The Applicability of the Patient-Specific Functional Scale (PSFS) in Rehabilitation for Patients with Acquired Brain Injury (ABI) - A Cohort Study

Implementation of a Patient-Reported Outcome Measure: A Quality Improvement Project

ABSTRACT

Patient-reported outcome measures (PROMs) are seen as increasingly beneficial to patient-centered clinical practice, but implementation of routine collection and utilization into clinical care can be challenging. Our interdisciplinary quality improvement (QI) team used the Institute for Health Care Improvement Model for Improvement methodology to address this problem in our outpatient neurorehabilitation program. We used a participatory approach to identify the PROM rehabilitation stakeholders found to be most appropriate to implement in the outpatient settings; chart audits were conducted to determine the extent to which clinicians implemented the PROM and documented a PROM-related goal. Opportunistic clinician feedback was collected to determine single PROM usefulness and acceptability. Our 4-month initiative demonstrated increased collection of a PROM, the Patient-Specific Functional Scale (PSFS), and incorporation into patient-centered goal. Use of QI methodology was beneficial when planning and executing our initiative. Future work is needed to examine factors to sustain PSFS use, incorporation into patient-centered goal setting, and maximize meaningful patient outcomes.

Occupational Therapy Practitioners' Perceptions on Addressing Cognition in Acute Care: A National Survey

This study aimed to identify commonly used standardized cognitive screens and functional performance assessments among occupational therapy practitioners at level 1 trauma centers in the USA. A survey completed by 269 occupational therapy practitioners revealed the most common cognitive screens and the association between cognitive tool training and standardized cognitive tool implementation. Implications for practice are discussed with suggestions for improving occupational therapy practice.

Individualized goals expressed by patients undergoing stroke rehabilitation: an observational study

OBJECTIVES

To explore the rehabilitation goals measured with the Patient-Specific Functional Scale (PSFS) in patients undergoing acute and subacute stroke rehabilitation. In addition, to assess whether PSFS goals corresponded to impairments and activity limitations, as identified by standardized measures.

DESIGN

Observational study.

PARTICIPANTS

A total of 71 participants undergoing inpatient stroke rehabilitation.

METHODS

The PSFS goals were linked to second-level categories in the International Classification of Functioning, Disability and Health (ICF), using established linking rules. Frequencies of the linked ICF categories were calculated. Frequencies of participants with limitations in walking, activities of daily living (ADL), vision, language, and cognition, were calculated, along with goals in corresponding areas of functioning.

RESULTS

The participants' goals were linked to 50 second-level ICF categories, comprising areas such as walking and moving, ADL, language, vision, and cognition. The most frequent ICF categories were "Moving around in different locations" (n = 24), "Walking" (n = 23), "Toileting" (n = 16), "Hand and arm use (n = 12) and "Fine hand use (n = 12)". Of participants with limitations in walking, cognition, and vision, 85%, 10%, and 16%, respectively, had goals in these areas.

CONCLUSION

Participants' goals included walking, ADL, language, vision, and cognition. Few with impairments in cognition or vision had goals in these corresponding areas on the PSFS.

Measurement Property Evaluation of the Arabic Version of the Patient-Specific Functional Scale for Patients with Stroke

Neurological disorders refer to disorders that occur due to disease or damage to the nervous system. Stroke is one of the most common neurological disorders in which individuals commonly present with motor and sensory deficits, leading to the limitations on the activities of daily life. Outcome measures are used to assess and monitor patients' condition change. The patient-specific functional scale (PSFS) is an outcome measure used to assess changes in performance levels in participants with a functional disability during daily activities. This study aimed to assess the reliability and validity of the Arabic version of the patient-specific functional scale (PSFS-Ar) in individuals with stroke. A longitudinal cohort study was used to examine the reliability and validity of the PSFS-Ar in patients with stroke. All participants completed the PSFS-Ar in addition to other outcome measures. Fifty-five individuals participated (fifty male, five female). The PSFS-Ar showed excellent test-retest reliability, with ICC2,1 = 0.96, p < 0.001. The SEM and MDC95 of the PSFS-Ar were 0.37 and 1.03, respectively. No floor and ceiling effect was observed in this study. Additionally, the construct validity of the PSFS-Ar showed 100% satisfaction with the pre-defined hypotheses. Since the number of female participants was very small in this study, the findings were established for male individuals with stroke. This study showed that the PSFS-Ar is a reliable and valid outcome measure for male individuals with stroke.

