Instruments for assessment of impairments and activity limitations in patients with hand conditions: A European Delphi study.

OBJECTIVE: To reach multidisciplinary European consensus on the assessment tools for impairments and activity limitations in patients with hand conditions. DESIGN: Electronic Delphi method. SUBJECTS: Thirty experts from European societies for hand therapy, hand surgery, and physical and rehabilitation medicine. METHODS: In 3 rounds, participants were asked which of 13 preselected categories of the Brief International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions should be assessed. In addition, they were asked to choose which of 55 preselected instruments they preferred for each category by confirming or rejecting instrument-specific statements. RESULTS: All 13 preselected ICF categories were considered relevant. Consensus was based on ≥ 75% agreement. After 3 rounds, 9 instruments were selected: Shape Texture Identification Test, Semmes Weinstein Monofilament Test, Visual Analogue Scale for pain, goniometer, Jamar Dynamometer, Pinch Gauge Device, Cold Intolerance Symptom Severity questionnaire, Canadian Occupational Performance Measure, and Disabilities of the Arm, Shoulder and Hand Questionnaire. It remained undecided whether to use the Nine-Hole Pegboard Test or the Purdue Pegboard Test. CONCLUSION: In this European Delphi study, multidisciplinary consensus was reached on 9 assessment tools for impairments and activity limitations in patients with hand conditions addressing 13 categories of the Brief ICF Core Set for Hand Conditions.

Construct validity of the canadian occupational performance measure in participants with tendon injury and Dupuytren disease.

BACKGROUND: In patient-centered practice, instruments need to assess outcomes that are meaningful to patients with hand conditions. It is unclear which assessment tools address these subjective perspectives best. OBJECTIVE: The aim of this study was to establish the construct validity of the Canadian Occupational Performance Measure (COPM) in relation to the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) in people with hand conditions. It was hypothesized that COPM scores would correlate with DASH and MHQ total scores only to a moderate degree and that the COPM, DASH questionnaire, and MHQ would all correlate weakly with measures of hand impairments. DESIGN: This was a validation study. METHODS: The COPM, DASH questionnaire, and MHQ were scored, and then hand impairments were measured (pain [numerical rating scale], active range of motion [goniometer], grip strength [dynamometer], and pinch grip strength [pinch meter]). People who had received postsurgery rehabilitation for flexor tendon injuries, extensor tendon injuries, or Dupuytren disease were eligible. RESULTS: Seventy-two participants were included. For all diagnosis groups, the Pearson coefficient of correlation between the DASH questionnaire and the MHQ was higher than .60, whereas the correlation between the performance scale of the COPM and either the DASH questionnaire or the MHQ was lower than .51. Correlations of these assessment tools with measures of hand impairments were lower than .46. LIMITATIONS: The small sample sizes may limit the generalization of the results. CONCLUSIONS: The results supported the hypotheses and, thus, the construct validity of the COPM after surgery in people with hand conditions.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Amputation surgery and postoperative management. Part 1.

BACKGROUND: Surgeons still use a range of criteria to determine whether amputation is indicated. In addition, there is considerable debate regarding immediate postoperative management, especially concerning the use of 'immediate/delayed fitting' versus conservative elastic bandaging. OBJECTIVES: To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 1 focuses on amputation surgery and postoperative management. STUDY DESIGN: Systematic literature design. METHODS: Literature search in five databases. Quality assessment on the basis of evidence-based guideline development. RESULTS: An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. CONCLUSION: The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for diagnosis, referral, assessment, and undergoing amputation of a lower extremity and can be used to provide patient information. CLINICAL RELEVANCE: This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Rehabilitation process and prosthetics. Part 2.

BACKGROUND: A structured, multidisciplinary approach in the rehabilitation process after amputation is needed that includes a greater focus on the involvement of both (para)medics and prosthetists. There is considerable variation in prosthetic prescription concerning the moment of initial prosthesis fitting and the use of replacement parts. OBJECTIVES: To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 2 focuses on rehabilitation process and prosthetics. STUDY DESIGN: Systematic literature design. METHODS: Literature search in five databases and quality assessment on the basis of evidence-based guideline development. RESULTS: An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. CONCLUSION: The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for treatment and reintegration of patients undergoing amputation of a lower extremity and can be used to provide patient information. CLINICAL RELEVANCE: This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.

