Clinical Outcome Variables Scale: A retrospective validation study in patients after stroke

Mobility, functionality and functional mobility: A review and application for canine veterinary patients

Mobility is an essential aspect of a dog's daily life. It is defined as the ability to move freely and easily and deviations from an animals' normal mobility capabilities are often an indicator of disease, injury or pain. When a dog's mobility is compromised, often functionality (ability to perform activities of daily living [ADL]), is also impeded, which can diminish an animal's quality of life. Given this, it is necessary to understand the extent to which conditions impact a dog's physiological ability to move around their environment to carry out ADL, a concept termed functional mobility. In contrast to human medicine, validated measures of canine functional mobility are currently limited. The aim of this review is to summarise the extent to which canine mobility and functionality are associated with various diseases and how mobility and functional mobility are currently assessed within veterinary medicine. Future work should focus on developing a standardised method of assessing functional mobility in dogs, which can contextualise how a wide range of conditions impact a dog's daily life. However, for a true functional mobility assessment to be developed, a greater understanding of what activities dogs do on a daily basis and movements underpinning these activities must first be established.

Developing a Clinical Prediction Rule for Gait Independence at Discharge in Patients with Stroke: A Decision-Tree Algorithm Analysis

OBJECTIVES

To develop a clinical prediction rule (CPR) for gait independence at discharge in patients with stroke, using the decision-tree algorithm and to investigate the usefulness of CPR at admission to the rehabilitation ward.

MATERIALS AND METHODS

We included 181 subjects with stroke during the postacute phase. The Chi-squared automatic interaction detection analysis method with 10-fold cross-validation was used to develop two CPRs; CPR 1 using easily obtainable data available at admission; CPR 2 using easily obtainable data available 1 month after admission, for prediction of gait independence at discharge.

RESULTS

The degree of independence of toileting was extracted as a first node in the development of two CPRs to predict gait independence at discharge. CPR 1 included the presence of delirium. CPR 2 included problem-solving abilities. The accuracy and area under the curve of CPR 1 were 84.5% and 0.911, respectively; those of CPR 2 were 89.0% and 0.958, respectively.

CONCLUSIONS

Toileting independence is a key factor in predicting the gait independence for the discharge of patients with stroke during the postacute phase. Early intervention, during the acute phase, for delirium and cognitive decline, as well as for toileting, increases the possibility of gait independence at discharge.

Improvement in postural alignment is associated with recovery of mobility after complex acquired brain injury: An observational study

PURPOSE

Determine how mobility changes over 6 months in people unable to walk at 8-weeks post-Acquired Brain Injury (ABI); if there is an association over time between postural alignment and mobility post-ABI; and if alignment after ABI becomes closer to healthy alignment over time.

METHODS

Fourteen adults with ABI, evaluated over 6 months, and a reference sample of 30 healthy adults were studied. The primary measure for changes in mobility was the Clinical Outcome Variables Scale (COVS). Secondary measures were sit-to-stand, timed standing holding rails, independent walking speed and number of testing conditions achieved. The Functional Independence Measure (FIM) was scored at rehabilitation admission and discharge. To analyze postural alignment, participants were recorded in sitting and standing, each repeated holding rails, and walking if able. Three-dimensional kinematic data were used to quantify whole-body postural alignment, equal to mean segment displacements from the base of support in the transverse plane. Associations between three-dimensional kinematic alignment scores and COVS scores were calculated using Linear Mixed-Effects Models.

RESULTS

Participants made significant improvements in COVS scores, most secondary mobility scores, and FIM scores over time (p ≤ .001). Relationships between increasing COVS scores and decreasing sitting and standing mal-alignment scores were statistically significant. Visual analysis of graphed segment positions indicated that sitting and standing alignment became more similar to healthy alignment over time; this was not clear for walking.

CONCLUSION

Improvement in postural alignment may be a factor for improving mobility in people with severe impairments after ABI.

