Community walking can be assessed using a 10-metre timed walk test.

BACKGROUND: A decline in mobility is a common feature of multiple sclerosis (MS). Community walking scales are used to categorize patients in their ability to move independently. The first purpose of this study was to determine which specific gait speed corresponded with the categories of the Modified Functional Walking Categories (MFWC). The second purpose was to determine the Minimally Important Change (MIC) in absolute gait speed using the MFWC and Expanded Disability Status Scale (EDSS) as external criteria. METHOD: MS patients were measured six times in 6 years. Gait velocity was measured with the 10-metre timed walk test (10-m TWT), the severity of MS was determined with the EDSS, and community walking was assessed with the MFWC. For each category of the MFWC, Receiver Operating Characteristic (ROC) curves were used to find the best possible cut-off point on the 10-m TWT. The MIC in absolute gait speed was determined using a change of one category on the MFWC or one point on the EDSS. RESULTS: A strong relationship was found between gait speed and the MFWC; all areas under the ROC curves (AUCs) were between 0.74 and 0.86. The MIC in absolute gait speed could not be determined, because the AUCs were below the threshold of 0.70 and changes in gait speed were small. CONCLUSIONS: Gait speed is related to community walking, but an MIC in absolute gait speed could not be determined using a minimally important change on the MFWC or the EDSS as external criteria.

The usefulness of evaluative outcome measures in patients with multiple sclerosis.

To select the most useful evaluative outcome measures for early multiple sclerosis, we included 156 recently diagnosed patients in a 3-year follow-up study, and assessed them on 23 outcome measures in the domains of disease-specific outcomes, physical functioning, mental health, social functioning and general health. A global rating scale (GRS) and the Expanded Disability Status Scale (EDSS) were used as external criteria to determine the minimally important change (MIC) for each outcome measure. Subsequently, we determined whether the outcome measures could detect their MIC reliably. From these, per domain the outcome measure that was found to be most sensitive to changes (responsive) was identified. At group level, 11 outcomes of the domains of physical functioning, mental health, social functioning and general health could reliably detect the MIC. Of these 11, the most responsive measures per domain were the Medical Outcome Study 36 Short Form sub-scale physical functioning (SF36pf), the Disability and Impact Profile (DIP) sub-scale psychological, the Rehabilitation Activities Profile sub-scale occupation (RAPocc) and the SF36 sub-scale health, respectively. Overall, the most responsive measures were the SF36pf and the RAPocc. In individual patients, none of the measures could reliably detect the MIC. In sum, in the early stages of multiple sclerosis the most useful evaluative outcome measures for research are the SF36pf (physical functioning) and the RAPocc (social functioning).

Effect of triamcinolone acetonide injections on hemiplegic shoulder pain : A randomized clinical trial.

UNLABELLED: Background and Purpose-Hemiplegic shoulder pain is not uncommon after stroke. Its origin is still unknown, and although many different methods of treatment are applied, none have yet been proved to be effective. We sought to study the efficacy of 3 injections of intra-articular triamcinolone acetonide on pain and arm function in stroke patients with hemiplegic shoulder pain. METHODS: -In a multicenter, randomized, placebo-controlled clinical trial, patients with hemiplegic shoulder pain received either 3 intra-articular injections of 40 mg triamcinolone acetonide or 1 mL physiological saline solution (placebo). Primary outcomes were pain measured according to 3 visual analogue scales (score range, 0 to 10), and arm function was measured by means of the Action Research Arm test and the Fugl-Meyer assessment scale; secondary outcomes were passive external rotation of the shoulder and general functioning measured according to Barthel Index and the Rehabilitation Activities Profile. RESULTS: -In the triamcinolone group (n=18), the median decrease in pain, 3 weeks after the last injection, was 2.3 (interquartile range, 0.3 to 4.3) versus 0.2 (interquartile range, -0.5 to 2.2) in the placebo group. This result was not statistically significant. The change in the other outcome measures did not differ significantly between the 2 treatment groups. Twenty-five patients reported side effects. CONCLUSIONS: -In the 37 participants included in this study, triamcinolone injections seemed to decrease hemiplegic shoulder pain and to accelerate recovery, but this effect was not statistically significant. Therefore, on the basis of the results of this study, these injections cannot be recommended for the treatment of patients with hemiplegic shoulder pain.

MS functional composite: relation to disease phenotype and disability strata.