Residual complaints after neuralgic amyotrophy.

OBJECTIVE: To develop recommendations regarding outcome measures and topics to be addressed in rehabilitation for persons with neuralgic amyotrophy (NA), this study explored which functions and activities are related to persisting pain in NA and which questionnaires best capture these factors. DESIGN: A questionnaire-based survey from 2 cross-sectional cohorts, one of patients visiting the neurology outpatient clinic and a cohort seen at a multidisciplinary plexus clinic. SETTING: Two tertiary referral clinics based in the Department of Neurology and Rehabilitation from a university medical center provided the data. PARTICIPANTS: A referred sample of patients (N=248) with either idiopathic or hereditary NA who fulfilled the criteria for this disorder, in whom the last episode of NA had been at least 6 months ago and included brachial plexus involvement. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two custom clinical screening questionnaires were used as well as the Shoulder Rating Questionnaire-Dutch Language Version, the Shoulder Pain and Disability Index (SPADI), the Shoulder Disability Questionnaire (SDQ), and Overall Disability Sum Score. RESULTS: The survey confirms the high prevalence of persisting pain and impairments. More than half of the patients were restricted by pain, while in those without pain 60% experienced residual paresis. Correlations show an intimate relation between pain, scapular instability, problems with overhead activities, and increased fatigability. A standard physical therapy approach was ineffective or aggravated symptoms in more than 50%. CONCLUSIONS: Pain and fatigue are strongly correlated to persisting scapular instability and increased fatigability of the affected muscles in NA. Our results suggest that an integrated rehabilitation approach is needed in which all of these factors are addressed. We further recommend using the SPADI and SDQ in future studies to evaluate the natural course and treatment effects in NA.

Predicting prosthetic use in elderly patients after major lower limb amputation.

BACKGROUND: The main determinants of prosthetic use known from literature apply to the younger patient with lower limb amputation. Studies aimed at identifying determinants of outcome of lower limb amputation in elderly patients with multimorbidity that rehabilitate in skilled nursing facilities (SNFs) are scarce. OBJECTIVES: To predict prosthetic use and physical mobility in geriatric patients admitted to SNFs for rehabilitation after lower limb amputation and the impact of multimorbidity. STUDY DESIGN: Prospective design. METHODS: Univariate and multivariate logistic and linear regression analyses were used to identify determinants that were independently related to prosthetic use and the timed-up-and-go test (TUG test). RESULTS: Of 55 eligible patients, 38 had complete assessments on admission and at discharge. Fifty per cent was provided with a prosthesis. Multimorbidity was present in 53% of the patients. Being able to ambulate independently, and having a transtibial amputation (rather than a higher level of amputation), without phantom pain determined prosthetic use (R(2)=56%), while cognitive abilities, low amputation level, and pre-operative functional abilities were independently associated with the TUG test (R(2)=82%). CONCLUSIONS: Elderly patients referred to an SNF for prosthetic training have a high probability of using a prosthesis when having an independent ambulation after transtibial amputation, without phantom pain. These patients should be considered for prosthetic training.

Geriatric rehabilitation of lower limb amputees: a multicenter study.

PURPOSE: The aim of this study was to determine factors independently associated with successful rehabilitation of patients with lower limb amputation in skilled nursing facilities (SNFs). METHODS: All patients admitted to one of the 11 participating SNFs were eligible. Multidisciplinary teams collected the data. Successful rehabilitation was defined as discharge to an independent living situation within 1 year after admission. Functional status at discharge, as measured with the Barthel index (BI), was a secondary outcome. Multivariate regression analyses were used to assess the independent contribution of each determinant to the two outcome measures. RESULTS: Of 55 eligible patients, 48 were included. Mean age was 75 years. Sixty-five percent rehabilitated successfully. Multivariate analyses showed that presence of diabetes mellitus (DM) (OR 23.87, CI 2.26-252.47) and premorbid BI (OR 1.37, CI 1.10-1.70) were the most important determinants of successful rehabilitation, whereas 78% of the variance of discharge BI was explained by premorbid BI, BI on admission, and 1-leg balance. CONCLUSION: The presence of DM and high premorbid BI were associated with discharge to an independent living situation within 1 year after admission. Premorbid BI, admission BI, and 1-leg balance were independently associated to discharge BI.

