Rehabilitation Domains Research Articles

Traumatic versus non-traumatic spinal cord injuries: are there differential rehabilitation outcomes?

Retrospective case review. To compare the rehabilitation outcomes between patients with traumatic spinal cord injuries and patients with non-traumatic spinal cord injuries, using The Needs Assessment Checklist (NAC), to observe if both the groups benefit from the same rehabilitation programme. Tertiary care, spinal cord injury rehabilitation unit (National Spinal Injuries Centre), Stoke Mandeville Hospital, UK. Information obtained with the NAC at two time points during patients' rehabilitation was examined. Statistical analysis investigated the rehabilitation outcomes both between and within groups. Initial differences were observed on admission between patients with traumatic and non-traumatic spinal cord injuries in five of the ten rehabilitation domains measured, with patients with non-traumatic injuries presenting with better outcomes. At a later stage in patients' rehabilitation, however, differences between the groups had lessened. Furthermore, the results demonstrated that the whole cohort made significant improvements in all the ten rehabilitation domains, with the same finding evident for both patients with traumatic and patients with non-traumatic spinal cord injuries. Patients with traumatic spinal cord injuries and patients with non-traumatic spinal cord injuries benefitted from the same rehabilitation programme in a spinal injury centre, making significant improvements in all ten rehabilitation domains measured, suggesting that it is effective to admit and rehabilitate patients with injuries resulting from both traumatic and non-traumatic aetiologies in the same specialised setting.

Introducing the revised applied model of deliberate imagery use for sport, dance, exercise, and rehabilitation

Received May 23rd 2012 - Accepted November 4th 2012 Abstract. This article reviews literature on cognitive and motivational imagery use in the sport, exercise, dance, and rehabilitation domains and outlines a revised applied model of imagery use. The original model by Martin, Moritz, & Hall, 1999 guides practitioners and researchers in determining what cognitive and/or motivational imagery to use in a particular situation for achieving a desired outcome. The revised model proposed builds on the original version by retaining its empirically- supported where, when, and components. Incorporating recent advancements in imagery research, the model distinguishes between what is imaged (i.e., the content) from why it is imaged (i.e., the function). The revised model also acknowledges the importance of the individual and how they interpret an image by including who and meaning components, as well as expanding on how imagery ability is likely to influence the relationship between imagery use and outcomes. Based on imagery's increased usage beyond the sport setting, this review explains how the revised model can also be applied to individuals in the exercise, dance, and rehabilitation settings. Finally, recommendations of how imagery can be effectively used and some predictions of the revised model are provided to encourage future research and application.

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.Implications for RehabilitationThe International classification of functioning, disability and health (ICF) is a widely used framework in the disability and rehabilitation domains; however, many criticisms of the framework and its current graphic exist.The ICF-conceptual revision (ICF-CR) is a new graphic representation of the ICF that enhances its biopsychosocial content, positions quality of life (QOL) as an emergent component, and allows for dynamic visualization which is more in line with the actual nature of human functioning and QOL.Users of the ICF may find the ICF-CR useful to incorporate into their own work.

Identifying implications of thrombolysis for stroke rehabilitation: Knowledge gaps in current research

Purpose: Thrombolysis with tissue plasminogen activator (rtPA) is currently used throughout the world in acute ischaemic stroke management. In this review, we will explore the status of our current knowledge about the effects of rtPA on specific rehabilitation domains and highlight some key knowledge gaps. Methods: Narrative review of the larger clinical and postmarketing surveillance studies. Results: To date, most of the previous research into rtPA for acute ischaemic stroke has focused on safety and efficacy using general outcome measures and has ceased following patients 90 days after rtPA administration. This research has provided valuable information about the safety and efficacy of rtPA and has facilitated the introduction of rtPA into clinical practice for stroke management. However there is a paucity of knowledge about the long-term recovery patterns of patients post-rtPA, including the effect of rtPA on specific rehabilitation domains and its impact on post-acute service delivery. Furthermore, limited information is available about the effect of rtPA on post-stroke quality of life and participation in society. Conclusion: These knowledge gaps have substantial implications for the long-term management of patients by rehabilitation teams. Increasing our knowledge in these areas may assist us to predict which individuals are most likely to benefit from thrombolysis with rtPA, and enable us to provide optimal rehabilitation programs to maximise functional outcomes and quality of life post-stroke.Implications for RehabilitationThrombolysis with tissue plasminogen activator (rtPA) is currently used throughout the world in acute ischaemic stroke management.Previous research into rtPA has focused on largely on safety and efficacy using general outcome measures.There is a lack of knowledge about the long-term recovery patterns and service requirements of patients post-rtPA, which has important implications for the management of these patients by rehabilitation teams.

