Reliability and Validity of the Craig Handicap Assessment and Reporting Technique for Japanese Individuals with Spinal Cord Injury

Therapeutic Lifestyle Intervention Targeting Enhanced Cardiometabolic Health and Function for Persons with Chronic Spinal Cord Injury in Caregiver/Care-Receiver Co-Treatment: A Study Protocol of a Multisite Randomized Controlled Trial

BACKGROUND

Chronic spinal cord injury (SCI) significantly accelerates morbidity and mortality, partly due to the increased risk of cardiometabolic diseases (CMD), including neurogenic obesity, dyslipidemia, and impaired glucose metabolism. While exercise and dietary interventions have shown some transient benefits in reducing CMD risk, they often fail to improve clinically relevant disease markers and cardiovascular events. Moreover, SCI also places caregiving demands on their caregivers, who themselves experience health and functional decline. This underscores the need for more substantial interventions that incorporate appropriate physical activity, heart-healthy nutrition, and behavioral support tailored to the SCI population.

OBJECTIVES

This randomized clinical trial (RCT) protocol will (1) assess the health and functional effects, user acceptance, and satisfaction of a 6-month comprehensive therapeutic lifestyle intervention (TLI) adapted from the National Diabetes Prevention Program (DPP) for individuals with chronic SCI and (2) examine the impact of a complementary caregiver program on the health and function of SCI caregivers and evaluate user acceptance and satisfaction. Caregivers (linked with their partners) will be randomized to 'behavioral support' or 'control condition'.

METHODS

Dyadic couples comprise individuals with SCI (18-65 years, >1-year post-injury, ASIA Impairment Scale A-C, injury levels C5-L1) and non-disabled SCI caregivers (18-65 years). Both groups undergo lock-step circuit resistance training, a calorie-restricted Mediterranean-style diet, and 16 educational sessions focused on diet/exercise goals, self-monitoring, psychological and social challenges, cognitive behavioral therapy, and motivational interviewing. The outcome measures encompass the cardiometabolic risks, cardiorespiratory fitness, inflammatory stress, multidimensional function, pain, life quality, independence, self-efficacy, program acceptance, and life satisfaction for SCI participants. The caregiver outcomes include multidimensional function, pain, quality of life, independence, and perceived caregiver burden.

DISCUSSION/CONCLUSIONS

This study evaluates the effects and durability of a structured, multi-modal intervention on health and function. The results and intervention material will be disseminated to professionals and consumers for broader implementation.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02853149 Registered 2 August 2016.

A comparison of one year outcomes between standardized locomotor training and usual care after motor incomplete spinal cord injury: Community participation, quality of life and re-hospitalization

CONTEXT/OBJECTIVE

Spinal cord injury (SCI) often results in a significant loss of mobility and independence coinciding with reports of decreased quality of life (QOL), community participation, and medical complications often requiring re-hospitalization. Locomotor training (LT), the repetition of stepping-like patterning has shown beneficial effects for improving walking ability after motor incomplete SCI, but the potential impact of LT on psychosocial outcomes has not been well-established. The purpose of this study was to evaluate one year QOL, community participation and re-hospitalization outcomes between individuals who participated in a standardized LT program and those who received usual care (UC).

DESIGN/SETTING/PARTICIPANTS

A retrospective (nested case/control) analysis was completed using SCI Model Systems (SCIMS) data comparing one year post-injury outcomes between individuals with traumatic motor incomplete SCI who participated in standardized LT to those who received UC.

OUTCOME MEASURES

Outcomes compared include the following: Satisfaction with Life Scale (SWLS™), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF™), and whether or not an individual was re-hospitalized during the first year of injury.

RESULTS

Statistically significant improvements for the LT group were found in the following outcomes: SWLS (P = 0.019); and CHART subscales [mobility (P = <0.001)]; occupation (P = 0.028); with small to medium effects sizes.

CONCLUSION

Individuals who completed a standardized LT intervention reported greater improvements in satisfaction with life, community participation, and fewer re-hospitalizations at one year post-injury in comparison to those who received UC. Future randomized controlled trials are needed to verify these findings.

Comparison of disability and quality of life between patients with pediatric and adult onset paraplegia

OBJECTIVE

To investigate the factors that affect disability and quality of life in patients with spinal cord injuries (SCIs) and to compare the degree of disability and quality of life in patients with SCI according to over and under 18 years of age when their injury occurred.

