Actual vs. best practices for young children with cerebral palsy: a survey of paediatric occupational therapists and physical therapists in Quebec, Canada.

RATIONALE: Cerebral palsy (CP) constitutes a substantial portion of paediatric rehabilitation, yet little is known regarding actual occupational therapy (OT) and physical therapy (PT) practices. This study describes OT and PT practices for young children with CP in Quebec, Canada. METHODS: This was a cross-sectional survey. All eligible, consenting paediatric occupational therapists (OTs) and physical therapists (PTs) were interviewed using a structured telephone interview based on vignettes of two typical children with CP at two age points--18 months and 4 years. Reported practices were grouped according to the International Classification of Functioning, Disability and Health (ICF). RESULTS: 91.9% of PTs (n=62; 83.8% participation rate) and 67.1% of OTs (n=85; 91.4% participation rate) reported using at least one standardized paediatric assessment. OT and PT interventions focused primarily on impairments and primary function (such as gait function and activities of daily living). Both professions gave little attention to interventions related to play and recreation/leisure. Clinicians reported the need for more training and education specific to CP and to the use of research findings in clinical practice. CONCLUSION: Wide variations and gaps were identified in clinicians' responses suggesting the need for a basic standard of OT and PT management as well as strategies to encourage knowledge dissemination regarding current best practice.

Waiting time for rehabilitation services for children with physical disabilities.

BACKGROUND: Early rehabilitation may minimize disability and complications. However, children often wait a long time to gain admission to rehabilitation centres. OBJECTIVES: To describe waiting times for paediatric physical and occupational therapy and to determine factors associated with these waiting times. RESEARCH DESIGN: The study was a prospective cohort design. Patients were followed from 1 January 1999 to 1 March 2000. SUBJECTS: All children with physical disabilities, aged 0-18 years, referred in 1999 from the Montreal Children's Hospital to paediatric rehabilitation centres. MEASURES: Data on date of referral, date of first appointment at the rehabilitation centre, age, gender, diagnosis, region and language were obtained from the rehabilitation transfer database. Primary family caregivers of children who were transferred to a rehabilitation facility participated in a telephone interview regarding their perceptions of the transfer process. RESULTS: There were 172 children referred to rehabilitation facilities. The mean age of the children was 2.5 years. Average waiting time was 157.4 days (SD 57.1) for occupational therapy and 129.4 days (SD 51.6) for physical therapy. Decreased waiting time was associated with living in the city as opposed to the suburbs (hazard ratio=1.77; 95% confidence interval=0.92-3.41) and inversely associated with age (hazard ratio=0.46; 95% confidence interval=0.34-0.62). Among the 41 primary family caregivers who participated in the survey, higher empowerment scores were associated with shorter waits for rehabilitation. CONCLUSION: Waiting time for rehabilitation services needs to be reduced. Empowered parents appear to manoeuvre within the system to reduce waiting times for their children.

Use of the UFOV to evaluate and retrain visual attention skills in clients with stroke: a pilot study.

OBJECTIVE: The objective of this pilot study was to examine the use of a visual attention analyzer in the evaluation and retraining of useful field of view in clients with stroke. METHOD: Fifty-two clients with stroke referred to a driving evaluation service were evaluated with a visual attention analyzer referred to as the UFOV. The UFOV assesses three aspects of visual attention: processing speed, divided attention, and selective attention. Seven participants were retested to determine the test-retest reliability of the UFOV. Six participated in the development of a training protocol and in a 20-session visual attention retraining program. RESULTS: UFOV scores indicated substantial reduction in visual attention in clients after stroke, with older participants performing the most poorly. Test-retest reliability was moderate (ICC = .70). Mean UFOV scores improved significantly after retraining. CONCLUSION: Although UFOV scores indicated poor visual attention skills in clients with stroke, preliminary information suggests that UFOV scores significantly improve with training.

Measuring the effect of intra-oral implant rehabilitation on health-related quality of life in a randomized controlled clinical trial.

The importance of assessing the impact of treatments for chronic conditions on an individual's quality of life has been well-established. In this randomized clinical trial, oral-health-related quality of life, measured with the Oral Health Impact Profile (OHIP), was compared between two groups of edentulous patients. One group (n = 54) received mandibular implant-supported overdentures, and the other group (n = 48) received conventional dentures. Assessments were performed pre-treatment and two months after the prostheses were delivered. The multivariate model showed that implant treatment was significantly associated with lower post-treatment OHIP scores (p = 0.0002), indicating a better quality of life. In addition, pretreatment OHIP scores, treatment allocation, age, sex, and marital status explained 31% of the variation in post-treatment OHIP scores (F = 0.0001). These results suggest that implant treatment provides significant short-term improvement over conventional treatment in oral-health-related quality of life.

