 2269) and registered in a primary health care centre. They received a mail questionnaire concerning demographic data, history of falls and injuries due to falls, physical and mental health status, gait problems, functional status, including social activities. The response rate was 62% (n = 405). Of the subjects aged 55 years and of those aged 65 years and over, 25% and 31% respectively fell at least once in the previous year. Half of the people reporting falls fell more than once. Serious injury occurred in 9% of the fallers, with 4% fractures. There is a significant association between falling and age and, even more clearly, between gait problems and age. The main risk factors of single and recurrent falls were female gender, physical health status and gait problems. Logistic regression analysis reveals that the main determinants of falling in general are gait problems and female gender and, of recurrent falling female gender, physical complaints and gait problems. Falls have some negative effect on functioning, i.e. mobility range and social activities, but this is overshadowed by mental status indicators and gait problems.

Cost analysis of transmural home care for terminal cancer patients

The economic implications of home care service programmes for oncology patients remain unclear. This quasi-experimental study investigated the costs of a transmural home care programme for terminal cancer patients and compared them to those of the standard care available. The programme intended to optimize communication, cooperation and coordination between the intra- and extra- mural health care organizations (transmural care). Complete sets of data could be retrieved for 57 of the 79 patients in the intervention group, and for 29 of the 37 patients in the control group. Comparison of the intervention and control group revealed significantly lower pharmaceutical and rehospitalization costs in the intervention group, whilst community nursing and home help costs were significantly higher. However, no significant difference could be found for total health care costs between the groups. In view of this, and that the programme has proved to have significantly positive effects on both the patient's and direct caregiver's quality of life, the installation of such programmes in every hospital with a multidisciplinary oncology unit is recommended.

Transmural care. A new approach in the care for terminal cancer patients: its effects on re-hospitalization and quality of life

Despite their wishes, terminal cancer patients are frequently readmitted to hospitals. This appears in part to be due to poor communication amongst professional caregivers and/or the overburdening of their (informal) caregivers. This quasi-experimental study investigated the effects of a transmural home care programme on re-hospitalization, quality of life and place of death for terminal cancer patients. The programme intended to optimize communication, cooperation and coordination between intra- and extra-mural health care organizations (transmural care). Initial patient characteristics of the intervention group (n = 79) matched those of the control group (n = 37) well. When compared to the control group, which received the standard community care, patients in the intervention group underwent significantly less re-hospitalization during the terminal phase of their illness (5.8 versus 11.5 days; P < 0.01) while the intervention contributed significantly positive to the patients' "physical" quality of life 1 month after the start of the intervention. A higher, but not significant (P = 0.06) percentage of patients in the intervention group also died at home (81 versus 65%). The introduction of measures to enhance coordination and cooperation of intra- and extramural care, seems to be an improvement compared to standard community care.

Effectiveness of home care programmes for patients with incurable cancer on their quality of life and time spent in hospital: systematic review

OBJECTIVE

To investigate whether for patients with incurable cancer comprehensive home care programmes are more effective than standard care in maintaining the patients' quality of life and reducing their "readmission time" (percentage of days spent in hospital from start of care till death).

DESIGN

Systematic review.

METHODS

A computer aided search was conducted using the databases of Medline, Embase, CancerLit, and PsychLit. The search for studies and the assessment of the methodological quality of the relevant studies were performed by two investigators, blinded from each other. Prospective, controlled studies investigating the effects of a home care intervention programme on patients' quality of life or on readmission time were included in the analyses.

RESULTS

Only 9 prospective controlled studies were found; eight were performed in the United States and 1 in the United Kingdom. Their methodological quality was judged to be moderate (median rating 62 on a 100 point scale). None of the studies showed a negative influence of home care interventions on quality of life. A significantly positive influence on the outcome measures was seen in 2 out of the 5 studies measuring patients' satisfaction with care, in 3/7 studies measuring physical dimensions of quality of life, in 1/6 studies measuring psychosocial dimensions, and in 2/5 studies measuring readmission time. The incorporation of team members' visits to patients at home or regular multidisciplinary team meetings into the intervention programme seemed to be related to positive results.

CONCLUSIONS

The effectiveness of comprehensive home care programmes remains unclear. Given the enormity of the problems faced by society in caring for patients with terminal cancer, further research is urgently needed.

Care process and satisfaction analysis of a transmural home care program

This study investigated both professional caregiver workload as well as the patients' and caregivers' satisfaction with a transmural home care program. Seventy-nine patients were included in the intervention program. The specialist nurse coordinator, general practitioner, community nurse providing 'intensive' community care, community nurses providing 'standard' community care, and the home helper spent in total an average of 7.5, 4.4, 55.6, 55.0, and 112.3 h, respectively, on each patient during the care process (mean survival of the 79 patients was 101.2 days). The 24 h telephone service and transmural home team were contacted in total 100 and 8 times, respectively. Patient and caregiver satisfaction with the care provided scored (very) high. Considering this acceptable workload and given that the program did not interfere with existing standard health care structures, it can be concluded that such care may easily be introduced by other hospitals and related primary care teams.