Reliability of the Clinical Outcome Variables Scale for children with cerebral palsy

Background/aims

It can be difficult for rehabilitation professionals to use lengthy scales and different outcome measures for diverse clinical conditions in busy outpatient settings. The Clinical Outcome Variables Scale is a functional mobility measure that is applied to various neurological conditions. Determining the inter- and intra-rater reliability of clinical outcome variable scale for children with cerebral palsy will further enhance its utility.

Methods

A total of 30 children aged between 3 and 16 years with cerebral palsy, who could obey single-step commands, were recruited for the study. Two independent assessors scored the children using the Clinical Outcome Variable Scale to determine inter-rater reliability. A repeat assessment was done by the principal assessor after 24 hours to establish intra-rater reliability. Reliability was estimated using intra-class correlation coefficient values.

Results

The Clinical Outcome Variables Scale had high Inter- and intra-rater reliability for the composite score (intraclass correlation coefficient=1), the general mobility subscale (intraclass correlation coefficient=0.99), and the ambulation subscale (intraclass correlation coefficient=0.99). The intraclass correlation coefficient for the individual test items were also showed a high correlation, with the variance between the tests and physiotherapists ranging from 0.95 to 1.

Conclusions

The Clinical Outcome Variables Scale demonstrated high inter- and intra-rater reliability when assessing functional mobility in children with cerebral palsy. Further studies should establish criterion validity and minimally clinically important difference values to maximise the use of the scale.

A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE

Supplemental Digital Content is Available in the Text.

Background:

Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient's status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings.

Methods:

To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy's Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions.

Results/Discussion:

Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient's balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care.

Disclaimer:

The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

The Adapted Physical Activity Program: A Theory-Driven, Evidence-Based Physical Activity Intervention for People with Brain Impairment

People with brain impairments are less active than the general population and consequently have an increased risk of chronic disease. To increase activity requires interventions that are theory driven and evidence based. Here, we describe the adapted physical activity program (APAP), a physical activity promotion program with demonstrated efficacy in community dwelling adults with brain impairments. Distinguishing features of the APAP include the following: delivery in the participants home/or community environment and the utilisation of the principals of community-based rehabilitation; the assessment of each of the domains of the International Classification of Functioning, Disability and Health (ICF) (i.e., health conditions, impairments, activity limitations, participation restrictions and personal and environmental characteristics) to determine how they will impact physical activity adoption and maintenance; the incorporation of theory-based physical activity adoption and maintenance strategies; the utilisation of lifestyle physical activity programs (including client-centred selection of activities) and/or structured exercise programs (requiring principles of exercise prescription). It is anticipated that this program description will permit researchers and/or practitioners to implement the program, replicate its evaluation and/or translate the program into multi-professional rehabilitation settings.

Instruments to evaluate mobility capacity of older adults during hospitalization: A systematic review

Independent mobility is a key factor in predicting morbidity and determining hospital discharge readiness for older patients. The main objective was identify and appraise relevant instruments for the measurement of mobility of hospitalized geriatric patients. A systematic review was performed in two consecutive steps. Based on the definition of mobility of the International Classification of Functioning (ICF). Step 1 identified mobility measurement instruments used to assess patients 60 years of age and over hospitalized in acute care or intensive geriatric rehabilitation unit. Aim of the instrument, coverage of mobility construct, applicability (format, training required, administration time and use of assistive devices) were extracted. For each included instrument, Step 2 identified and appraised articles reporting about their measurement properties. Consensus-based Standards for the selection of health status Measurement INstruments (COSMIN) was used by two independent reviewers to critically appraise and compare the measurement properties. Step 1 resulted in 6350 articles, of which 28 articles reported about 17 different instruments. Step 2 retained 11 instruments with 70 articles reporting about their measurement properties in various settings. Judgement-based instruments (n=5) covered the ICF mobility construct more broadly than performance-based measures (n=6). Our results showed that 3 instruments (DEMMI, SPPB and Tinetti scale) had the most extensive and robust measurement properties, and from those, SPPB and DEMMI covered the mobility construct more broadly but SPPB had the longest administration (10-15min). Conclusion SPPB presents the best balance between mobility coverage, measurement properties and applicability to acute care or intensive geriatric rehabilitation unit.

