Cognitive status at discharge from the hospital determines discharge destination in traumatic brain injury patients.

PURPOSE: To determine which basic and functional status characteristics of patients with a moderate or severe traumatic brain injury (TBI) are associated with discharge destination. METHOD: Cross-sectional study among TBI patients. The study included 111 patients aged 16-67 years with a moderate-to-severe TBI (Glasgow Coma Scale (GCS) score 3-14). Functional outcome was assessed with Barthel Index (BI), Functional Independence Measurement (FIM), Level of Cognitive Functioning Scale (LCFS), Functional Assessment Measurement (FAM), Supervision Rating Scale (SRS) and Neurobehavioural Rating Scale (NRS). Patients were interviewed at the time of being discharged from hospital. Outcome variable was discharge destination; (1) home vs. institution and (2) rehabilitation centre vs. nursing home. RESULTS: Gender, age and length of stay were not associated with discharge destination. TBI severity, physical status, level of arousal and cognitive status were univariately associated. Multivariate analyses, however, showed that the risk of being admitted to an institution was significantly higher for those with severe TBI (adjusted OR = 14) and/or lowered cognitive status at the time of discharge from hospital (adjusted OR = 12). CONCLUSIONS: Discharge destination is associated with TBI-severity at admittance to the hospital and cognitive status at discharge from the hospital.

Being restricted in participation after a traumatic brain injury is negatively associated by passive coping style of the caregiver.

PURPOSE: To examine whether the caregivers' coping style is associated with the functional outcome of the traumatic brain injury (TBI) patient 1 year post-injury. METHOD: A cross-sectional study among patients with a TBI, including their primary caregivers. The study included 51 patients aged 17-64 years with a moderate-to-severe TBI and 51 caregivers (23 parents and 28 partners) aged 23-67 years. The coping preferences of the caregivers were assessed at minimum 6 and maximum 12 months post-injury, by filling out the Utrecht Coping List (UCL) and were related to limitations in activity, as measured with the Frenchay Activities Index and with restrictions in participation as measured with the Sickness Impact Profile-68 of TBI patients 1 year post-injury. The patients were interviewed at their homes; the caregivers received and returned the UCL by mail. RESULTS: The patients' age and the caregivers' coping style are independently associated with restrictions in participation 1 year post-injury. CONCLUSIONS: A passive coping style of the primary caregiver is negatively associated with the patient's functional outcome in terms of participation in society.

Reliability and sensitivity to change of measurement instruments used in a traumatic brain injury population.

OBJECTIVE: To compile a minimum data set for the follow-up of traumatic brain injury patients from discharge from hospital to one year post injury to assess functioning and participation in the physical, cognitive and psychosocial domains, and in quality of life. DESIGN: Repeated questionnaire interviews by two observers to establish inter-observer reliability of the measurement instruments at discharge and at one year post injury, as well as their sensitivity to change over time in traumatic brain injury patients. SETTING: Department of neurosurgery of an academic hospital, department of a rehabilitation centre, and at the patients' homes in the Netherlands. SUBJECTS: The study at discharge included 25 patients aged 18-50 years with a moderate to severe traumatic brain injury (Glasgow Coma Scale score 3-14), whereas the one year post injury study included 14 patients aged 19-51 years. MAIN (OUTCOME) MEASURES: Physical domain: Barthel Index (BI), Functional Independence Measurement (FIM), Glasgow Outcome Scale (GOS), GOS Extended (GOSE). Cognitive domain: Disability Rating Scale (DRS), Functional Assessment Measurement (FAM), Levels of Cognitive Functioning Scale (LCFS), Neurobehavioural Rating Scale (NRS). Psychosocial domain: Community Integration Questionnaire (CIQ), Employability Rating Scale (ERS), Frenchay Activity Index (FAI), Multi Health Locus of Control (MHLC), Rehabilitation Activities Profile (RAP), Social Support List (SSL), Supervision Rating Scale (SRS), Wimbledon Self Reporting Rating Scale (WSRS). Quality of life: Coop/Wonca Charts (Coop), Rand SF-36 (Rand-36), Sickness Impact Profile-68 (SIP-68). RESULTS: At both discharge and at one year post injury, in the physical domain the FIM showed excellent squared weighted kappa (SWK ranging from 0.75 to 0.80), and intraclass correlation coefficient (ICC ranging from 0.75 to 0.92), and a relatively small standard error of measurement (SEM 3.22) and smallest detectable difference (SDD 8.92). In the cognitive domain the FAM and the NRS showed excellent SWK, and ICC, and a relatively small SEM and SDD. In the psychosocial domain the FAI showed excellent SWK (0.89), and ICC (0.87), and a relatively small SEM (2.64) and SDD (7.31). For quality of life, at both discharge and at one year post injury the SIP-68 and the Coop showed excellent SWK (0.87), and ICC (0.89), and a relatively small SEM (3.79) and SDD (10.51). At both time points SWK and ICC ranged from 0.80 to 0.89, SEM ranged from 1.47 to 1.98, and the SDD was 4.07. CONCLUSIONS: An example of a reliable minimum data set that is also able to detect changes over time is: the FIM, the FAM and the Coop for the early stages in recovery, extended with the NRS, the FAI, and the SIP-68 later in recovery, thereby covering all relevant domains after traumatic brain injury.