Transmural care of terminal cancer patients: effects on the quality of life of direct caregivers

BACKGROUND

The burden of caring for terminal cancer patients has a negative effect on the informal caregivers' quality of life.

OBJECTIVES

To investigate the effects of a transmural home care intervention program for terminal cancer patients on the direct caregivers' (the patient's principal informal caregiver) quality of life, compared with standard care programs. The intervention program intended to optimize the cooperation and coordination between the intramural and extramural health care organizations (transmural care).

METHODS

Direct caregivers of terminal cancer patients (estimated prognosis of less than 6 months) could be included in this quasi-experimental study. The direct caregivers' quality of life was measured in a multidimensional way 1 week before (T1), 1 week after (T2), and 4 weeks after (T3) the patient's discharge from the hospital (discharge being the starting point of the intervention), then again at 3 months after the patient's death (T4). Factor analyses on the four outcome measures yielded one factor. This was considered the primary outcome measure and was named the Overall Quality of Life Index (OQOLI).

RESULTS

Multiple regression analyses showed that the intervention contributed significantly positively to the direct caregivers' OQOLI at T2 (beta=.30; p < .05) and T4 (beta=.28; p < or = .05), compared with standard care.

CONCLUSION

Transmural care forms a significantly positive contribution to the OQOLI of direct caregivers of terminal cancer patients 1 week after the patient's discharge from the hospital and 3 months after the patient's death. Good terminal care also appears to be important for direct caregivers as well, with respect to perceived quality of life.

Predictors of health status and life satisfaction in spinal cord injury

OBJECTIVE

To analyze relationships between injury-related variables, demographic variables, functional health status, and life satisfaction of people with spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

A community in the Netherlands.

SUBJECTS

Three hundred eighteen people with SCI, aged 18 to 65 years. Mean age was 39.4 years and mean time after injury was 3.6 years.

MAIN OUTCOME MEASURES

Health status was measured with the SIP68. Its six scales were aggregated to three dimensions, measuring physical, psychologic, and social functioning. Life satisfaction was measured with the Life Satisfaction Questionnaire. Data were analyzed by path analysis using LISREL V8.

RESULTS

Obtained scores showed that respondents suffered from serious limitations in physical functioning and social functioning, had only a few limitations in psychologic functioning, and were satisfied with their lives in general and with most life domains. Physical functioning was accurately predicted by injury-related variables, but psychologic functioning was not. Next to level and completeness of the injury, the number of secondary complications turned out to be a predictor of functional health. In a path model that had a close fit with the data, injury-related variables were related to health status but not to life satisfaction. Social functioning (-.48), marital status (-.38), psychologic functioning (-.19), and age (-.16) were significant predictors of life satisfaction (total R2=.44).

CONCLUSIONS

This study points out the high prevalence of secondary complications and their importance to the health status of people with SCI. Level of social and psychologic functioning are more important predictors of life satisfaction than the seriousness of the injury.

Construct validation of the Hoensbroeck Disability Scale for Brain Injury in acquired brain injury rehabilitation

PURPOSE

To evaluate the construct validity of the Hoensbroeck Disability Scale for Brain Injury (HDSB) against the Disability Rating Scale (DRS).

METHODS

The HDSB was correlated with the DRS at admission, 6 weeks later and at discharge in 33 brain injured patients during post-acute rehabilitation. Next, to study the longitudinal construct validity of the HDSB the mean changes in score of the HDSB and the DRS were correlated. Finally, the sensitivity to change over a 6-week period was evaluated by comparison of the effect sizes of the HDSB scores with the DRS scores.

RESULTS

The HDSB subscales correlate high and in the expected direction with the DRS at all three points in time. The correlation of the changes between HDSB and DRS is moderate, but in the expected direction. The sensitivity to change in time of the HDSB is lower than that of the DRS.

CONCLUSIONS

This study supports the validity of the HDSB as an instrument to describe the disability of acquired brain injury patients at a single point in time. Its ability to measure changes in disability over time is questionable and needs further investigation.