DESIGN

Cohort study.

SETTING

Two academic hospitals in Istanbul, Turkey.

PARTICIPANTS

Forty patients with SCI were included in this study. Group 1 included 20 patients with SCI who were younger than 18 years of age when their injury occurred, Group 2 included 20 patients who were older than 18 years of age when their injury occurred.

OUTCOME MEASURES

Patients' demographics, duration of SCI and degree of disability were assessed using the Craig Handicap Assessment and Reporting Technique (CHART). Quality of life was assessed using the World Health Organization Quality of Life Scale Short Form (WHOQOL-Bref). Depression was assessed using the Beck Depression Inventory (BDI).

RESULTS

Although there was no significant difference between the BDI scores and CHART scores of the two groups, environment domain scores in the WHOQOL-Bref were significantly higher in Group 2 than in Group 1 (P<0.05). No significant correlation was found between age of SCI onset, disease duration, ASIA scores, depression scores, total CHART scores for all patients.

CONCLUSION

Adaptation to environment was significantly better in those who suffered SCI during adulthood than in pediatric patients with SCI. Disability level was not associated with age of disease onset, disease duration, neurological status, depression level.

Preliminary investigation of the reliability and validity of the BIRT Independent Living Scale

PURPOSE

Neurorehabilitation aims to increase independence and participation in ordinary life. It is argued that the fundamental indices of this are independent living and engagement in occupational or productive activity. The Brain Injury Rehabilitation Trust Independent Living Scale was designed to capture change in levels of participation and independence following neurorehabilitation. With greater use of outcome measures in health care, it becomes necessary to develop tools which are simple to use and that capture the holistic impact of rehabilitation. This study examines the inter-rater reliability and validity of the Brain Injury Rehabilitation Trust Independent Living Scale, which comprises two single item, multiple-choice sub-scales.

METHOD

Inter-rater reliability was assessed by comparing the ratings on the Brain Injury Rehabilitation Trust Independent Living Scale, by five pairs of graduate psychologists, of 37 individuals who had undergone neurorehabilitation. Retrospective data collected by other members of the clinical team for the Mayo-Portland Adaptability Inventory-4, Supervision Rating Scale and Care And Needs Scale were correlated with the Brain Injury Rehabilitation Trust Independent Living Scale to establish concurrent validity.

RESULTS

Weighted kappa coefficients revealed moderate (occupation) to strong (accommodation) inter-rater reliability for the two sub-scales. All correlations between the Brain Injury Rehabilitation Trust Independent Living Scale and the Mayo-Portland Adaptability Inventory-4, Supervision Rating Scale and the Care And Needs Scale were high, demonstrating good concurrent validity.

CONCLUSIONS

This study highlights some of the psychometric properties of the Brain Injury Rehabilitation Trust Independent Living Scale and demonstrates its utility in assessing independent living ability and level of social participation after neurorehabilitation. Implications for rehabilitation The BIRT Independent Living Scale is a validated method for ranking accommodation and occupation status as an indicator of independent living ability and occupational activity. The two freely available single-item scales emerging from this study provide a brief method for measuring independent living ability and participation following rehabilitation in research and clinical practice. The BIRT Independent Living Scale's simplicity means it does not require specific training to administer, facilitating its use by a wide range of multidisciplinary staff members and researchers.

Differences in health, participation and life satisfaction outcomes in adults following paediatric- versus adult-sustained spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To compare differences in self-reported health status, participation and life satisfaction outcomes between adults with a spinal cord injury (SCI) sustained during paediatric (P) versus adulthood (A) years.

SETTING

Ontario, Canada.

METHODS

Secondary analysis of data from the Study of Health and Activity in People with SCI. Eighty-seven participants who sustained an SCI prior to age 19 (M±s.e.=25±1.5 years postinjury (YPI)) were matched for lesion level (C2-L5), severity (complete/incomplete), gender, age, education and ethnicity with 87 participants who sustained an SCI at ⩾age 19 years (M_YPI=12.8±1.1).

RESULTS

Those with a paediatric SCI reported significantly less pain, fewer visits to the physician in the past year, greater functional independence, social participation, occupational participation and minutes per day of moderate-to-vigorous physical activity than those who sustained an SCI in adulthood. No significant differences were found for the measures of depression, perceived health status or life satisfaction (P>0.05). With the exception of moderate-to-vigorous physical activity and visits to the physician in the past year, between-group differences were independent of YPI.