Clinical presentation, associated disorders and aetiological moments in Cerebral Palsy: a Dutch population-based study.

PURPOSE: Cerebral Palsy (CP) contains varying clinical presentations, associated disorders and aetiological moments. Quantitative data and trends on these aspects were lacking in The Netherlands. METHOD: Within a population-based study on prevalence, presentation and functioning of Dutch children with CP born in the years 1977-1988, individual history taking, examination and medical file checking was done by experienced clinicians. Clinical subtypes, motor disability, important co-morbidity (mental retardation, visual disability and epilepsy) were recorded, aetiological moments identified if possible. By comparing the four most recent years with the earlier years possible trends were studied. RESULTS: A quarter of children beforehand recorded as CP did not meet inclusion criteria after individual examination. Spastic subtypes accounted for over 90% of all CP cases: bilateral spastic cerebral palsy as a group are the majority although spastic hemiplegia is percentage-wise the largest individual clinical subtype. Epilepsy and mental retardation are common. Clinical patterns and associated disorders remained rather constant comparing earlier to more recent birth years. CONCLUSIONS: An early diagnosis of CP may be challenged. General clinical patterns remained rather constant in following years, as did most studied items. Even if this study revealed a prevalence rise, no aspect stood out as a possible explanation for this prevalence rise. Comparable studies performed elsewhere showed similar findings.

Tetraplegia Hand Activity Questionnaire (THAQ): the development, assessment of arm-hand function-related activities in tetraplegic patients with a spinal cord injury.

STUDY DESIGN: Development of Tetraplegia Hand Activity Questionnaire (THAQ). SETTING: Patients and spinal cord injury (SCI) professionals from five rehabilitation centres in the Netherlands and Belgium. OBJECTIVE: To construct a disease-specific questionnaire to evaluate interventions to the arm-hand of tetraplegics in terms of gained and lost activities relevant to the patient. METHODS: All arm-hand function-related activities were inventoried by examining existing scales and interviewing spinal cord injury patients and professionals in the field. Subsequently, item reduction was achieved; first, in the technical construction by incorporating all activities in an item list, then reducing the list by selecting the items most likely to be sensitive to change after surgical or functional electro stimulation interventions on the arm-hand as judged by an expert panel, using a Delphi method. RESULTS: The arm-hand-related activity inventory comprised 652 activities. The technical construction of the items and the Delphi procedure resulted in a questionnaire with 153 items. The experts considered many of the 'new' activities more relevant for the evaluation of hand function interventions than those found in scales studied in the literature. This is reflected in a relatively large proportion of new activities (69%) for the item list of the THAQ, and even more in the domains work/admin/telecom (88%) and leisure (100%). CONCLUSION: The questionnaire constructed to assess hand function-related activities contains relevant activities to evaluate arm-hand function-related interventions for tetraplegic SCI patients.

Traumatic brain injury: classification of initial severity and determination of functional outcome.

PURPOSE: The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. METHOD: The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. RESULTS: Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. CONCLUSIONS: Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.

