Enhancing the conceptual clarity and utility of the international classification of functioning, disability & health: the potential of a new graphic representation.

PURPOSE: To present a new graphic representation of the international classification of functioning, disability and health (ICF), entitled the ICF-conceptual revision (ICF-CR). The ICF-CR aims to be clearer and more usable tool than the ICF graphic currently used by starting to address criticisms of the ICF raised in the literature, with a focus on positioning quality of life (QoL) in relation to the ICF's other components. METHOD: This is a conceptual paper based on a review of criticisms of the ICF and related literature published on human functioning. RESULTS: In addition to criticisms of the current graphic, four criticisms of the ICF are discussed in relation to the development of the ICF-CR, including: the lack of development of biopsychosocial theory, the lack of clarity between activities and participation, the language used, and the absence of QoL. General systems theory is used to help construct the new graphic in addressing these criticisms and to position QoL. CONCLUSIONS: The ICF-CR is designed to be a more responsive graphic of human functioning; one which enhances the clarity of principles integral to the ICF, including biopsychosocial theory and universalism. It is hoped the ICF-CR will promote continued discussion toward the goal of enhancing the ICF, both visually and conceptually.

Upper Extremity Motor Learning among Individuals with Parkinson's Disease: A Meta-Analysis Evaluating Movement Time in Simple Tasks.

Motor learning has been found to occur in the rehabilitation of individuals with Parkinson's disease (PD). Through repetitive structured practice of motor tasks, individuals show improved performance, confirming that motor learning has probably taken place. Although a number of studies have been completed evaluating motor learning in people with PD, the sample sizes were small and the improvements were variable. The purpose of this meta-analysis was to determine the ability of people with PD to learn motor tasks. Studies which measured movement time in upper extremity reaching tasks and met the inclusion criteria were included in the analysis. Results of the meta-analysis indicated that people with PD and neurologically healthy controls both demonstrated motor learning, characterized by a decrease in movement time during upper extremity movements. Movement time improvements were greater in the control group than in individuals with PD. These results support the findings that the practice of upper extremity reaching tasks is beneficial in reducing movement time in persons with PD and has important implications for rehabilitation.

Dual-task interference: the effects of verbal cognitive tasks on upright postural stability in Parkinson's disease.

Although dual-task interference has previously been demonstrated to have a significant effect on postural control among individuals with Parkinson's disease, the impact of speech complexity on postural control has not been demonstrated using quantitative biomechanical measures. The postural stability of twelve participants with idiopathic Parkinson's disease and twelve healthy age-matched controls was evaluated under three conditions: (1) without a secondary task, (2) performing a rote repetition task and (3) generating a monologue. Results suggested a significant effect of cognitive load on biomechanical parameters of postural stability. Although both groups increased their postural excursion, individuals with Parkinson's disease demonstrated significantly reduced excursion as compared with that of healthy age-matched controls. This suggests that participants with Parkinson's disease may be overconstraining their postural adjustments in order to focus attention on the cognitive tasks without losing their balance. Ironically, this overconstraint may place the participant at greater risk for a fall.

Predictive validity of the UPDRS postural stability score and the Functional Reach Test, when compared with ecologically valid reaching tasks.

Balance problems and falls are a common concern among individuals with Parkinson's disease (PD). Falls frequently occur during daily activities such as reaching into cupboards in the kitchen or bathroom. This study compared the correlation among two standard postural stability tests - the postural stability score on the Unified Parkinson's Disease Rating Scale (UPDRS) and the Functional Reach Test (FRT) - and ecologically valid reaching tasks that correspond to reaching at different cupboard heights among 20 individuals with PD and 20 age-matched controls. Both the FRT and the UPDRS postural stability tests are quick measures that can be performed during the clinical examination. The FRT, but not the postural stability score, demonstrated a significant correlation with the ecologically valid reaching tasks, among individuals with PD. Furthermore the FRT scores did not correlate with the UPDRS postural stability scores, indicating that these are measuring different aspects of balance. This study suggests that the FRT score may better predict the risk of postural instability encountered during daily activities among individuals with PD.

Plantar cutaneous sensory stimulation improves single-limb support time, and EMG activation patterns among individuals with Parkinson's disease.