Development and Preliminary Validation of the Acute Brain Injury Physiotherapy Assessment (ABIPA)

Background and aims: For patients with a severe brain injury there is no objective physiotherapy assessment tool that is responsive to the incremental changes in motor recovery in the acute stage. The aims of this study were to identify the items of neuro-motor recovery and scoring criteria for the Acute Brain Injury Physiotherapy Assessment (ABIPA) and determine responsiveness to change and concurrent validity against accepted standard measures of consciousness and physical function in the severe brain injury population.

Method: The literature was searched and an expert consensus panel of experienced clinical physiotherapists informed item selection and developed practical assessment guidelines. The ABIPA was investigated for responsiveness to change and concurrent validity against the Glasgow Coma Scale (GCS), Clinical Outcome Variable Scale (COVS) and Motor Assessment Scale (MAS). Eleven patients (9 males; cohort 41 ± 18 years) with moderate/severe brain injury were recruited, and assessed on days 1, 3, 7 and then weekly until discharge.

Results: The ABIPA demonstrated good to excellent correlations overall with the GCS (rho > .76, p ≤ .001), COVS (rho > .82, p ≤ .001) and MAS (rho > 0.66, p ≤ .001). On day 3, the ABIPA showed the greatest responsiveness to change (standardised response means (SRM) > .83) compared to other measures (SRMs < .77). At discharge all tools demonstrated change in neuro-motor recovery.

Conclusions: The ABIPA is a promising tool for detecting incremental changes in neuro-motor recovery early after severe brain injury.

Walking tests for stroke survivors: a systematic review of their measurement properties

PURPOSE

To provide an overview of walking tests including their measurement properties that have been used in stroke survivors.

METHOD

Electronic databases were searched using specific search strategies. Retrieved studies were selected by using specified inclusion criteria. A modified consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was applied for methodological quality assessment of the included studies. A quality assessment for statistical outcomes was used to assess measurement properties of the walking tests. Tests that were included were categorized according to the framework of the international classification of functioning, disability and health (ICF).

RESULTS

Thirty-two studies, evaluating 23 walking tests, were included. The tests assessed walking using the outcome measures of walking speed, walking distance, functional ambulation and walking on different surfaces. The methodological design and statistical methods of most studies evaluating reliability and criterion validity were sufficient, and found the outcome measures to be reliable and valid. However, data on measurement error, minimal important difference and minimal important change were lacking and responsiveness was correctly evaluated in one study only.

CONCLUSIONS

Many walking tests have been clinimetrically evaluated in stroke survivors. Most walking tests were found to be reliable and valid.

Effect of ankle-foot orthosis on postural control after stroke: a systematic review

INTRODUCTION

Stroke is currently the main cause of permanent disability in adults. The impairments are a combination of sensory, motor, cognitive and emotional changes that result in restrictions on the ability to perform basic activities of daily living (BADL). Postural control is affected and causes problems with static and dynamic balance, thus increasing the risk of falls and secondary injuries. The purpose of this review was to compile the literature to date, and assess the impact of ankle-foot orthosis (AFO) on postural control and gait in individuals who have suffered a stroke.

DEVELOPMENT

The review included randomised and controlled trials that examined the effects of AFO in stroke patients between 18 and 80 years old, with acute or chronic evolution. No search limits on the date of the studies were included, and the search lasted until April 2011. The following databases were used: Pubmed, Trip Database, Cochrane library, Embase, ISI Web Knowledge, CINHAL and PEDro. Intervention succeeded in improving some gait parameters, such as speed and cadence. However it is not clear if there was improvement in the symmetry, postural sway or balance.

CONCLUSIONS

Because of the limitations of this systematic review, due to the clinical diversity of the studies and the methodological limitations, 0these results should be considered with caution.