Determinants of locomotor disability in people aged 55 years and over: the Rotterdam Study.

Locomotor disability, as defined by difficulties in activities of daily living related to lower limb function, can be the consequence of diseases and impairments of the cardiovascular, pulmonary, nervous, sensory and musculoskeletal system. We estimated the associations between specific diseases and impairments and locomotor disability, and the proportion of disability attributable to each condition, controlling for age and comorbidity. The Rotterdam Study is a prospective follow-up study among people aged 55 years and over in the general population. Locomotor disability in 1219 men and 1856 women was assessed with the Stanford Health Assessment Questionnaire. Diseases and impairments were radiological osteoarthritis, pain of the hips and knees, morning stiffness, fractures, hypertension, vascular disease, ischemic heart disease, stroke, heart failure, chronic obstructive pulmonary disease (COPD), depression, Parkinson's disease, osteoporosis, diabetes mellitus, overweight, and low vision. Adjusted odds ratios, etiologic and attributable fractions were calculated for locomotor disability. The occurrence of locomotor disability can partly be ascribed to joint pain, COPD, morning stiffness, diabetes and heart failure in both men and women. In addition in women osteoarthritis, osteoporosis, low vision, fractures, stroke and Parkinson's disease are significant etiologic fractions. In men with morning stiffness, joint pain, heart failure, diabetes mellitus, and COPD a significant proportion of their disability is attributable to this impairment. In women this was the case for Parkinson's disease, morning stiffness, low vision, heart failure, joint pain, diabetes, radiological osteoarthritis, stroke, COPD, osteoporosis, and fractures of the lower limbs, in that order. We conclude that locomotor complaints, heart failure, COPD and diabetes mellitus contribute considerably to locomotor disability in non-institutionalized elderly people.

Assessing joint pain complaints and locomotor disability in the Rotterdam study: effect of population selection and assessment mode.

OBJECTIVE: To assess the prevalence of self-assessed and physician-assessed disability and joint pain, their association, and the effect of cohort reduction and mode of assessment. DESIGN: Cross-sectional population survey. SETTING: General population, age 55 years and older. SUBJECTS: Independently living participants of the Rotterdam Study, including 1,156 men and 1,739 women. OUTCOME MEASURES: Self-reported and physician-assessed joint complaints. Patients' self-assessment of locomotor disability was by response to questions from the Stanford Health Assessment Questionnaire; physicians assessed patients' disability by administering activity tests. RESULTS: Reduction of the study cohort because of nonresponse and missing data had no influence on the frequency and effect measures. The physician-assessed prevalence of pain of the hips, knees, or feet was significantly lower than the self-assessed prevalence, with the percentage agreement being 83% for men and 74% for women, with kappa-values of approximately .40. The prevalence of physician-assessed locomotor disability was also significantly lower than the self-assessed disability, with the percentage agreement being 83% for men and 78% for women, with kappa values of .41 and .47, respectively. The associations of joint complaints with disability were similar for both modes of assessment. CONCLUSION: Cohort reduction caused by nonresponse and missing data had no influence on estimates of frequency and association. Self-assessment gives higher prevalences of joint complaints and locomotor disability than physician assessment, but the associations between complaints and disability were the same.

Coping with pain in the hip or knee in relation to physical disability in community-living elderly people.

OBJECTIVE: To investigate the use of pain coping strategies by community-living older people with pain in the hip or knee and the mediating role of coping with pain in the relationship between the chronicity of pain and physical disability. METHODS: A group of 157 people with pain "in the last month" was identified. Coping with pain was assessed with the Pain Coping Inventory, physical disability with the Sickness Impact Profile, and household and sport activities with a validated structured interview method. RESULTS: People with chronic pain used relatively more "resting," and "reducing demands" as pain coping strategies. Pain chronicity made a significant contribution to physical disability; however, when corrected for other variables in a regression model, no significant partial correlation was found. CONCLUSION: We conclude that pain coping has a mediating role in the relationship between pain chronicity and physical disability. Less use of "resting" and a physically active lifestyle are independently associated with less physical disability.