Assessing the responsiveness of a functional status measure: the Sickness Impact Profile versus the SIP68

In this study, the Sickness Impact Profile (SIP) and the SIP68 are studied for their ability to detect changes in health-related behavioral status. Methodological approaches toward responsiveness are invented and discussed. Next, literature findings on the responsiveness of the SIP are presented and judged for their validity. The SIP appeared to be able to demonstrate changes in the expected direction and in accordance with changes detected by other instruments. Using data from seven different longitudinal projects in populations with different diagnoses, the responsiveness of both the SIP136 and the SIP68 are subsequently studied and compared. In all populations, changes in functional status were indicated by both instruments. In terms of effect sizes, the SIP136 and the SIP68 do not differ significantly in their responsiveness. Moreover, changes detected by both SIPs appear to be valid representations of changes in health-related functional status.

Daily functioning of the lower extremity amputee: an overview of the literature

The aim of this paper is to review the existing literature on the incidence, morbidity and mortality of lower limb amputation. The functional level of the lower limb amputee and the predictive factors for functioning with a prosthesis are reviewed, both for unilateral and for bilateral amputees. The reported incidence of lower extremity amputation (LEA) varies considerably between different Western countries. The mean survival of LEA patients ranges between two and five years. Assessment of functional outcome is carried out differently. Studies are not comparable and most concern selected groups of amputees. Increasing age, concurrent disease and poor compliance are prognostic factors for a low functional level. For optimal planning of rehabilitation it is necessary to study a complete cohort of amputees with respect to these prognostic factors.

Membership of a patients' association and well-being. A study into the relationship between membership of a patients' association, fellow-patient contact, information received, and psychosocial well-being of people with a neuromuscular disease

This article presents the results of a study into the relationship between membership of a patients' association, information received, fellow-patient contact and psychosocial well-being. Data were collected from a group of people with myotonic dystrophy and spinal muscular atrophy (n = 349). About 60% of this group are members of a patients' association for people with a neuromuscular disease. No direct relationship was found between membership of the patients' association and well-being. Membership, however, was positively related to the number of fellow-patients with whom one has had personal contact and also to the amount of information received about the disease and related factors. Having personal contact with more fellow-patients was related to a better well-being in the group of patients who had a relatively low level of physical functioning. There were no indications that receiving information leads to better well-being. The results of this study indicate that membership of a patients' association, through promoting fellow-patients contacts, can be beneficial to people with a chronic disease, especially to people who are relatively severely ill.

The sickness impact profile: SIP68, a short generic version. First evaluation of the reliability and reproducibility

In previous research a short version of the Sickness Impact Profile (SIP136) was developed, containing 68 items. This SIP68 is intended as a short generic alternative to the original SIP. High reliability of the SIP68 was reported when it was extracted from the SIP136. This paper is a report on the first reliability testing of the SIP68 administered as an independent instrument without the context of the SIP136. To establish the test-retest reliability and the internal consistency of the new instrument, 51 patients of an outpatient department of rheumatology completed the SIP68 twice, with an interval of 48 hours. To compare the performance of the independent SIP68 with the SIP68 extracted from the SIP136, the SIP136 also was completed two times by the same 51 respondents. Test-retest reliability for both administration types was assessed by means of the intraclass correlation coefficient and the Jaccard's similarity ratio. Internal consistency was assessed by means of Cronbach's alpha. The reliability appears to be high in both the independent SIP68 as well as the extracted SIP68. Moreover, the reliability of the independent SIP68 appears to be as high as for the SIP136. These findings were very encouraging, indicating that the SIP68 may very well serve as a generic alternative to the SIP136.

The development of a short generic version of the Sickness Impact Profile

This study concerns the development of a short version of a well-known and much used clinimetric instrument called the Sickness Impact Profile (SIP). The SIP is a generic measure of functional status. Based on findings of a principal components analysis of over 800 SIPs from a multi-diagnostic population, a selection of 68 items divided over 6 dimensions was made and initially tested. As no support was found for the statistical validity of the categorical structure of the original SIP, a new structure, discovered through principal components analysis, was used as the basis for selecting items. Comparison of the scores on the selection with information provided by the original SIP showed very promising results: the 68 item selection may serve as a valid short SIP-version.

Sickness Impact Profile: the state of the art of a generic functional status measure

The Sickness Impact Profile (SIP) is a widely used health status measure, known to be valid and reliable. After the final development and testing in 1978, however, in which several methodological aspects were investigated, no descriptions of research projects that systematically evaluate the methodological and theoretical aspects of the instrument were found. In this article a review is presented of literature on the SIP. This review is the first step taken in a project that evaluates the SIP. The instrument appears to be a reliable instrument with sufficient content validity. It shows good correlations with other health status and functional status measures. Yet a number of questions about the SIP remain unanswered. Theoretical implications of the construct of sickness, the effect of age and gender on SIP scores, the construct validity judged by factor analysis, the responsiveness of the instrument, and the possibilities to use proxy-respondents or to shorten the list and to simplify the scoring procedure still have to be studied. If the instrument is to be used as an international standard measure of functional status, these topics should be thoroughly examined.