Visual testing for readiness to drive after stroke: a multicenter study.

OBJECTIVE: The purpose of this study was to determine the ability of a visual-perception assessment tool, the Motor-Free Visual Perception Test, to predict on-road driving outcome in subjects with stroke. DESIGN: This was a retrospective study of 269 individuals with stroke who completed visual-perception testing and an on-road driving evaluation. Driving evaluators from six evaluation sites in Canada and the United States participated. Visual-perception was assessed using the Motor-Free Visual Perception Test. Scores range from 0 to 36, with a higher score indicating better visual perception. A structured on-road driving evaluation was performed to determine fitness to drive. Based on driving behaviors, a pass or fail outcome was determined by the examiner. RESULTS: The results indicated that, using a score on the Motor-Free Visual Perception Test of < or =30 to indicate poor visual-perception and >30 to indicate good visual perception, the positive predictive value of the Motor-Free Visual Perception Test in identifying those who would fail the on-road test was 60.9% (n = 67/110). The corresponding negative predictive value was 64.2% (n = 102/159). Univariate logistic regression analyses revealed that older age, low Motor-Free Visual Perception Test scores and a right hemisphere lesion contributed significantly to identifying those who failed the on-road test. CONCLUSIONS: The predictive validity of the Motor-Free Visual Perception Test is not sufficiently high to warrant its use as the sole screening tool in identifying those who are unfit to undergo an on-road evaluation.

Proxy use of the Canadian SF-36 in rating health status of the disabled elderly.

Professionals have often depended on proxies to assess health status of elderly individuals unable to provide this information. This study set out to estimate agreement between elderly subjects and their proxies on perceptions of health status, when patients were inpatients in a rehabilitation setting or outpatients in a day hospital, and to determine if there were overestimations or underestimations by proxies. Eighty-three consenting elderly patients living in Montreal, Canada, completed a generic health-status questionnaire, the SF-36, and named a significant other and a health care provider who knew them well. These individuals completed the same questionnaire on behalf of the patients. Agreement between patient and proxy was assessed pairwise (patient/health professional and patient/significant other) using intraclass correlation coefficients. The possibility of a biased rating by type of proxy was determined via paired t-tests. When concordance within respondent pairs was examined, results indicated only poor to moderate agreement regardless of setting and type of proxy for all scales. A trend toward underestimating by proxies was found. Proxy completion of health status questionnaires did not provide similar information, but these preliminary findings need replication.

Predicting ability to drive after stroke.

OBJECTIVE: To determine the ability of perceptual testing to predict on-road driving outcome in subjects with stroke. STUDY DESIGN: Historical cohort study of 84 individuals with stroke who completed both the perceptual testing and the on-road driving evaluation conducted in a driving evaluation service. MEASURES: Perceptual tests, such as the Motor Free Visual Perception Test (MVPT) and Trail Making B test, and an on-road driving evaluation. Based on driving behaviors, a pass or fail outcome was determined by the examiners. RESULTS: Subjects who passed the on-road evaluation had better average scores on the majority of perceptual tests compared with those who failed. The MVPT was the most predictive of on-road performance (positive predictive value=86.1%; negative predictive value=58.3%). The combination of tests resulting in the most predictive and parsimonious model was the MVPT plus Trail Making B, such that those who scored poorly on both were 22 times more likely to fail the on-road evaluation. CONCLUSION: A screening process is useful in identifying persons who are not ready to undergo an on-road driving evaluation.

A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation.

BACKGROUND AND PURPOSE: A new gait training strategy for patients with stroke proposes to support a percentage of the patient's body weight while retraining gait on a treadmill. This research project intended to compare the effects of gait training with body weight support (BWS) and with no body weight support (no-BWS) on clinical outcome measures for patients with stroke. METHODS: One hundred subjects with stroke were randomized to receive one of two treatments while walking on a treadmill: 50 subjects were trained to walk with up to 40% of their body weight supported by a BWS system with overhead harness (BWS group), and the other 50 subjects were trained to walk bearing full weight on their lower extremities (no-BWS group). Treatment outcomes were assessed on the basis of functional balance, motor recovery, overground walking speed, and overground walking endurance. RESULTS: After a 6-week training period, the BWS group scored significantly higher than the no-BWS group for functional balance (P = 0.001), motor recovery (P = 0.001), overground walking speed (P = 0.029), and overground w alking endurance (P = 0.018). The follow-up evaluation, 3 months after training, revealed that the BWS group continues to have significantly higher scores for overground walking speed (P = 0.006) and motor recovery (P = 0.039). CONCLUSIONS: Retraining gait in patients with stroke while a percentage of their body weight was supported resulted in better walking abilities than gait training while the patients were bearing their full weight. This novel gait training strategy provides a dynamic and integrative approach for the treatment of gait dysfunction after stroke.