Associations of radiological osteoarthritis of the hip and knee with locomotor disability in the Rotterdam Study.

OBJECTIVE: To assess the contribution of radiological osteoarthritis of the hips and knees to disabilities in the activities of daily living related to lower limb function. METHODS: During a home interview 1156 men and 1739 women, randomly chosen from the source population of all independently living residents aged 55 years and over living in a district of Rotterdam (the Rotterdam Study) were asked about locomotor disability by six questions of the Health Assessment Questionnaire (HAQ) and about pain in the hips and knees in the past month. Radiographs of hips and knees were scored according to the Kellgren grading system for osteoarthritis. RESULTS: The prevalence of locomotor disability, defined as at least some difficulty with three or more out of six lower limb functions, was 20.2% for men and 31.9% for women; hip pain was present in 8.3% of the men and 16.6% of the women; knee pain in 12.6% of the men and 22.3% of the women. The prevalence of radiological osteoarthritis grade 2+ of the hip was 14.1% for men and 15.9% for women, and of the knee 16.3% and 29.1% respectively. The odds ratio (OR) (95% confidence intervals) of hip radiological osteoarthritis for locomotor disability adjusted for age and all other variables was for men: 1.4 (0.9, 2.1) and for women: 2.2 (1.6, 2.9). The ORs of knee radiological osteoarthritis adjusted for age and all other variables were 1.1 (0.9, 2.1) and 1.4 (1.1, 1.8) respectively. Severe radiological osteoarthritis (grade 3+) was stronger associated. The ORs of pain in the hips or knees and morning stiffness were much higher (between 2.7 and 5.5 for men and between 2.1 and 5.1 for women). CONCLUSIONS: Radiological osteoarthritis of the hip and knee are only weak independent predictors of locomotor disability in women, and not at all independently associated with locomotor disability in men. Age, pain of the hips and knees, and morning stiffness seem to be the most important independent determinants of locomotor disability.

Vitamin D receptor genotype is associated with radiographic osteoarthritis at the knee.

Osteoporosis and osteoarthritis are age-related disorders of the skeleton with genetic components. Low bone density is a risk factor for osteoporotic fracture while osteoarthritis is associated with increased bone density. The 1,25-dihydroxyvitamin D3 receptor (VDR) gene locus was previously found to be associated with bone density. We therefore studied the relationship between radiographic osteoarthritis at the knee and VDR genotype in a population-based sample (n = 846), using molecular haplotyping of anonymous intragenic DNA polymorphisms. Radiographic osteoarthritis was defined using the Kellgren score, which is based on the assessment of osteophytes and joint space narrowing (JSN). We show that one VDR haplotype allele is significantly overrepresented in individuals with knee osteoarthritis and associated with a 2.27-fold increased relative risk (95% confidence interval 1.46, 3.52). Adjustment for bone density at the femoral neck did not change these results, indicating that the association is not mediated by bone density. The association appeared to be largely explained by the presence of osteophytes rather than JSN. Our results indicate a role of the VDR gene in the pathogenesis of osteophytes while linkage disequilibrium with another nearby gene, i.e., the collagen type IIa1 gene encoding the most abundant protein in cartilage, might contribute to the association.

Differences in health status of older adults with pain in the hip or knee only and with additional mobility restricting conditions.

OBJECTIVE: To determine differences in health status of people aged 55 to 74 years with pain in the hip or knee only and with additional mobility restricting conditions. METHODS: A subsample from a community based study on pain, disability, comorbidity, and radiological osteoarthritis (OA) was used to identify a group with current pain in the hip or knee only (n = 62), a group with additional mobility restricting conditions (n = 124), and a reference group without pain and radiological OA (n = 72). Health status was measured with the IRGL instrument (Impact of Rheumatic diseases on General health and Lifestyle). Additional mobility restricting conditions were self-reported. RESULTS: The most reported additional conditions were more widespread joint pain and stiffness, and cardiovascular and respiratory problems. The group with pain in the hip or knee only had less mobility than the reference group (p < 0.05), but had higher mobility (p < 0.05), less pain (p < 0.001), less psychological distress (p < 0.01), and less effect of symptoms on daily life (p < 0.001) than the group with additional conditions. No differences were found in background variables or comorbidity. Multivariate logistic regression analysis showed that the group with additional conditions differed from the group with knee or hip pain only with respect to joint pain (OR 1.18), cheerfulness (OR 0.9), and effect on daily life (OR 1.1). CONCLUSION: The health status of people with pain in the hip or knee only is comparable to that of a reference group without pain. Health status is lower when pain in the hip or knee is present in combination with additional mobility restricting conditions. This last group is at greater risk of psychological distress and physical dysfunctioning.