Effects of aerobic exercise therapy and cognitive behavioural therapy on functioning and quality of life in amyotrophic lateral sclerosis: protocol of the FACTS-2-ALS trial.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a fatal progressive neurodegenerative disorder affecting motor neurons in the spinal cord, brainstem and motor cortex, leading to muscle weakness. Muscle weakness may result in the avoidance of physical activity, which exacerbates disuse weakness and cardiovascular deconditioning. The impact of the grave prognosis may result in depressive symptoms and hopelessness. Since there is no cure for ALS, optimal treatment is based on symptom management and preservation of quality of life (QoL), provided in a multidisciplinary setting. Two distinctly different therapeutic interventions may be effective to improve or preserve daily functioning and QoL at the highest achievable level: aerobic exercise therapy (AET) to maintain or enhance functional capacity and cognitive behavioural therapy (CBT) to improve coping style and cognitions in patients with ALS. However, evidence to support either approach is still insufficient, and the underlying mechanisms of the approaches remain poorly understood. The primary aim of the FACTS-2-ALS trial is to study the effects of AET and CBT, in addition to usual care, compared to usual care alone, on functioning and QoL in patients with ALS. METHODS/DESIGN: A multicentre, single-blinded, randomized controlled trial with a postponed information model will be conducted. A sample of 120 patients with ALS (1 month post diagnosis) will be recruited from 3 university hospitals and 1 rehabilitation centre. Patients will be randomized to one of three groups i.e. (1) AET + usual care, (2) CBT + usual care, (3) Usual care. AET consists of a 16-week aerobic exercise programme, on 3 days a week. CBT consists of individual psychological support of patients in 5 to 10 sessions over a 16-week period. QoL, functioning and secondary outcome measures will be assessed at baseline, immediately post intervention and at 3- and 6-months follow-up. DISCUSSION: The FACTS-2-ALS study is the first theory-based randomized controlled trial to evaluate the effects, and the maintenance of effects, of AET and CBT on functioning and QoL in patients with ALS. The results of this study are expected to generate new evidence for the effect of multidisciplinary care of persons with ALS. TRIAL REGISTRATION: Dutch Trial Register NTR1616.

Evidence for bilaterally delayed and decreased obstacle avoidance responses while walking with a lower limb prosthesis.

OBJECTIVE: To examine whether the increased failure rates in obstacle avoidance of patients with lower limb amputation can be understood on the basis of increased delay and/or decreased amplitudes of obstacle avoidance responses. METHODS: Subjects performed obstacle avoidance on a treadmill while EMG recordings were made of several major muscles of the leg. RESULTS: It was found that subjects with a lower limb amputation have delayed responses (e.g. delays of 20 ms for the Biceps Femoris) and have decreased response amplitudes (36-41% smaller). Furthermore, such changes were observed not only on the prosthetic side, but also on the sound side. The decreased amplitudes were associated with increased failure rates in the obstacle avoidance task. CONCLUSIONS: It is concluded that the bilaterally delayed and reduced responses in persons with a lower limb prosthesis reflect a basic reorganization within the central nervous system aimed at providing synchronized activity in both lower limbs, even though the peripheral deficit involves only one limb. SIGNIFICANCE: The present results on obstacle avoidance responses can be used to evaluate future prosthetic training involving obstacle crossings for amputee rehabilitation.

Clinimetric properties of instruments to assess activities in patients with hand injury: a systematic review of the literature.