OBJECTIVE: The MS Functional Composite (MSFC), a recently developed outcome measure for clinical trials, was applied to 240 patients with MS to explore its utility in different subgroups of MS and for comparison with the Expanded Disability Status Scale (EDSS). METHOD: Three clinical dimensions were examined: arm/hand function, leg function/ambulation, and cognition. Predictions of relative scores on the MSFC and its components in three major MS phenotypes (relapsing-remitting, primary progressive, and secondary progressive) and three strata of disability were developed and tested. Also, correlations with EDSS were calculated and the effect of an external reference population was assessed. RESULTS: Mean MSFC score was positive in the relapsing-remitting (0.4) and mildly disabled (0.4) groups and negative in the secondary progressive (-0.3), primary progressive (-0.4), and moderately (-0.07) and severely disabled (-1.0) groups. The correlation between EDSS and MSFC was strong (-0.68). EDSS correlated strongly with ambulation in secondary and primary progressive patients and severely disabled patients, moderately with arm/hand function for all analyzed groups, and not at all with cognition. Comparison with an external reference population showed changes in MSFC- and Z-scores, but did not result in altered differences between the subgroups. CONCLUSION: Our prospective study in subgroups of MS confirmed and extended the construct validity of the MSFC. The MSFC also showed good concurrent validity with the EDSS, and includes information about cognition.

Inter- and intra-rater agreement of the Rehabilitation Activities Profile.

The objective of the study was to determine the inter- and intra-rater agreement of the Rehabilitation Activities Profile (RAP). The RAP is an assessment method that covers the domains of communication, mobility, personal care, occupation and relationships. Each domain consists of items which are further divided in sub-items for in-depth analysis. The RAP allows quantification of the severity of disabilities, handicaps and perceived problems of a patient with regard to the items and sub-items. For this purpose ordinal 4-point Likert scales were constructed. The RAP can be used for goal setting and evaluation of rehabilitation. Because of the broad intended use of the RAP and its construction, a special design for the reliability study was needed. The study was carried out in 5 rehabilitation facilities with the participation of various professions. The items and sub-items of the RAP were divided over these professions according to their expertise. Pairs of interviewers were formed that questioned a patient. For the determination of inter- and intra-rater agreement each pair of interviewers was allowed to question a patient only once. To establish the intra-rater agreement, video recordings were made during the interviews. The median (weighted) kappa value and percentage of agreement about the severity grading of a disability or handicap for all items and sub-items exceeded 0.84 and 81%, respectively, with regard to the inter- and intra-rater agreement. For the severity grading of perceived problems these values were 0.91 and 86%. The interpretation of kappa was hindered by two paradoxes recently described in the literature. The paradox "high agreement but low kappa" manifested itself in particular. It is concluded that inter- and intra-rater agreement of the RAP can be considered to be good to very good.

Responsiveness of the rehabilitation activities profile and the Barthel index.

The goal of this study was to compare the responsiveness for clinically meaningful change over time of a newly designed functional status scale, the Rehabilitation Activities Profile (RAP), with more frequently used Barthel Index (BI). Four techniques for the quantification of responsiveness were utilized: effect sizes, p-values, t-statistics and ROC curves. The patient's return home was chosen as external criterion. An inception cohort of stroke patients was followed during 26 weeks. All patients still hospitalized on the 14th day after the stroke were included. The functional assessments took place at 2, 3, 4, 8, 12, and 26 weeks after stroke. The patients were visited at the hospital, home, nursing home, or rehabilitation center. Of the 125 patients included in the study, 18 patients died during the observation period, 2 patients were lost to follow-up, and 1 patient refused to cooperate after 12 weeks. After 26 weeks, 104 patients remained for analysis. Three time periods were discerned: 2 to 12 weeks (early response), 12 to 26 weeks (late response), and 2 to 26 weeks after stroke (overall response). The effect sizes of the RAP were consistently higher on all three time periods than those of the BI. The p-value of the overall response mean change score of the RAP appeared to discriminate between patients returning home and those not returning home, whereas the BI failed on this point (p = 0.004 vs. 0.496). Using t-statistics, the RAP showed a higher efficiency in expressing change on all time periods (relative efficiency = 1.42, 1.77, and 1.43, respectively). The receiver operating characteristic surface area of the RAP score was higher than the area of the BI score (0.74 and 0.59, respectively for the early response period). In conclusion, all results seemed to indicate that the RAP is more responsive than the BI when returning home is chosen as an external criterion.