On Enhancing Competent Work with African American Clients: Challenging Persistent Racial Disparity Trends by Examining the Role of the Working Alliance

Trends of racial disparities continue to persist across a variety of rehabilitation domains (e.g., acceptance rates, types of services offered, rehabilitation outcomes). African Americans consistently have poorer rehabilitation outcomes when compared to their White counterparts. Scholars have identified issues of racial bias in clinical judgment within cross-racial client-counselor relationships as a likely central factor contributing to this trend. The strength of the working alliance between counselor and client has been shown to be predictive of positive client outcomes. Factors within the helping relationship, such as color-blind attitudes and racial microaggressions, which have been shown to erode the alliance with African American clients, are discussed, as well as the use of broaching strategies to directly address the issue of race with clients as a means of strengthening the working alliance.

Knowledge Representation for Prognosis of Health Status in Rehabilitation

In this article, key points are discussed concerning knowledge representation for clinical decision support systems in the domain of physical medicine and rehabilitation. Information models, classifications and terminologies, such as the “virtual medical record” (vMR), the “international classification of functioning, disability and health” (ICF), the “international classification of diseases” (ICD) and the “systematized nomenclature of medicine—clinical terms” (SNOMED CT), are used for knowledge integration and reasoning. A system is described that supports the measuring of functioning status, diversity, prognosis and similarity between patients in the post-acute stage, thus helping health professionals’ prescription of recommendations.

Getting the message across: Principles for developing brief-Knowledge Transfer (b-KT) communiqués

This feature article on knowledge transfer presents principles and strategies to support the development of short communiqués to end-users. Formal and informal knowledge brokers are the targeted users of the strategies. Research studies and conceptual literature in knowledge transfer informed the development of brief-Knowledge Transfer (b-KT) principles. Principles are explained and a sample of how they informed the development of KIT-Tip Sheets is offered to promote ways to use principles in knowledge dissemination. b-KT principles can be used as a framework to guide the development of short communiqués by knowledge brokers in work practice but also in the health, social and rehabilitation domains. In addition, these principles promote the participation of end-users in the development of knowledge transfer. Formal evaluation is needed on the use of these principles in achieving the uptake and use of knowledge by end-users.

Improved Haptic Linear Lines for Better Movement Accuracy in Upper Limb Rehabilitation

Force feedback has proven to be beneficial in the domain of robot-assisted rehabilitation. According to the patients' personal needs, the generated forces may either be used to assist, support, or oppose their movements. In our current research project, we focus onto the upper limb training for MS (multiple sclerosis) and CVA (cerebrovascular accident) patients, in which a basic building block to implement many rehabilitation exercises was found. This building block is a haptic linear path: a second-order continuous path, defined by a list of points in space. Earlier, different attempts have been investigated to realize haptic linear paths. In order to have a good training quality, it is important that the haptic simulation is continuous up to the second derivative while the patient is enforced to follow the path tightly, even when low or no guiding forces are provided. In this paper, we describe our best solution to these haptic linear paths, discuss the weaknesses found in practice, and propose and validate an improvement.

Fractal Fluctuations and Complexity: Current Debates and Future Challenges

Complexity is perhaps one of the less properly understood concepts, even within the scientific community. Recent theoretical and experimental advances, however, based on the close relationship between the complexity of the system and the presence of 1/f fluctuations in its macroscopic behavior, have opened new domains of investigation, which consider fundamental questions as well as more applied perspectives. These approaches allow a better understanding of how essential macroscopic functions could emerge from complex interactive networks. In this review we present the current state of the theoretical debate about the origins of 1/f fluctuations, with special focus on recent hypotheses that establish a direct link between complexity and fractal fluctuations. Further, we clarify some lines of opposition, especially between idiosyncratic versus nomothetic conceptions, and global versus componential approaches. Finally, we discuss the deep questioning that this approach can generate with regard to current theories of motor control and psychological processes, as well as some future developments which may be evoked, especially in the domain of physical medicine and rehabilitation.