OBJECTIVE: To perform a systematic review of the literature to assess the clinimetric properties of instruments measuring limitations of activity. DATA SOURCES: The Medline, Cochrane Library, Picarta, Occupational Therapy-seeker, and CINAHL databases were searched for English or Dutch language articles published between 2001 and 2006. STUDY SELECTION: Two reviewers independently reviewed the identified publications for eligibility (based on the title and abstract), methodologic criteria, and clinimetric properties. To evaluate the available information of the clinimetric properties, the quality criteria for instrument properties were used. DATA EXTRACTION: All the clinimetric properties of the 23 instruments were described based on the publications that were included. DATA SYNTHESIS: In total, 103 publications were retrieved, 79 of which were eligible for inclusion. Of these, 54 met the methodologic quality criteria. Twenty-three instruments were reviewed, divided into (1) pegboard tests measuring fine hand use only; (2) instruments measuring fine hand use only, by picking up, manipulating, and placing different objects; (3) instruments measuring single tasks (and fine hand use) by scoring task performance; and (4) questionnaires. The reliability, validity, and responsiveness of only 5 instruments were adequately described in the literature; the description of the clinimetric properties of the other instruments was inadequate. CONCLUSIONS: None of the instruments had a positive rating for all the clinimetric properties.

Study of the human pelvis using CAT-scan: gender differences and anatomy of the ramus ossis ischii.

OBJECTIVE: In a descriptive study we present the CAT-scan norm data of pelvic sizes in Caucasian men and women. The study was performed to investigate possible differences in pelvic sizes between men and women and the inter-individual range of pelvic sizes. The data may be useful as a guide in the development of orthoses and prostheses. METHODS: Pelvis CAT-scans of 40 subjects, 20 males (23-66 years) and 20 females (20-72 years) were investigated. The research was approved by the regional ethics committee. RESULTS: The angle of the ramus ossis ischii (ROI) with the line of progression in the transverse plane (angle a) was 38.6 degrees (SD 3.4) in females and 31.8 degrees (SD 4.4) in males. This difference was statistically significant (Student's t-test (p < 0.0001). The ROI angle in the coronal plane (angle b) was negative or zero both in males and females. The horizontal distance between the medial border of the ROI and the lateral border of the femur (RF distance) was slightly smaller in females (95 mm) compared to males (107 mm), but this difference was not statistically significant. The distance between the midfemoral line and the anterior surface of the leg was also slightly smaller in females (89 mm) than in males (106 mm) but the difference was not statistically significant. We found a linear relation between the total AP soft tissue distance and the soft tissue circumference of the proximal leg at the level of the ROI. CONCLUSION: There are significant gender differences in pelvic size and shape. The medial plane of the ROI is not in a slight angle of inclination towards the midline but appears to be zero. The medial contour of the ROI in the AP direction is slightly curved.

From satisfaction to expectation: the patient's perspective in lower limb prosthetic care.

PURPOSE: To obtain information about the wishes and experiences of patients with a lower limb amputation with regard to prosthetic prescription and their exchange of information with the healthcare providers. DESIGN: Cross-sectional questionnaire. SETTING: Outpatient clinic of a Rehabilitation Centre. STUDY PARTICIPANTS: A random sample of patients with a lower limb amputation (n = 81). MAIN OUTCOME MEASURES: In analogy with the QUOTE questionnaire a focus group technique was used. Prosthetic users formulated 24 specific items, which were of importance according to them. The items were divided into 4 categories: (i) service demand, (ii) prosthetic prescription, (iii) information, (iv) insurance aspects. The questionnaire consisted of two sets (A and B) of 24 items rating importance of items and experience in everyday practice. To identify different dimensions within the 24 items, a factor analysis in SPSS was performed for lists A and B followed by a varimax rotation. Impact factors were calculated by multiplying the mean score of importance on an item with the percentage of patients that experienced this item as negative. RESULTS: A total of 113 questionnaires were sent by e-mail with a response of 73%. The outcomes of the questionnaires resulted in 2 sets of information: One concerning the importance of several items in the process of prosthetic prescription, the other the experience of the prosthetic user about those items. By multiplying the scores on importance by the percentage of negative experience per item (impact score) points of improvement for clinical practice were formulated. CONCLUSIONS: A discrepancy between the needs of patients and what they experience in their contacts with clinical professionals as the most important dimension was noticed. A questionnaire with specific items for a homogeneous target group is a good method to formulate points of improvement for clinical practice in healthcare.