Measuring subluxation of the hemiplegic shoulder: reliability of a method.

OBJECTIVE: Subluxation of the shoulder after stroke can be measured according to the method described by Van Langenberghe and Hogan. METHODS: To evaluate the reliability of this method, the shoulder radiographs of 25 patients were available for this study. Two independent raters each assessed these radiographs twice. RESULTS: The intrarater reliability was good: percentage of agreement was 88 and 84%, weighted kappa, 0.69 [95% confidence interval (CI), 0.38-1.0] and 0.78 (95% CI, 0.60-0.95) for raters 1 and 2, respectively. The interrater reliability was poor: percentage of agreement was 36 and 28%, kappa, 0.11 (95% CI, 0.0-0.31) and 0.09 (95% CI, 0.0-0.23) in sessions 1 and 2, respectively. Subsequently the original method was adjusted by combining two categories (no subluxation and beginning subluxation) into one ("no clinically important subluxation"). CONCLUSIONS: After this adjustment of the categories, the interrater reliability improved [percentage of agreement, 72%, and kappa, 0.49 (95% CI, 0.18-0.80)], but did not reach acceptable values.

Measurement of the effect of a bolus dose of intrathecal baclofen by a repetitive movement test.

We assessed the repetitive movement (RM) test for measuring the effect of a trial bolus dose of intrathecal baclofen on spasticity. The RM test measures passive range of motion (ROM) by electrogoniometry and stretch reflex activity (SRA) of the flexors and extensors of the knee and ankle by surface electromyography. The SRA has a dynamic component (dynamic stretch reflex, DSR) and a tonic component (tonic stretch reflex, TSR). Four hypotheses were formulated: (a) RM results show a negative relationship between SRA and ROM; (b) values on the RM test are correlated with clinical scores of tonus and spasticity; (c) RM results show a reduction in SRA after administration of the clinically optimal dose of baclofen; and (d) RM results show a dose-dependent effect of intrathecal baclofen on SRA. Twenty-four patients were selected because they had impairments and disabilities caused by intractable spasticity. A bolus of baclofen was administered with incremental doses (25-150 micrograms) until an optimal effect or no effect was obtained. The main outcome measures were RM test and clinical assessments of the Ashworth and spasm score. The results were (a) For the ankle a negative correlation was found between ROM and TSR of the flexor and extensors; for the knee a significant negative correlation was found only with the DSR of the biceps femoris. (b) A positive correlation was found between the Ashworth score and TSR of the extensors and between the spasm score and DSR and TSR of the gastrocnemius muscle. (c) Significant differences were found between baseline measurements and the optimal dose of baclofen for all measures. (d) A significant dose-dependent effect of intrathecal baclofen on the level of SRA was observed. The RM test is thus a useful clinical tool for objectively measuring the effect of intrathecal baclofen administration on spasticity in patients with an upper motor neuron syndrome.

Randomized trial of 4-aminopyridine in patients with chronic incomplete spinal cord injury.

OBJECTIVE: To test the efficacy of 4-aminopyridine (4-AP) on functional status, walking speed and vibration perception in patients with chronic, incomplete spinal cord injury. METHODS: Twenty SCI patients were randomized in a trial with a double-blind, crossover design to receive four weeks of orally administered 4-AP, followed by a two-week wash-out period and four weeks of placebo, or vice versa. The total daily dose of 4-AP during the four weeks of treatment was systematically increased to a maximum of 0.5 mg/kg body weight. Evaluation of (side-)effects took place at the beginning, after one week, and at the end of each four-week study period. RESULTS: No significant benefit was found on functional status (COOP-WONCA). A statistically significant treatment effect was found on the vibration perception threshold (VPT) in the left fingers, during the first study period. On average, patients receiving 4-AP treatment responded less favourably (mean increase in VPT of 0.29 (0.31) microm) than patients receiving placebo (mean decrease in VPT of 0.05 (0.35) microm) (p=0.04). Neither comfortable nor maximum walking speed altered significantly following 4-AP treatment. CONCLUSIONS: No statistically significant, functional benefit from 4-AP was found for patients in the present study. Furthermore, no support was found for the possibility that an a priory selection of responsive patients would have yielded more favourable results.

Quality of life in multiple sclerosis: the disability and impact profile (DIP).