Measurement Properties of the Patient-Specific Functional Scale in Rehabilitation for Patients With Stroke: A Prospective Observational Study

OBJECTIVE

This study investigated the validity, reliability, responsiveness, and interpretability of the Patient-Specific Functional Scale (PSFS) in subacute stroke rehabilitation to determine its suitability to measure patient-identified rehabilitation goals.

METHODS

A prospective observational study was designed according to the checklist from Consensus-Based Standards for Selecting Health Measurement Instruments. Seventy-one patients diagnosed with stroke were recruited in the subacute phase from a rehabilitation unit in Norway. The International Classification of Functioning, Disability and Health was used to assess the content validity. Assessment of construct validity was based on hypotheses for correlation of the PSFS and comparator measurements. We assessed reliability by calculating the Intraclass Correlation Coefficient (ICC) (3.1) and the standard error of measurement. The assessment of responsiveness was based on hypotheses for the correlation of change scores between the PSFS and the comparator measurements. A receiver operating characteristic analysis was conducted to assess responsiveness. The smallest detectable change and minimal important change were calculated.

RESULTS

Eighty percent of the PSFS items were classified as activities and participation in the International Classification of Functioning, Disability and Health, indicating satisfactory content validity. The reliability was satisfactory with an ICC of 0.81 (95% CI = 0.69-0.89). The standard error of measurement was 0.70 point, and the smallest detectable change was 1.94 points. Five of 7 hypotheses were confirmed for construct validity, and 5 of 6 were confirmed for responsiveness, indicating moderate construct validity and high responsiveness. Assessing responsiveness with a criterion approach resulted in an area under the curve of 0.74. A ceiling effect was identified for 25% of the participants 3 months after discharge. The minimal important change was estimated to be 1.58 points.

CONCLUSION

This study demonstrates satisfactory measurement properties for the PSFS in individuals undergoing inpatient stroke rehabilitation.

IMPACT

This study supports the use of the PSFS to document and monitor patient-identified rehabilitation goals in patients receiving subacute stroke rehabilitation when applied using a shared decision approach.

Sub-symptom threshold aerobic exercise for patients with persisting post-concussion symptoms and exercise intolerance after mild traumatic brain injury - a study protocol with a nested feasibility study for a randomized controlled trial

BACKGROUND

Persistent post-concussion symptoms (PPCS) affect between 34 and 46% after a mild traumatic brain injury (mTBI). Many also experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE (exercise at an intensity level that does not increase symptoms) is proposed as a treatment to both reduce the symptom burden and increase the exercise tolerance after the injury. It is unclear if this also applies in a more chronic phase after mTBI.

MAIN PURPOSE

The main purpose of this study is to evaluate whether SSTAE in addition to ordinary rehabilitation will lead to clinically meaningful improvement of symptom burden, normalize exercise tolerance, increase physical activity, improve health-related quality of life, and reduce patient-specific activity limitations compared to a control group that only receives ordinary rehabilitation.

DESIGN

Randomized, controlled, single-blind parallel-group study with three measurement times; T0 at baseline, T1 after the intervention and T2 six months after T1.

METHODS

Patients between the ages of 18 and 60 with exercise intolerance and persistent PPCS (> 3 months) will be recruited to the study and randomized to two groups. All patients will receive follow-up at the outpatient TBI clinic. The intervention group will in addition receive SSTAE for 12 weeks with exercise diaries and a retest every 3 weeks for optimal dosage and progression. The Rivermead post-concussion symptoms questionnaire will be the main outcome measure. The secondary outcome measure will be a test of exercise tolerance-the Buffalo Concussion Treadmill Test. Other outcome measures include the patient-specific functional scale that measures patient-specific activity limitations, as well as outcome measures for diagnosis-specific health-related quality of life, anxiety and depression, specific symptoms such as dizziness, headache and fatigue, and physical activity.