Parkinson's disease is a chronic neurological disorder that results in gait and posture impairment. There is increasing evidence that these motor impairments may be partially due to deficits within the sensory system. In this study, the effects of a facilitatory insole that provides increased plantar sensory stimulation, was evaluated during gait, in a group of individuals with Parkinson's disease in comparison with healthy age-matched controls. Spatial-temporal parameters of gait were evaluated using an instrumented carpet, and muscle activation patterns were evaluated using surface EMG. All participants were tested with both a facilitatory (ribbed) insole and a conventional (flat) insole while walking 20 feet. Results indicated that the use of the facilitatory insole produced a significant increase in single-limb support time. Additionally, the muscle activation sequence of the tibialis anterior was normalized by the facilitatory insole, at the time of initial ground contact. These changes may lead to an overall improvement in gait pattern and stability, and suggest that the use of this type of facilitatory insole may be a useful treatment strategy for improving the gait of individuals with Parkinson's disease. This also provides support for the role of facilitation of the sensory system in improving motor output in individuals with Parkinson's disease.

The influence of external orthotic support on the adaptive gait characteristics of individuals with chronically unstable ankles.

External orthotic supports or braces are used clinically to treat individuals with chronically unstable ankles. Braces have efficacious effects on dynamic strength, passive tissue tension, and proprioception, but their effects on gait remains undetermined. The purpose of this study was to determine if overground locomotion, including walking up a step and a curb are influenced by orthotic device use. Twenty subjects, 10 with no previous injury and 10 with chronically unstable ankles, performed with no brace, a flexible brace and a semi-rigid brace while walking on a level surface, up a step and on a ramp. Differences were noted in kinematic and kinetic gait parameters between groups and between step and ramp conditions, suggesting that gait patterns vary between individuals who have had ankle sprain and those who have not. Few differences were noted between the brace and no brace conditions for both groups. Adding to the previously described efficacious benefits, we conclude that bracing does not alter selected gait parameters in individuals who have chronic ankle instability.

Association among neuromuscular and anatomic measures for patients with knee osteoarthritis.

OBJECTIVE: To investigate neuromuscular and anatomic factors involved in varus gonarthrosis by identifying measures associated with degenerative changes. DESIGN: Descriptive study. Individual measures that explained substantial portions of the variability in ratings of knee joint-degenerative changes in patients with knee medial compartment osteoarthritis. SETTING: Outpatient orthopedic clinic and biomechanics and muscular assessment laboratory. PATIENTS: Volunteer sample of 20 subjects (age range, 59 +/- 9 yr) with no history of neurologic disease. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: We assessed degenerative changes, varus alignment, standing balance, and knee proprioception. Weight-bearing radiographs were used to assess the extent of degenerative changes and the degree of varus alignment. Single-limb standing balance control was assessed through tests performed on a force platform. Knee proprioception was assessed with an isokinetic dynamometer, using a joint angle replication test. RESULTS: Forward-stepwise multiple linear regression indicated that the extent of degenerative changes could be best predicted from a linear combination of the independent variables, varus alignment, and standing balance (R =.80, F(2,17) = 14.81, p =.0002). Sixty-four percent of the variability in ratings of degenerative changes was explained by alignment and standing balance measures (37% by varus alignment, 27% by standing balance). Alignment and balance measures were poorly correlated (r =.12, p =.63), further suggesting that they provided different information about gonarthrosis. CONCLUSIONS: Although varus alignment is widely accepted as a clinically important factor in gonarthrosis, and is the focus of many treatment efforts, our results suggest that objective measures of standing balance are also important. As a result, the potential impact of rehabilitation to improve the control of standing balance should be further evaluated in this patient population.

Knee bracing after ACL reconstruction: effects on postural control and proprioception.