The effect of a static wrist orthosis on hand function in individuals with rheumatoid arthritis.

OBJECTIVE: To determine the effect of a wrist orthosis on work performance, hand dexterity, and pain during task performance, 40 individuals with rheumatoid arthritis were studied using a 2 period, crossover design. METHODS: Each patient was fitted with a Futuro wrist orthosis. Dexterity was measured with and without the orthosis using the Jebsen Hand Function Test. Work performance was assessed using 2 tasks (one simulating the use of shears, the other the use of a screwdriver) on a work simulator. All tasks were performed both with and without the orthosis, with the order of orthosis versus no orthosis randomly assigned. Pain before and after performing tasks was assessed using a 10 cm horizontal visual analog scale. RESULTS: While on the screwdriver task work performance was less with the orthosis (p = 0.0002); on the shears task there was no significant difference in work performance with and without the orthosis. The average pain after performing both tasks was significantly less with the orthosis on. A 2 factor analysis of variance model with repeated measures suggested that taking into account the reduced work performance during splint wear, pain was still significantly reduced with splint wear. The average time to complete all 7 tasks on the Jebsen Hand Function Test was longer when the subjects wore the splint compared to when they did not (62.0 vs 57.6 s, respectively; p = 0.0086). CONCLUSION: The results suggest that the effect of splint wear on work performance is highly task specific, and thus the ergonomic demands of the individual's daily life must be considered if a splint is to provide maximal effectiveness.

Differences in pain medication use in stroke patients with aphasia and without aphasia.

BACKGROUND AND PURPOSE: While individuals with stroke are known to experience pain for a variety of reasons including premorbid conditions and stroke-specific sequelae, there are some groups of individuals with stroke, who because of aphasia, are unable to express their pain. This study investigated whether there exists an association between severity of aphasia and overall pain medication use as indicated (1) by the proportion of individuals medicated according to aphasia severity and (2) by the dosage of pain medication used according to aphasia severity. METHODS: The study involved a retrospective chart review of 207 charts of patients with stroke admitted to the Jewish Rehabilitation Hospital (JRH), Laval, Canada. Patients were classified into three groups according to level of expressive aphasia: those without aphasia, those with mild-to-moderate aphasia, and those severe aphasia. Information on medications used primarily for pain management was elicited for the first 21 days and the last 5 days of hospitalization. Any substitution, increase, elimination, or addition of pain medication during hospitalization was also monitored. RESULTS AND CONCLUSIONS: While the findings indicate that pain medication prescriptions were similar for all patients, a significantly smaller number of individuals with aphasia received pro re nata (prn) "as required" pain medication when compared with those without aphasia, for the first 21 days and for the last 5 days of hospitalization at the JRH. Similarly, when daily dose was monitored for the same time periods, individuals with aphasia were found to have received less medication for pain than those without aphasia.

Refusal and information bias associated with postal questionnaires and face-to-face interviews in very elderly subjects.

Our objectives were (1) to analyze the refusal bias associated with postal questionnaires and face-to-face interviews and (2) to compare responses elicited from a postal questionnaire with those provided by a face-to-face interview in subjects over 75 years of age. Our methods included a postal questionnaire sent to a representative sample of community-dwelling elderly individuals (n = 842). All subjects were also invited to participate in an in-home interview conducted by a trained nurse. One hundred and six subjects (12.6%) were nonrespondents to the postal questionnaire. These nonrespondents were more cognitively impaired, more disabled, and showed a higher 1-year mortality rate (13.2 versus 5.2%) than respondents. Late respondents who needed a reminder letter were similar to nonrespondents. One hundred and eighty-seven subjects (22.2%) refused to participate in the home interview. These nonparticipants were similar to the participants on age, sex, 1-year mortality rate, and responses given to all but two postal questions. Comparison of postal questionnaire responses and face-to-face responses revealed that agreement was substantial to moderate for factual information (kappa = 0.41 to 0.80) but poor for clinical information (depression, cognitive impairment, disability). A short index including age, sex, and six questions on disability was useful in identifying disabled subjects by a postal questionnaire. Our conclusion is that nonresponse bias is evidenced when postal questionnaires are utilized in the very elderly population and caution should be used when interpreting health data obtained by this technique. Refusal bias from face-to-face interviewing is less important in this population.