Evidence-Based Quality Indicators for Stroke Rehabilitation

Previous stroke performance measures consider aspects of postacute treatment, but there are only few specific quality indicators or standards for poststroke rehabilitation. The purpose of this study was to develop a set of indicators for measuring the quality of postacute stroke rehabilitation in inpatient and outpatient facilities using a standardized evidence-based approach. Quality indicators were developed between January 2009 and February 2010 by an interdisciplinary board of healthcare professionals from rehabilitation centers cooperating in the Berlin Stroke Alliance. The Berlin Stroke Alliance is a regional network of >40 providers of acute treatment, rehabilitation, and aftercare aiming to improve stroke services within Berlin and Brandenburg. The indicators were developed according to published international recommendations and predefined methodological requirements. The applied standards included a systematic literature review, a rating of published evidence, an external peer review, and the evaluation in a pilot study before implementation. Of an initial list of 33 indicators, 20 indicators were rated as being appropriate. After completion of the pilot phase, we agreed on a set of 18 indicators. The indicators measure processes (9 indicators), outcomes (5 indicators), and structures (4 indicators) in the following domains of stroke rehabilitation: completion of diagnostics; secondary prevention; cognition and affect; speech and swallowing; management of complications; sensorimotor functions and mobility; discharge status; and aftercare. Documentation of evidence-based quality indicators for stroke rehabilitation in clinical routine is feasible and can serve as a first step toward implementing standardized cross-institutional quality assurance programs for stroke rehabilitation.

Análise do perfil, funções e habilidades do fisioterapeuta com atuação na área esportiva nas modalidades de futebol e voleibol no Brasil

To analyze the profile of Brazilian physical therapists working with soccer and volleyball professional teams, by verifying their level of education (graduate or undergraduate), as well as their role and insertion within the interdisciplinary team. Structured questionnaires were administered to forty-nine physical therapists working at soccer, volleyball clubs and Brazilian national teams. These questionnaires provided data on social demographic, characteristics of the work environment and organization of clinical practice and its domains. From the 49 participants in this study only five were female. Mean age of all participants was 32.2 years. The majority of the sports physical therapists had specialization degrees in different areas (78.2%), were hired through referral (78.2%), worked more than 8 hours a day or were exclusively dedicated to their clubs (80.0%) and earned seven to ten Brazilian minimal wages (58.2%). They reported to have participation in the domains of emergency care (87.3%), prevention (92.7%), functional rehabilitation (98.2%) and return to competition (100%). They had interdisciplinary relationships with physical educators during functional rehabilitation programs (70.9%) and with physicians in the decision process of return to activity after rehabilitation (74.5%) and on the veto of an athlete to take part in practices or matches (63.6%). Therapists also complained of threats to their professional autonomy, specially directed by the team's physician. There is still a need to invest in continuing education of sports physical therapists with the objective to improve their educational level and to strengthen their professional autonomy.

Guest Editorial Special Issue on Rehabilitation Robotics

The 16 papers in this special section have been logically organized into four different groups: enabling technologies for rehabilitation robotics; two robotic systems used for assisted diagnosis of pathologies of interest in the rehabilitation domain; different robotic systems applied to assisted physical rehabilitation; and robotic systems used for assisted psychophysiological rehabilitation.

Development and initial evaluation of a smart resistance training system

Resistance training equipment is designed to provide specific groups of muscles with an artificially high stress input for short durations. In the sports and, in particular, the rehabilitation domains, control and customization of the applied torque and velocity profiles applied to the musculoskeletal system is desired, since individual biomechanics, training, and rehabilitation requirements and capabilities differ. A ‘smart training system’ (STS) that supports a unique resistance profile generation and control capability is discussed in this paper. Any resistance profile, i.e. combinations of torques, velocities, and positions, can be generated by either user calibration activities, e.g. via isometric and isokinetic exercises, or designed, e.g. inertial load emulation via integrated profile design software, and utilized within the system. Since the STS is capable of providing either passive braking, e.g. isotonic, isometric, or active driving, e.g. isokinetic eccentric, resistances, safe operation is paramount. Integrated profile monitoring software (to ensure that the user never exceeds calibrated capability) and mechanical, electrical, and electromechanical safety systems are utilized within the STS. Control and monitoring of torque—velocity—position profiles enables unique exercise modes to be designed and implemented. A novel exercise mode (termed ‘variokinetic’) is discussed in this paper that supports an active (or passive) resistance based upon the instantaneous torque, velocity, and position requirements of the musculoskeletal joint. The value of this mode is not established in this paper; only a demonstration of the capability of the system to support these variokinetic profiles, and, hence, support future sports or rehabilitation specific resistance profile training. Preliminary results are reported that indicate the software and hardware systems are capable of providing the desired real-time actuation and feedback capabilities, and could, if developed further, provide a wide range of users with an efficient and effective alternative to existing exercise methods and machines.