DISCUSSION

This study will add knowledge about the effect of SSTAE and whether it should be implemented in rehabilitation for the adult population with persistent PPCS after mTBI. The nested feasibility trial showed that the SSTAE intervention was safe and that the study procedures and delivery of the intervention overall were feasible. However, minor amendments to the study protocol were made prior to the commencement of the RCT.

TRIAL REGISTRATION

Clinical Trials.gov, NCT05086419. Registered on September 5th, 2021.

Patient-Reported Problem Areas in Chronic Traumatic Brain Injury

OBJECTIVE

The aims of this study were to (1) assess self-reported main problem areas reported by patients with traumatic brain injury (TBI) and their family members in the chronic phase, and (2) compare the self-prioritized problems with difficulties captured by questionnaires and neuropsychological screening through linking to the International Classification of Functioning, Disability and Health (ICF).

SETTING

Outpatient clinic at the Oslo University Hospital, Norway.

PARTICIPANTS

In total, 120 patients with TBI were recruited, of whom, 78 had a participating family member. Eligibility criteria were a clinical TBI diagnosis with verified intracranial injury, living at home, aged 18 to 72 years, 2 years or more postinjury, and experiencing perceived TBI-related difficulties, reduced physical and mental health, or difficulties with participation in everyday life. Patients with severe psychiatric or neurological disorders or inability to participate in goal-setting processes were excluded.

DESIGN

Cross-sectional.

MAIN MEASURES

Target Outcomes, that is, 3 main TBI-related problem areas reported by patients and family members, collected in a semistructured interview; standardized questionnaires of TBI-related symptoms, anxiety, depression, functioning, and health-related quality of life; neuropsychological screening battery.

RESULTS

Target Outcomes were related to cognitive, physical, emotional, and social difficulties. Target Outcomes were linked to 12 chapters and 112 distinct categories in the ICF, while standardized measures only covered 10 chapters and 28 categories. Some aspects of post-TBI adjustment were found to be insufficiently covered by the ICF classification, such as identity issues, lack of meaningful activities, and feeling lonely.

CONCLUSION

The Target Outcomes approach is a useful assessment method in a population with chronic TBI. The standardized questionnaires capture the spectrum of problems, whereas the Target Outcomes approach captures the prioritized individual problems hindering everyday life after TBI. While the standardized measures are an irreplaceable part of the assessment, Target Outcomes ensures patient involvement and may help clinicians better tailor relevant rehabilitation efforts.

Stroke survivors' perspectives on recovering in rural and remote Australia: A systematic mixed studies review

INTRODUCTION

Stroke survivors recovering in rural and remote locations often have little or no access to rehabilitation services. The purpose of this study was to review the literature on recovering in rural and remote Australia, from the perspective of stroke survivors. Use of technology to support recovery was also explored.

METHODS

A systematic mixed studies review was conducted and reported according to the ENTREQ and PRISMA statements. MEDLINE (Ovid), CINAHL (EBSCOhost), Scopus, PsycINFO (ProQuest), Cochrane Library and Google Scholar were searched from inception to May 2021 for studies investigating stroke survivors' perspectives on recovering in rural or remote Australia. Qualitative, quantitative or mixed methods studies were included. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Studies were not excluded or weighted according to methodological quality. To review the perspectives of stroke survivors on recovering, findings of included studies were mapped to the Living My Life framework and integrated using a convergent qualitative synthesis. The review protocol was registered on PROSPERO (CRD42017064990).

RESULTS

Eight studies met the inclusion criteria: six qualitative, one quantitative and one mixed methods. Methodological quality of the small number of studies ranged from low to high, indicating further high-quality research is needed. Included studies involved 152 stroke survivors in total. Review findings indicated that recovering was driven by working towards what mattered to stroke survivors, in ways that matched their beliefs and preferences and that worked for them in their world, including use of technology.

CONCLUSION

Stroke survivors recovering in rural and remote locations want to live their life by doing what matters to them, despite the challenges they face. They want support in ways that work for them in their environment. Further research is required to tailor support for stroke survivors that is specific to their life in rural and remote locations.