PURPOSE: To evaluate the effects an anterior cruciate ligament (ACL) brace has on various measures of knee proprioception and postural control. METHODS: Thirty subjects (mean age 27 +/- 11 yr) having undergone unilateral ACL reconstruction were tested with and without wearing their own custom-fit brace on their involved limb. Proprioception was assessed using joint angle replication tests completed on an isokinetic dynamometer. Postural control was assessed using a series of single-limb standing balance tests completed on a force platform. The balance tests included: 1) standing on the stable platform with eyes open, 2) standing on a foam mat placed over the platform with eyes open, 3) standing on the platform with eyes closed, and 4) standing on the platform after landing from a maximal single-limb forward hop. RESULTS: The brace provided a small but statistically significant improvement in proprioception (mean reduction in error scores between target and reproduced angles = 0.64 +/- 1.4 degrees, P = 0.02). For the postural control tests, there was a significant brace condition by test situation interaction (P = 0.02), with the brace providing a small but statistically significant improvement during the test completed on the stable platform with eyes open (mean reduction in center of pressure path length = 4.2 +/- 8.4 cm, P = 0.02) but not during the other more challenging test situations. Additional post hoc analyses indicated that the relationship between knee proprioception and postural control measures were low and not significant (r = 0.003 to 0.19, P > 0.32), consistent with the suggestion that changes in knee proprioception can occur in the absence of substantial changes in postural control. Also, standing balance tests that challenged the somatosensory contribution to postural control (i.e., those completed on foam, or with eyes closed) were significantly related to single-limb forward hop distances (r = -0.4, P < 0.05), whereas performance during the proprioception test was not (r = 0.1, P > 0.50). CONCLUSIONS: In general, bracing appears to improve performance during tasks characterized by relatively limited somatosensory input but not during tasks characterized by increased somatosenory input. The small magnitude of the improvements, coupled with their apparent lack of carry over to more difficult and functionally relevant tasks, questions the clinical benefit of the present effects of bracing.

Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control.

OBJECTIVE: To evaluate the effects of a functional knee brace specifically designed for patients with varus gonarthrosis on measures of proprioception and postural control. SUBJECTS: Fourteen men and six women (aged 59+/-9 yr) with measurable varus alignment and osteoarthritis of the knee medial compartment. METHODS: Proprioception was assessed in the sitting position using an isokinetic dynamometer and was quantified as the ability to replicate target knee-joint angles. Postural control was assessed with a force platform using tests of single-limb standing balance performed, while the patient was standing on a stable surface and standing on foam, and was quantified as the total length of the path of the centre of pressure. All tests were performed with and without the patient's own custom-fit valgus brace. RESULTS: Proprioception was significantly improved following application of the brace [mean difference=0.7 degrees, 95% confidence interval (CI)=0.2 to 1.1 degrees ). Postural control was not significantly affected by the use of the brace during the stable surface test (mean difference=2.6 cm, 95% CI=-4.3 to 9.5 cm) or the foam surface test (mean difference=0.9 cm, 95% CI=-7.5 to 9.4 cm). CONCLUSION: Although enhanced proprioception may be partially responsible for reported improvements with the use of a brace, the present findings call into question the functional importance of the small changes observed.

Biomechanical analysis of four supports for the subluxed hemiparetic shoulder.

External support systems, such as slings and lapboards, may reduce shoulder subluxation in individuals with hemiplegia. However there is controversy among occupational therapists concerning the most appropriate method to support the affected arm. The purpose of the present paper is to report the biomechanical analysis of four support systems; two shoulder support systems, a Bobath axillary roll, and a laptray. Two dimensional static biomechanical analyses determine the mechanical characteristics of each of these four support systems. The results of the analyses demonstrate the magnitude of the shoulder loading and the effectiveness of the various components of each of the systems. The effect of changing some of the characteristics of the slings is demonstrated. Slings with straps over the unaffected shoulder provide continuous support for the flaccid extremity. The Bobath axillary roll may introduce an unwanted lateral force. Lapboards must be maintained at an appropriate distance from the subluxed shoulder to be effective. This theoretical analysis of supports systems will provide therapists information to help them understand effective supports for subluxation.

Eccentric/concentric ratios at selected velocities for the invertor and evertor muscles of the chronically unstable ankle.