Predictive validity of a postal questionnaire for screening community-dwelling elderly individuals at risk of functional decline.

Screening elderly individuals who are at risk of functional decline in the community is essential in order to implement effective programmes of assessment and surveillance in a context of secondary prevention. The postal questionnaire technique consists of sending a simple questionnaire to all elderly individuals living in a defined area in order to identify those who are at risk. The objective of this study was to develop a postal questionnaire and to test its capacity to predict functional decline in community-dwelling elderly people. A 21-item postal questionnaire was sent with a birthday card to a representative sample of community-dwelling individuals over the age of 75 years (n = 842). One month after sending the questionnaire, all subjects were contacted by a nurse for an in-home interview (n = 655) that included assessment of functional autonomy. One year later, the subjects (n = 607) were reassessed by the same nurse. Of the eligible subjects, 87.4% returned the postal questionnaire. During the year following the completion of the postal questionnaire, 43 subjects died, 13 were institutionalized and 109 had experienced a significant decrease on the autonomy scale, for a total annual occurrence of functional decline of 27.2%. Age and 14 of the 21 items of the questionnaire were associated with a significant relative risk of functional decline. The relative risk associated with not responding to the questionnaire was 2.1. A stepwise logistic regression analysis showed that six items were independent predictors of functional decline. This 6-item Sherbrooke Postal Questionnaire identifies as positive 56% of the population with 75% sensitivity and 52% specificity. We conclude that a postal questionnaire is a feasible and valid technique for screening elderly individuals at risk for functional decline.

Barthel Index information elicited over the telephone. Is it reliable?

This study examined the comparability of estimates of functional status elicited through a telephone interview and a face-to-face interview. The Barthel Index, a commonly used measure to assess activities of daily living, was administered over the telephone and then again in the home to 366 individuals, up to 5 yr after their discharge from a rehabilitation hospital. One-half of the telephone interviews were performed by health professionals and the other half by trained lay interviewers; all of the home interviews were performed by health professionals. Proxy-respondents provided information for those unable to respond for themselves. The percent agreement between the scores on the telephone and on the home interview was always greater than 90%; the intraclass correlation coefficient for the telephone/home comparison was 0.89. Responses between the modes of interview were more consistent when provided by self-respondents than when provided by proxies. The telephone assessment worked well in identifying those who did not have functional disabilities; all individuals who scored 100 on the home interview, scored 95 or better on the telephone. When differences arose, they were always in those considered to have moderate to severe impairment and were most often (23 of 29 times) in the direction of higher scores, indicative of less disability, on the telephone. The results of this study suggest that, with the exception of a small subgroup of patients, functional status can be elicited reliably over the telephone by both lay persons and health professionals.

Health-related information postdischarge: telephone versus face-to-face interviewing.

This study had two primary aims: (1) to determine the usefulness of a telephone-administered health status questionnaire as an epidemiological survey instrument in groups at high risk for morbidity and disability; and (2) to evaluate the value of a telephone interview for making judgments about individual patient management. A structured telephone interview was compared with a face-to-face interview in 366 individuals with a stroke or an orthopedic condition up to 5 years after discharge from a rehabilitation hospital. Standardized assessments including the Barthel Index, the Zung Scale, the Reintegration to Normal Living (RNL) Index, and the Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ), along with questions on health, medication use, and health events were administered using both modes. Comparability between the modes was also assessed according to the type of respondent, self, or proxy. On the Barthel Index, the Zung Scale, the RNL Index, and the SPMSQ the percentage of patients indicated as having no disability was similar between the modes. Proxies' responses were, in general, as consistent between the modes as patients' responses. The reliability coefficients indicated moderate to substantial agreement between the modes on the majority of indices and health-related questions. Discord between modes, when present, was greatest for individuals with moderate and severe disability, with less frequent reporting of disability on the telephone. This study supports the use of telephone interviews in determining the prevalence of disability in the community and supports the use of the telephone interview in the case finding process.

Assessing ability to drive following an acute neurological event: are we on the right road?

Every day in Canada occupational therapists are asked to assess clients with neurological impairments and to provide recommendations to provincial licensing bureaus regarding the individual's fitness to drive. These decisions have great impact on the client and on society. In this paper we briefly review the findings that have been published regarding the assessment of individuals with neurological conditions who wish to resume driving. In addition, a description of the tools commonly used to assess individuals is provided, along with where available, the measurement properties of each. Finally, the Driving Evaluation Service of a physical rehabilitation centre is described.