CONCLUSIONS

Regardless of time since injury, people who sustained a paediatric SCI reported better health and greater participation than those injured in adulthood. Nevertheless, both groups scored well below able-bodied normative values for all measures. The results highlight the importance of a comprehensive life-course approach to SCI rehabilitation, irrespective of age at the time of injury.

The impact of the World Health Organization 8-steps in wheelchair service provision in wheelchair users in a less resourced setting: a cohort study in Indonesia

Background

For people who have a mobility impairment, access to an appropriate wheelchair is an important step towards social inclusion and participation. The World Health Organization Guidelines for the Provision of Manual Wheelchairs in Less Resourced Settings emphasize the eight critical steps for appropriate wheelchair services, which include: referral, assessment, prescription, funding and ordering, product preparation,fitting and adjusting, user training, and follow-up and maintenance/repairs. The purpose of this study was to investigate how the provision of wheelchairs according to the World Health Organization’s service provision process by United Cerebral Palsy Wheels for Humanity in Indonesia affects wheelchair recipients compared to wait-listed controls.

Methods

This study used a convenience sample (N = 344) of Children, Children with proxies, Adults, and Adults with proxies who were on a waiting list to receive a wheelchair as well as those who received one. Interviews were conducted at baseline and a 6 month follow-up to collect the following data: Demographics and wheelchair use questions, the World Health Organization Quality of Life-BREF, Functional Mobility Assessment, Craig Handicap Assessment Recording Technique Short Form. The Wheelchair Assessment Checklist and Wheelchair Skills Test Questionnaire were administered at follow up only.

Results

167 participants were on the waiting list and 142 received a wheelchair. Physical health domain in the World Health Organization Quality of Life-BREF improved significantly for women who received a wheelchair (p = 0.044) and environmental health improved significantly for women and men who received a wheelchair as compared to those on the waiting list (p < 0.017). Satisfaction with the mobility device improved significantly for Adults with proxies and Children with proxies as compared to the waiting list (p < 0.022). Only 11 % of Adults who received a wheelchair reported being able to perform a “wheelie”. The condition of Roughrider wheelchairs was significantly better than the condition of kids wheelchairs for Children with proxies as measured by the Wheelchair Assessment Checklist (p = 0.019).

Conclusions

Wheelchair provision according to World Health Organization’s 8-Steps in a less-resourced setting has a range of positive outcomes including increased satisfaction with the mobility device and better quality of life. Wheelchair provision service could be improved by providing more hours of wheelchair skills training. There is a need for outcome measures that are validated across cultures and languages.

An examination of the psychometric properties of the community integration questionnaire (CIQ) in spinal cord injury

OBJECTIVE

To examine the psychometric properties of the Community Integration Questionnaire (CIQ) in large samples of individuals with spinal cord injury (SCI).

DESIGN

Longitudinal 12-month survey study.

SETTING

Nation-wide, community dwelling.

PARTICIPANTS

Adults with SCI: 627 at Time 1, 494 at Time 2.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The CIQ is a 15-item measure developed to measure three domains of community integration in individuals with traumatic brain injury: home integration, social integration, and productive activity. SCI consumer input suggested the need for two additional items assessing socializing at home and internet/email activity.

RESULTS

Exploratory factor analyses at Time 1 indicated three factors. Time 2 confirmatory factor analysis did not show a good fit of the 3-factor model. CIQ scores were normally distributed and only the Productive subscale demonstrated problems with high (25%) ceiling effects. Internal reliability was acceptable for the Total and Home scales, but low for the Social and Productive activity scales. Validity of the CIQ is suggested by significant differences by sex, age, and wheelchair use.

CONCLUSIONS

The factor structure of the CIQ was not stable over time. The CIQ may be most useful for assessing home integration, as this is the subscale with the most scale stability and internal reliability. The CIQ may be improved for use in SCI by including items that reflect higher levels of productive functioning, integration across the life span, and home- and internet-based social functioning.

Factors Related to Independent Social Living of Poststroke Patients with Mild Impairment

PURPOSE

To evaluate factors related to independent social living of poststroke patients with mild impairment who live at home after hospitalization.

PARTICIPANTS

Forty-one participants were selected who scored 80 points or more on the Barthel Index (BI) and 25 or more points on the revised Hasegawa Dementia Scale (HDS-R). All of them returned home after receiving functional exercises for poststroke rehabilitation.