OBJECTIVE: The use of muscle balancing by the clinician to determine return to activity or discharge of a patient is not a well understood measure. Because of the lack of information on the poorly understood concept of eccentric/concentric (E/C) ratios at the ankle, the purpose was to determine the E/C ratios for the invertor and evertor muscles at various velocities in healthy and chronically unstable ankles. METHODS: Ten subjects with healthy ankles and 14 with chronically unstable ankles performed five maximal effort reciprocal eccentric/contraction contractions on an isokinetic dynamometer at four velocities (60, 120, 180, and 240 degrees/s) and for each physiological movement of inversion and eversion. Data were analysed using a two way mixed model analysis of variance with repeated measures, with Tukey's test used for post hoc analysis. RESULTS: Although the chronically unstable ankle was significantly weaker (p < 0.05) eccentrically and concentrically for inversion and eversion, the main effect of the E/C ratios for the ankle was not significant for either joint motion. The main effect of velocity was significant (p < 0.05) for each joint motion, but no significant interaction effects were observed. As velocity increased, the E/C ratio increased, except at 180 and 240 degrees/s for either ankle group. CONCLUSIONS: Chronic ankle instability and muscle weakness co-exist. Adequate E/C ratios in the chronically unstable ankle may exist in the absence of normal strength values.

Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee.

OBJECTIVE: To determine whether elderly individuals with chronic pain as a result of osteoarthritis of the hip and/or knee would report adaptations to their activities, or occupational adaptations, as a coping response to pain and, if so, to describe these adaptations and their relation to chronic pain, functional difficulty, depression, social support, and life satisfaction. DESIGN: Thirty elderly individuals completed rating scales and a structured questionnaire designed to measure occupational adaptation and the importance of activity. SETTING: Participants were community-dwelling elderly individuals and were interviewed in their homes or in a research office setting. PATIENTS: Consecutive orthopedic surgeon, family physician, or Arthritis Society patients, whose names were provided with the patient's consent, to the researcher. RESULTS: Individuals reported two approaches to occupational adaptation: they changed how they performed personal activities of daily living that they rated as most important and they stopped performing a number of avocational activities that they rated as less important. Statistically significant correlations were found among occupational adaptation, pain, depression, and difficulty with functioning. These variables were inversely related to life satisfaction. CONCLUSIONS: This sample of elderly individuals with chronic pain described occupational adaptations, or adaptations to "doing," as a means of coping with their chronic pain. There appeared to be a relation among pain, functional difficulty, depression, social support, and occupational adaptation. Additional research to increase the understanding of occupational adaptation as a means of coping with chronic pain is warranted.

Effectiveness of external orthotic support on passive soft tissue resistance of the chronically unstable ankle.

Functional ankle instability, orthoses, and passive resistive torque tolerated have not been researched. The purpose of the study was to evaluate the passive resistance torque exerted by a flexible and semirigid orthosis for individuals with chronic instability. Twenty-two subjects were evaluated on the passive ankle resistance unit during unbraced, flexible, and semirigid brace conditions. Data from the final three trials for each condition were analyzed using a multiple analysis of variance with repeated measures for resistive torque and inversion range of motion. The semirigid and flexible braces tolerated significantly greater torque forces and less inversion range than the unbraced condition (P < 0.000). External orthotic support, in particular that of a semirigid orthosis, may be beneficial toward reducing injury or be an effective prophylactic for the healthy population.

Monitoring recovery following syndesmosis sprain: a case report.

A sprain to the tibial-fibular syndesmosis often results in prolonged rehabilitation or surgical intervention before recovery occurs. This paper documents gait recovery both before and after surgery for a syndesmosis sprain. Ground reaction force (GRF) data were available before injury and before surgery. Data were also collected every 3 days from 4 days to 4 months after syndesmosis screw removal (8 weeks after surgery). Weightbearing during the stance phase of gait did not approach normal values until approximately 4 months after syndesmosis screw removal. The push-off phase of gait also was slow to recover. When it was possible for the subject to use one or two crutches, differences in GRF were evident, such that walking with one crutch demonstrated increased force production at the ground. Bracing the ankle with a semirigid brace increased GRF, whereas a boot-type lace-up brace resulted in decreased GRF. In this case report of a combined ankle and syndesmosis sprain, results suggest the weightbearing and push-off force were seriously compromised. Decreasing the number of walking assistive devices and wearing a semirigid ankle brace increased the amount of weightbearing through the affected leg and may have merit in encouraging muscle function.

Waterloo Vision and Mobility Study: gait adaptations to altered surfaces in individuals with age-related maculopathy.