Seventy-three Dutch and Flemish patients with definite multiple sclerosis (MS) were assessed by means of the Disability and Impact Profile (DIP), which is a 2 x 39 item, self-administered questionnaire with parallel questions about disabilities and their importance for or impact on the patient, resulting in a profile of weighted scores. It was designed as a tool for clinical assessment of quality of life (QoL) domains in MS patients. Group data showed more than 50% loss on weighted scores for "walk", "clean home", "work" and "worry about deterioration". In individual patients a median of 7 (range 0-23) major disruptions of quality of life (MD-QoL: loss on weighted score more than 50%) was found. Prevalence of MD-QoL in more than 10% of the patients was found for as many as 31 disabilities and > 50% for 3 ("clean home", "work" and "worry about deterioration"). Results in the MS group were compared with available data from 25 patients with rheumatoid arthritis (RA) and 25 patients with a spinal cord lesion (SCl). Weighted scores of "read", "memory" and "concentration" were significantly lower in the MS group than in the RA and SCl groups. Significantly lower weighted scores in both the MS and RA groups were found for "worry about deterioration", "physical endurance", "clean home", "work", "see" and "write". In conclusion, major disruptions in many domains of QoL were found in MS patients. Weighted score profiles for MS were in accordance with clinical manifestations. Unlike Kurtzke's Extended Disability Status Scale, DIP assesses a wide range of potentially MS-affected human activities, and also takes into account the subjective perception of disabilities.

Two strategies of transferring from sit-to-stand; the activation of monoarticular and biarticular muscles.

In this study, two different strategies of rising from a chair were compared, using integrated biomechanical and electromyographic analyses. Nine healthy subjects were instructed to rise using two different strategies: natural sit-to-stand transfer (NSTS) and a sit-to-stand transfer with full flexion of the trunk (FSTS). Sagittal kinematics and ground reaction forces were registered. Muscle activity of nine muscles of the right leg were recorded by means of surface EMG. All signals were synchronized at seat-off. The results show that no differences occur between the kinematics of knee and ankle, whereas the hip flexion is, as expected, higher during FSTS. The higher moment about the knee during NSTS is shifted to proportionally higher moments about the hip and ankle during FSTS. It is mainly the differences in the EMG-levels of the biarticular hip and knee muscles which might explain the differences in net moment. These results are in accordance with a theory about a particular role of biarticular muscles. On the other hand, the shift from knee to ankle cannot be associated with a particular increase in activity of the biarticular m.gastrocnemius. It is hypothesized that about the ankle, control of stability is preferred over movement control. An important conclusion for rehabilitation medicine is that a lower net moment about the knee in FSTS does not automatically imply that this reduces the load on the knee extensors.

The application of generalizability theory to reliability assessment: an illustration using isometric force measurements.

BACKGROUND AND PURPOSE: The objective of this study was to examine the potential use of the generalizability theory for assessing reliability of muscle force measurements in clinical applications. Reliability is expressed in terms of standard error of measurement (SEM) and the indexes derived from the SEM. Using generalizability theory, potential sources of measurement error can be recognized and estimated. SUBJECTS: Ten healthy women, aged 23 to 47 years (means = 29.5, SD = 7.1), participated in the study. METHODS: The method is illustrated by presenting a pilot study. Repeated measurements of maximal isometric knee extension force were carried out by two therapists. The time interval between measurement occasions was 1 week. A functional prototype of a hand-held dynamometer was used, and measurements were carried out according to standardized test protocols. RESULTS: Relatively important sources of measurement error were associated with interaction effects between subject and therapist as well as with interactions including the factor occasion. The SEM of the net knee moment was estimated for various hypothetical applications of the dynamometer. CONCLUSION AND DISCUSSION: It is concluded that the SEM, the corresponding confidence interval, and the smallest detectable difference are practical measures for expressing reliability of measurements on an individual. Generalizability theory is a powerful tool for estimating the magnitude of multiple sources of measurement error and for assessing the reliability of measurements tailored to specific clinical applications.

The responsiveness of the Action Research Arm test and the Fugl-Meyer Assessment scale in chronic stroke patients.