METHOD

The functional data of inpatients and the results of a mailed questionnaire based on the Tokyo Metropolitan Institute of Gerontology (TMIG) index and the Craig Handicap Assessment and Reporting Technique, revised Japanese version (CHART-J), were compared.

RESULTS

Of the 6 CHART dimensions, Social Integration and Economic Self-sufficiency did not correlate with functional data during the hospitalized period. Participants generally scored lower in Occupation than in the other CHART dimensions with a higher standard deviation.

CONCLUSION

From the viewpoint of functional impairment of poststroke patients, their motor function can be estimated relatively easily, but such dimensions as Social Integration and Economic Self-sufficiency are more difficult to evaluate with other methods. CHART is useful for evaluating the social activity of poststroke patients who live at home.

The cross-cultural equivalence of participation instruments: a systematic review

PURPOSE

Concepts such as health-related quality of life, disability and participation may differ across cultures. Consequently, when assessing such a concept using a measure developed elsewhere, it is important to test its cultural equivalence. Previous research suggested a lack of cultural equivalence testing in several areas of measurement. This paper reviews the process of cross-cultural equivalence testing of instruments to measure participation in society.

METHODS

An existing cultural equivalence framework was adapted and used to assess participation instruments on five categories of equivalence: conceptual, item, semantic, measurement and operational equivalence. For each category, several aspects were rated, resulting in an overall category rating of 'minimal/none', 'partial' or 'extensive'. The best possible overall study rating was five 'extensive' ratings. Articles were included if the instruments focussed explicitly on measuring 'participation' and were theoretically grounded in the ICIDH(-2) or ICF. Cross-validation articles were only included if it concerned an adaptation of an instrument developed in a high or middle-income country to a low-income country or vice versa.

RESULTS

Eight cross-cultural validation studies were included in which five participation instruments were tested (Impact on Participation and Autonomy, London Handicap Scale, Perceived Impact and Problem Profile, Craig Handicap Assessment Reporting Technique, Participation Scale). Of these eight studies, only three received at least two 'extensive' ratings for the different categories of equivalence. The majority of the cultural equivalence ratings given were 'partial' and 'minimal/none'. The majority of the 'none/minimal' ratings were given for item and measurement equivalence.

CONCLUSION

The cross-cultural equivalence testing of the participation instruments included leaves much to be desired. A detailed checklist is proposed for designing a cross-validation study. Once a study has been conducted, the checklist can be used to ensure comprehensive reporting of the validation (equivalence) testing process and its results.

IMPLICATIONS FOR REHABILITATION

• Participation instruments are often used in a different cultural setting than initial developed for. • The conceptualization of participation may vary across cultures. Therefore, cultural equivalence – the extent to which an instrument is equally suitable for use in two or more cultures – is an important concept to address. • This review showed that the process of cultural equivalence testing of the included participation instruments was often addressed insufficiently. • Clinicians should be aware that application of participations instruments in a different culture than initially developed for needs prior testing of cultural validity in the next context.

Validation and cross-cultural adaptation of the Persian version of Craig Handicap Assessment and Reporting Technique (CHART) short form

OBJECTIVE

To test the psychometric specifications of the Persian version of the Craig Handicap Assessment and Reporting Technique (CHART) short form in an Iranian population.

DESIGN

Cross-sectional study.

SUBJECTS

Fifty-two individuals with a mean age of 49.3 years (SD 7.9, minimum 38 years and maximum 80 years), who had chronic spinal cord lesions, were included in this study. Most of them were paraplegic (88.5%) and unemployed (76.9%).

METHODS

Reliability (internal consistency) of the measure was examined by applying Cronbach's alpha. In addition, validity (construct) was tested by Pearson's correlation.

RESULTS

Overall, the internal consistency of the questionnaire was found to be satisfactory (Cronbach's alpha 0.613). Regarding construct validity, the minimum and maximum significant correlations were among Physical Component Summery and Cognitive Independence (r = 0.267, p < 0.05), Vitality and Social Integration (r = -0.429, p < 0.01) respectively.

CONCLUSION

By analyzing data regarding the psychometric specifications of the Persian version of CHART, we can conclude that this version is a valid, reliable and unique measure that can be used for spinal cord-injured individuals. As demonstrated in our preliminary study, it is easy to be filled out and is not confusing. Implications for Rehabilitation The Persian version of the CHART has been successfully validated. It can be used by those working specifically in the field of spinal cord injury and also more generally. It will enable both initial assessment and follow-up for people in Persian-speaking areas of the world.