Aphasia therapy on a neuroscience basis

Background: Brain research has documented that the cortical mechanisms for language and action are tightly interwoven and, concurrently, new approaches to language therapy in neurological patients are being developed that implement language training in the context of relevant linguistic and non‐linguistic actions, therefore taking advantage of the mutual connections of language and action systems in the brain. A further well‐known neuroscience principle is that learning at the neuronal level is driven by correlation; consequently, new approaches to language therapy emphasise massed practice in a short time, thus maximising therapy quantity and frequency and, therefore, correlation at the behavioural and neuronal levels. Learned non‐use of unsuccessful actions plays a major role in the chronification of neurological deficits, and behavioural approaches to therapy have therefore employed shaping and other learning techniques to counteract such non‐use. We wish to thank Chris Code, Barbro Johansson, Bettina Mohr, and two anonymous referees for their comments on an earlier version of this article and for their helpful suggestions. This work was supported by the Medical Research Council (UK) and by the European Community under the “New and Emerging Science and Technologies Programme” (NESTCOM project) and by the Ministerio de Educacion y Ciencia, Spain (SEJ2007‐67793). Aims: Advances in theoretical and experimental neuroscience have important implications for clinical practice. We exemplify this in the domain of aphasia rehabilitation. Main Contribution: Whereas classical wisdom had been that aphasia cannot be significantly improved at a chronic stage, we here review evidence that one type of intensive language‐action therapy (ILAT)—constraint‐induced aphasia therapy—led to significant improvement of language performance in patients with chronic aphasia. We discuss perspectives for further improving speech‐language therapy, including drug treatment that may be particularly fruitful when applied in conjunction with behavioural treatment. In a final section we highlight intensive and rapid therapy studies in chronic aphasia as a unique tool for exploring the cortical reorganisation of language. Conclusions: We conclude that intensive language action therapy is an efficient tool for improving language functions even at chronic stages of aphasia. Therapy studies using this technique can open new perspectives for research into the plasticity of human language circuits.

What Education Means to People with Psychiatric Disabilities: A Content Analysis

This article examines what supported education means to people coping with psychiatric disabilities and tries to understand whether the educational endeavor has an additional personal value for the consumers beyond its instrumental value. It identifies rehabilitation domains that are most important and best achieved within supported education. Our approach is qualitative: we analyze letters written by students with psychiatric disabilities who have successfully completed high school courses and, through content analysis, identify 45 parameters that illuminate the meaning of the experience for the students. We analyze these parameters in terms of Maslow's Hierarchy of Needs. We find that for our population education is also a process of recovery of lost roles and capabilities and fulfills self-actualization needs. The shift from the “patient” to the “student” role is a very powerful one. To exchange the patient role for one that brings with it prestige and power promotes rehabilitation in ways that “merely...

Botulinum Toxin for Spasticity in Children With Cerebral Palsy: A Comprehensive Evaluation

Spasticity is a prevalent disabling clinical symptom for children with cerebral palsy. Treatment of spasticity with botulinum toxin in children with cerebral palsy was first reported in 1993. Botulinum toxin provides a focal, controlled muscle weakness with reduction in spasticity. Interpretation of the literature is difficult because of the paucity of reliable measures of spasticity and challenges with measuring meaningful functional changes in children with disabilities. This study documents the effects of botulinum toxin A injections into the gastrocnemius muscles in children with spastic diplegia. Outcomes are evaluated across all 5 domains of the National Centers for Medical and Rehabilitation Research domains of medical rehabilitation. A randomized, double-masked, placebo-controlled design was applied to 33 children with spastic diplegia with a mean age of 5.5 and Gross Motor Function Classification System Levels of I through III. Participants received either 12 U/kg botulinum toxin A or placebo saline injections to bilateral gastrocnemius muscles. Outcomes were measured at baseline and 3, 8, 12, and 24 weeks after injection. Significant decreases in the electromyographic representation of spasticity were documented 3 weeks after botulinum toxin A treatment. A significant decrease in viscoelastic aspects of spasticity was present at 8 weeks, and subsequent increases in dorsiflexion range were documented at 12 weeks for the botulinum toxin A group. Improvement was found in performance goals at 12 weeks and in maximum voluntary torque and gross motor function at 24 weeks for the botulinum toxin A. There were no significant differences between groups in satisfaction with performance goals, energy expenditure, Ashworth scores, or frequency of adverse effects. The safety profile of 12 U/kg of botulinum toxin A is excellent. Although physiologic and mechanical effects of treatment with botulinum toxin A were documented with functional improvement at 6 months, family satisfaction with outcomes were no different. Communication is needed to ensure realistic expectations of treatment.