The responsiveness of the Action Research Arm (ARA) test and the upper extremity motor section of the Fugl-Meyer Assessment (FMA) scale were compared in a cohort of 22 chronic stroke patients undergoing intensive forced use treatment aimed at improvement of upper extremity function. The cohort consisted of 13 men and 9 women, median age 58.5 years, median time since stroke 3.6 years. Responsiveness was defined as the sensitivity of an instrument to real change. Two baseline measurements were performed with a 2-week interval before the intervention, and a follow-up measurement after 2 weeks of intensive forced use treatment. The limits of agreement, according to the Bland-Altman method, were computed as a measure of the test-retest reliability. Two different measures of responsiveness were compared: (i) the number of patients who improved more than the upper limit of agreement during the intervention; (ii) the responsiveness ratio. The limits of agreement, designating the interval comprising 95% of the differences between two measurements in a stable individual, were -5.7 to 6.2 and -5.0 to 6.6 for the ARA test and the FMA scale, respectively. The possible sum scores range from 0 to 57 (ARA) and from 0 to 66 (FMA). The number of patients who improved more than the upper limit were 12 (54.5%) and 2 (9.1%); and the responsiveness ratios were 2.03 and 0.41 for the ARA test and the FMA scale, respectively. These results strongly suggest that the ARA test is more responsive to improvement in upper extremity function than the FMA scale in chronic stroke patients undergoing forced use treatment.

Computer-assisted hand-held dynamometer: low-cost instrument for muscle function assessment in rehabilitation medicine.

In rehabilitation medicine, muscle function is assessed during the physical examination of the patient. Although a simple hand-held instrument improves the assessment of static strength, it is rarely used in clinical practice, where dynamic measurements are preferred. A computer-assisted hand-held dynamometer (CAHNDY) has been developed that enables the clinician to measure dynamic muscle function in a standardised manner, using simple (i.e. portable and low-cost) apparatus. The CAHNDY comprises a force transducer and a movement transducer interfaced to a personal computer. In the study dynamic measurement protocols are used, based on a biomechanical analysis of daily activities. In this way, iso-functional profiles can be established, describing the kinematics of muscle function in its functional context. Using the iso-functional profiles as a basis for standardisation, the double feedback algorithm of the CAHNDY assists the tester in meeting this standard, during maximal muscle function testing. In a multi-centre trial, the CAHNDY is evaluated by physical therapists for knee extensor and flexor function. The CAHNDY enables iso-functional dynamic muscle function testing, although application is limited by the maximal strength of the tester. It is concluded that the CAHNDY is suitable for use in rehabilitation medicine.

Passive stiffness characteristics of ankle plantar flexors in hemiplegia.

OBJECTIVE: To assess the feasibility and reliability of ankle plantar flexor stiffness measurements in hemiplegia. DESIGN: Repeated measurements in five consecutive weeks. BACKGROUND: In hemiplegia, an equinovarus positioning of the foot might be caused by an increased stiffness of the m. triceps surae. METHODS: In eight hemiplegic patients the net joint torque of passive muscle stretch was measured as a function of ankle-angle by a dynamometer, at both sides. Ankle-stiffness was characterised and also a biomechanical model of the passive muscle was fitted. RESULTS: In the vast majority of measurements it was possible to obtain measurements that were not distorted by involuntary muscle contraction. These measurements showed for the angle at which a passive plantar moment of 10 N m was reached a standard error of measurement of less than 2.7 degrees. The muscle model showed the increased stiffness as a shortening of the muscle-fibre-length. CONCLUSION: The feasibility of this method to measure muscle stiffness was fair to good in hemiplegic patients. Provided the abandoning of involuntary muscle activity, the reproducibility warrants application in clinical practice at an individual level. The use of the model relates this changes to a shortened m. soleus and/or m. gastrocnemius. RelevanceEffective clinical decisions for treatment of equinovarus positioning of the foot in the hemiplegic individual, should consider excessive involuntary contractions of the m. triceps surae complex (i.e., spasticity), as well as shortened muscle tissue resulting in high stiffness. Despite the importance of increased stiffness there have been no validated methods of measurement.

Biomechanics and muscular activity during sit-to-stand transfer.

In the present study 10 healthy subjects were measured, performing sit-to-stand transfers in a natural way. Starting position and speed of movement were standardized. Sagittal kinematics, the ground reaction force, and muscle activity of nine leg muscles were recorded. During sit-to-stand transfer the mass centre of the body was moved forward and upward. Based on the velocity of the mass centre of the body three phases were distinguished. In horizontal direction forward rotation of the upper body contributed to the velocity of the mass centre of the body, whereas extension of the legs contributed considerably in vertical direction. After seat-off most muscles were concentrically active, whereas the shortening velocity of the rectus femoris was very low. Thus hip and knee joints were extended and a relatively high knee moment was delivered to control the ground reaction force in a slightly backward direction. Co-contraction of hamstrings and rectus femoris in sit-to-stand transfer was judged to be efficient.