Health of people with spinal cord injury in Singapore: implications for rehabilitation planning and implementation

PURPOSE

This study aimed to provide a broad overview of the health of people with spinal cord injury (SCI) in Singapore, so as to highlight areas of potential need. These areas could then guide future research and rehabilitation programme development.

METHODS

Demographic data, injury information and information about SCI-related secondary impairments, chronic conditions and their associated risk factors, medical and hospital utilisation, participation (Craig Handicap Assessment and Reporting Technique) and life satisfaction (Satisfaction with Life Scale) were collected via interviews from people living with traumatic SCI.

RESULTS

On average, participants (50 men and 5 women) were aged 48.3 ± 16.54 years and had had their SCIs for 5 years. -75% with tetraplegia. The most prevalent SCI-related secondary impairments were pain, spasms, bladder problems, bowel problems and oedema. Chronic conditions and their associated risk factors were prevalent. Participation and life satisfaction scores were lower than those reported for similar populations cross-culturally.

CONCLUSION

The study revealed several health areas that may be affecting the overall health of people with SCI in Singapore. By focusing on community reintegration and health promotion, physiotherapists and other rehabilitation professionals may augment health outcomes and improve the quality of life of this population in Singapore.

A review of instruments assessing participation in persons with spinal cord injury

STUDY DESIGN

A systematic search of the literature.

OBJECTIVES

To critically review instruments that assess participation in persons with spinal cord injury (SCI).

SETTING

Vancouver, British Columbia.

METHODS

Four electronic databases (MEDLINE/PubMed, CINAHL, EMBASE and PsychInfo) were searched for studies published between 1980 and March 2008. Instruments were included if information was published in English in at least one peer-reviewed journal on its measurement properties (reliability, validity and responsiveness) in a sample that included adults with SCI. Instruments were evaluated using criteria proposed for disability outcome measures.

RESULTS

Six instruments were included: Craig Handicap Assessment and Reporting Technique (CHART); Impact on Participation and Autonomy Questionnaire (IPA); Assessment of Life Habits Scale (Life-H); Occupational Performance History Interview; Physical Activity Recall Assessment for People with Spinal Cord Injury; and Reintegration to Normal Living Index. Evidence supporting the reliability of the instruments was reported for four of the six instruments and was adequate. Validity was assessed in all the instruments. Only the Life-H and CHART have been compared with each other. No evidence on responsiveness was available.

CONCLUSION

The instruments differ in how participation is operationalized. Currently, the CHART that measures objective aspects of participation has the most evidence supporting its measurement properties. More evidence is becoming available for instruments such as the IPA, which consider the person's perspective. It is important to determine what information about participation is required before selecting an instrument.

Participation following traumatic spinal cord injury: an evidence-based review for research

BACKGROUND/OBJECTIVE

To report an evidence-based review of participation instruments that have been used in spinal cord injury (SCI) clinical practice and research.

METHODS

Rehabilitation literature was searched for instruments used by at least 2 independent SCI researchers since 2000. Each instrument was reviewed by 2 committee members. One person reviewed the scale and documented the level of use and psychometric properties. The second committee member verified the values and made suggestions for changes.

RESULTS

Three instruments met the review criteria: Craig Handicap Assessment and Reporting Technique (CHART), Assessment of Life Habits (LIFE-H), and the Impact on Participation and Autonomy (IPA). Each instrument incorporates different perspectives in the measurement of participation. The LIFE-H uses a qualitative approach, whereas the CHART adopts a quantitative approach; both are based on societal norms of participation. In contrast, the IPA integrates individual choice and control in defining participation. CHART is the most widely used instrument, although its development predates the development of the ICF. The IPA is a relatively new instrument, and its psychometric properties have only recently published.

CONCLUSIONS

Continuing research is needed to develop conceptually and psychometric valid measures of participation for use with people with SCI. Priorities include understanding the relationship between objective and subjective indicators of participation, describing the dimensions of participation, and identifying appropriate measurement models and psychometric approaches to evaluate the nonhierarchical character of participation. Researchers and clinicians should be aware of the strengths and limitations of existing measures to make informed decisions about appropriate instruments.