High failure rates when avoiding obstacles during treadmill walking in patients with a transtibial amputation.

OBJECTIVE: To investigate if and to what extent patients with a transtibial amputation are less successful in avoiding unexpected obstacles while walking than healthy adults. DESIGN: Experimental 2-group design. SETTING: Dutch rehabilitation center. PARTICIPANTS: Eleven patients with a transtibial amputation and 14 healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects walked on a treadmill at .56m/s. In 2 series of 12 trials each, an obstacle was dropped in front of the prosthetic or the nonprosthetic leg of the amputation group and the left leg of the control group at different phases during the step cycle. It was noted which avoidance strategy was used (a long step strategy [LSS] or a short step strategy [SSS]) and whether the obstacle was avoided successfully or not. These data were expressed as a percentage of the total number of trials completed by each subject. RESULTS: With either leg, the amputation group made significantly more errors than the control subjects (prosthetic leg, 24%+/-17%; nonprosthetic leg, 21%+/-17% vs 2%+/-2% for the control group). Highest failure rates were in the amputation group when time pressure was high, requiring an SSS, especially on the prosthetic side. An LSS under time pressure, however, nearly always resulted in failure for both the prosthetic and nonprosthetic legs. Subjects with the longest time since amputation were most successful in avoiding unexpected obstacles. CONCLUSIONS: Under time pressure, patients with a lower-leg prosthesis perform best when they use their nonprosthetic leg as the lead limb in an SSS. The fact that some subjects with the longest time since amputation made no errors suggests that over many years it is possible to relearn the appropriate avoidance reactions sufficiently fast.

Use of the Delphi Technique for developing national clinical guidelines for prescription of lower-limb prostheses.

The aim of this project was the development of evidence- and consensus-based clinical practice guidelines for lower-limb prosthesis prescription for achieving transparency and consensus among clinicians, manufacturers, and insurance companies. This article describes a modified Delphi Technique, which is based on different methods of collecting evidence, and its role in the development of national clinical guidelines for prosthesis prescription. We used a multimethod approach to develop guidelines for the clinical practice of prosthesis prescription for lower-limb amputees. The Delphi Technique was central in the process, and the panel was made up of experts from three key disciplines on a national level. Our approach involved various methods: a systematic review, a survey of national clinical practice on prosthesis prescription, and interviews with experts. These activities resulted in 45 postulates about prosthesis prescription. The views of the national expert panel were then presented at a consensus development conference. The participants in the Delphi Technique sessions reached a consensus on 37 of the postulates on prosthesis prescription for lower-limb amputees. The postulates were categorized according to amputation level and partitioned into different domains. The total process resulted in the development of draft clinical guidelines comprising guidance for prescribing prostheses for the lower limb. The scope and applicability of these guidelines will have to be measured and evaluated in future work.

A systematic literature review of the effect of different prosthetic components on human functioning with a lower-limb prosthesis.

A correct prosthetic prescription can be derived from adapting the functional benefits of a prosthesis to the functional needs of the prosthetic user. For adequate matching, the functional abilities of the amputees are of value, as well as the technical and functional aspects of the various prosthetic components. No clear clinical consensus seems to be given on the precise prescription criteria. To obtain information about different prosthetic components and daily functioning of amputees with a prosthesis, we performed a systematic literature search. The quality of the studies was assessed with the use of predetermined methodological criteria. Out of 356 potentially relevant studies, 40 studies eventually qualified for final methodological analysis and review. Four satisfied all the criteria and were classified as A-level studies, 26 as B-level, and 10 studies as C-level studies. Despite a huge amount of literature, our formal clinical knowledge had considerable gaps concerning the effects of different prosthetic components and their mechanical characteristics on human functioning with a lower-limb prosthesis. Therefore, with regard to prosthetic guideline development, we must still largely rely on clinical consensus among experts. The integration of knowledge from research with the expert opinion of clinical professionals and the opinions and wishes of consumers can form a solid base for a procedure on guideline development for prosthetic prescription.