Risk factors for fractures due to falls.

A matched case-control study was carried out to identify risk factors for fractures due to falls. All falls that occurred at a rehabilitation hospital from 1981 to 1988 were identified and classified as index falls (falls resulting in fractures) or referent falls (falls not resulting in fractures). For each of the 94 index falls, four referent falls were chosen at random (n = 376) from all other falls occurring in the same four week period. The average age of the individuals sustaining the index fall was 76.8 +/- 10.4 years, and 68% were female; in contrast, the average age of the individuals sustaining the referent fall was 72.0 years (+/- 13.2), and 32% were female. Fractures of the hip predominated (n = 40; 42.6%) and fractures of the ribs were the second most prevalent (n = 20; 21.4%). Fractures most often ensured from a fall from the upright position. Of the 24 variables considered in the conditional logistic regression model, advanced age, being female, being ambulatory, experiencing disorientation, use of vitamin supplements, and use of antiulcer medications were significantly associated with the risk of a fracture. Thus, because fractures are potentially life-threatening, strategies to prevent falls should be targeted especially towards those who are at risk to sustain a fracture from a fall. However, to be compatible with rehabilitation goals, the preventive strategies must strike a balance between the achievement of functional autonomy and patient safety.

Changing rates of stroke in the province of Quebec, Canada: 1981-1988.

Using more than 37,000 hospital discharges attributed to hemorrhagic or occlusive stroke in the province of Quebec, Canada, we analyzed trends in stroke incidence during the period 1981-1988. There were large and statistically significant (p less than 0.05) increases in the rates of hemorrhagic stroke over this period. Dramatic increases occurred among men in the rates of both intracerebral (International Classification of Diseases--Ninth Revision [ICD9] code 431) and intracranial (ICD9 code 432) hemorrhagic strokes (40-204% depending on age). In contrast, the rates of occlusion of the precerebral arteries (ICD9 code 433) declined in younger men and women but increased substantially (107%) in older men. Rates of occlusion of the cerebral arteries (ICD9 code 434) declined in men over the age of 50 years and in women aged 50-79 years. Despite the decline in the rate of occlusion of the cerebral arteries, the rate of hemorrhagic stroke appears to have increased. Changes in the hospitalization rates for hemorrhagic stroke were not accompanied by consistent decreases in the case-fatality rate. This finding tends to support the hypothesis of an actual increase in the hospitalization rate fo hemorrhagic stroke rather than an artifactually elevated rate due to enhanced diagnosis by computed tomography.

Recovery time of independent function post-stroke.

Stroke patients undergoing physical rehabilitation were monitored daily to determine the length of time needed to recover independent function. Of the 93 patients admitted, there were 45 who could not attain the sitting position independently, 75 who could not walk independently and 75 who could not negotiate the stairs independently. By discharge, 25 of 45 patients (55.6%) were able to attain sitting from supine independently, 35 of 75 patients (46.7%) achieved the ability to walk independently but only 25 of 75 patients (33.3%) learned to negotiate stairs independently. The time from admission to achievement of independent function and the time from onset of stroke to achievement of independent function was modeled in relation to explanatory variables: age, sex, side of lesion, comorbidity, the presence of depression and the extent of impairment in perception, cognition, auditory comprehension and verbal expression. Four variables were found to influence recovery time: age influenced the rate of recovery of walking and stair climbing; perceptual impairment influenced the rate of achieving independent sitting and stair climbing; and depression and comprehension influenced walking.

Change in response time of stroke patients and controls during rehabilitation.

In this study we investigated motor response times of stroke patients at admission to a rehabilitation hospital and again after 6 wk of hospitalization. A prospective comparative study was carried out on 164 stroke patients; 48 hospitalized patients served as controls. Mean motor response times to visual stimuli presented in the left and right visual fields and to centrally presented stimuli were studied. The principle finding was that stroke patients improved significantly in their response times from initial to final evaluation. While at initial assessment they performed significantly more slowly than controls, by final assessment the response times of the two groups did not differ. Visual hemineglect influenced change in response time differentially depending on side of lesion: right hemisphere lesion patients with neglect improved, whereas left hemisphere lesion patients with neglect actually deteriorated. The presence of depression influenced right hemisphere lesion patients' response times and change in response times but it did not have any influence for left hemisphere lesion patients. The findings that response time generally improved during rehabilitation has important implications for the treatment of individuals with brain injury. It will be important to identify therapeutic practices which will be effective in the remediation of response time for all patients. Ultimately the goal of intervening in slow response time is to improve performance of functional activities which are influenced by an individual's ability to respond to visual stimuli.