Establishing recommendations for physical medicine and rehabilitation: the SOFMER methodology

Objective The development of a rigorous methodology based on published results of clinical trials, evaluation of daily practice in France and multidisciplinary expert opinion to elaborate recommendations for rehabilitation interventions. Methods and results The following describes the methodology of SOFMER (Société Française de Médecine Physique et de Réadaptation [French Society of Physical Medicine and Rehabilitation]) for developing recommendations for rehabilitation interventions. The test case was developing recommendations for rehabilitation in hip or knee osteoarthritis (OA) and hip or knee arthroplasty. Physicians in rehabilitation, orthopedic surgery and rheumatology identified, synthesized, and analyzed data from the literature by use of the usual French system of grading trials (the French Agency for Accreditation and Evaluation in Healthcare [ANAES] scale). The data were published results of comparative controlled studies such as randomized controlled trials, controlled clinical trials, cohort studies, case control studies, reviews of clinical trials, and case series, as well as uncontrolled cohort studies. The resulting recommendations were presented to the three annual French national congresses of rehabilitation, rheumatology, and orthopedic surgery for comment and for adapting to French professional practice. Finally, a panel of multidisciplinary experts (physicians in physical medicine and rehabilitation, rheumatologists, orthopedic surgeons, general practitioners, physical therapists, social workers, podologists, occupational therapists, nurses, and patients) validated the recommendations. Conclusion The SOFMER methodology could be an interesting tool for use in developing recommendations elaborated by all the concerned medical and surgical specialists in the wide domain of rehabilitation.

Assessment, training and quality: Evaluation of some vocational rehabilitation programmes

Aim of this contribution is to illustrate some topics of recent research in the vocational rehabilitation domain. First, three evaluation studies of new vocational rehabilitation programmes in vocational rehabilitation centers are described. These studies concern individually tailored educational programmes and tele-tutoring. This is followed by the presentation of a study concerned with the development and validation of an instrument for diagnosing planning competence. Thirdly, the development of an objective, standardized tool for monitoring the quality of rehabilitation processes during vocational training will be presented.

Approaches to Improving Health Status in Chronic Obstructive Pulmonary Disease: One or Several?

Health outcomes represent a broad group of endpoints used in clinical practice to assess the efficacy and effectiveness of interventions and to assess disease outcomes. Health status is one of the widely applied patient-reported health outcomes. The outcome of a variety of interventions, targeting local impairment or local airway inflammation, is evaluated by health status measurements; these global or summative outcomes indeed quantify the overall effect of a number of biological processes. Targeting the systemic compartment to improve health status is already widely applied in the domain of pulmonary rehabilitation. Challenging developments targeting systemic inflammation and biological processes related to systemic inflammation are particularly addressed in this review.

Reliability and construct validity of the client-centred rehabilitation questionnaire

Purpose. A key component in assessing the performance of rehabilitation services is the client's perspective. The purpose of this paper is to report on the development of a publicly available measure of client-centred rehabilitation (CCRQ) that can be used for discriminative and evaluative purposes.Method. Mixed qualitatative and quantitative methods were used. Phase 1: Identification of seven domains of client-centred rehabilitation based on a literature review, focus groups with clients, and review by content experts. Phase 2: Item generation for the seven conceptually derived subscales and cognitive interviews with inpatient rehabilitation patients. Phase 3: Psychometric testing for internal reliability, test-retest reliability and discriminative construct validity using data from a mailed, self-administered survey to 1568 patients discharged from two large inpatient rehabilitation facilities.Results. The seven conceptually derived subscales all have strong internal (0.72 – 0.87) and test-retest reliability (0.74 – 0.85). Discriminative construct validity is demonstrated by the ability of subscales to identify significant differences between programs within two rehabilitation facilities.Conclusions. The results for the reliability and validity of this measure support its value for use in clinical and quality improvement work as well as research.