Walking is an extremely complex task that can become seriously challenged if one of the sensory systems which provides input to the motor system is compromised. The present study evaluated gait adaptations to altered surface characteristics and high and low ambient light conditions by subjects with age-related maculopathy (ARM). Twenty subjects with ARM and 20 control subjects walked along a 6 m path, along which they met 1 of 3 altered surfaces (compliant, uneven, or shiny). Kinematic data and ground reaction forces information were analyzed to discern gait adaptation strategies used by the ARM group. Ten trials on each surface were collected under both high and low ambient light levels. The ARM subjects were found to be generally more cautious when walking on the altered surfaces. For example, they walked more slowly, with a longer swing time. However, gait adaptations in the ARM group were not merely scaled versions of normal gait but were adjustments to adapt to environmental changes. Gait was modified to avoid tripping over a surface edge, to prevent slipping at heel contact, and to balance during stance. These adaptations enabled subjects to maintain safe mobility when walking in a challenging environment.

Analysis of upper extremity movement in four sitting positions: a comparison of persons with and without cerebral palsy.

The purposes of this study were to compare the arm movements of persons with and without cerebral palsy and to determine if the alteration of the seat angle of a chair affected the quality of those movements. Twelve subjects--3 men and 3 women with spastic cerebral palsy and 3 men and 3 women without any known anomalies that could affect arm movements--were studied. The number of movement elements constituting a reach was used to measure the quality of movements. The findings demonstrated significant differences in the number of movement elements used by the subjects with and without cerebral palsy regardless of position. No significant differences could be attributed to the seating positions. Implications are discussed in relation to the method used in the analysis of movements and the effect of the findings for research and treatment.

Electromyographic analysis of reach in individuals with cerebral palsy.

Electromyographic analysis in both the time domain (root mean square EMG) and the frequency domain (mean power frequency EMG) of the biceps, triceps, wrist extensors and wrist flexors were analysed in six young cerebral palsied adults and six normal individuals. The subjects sat in a Rifton positioning chair. Each subject's right arm was positioned with the shoulder adducted, the elbow at 90 degrees and the hand resting on the arm rest. The subject then reached the right arm forward to grasp a dowel which was placed at shoulder level in front of the subject. There was no significant difference between the time it took the two groups to do the required movement. The RMS analysis indicated the muscle activation was variable among subjects, with evidence of concontraction of the antagonist muscles for the disabled group. The frequency analysis indicated that the disabled group had significantly lower mean power for the biceps and the wrist extensor muscles compared to the normal group. Neurological differences or fibre type abnormalities may account for these differences.

The biomechanics of prehension.

Occupational therapists who work with people who have physical dysfunctions are often involved in the treatment of hand injuries or disabilities. This article describes some of the mechanical principles that affect hand function, including kinematics, kinetics (force and torque), friction, stress, and strain. Practical occupational therapy examples are used to explain these principles.

Wrist muscle tone and self-care skill in persons with hemiparesis.

The purpose of this research was to investigate the interaction between muscle tone at the wrist and self-care function in persons with hemiparesis. Dynamic and static muscle tone measurements were taken at the wrist. Self-care ability was measured with a chart review and the Klein-Bell Scale. The results of the study did not support the assumption that there is a significant relationship between muscle tone and activities of daily living for persons with hemiparesis. Perhaps other variables such as the general state of health, cognition, and perception should also be considered during the treatment of self-care.

Grip strength and dexterity in adults with developmental delays.

The purpose of this study was to determine the usefulness of dexterity and grip strength assessments by comparing the scores of adults with developmental delays with adult norms. A second purpose was to determine the correlations among the assessment instruments. Fifty-six developmentally disabled adults performed the box and block test, the nine hole peg test, and grip strength. Males performed significantly better on grip strength than females, but there was no significant difference on dexterity scores. Males scored significantly lower than established norms on all tests except the left nine hole peg test. Females scores were significantly lower than norms on all tests except the left and right nine hole peg test. Dexterity test scores on one side of the body were highly correlated with those on the other side, but grip strength was not highly correlated with dexterity. This suggests that occupational therap~sts need to treat dexterity and grip as separate entitles. The present results may provide guidelines to determine average performance for adults with developmental delays.