The association of abnormalities on physical examination of the hip and knee with locomotor disability in the Rotterdam Study.

To assess the influence of abnormalities found on physical examination of the hips and knees on disability 1156 men and 1739 women aged > or = 55 yr (the Rotterdam Study) were asked about locomotor disability (LD) using six questions of the Health Assessment Questionnaire (HAQ). The prevalence of LD was 20.2% for men and 31.9% for women. Moderately restricted range of motion of the hips and knees occurred in 34.5% of the men and 38.6% of the women. The prevalence of instability of the knees was 12.5% for men and 16.8% for women. Varus deformity in men (10.1%) and valgus deformity in women (15.0%) were the most common deformities of the knees. Restricted flexion of the hips was the strongest determinant of LD. Age-adjusted odds ratios for restricted hip flexion of LD were 4.7% (95% CI: 3.2-6.8) for men and 3.5 (2.7-4.5) for women. Valgus deformity, knee instability and obliquity were risk factors only in women. Adjustment of these odds ratios for morning stiffness and joint pain did not alter the estimates.

Physical and psychosocial disability in elderly subjects in relation to pain in the hip and/or knee.

OBJECTIVE: To determine physical and psychosocial disability in subjects aged 55 to 74 years living in the community, in relation to pain in the hip and/or knee, and to explore the relationships between pain, physical and psychosocial disability, and selected background variables. METHODS: A subsample from a community based study on pain, disability, and radiological osteoarthritis (ROA) was used to identify groups with sporadic, episodic, and chronic pain and a reference group. Disability was assessed with the Sickness Impact Profile. Data were available for 306 subjects (response 83%). RESULTS: The mean physical disability in the group with chronic (and more severe) pain (N = 59) was 5.4 times and psychosocial disability was 3.6 times higher than those of a reference group (N = 72). The body mass index, the existence of extra mobility problems, and ROA were independently positively related to physical disability. Male sex, having extra mobility problems, and moderate ROA were independently positively related to psychosocial disability. CONCLUSION: Subjects with more chronic (and severe) pain in the hip and/or knee had relatively high levels of physical as well as psychosocial disability, compared to a reference group without any signs of OA. Pain chronicity had no significant contribution to physical disability, if corrected for other factors. Both forms of disability in subjects with pain were better predicted by ROA and by problems other than pain in the hip or knee alone, than by the chronicity of the pain.

Association of radiographically evident osteoarthritis with higher bone mineral density and increased bone loss with age. The Rotterdam Study.

OBJECTIVE: To investigate the relationship of osteoarthritis (OA) to bone mineral density (BMD) and rate of bone loss. METHODS: The study group consisted of 2,745 persons (1,624 women) from the general elderly population. Disability was assessed by the Health Assessment Questionnaire. Femoral neck BMD was measured at baseline and, in 1,723 subjects, after 2 years of followup. Knee and hip radiographic OA was assessed on anteroposterior radiographs. RESULTS: With the exception of knee radiographic OA in men, radiographic OA was associated with significantly increased BMD (3-8%). BMD increased significantly according to the number of affected sites and the Kellgren score. Radiographic OA was also associated with significantly elevated bone loss with age (in men, only for radiographic OA of the hip). A significant increase in relation to the number of affected sites and the Kellgren score (except with regard to knee OA in men) was found, independent of disability. CONCLUSION: Radiographic OA is associated with high BMD and increased rate of bone loss. This suggests a more pronounced difference in BMD earlier in life.

[Locomotor disability in the elderly; the ERGO Study (Erasmus Rotterdam Health and the Elderly). ERGO Study Group]. / Locomotore beperkingen bij ouderen; het ERGO-onderzoek. ERGO-onderzoeksgroep.

OBJECTIVE: Determination of the prevalence of locomotor disability and its association with signs and symptoms of the hips and knees in a Dutch general population aged 55 years and over. DESIGN: Cross-sectional population-based study. SETTING: Rotterdam-Ommoord, the Netherlands. METHOD: During home interviews of 1,901 men and 3,132 women aged 55 years and over living in the Ommoord district of Rotterdam, locomotor disability was assessed using the Health Assessment Questionnaire (HAQ). Morning stiffness and pain in the hips and knees during the past month were assessed. At the research centre weightbearing radiographs of the hips and knees were taken. Radiological osteoarthritis was defined as Kellgren score 2 or more. A complete physical examination of the hips and knees was performed. RESULTS: The prevalence of locomotor disability was 21.9% for independently living men and 36.0% for independently living women. In homes for the elderly these figures were 84.0% en 96.5%, respectively. There were significantly elevated age-adjusted odds ratios for locomotor disability for women, people in homes for the elderly, independently living men with only primary education, independently living participants with a below-median net annual income and widowed men in homes for the elderly. Taking the associations between the independent variables into account only morning stiffness, pain in the hips and knees and restricted flexion of the hips and knees were independently associated with locomotor disability in men. In women radiological osteoarthritis of the hips and knees, restricted endorotation of the hip, instability and valgus deformity of the knees were also associated with disability. CONCLUSION: The prevalence of locomotor disability in people aged 55 years and over in the general population was high and associated with female sex, low education, low income and living in a home for the elderly. Of the signs and symptoms of the hips and knees only pain in the hips and knees, morning stiffness and restricted flexion of the hip were independently associated with locomotor disability. Radiological osteoarthritis of the hip and knee did not contribute much to the explanation of locomotor disability.

Association of locomotor complaints and disability in the Rotterdam study.

OBJECTIVE: To determine the association between joint complaints and locomotor disability. METHODS: During a home interview survey 1901 men and 3135 women aged 55 years and over (the Rotterdam Study) were asked about joint pain and morning stiffness in the past month, and locomotor disability was assessed by six questions from the Health Assessment Questionnaire (HAQ). RESULTS: The prevalence of locomotor disability was 24.5% for men and 40.5% for women. The prevalence of joint pain in men was 0.7% for pain in the hips, knees, and feet simultaneously, 3.7% for pain at two joint sites, 16.0% for pain at one joint site, and 20.4% for pain in the hips and/or knees and/or feet (any joint site); the corresponding estimates for women were 1.9%, 9.0%, 23.7%, and 34.5%, respectively. The prevalence of generalised morning stiffness was 4.9% for men and 10.4% for women. The age adjusted odds ratios for locomotor disability in men ranged from 2.4 of pain at one joint site to 8.8 of pain at all three joint sites; for women these odds ratios varied between 2.5 and 5.7, respectively. The age adjusted odds ratios of generalised morning stiffness were 8.0 for men and 7.3 for women. CONCLUSION: There is a strong and independent association between locomotor disability and age, joint pain, and generalised morning stiffness in people aged 55 years and over. The odds for locomotor disability increase onefold for every year increase in age, while the presence of generalised morning stiffness is of greater influence than the presence of joint pain.

[Prevalence of chronic diseases in the elderly; the ERGO study (Erasmus Rotterdam Health and the Elderly)]. / De prevalentie van chronische ziekten bij ouderen; het ERGO-onderzoek.

In the Rotterdam Study, prevalence and determinants of chronic diseases in the elderly (age > or = 55 years), were investigated in inhabitants of Ommoord, a suburb of Rotterdam. The study focused on cardiac diseases (myocardial infarction, angina pectoris, cardiovascular risk factors), glaucoma, macular degeneration, osteoporosis, osteoarthrosis and invalidity, dementia (Alzheimer's disease, vascular dementia, Parkinson's disease), epilepsy, cerebrovascular accident. The number of participants was 7983 (3105 men, 4878 women), a response of 78%. The participants were interviewed and were twice examined in an out-patient clinic. The results will be described in subsequent issues of this journal.