Measurement of impaired muscle function of the gastrocnemius, soleus, and tibialis anterior muscles in spastic hemiplegia: a preliminary study.

Based on the results of several electrodiagnostic and biomechanical studies, the following classification of muscle dysfunction in spastic hemiplegia is proposed: changes in muscle activation (excess symptoms, e.g., spasticity, and deficit symptoms, e.g., paresis); changes in muscle stiffness; and changes in muscle length. The clinical significance of this classification is that different types of muscle dysfunction might require specific treatment. The authors have developed techniques to measure quantitatively each type of muscle dysfunction: free frequency repetitive movement (FFRM) and torque angle diagram (TAD). Surface EMGs of tibialis anterior, gastrocnemius, and soleus muscle are recorded during active (FFRM) and passive (TAD) ankle movements. EMG data are converted to parameters for abnormal muscle activation (excess and deficit symptoms). Parameters for muscle stiffness and muscle length are derived from the hysteresis curve of the TAD. This article describes the measurements and the results of a validation study. For the validation study, four hypotheses were formulated: 1) in nonimpaired control subjects, parameters expressing abnormal muscle activation are low; 2) in hemiplegic subjects, differences between the affected and the unaffected sides will be found for all types of parameters; 3) after local anaesthesia of the tibial nerve on the hemiplegic side, excess symptoms will decrease, while muscle stiffness remains unchanged; and 4) despite a uniform gait pattern, between-subject differences can be detected with regard to muscle activation, stiffness, and length. The first hypothesis was tested and confirmed in two controls; the remaining three were tested and confirmed in ten hemiplegic subjects (mean age 47.7 yrs, mean time since onset 10.7 yrs). However, the level of co-contraction of the gastrocnemius muscle was low, probably indicating that the clinical significance of this phenomenon might be limited. The results support the validity of the proposed classification and measurements.

Subjective weighting of disability: an approach to quality of life assessment in rehabilitation.

The impact of various disabilities may differ greatly from individual to individual. Therefore, for a full assessment of a rehabilitee, objective aspects of disability should be supplemented with disability perception. The purpose of this study was to construct a self-administered questionnaire of 39 abilities/activities based on the ICIDH D-code, with parallel questions about '(dis)ability' and 'impact'. The instrument was used to obtain data from 60 disabled people. Fifty forms (83%) were returned from 25 patients with spinal cord injury and 25 patients with rheumatoid arthritis. Mean time to fill out the questionnaire was 24 minutes. A first attempt to validate the 'weighted score' with an open question about the most negative aspects of the disease showed a (very) good correspondence in 74%. An information gain as a result of the impact question was noted in 44%. This instrument has attractive properties for clinical use and research purposes in rehabilitation medicine. It was developed for the identification of needs of individual patients. The 'weighted scores' allow the setting of priorities in an individually tailored rehabilitation programme. Future applications might include monitoring the progress of a rehabilitee and identification of group needs.

Impairment assessment in rehabilitation medicine: the potential role of technology to assist clinical decision making.

Assessment in rehabilitation medicine needs to be conceptualized using the ICIDH. Generally, an un-impaired function is conditional for good performance at the disability level. So, treatment at the level of impairment might be necessary to eventually minimize the amount of disability. At this point it is compulsory to assess the impairment firstly for an indication of the therapy, and also during and/or after the impairment therapy for evaluation. Finally, the tentative idea that the impairment was responsible for the disability is subjected to evaluation using the D-level assessment again. In this concept, specific assessment of impairment is nested within the assessment at the level of disability. It is concluded that this framework of clinical decision making in rehabilitation medicine can be used to judge whether instruments for impairment assessment will potentially be useful in clinical decision making.

Rehabilitation Activities Profile: the ICIDH as a framework for a problem-oriented assessment method in rehabilitation medicine.

The Rehabilitation Activities Profile (RAP) is an ICIDH-based assessment method that covers the domains of communication, mobility, personal care, occupation, and relationships. Disabilities and handicaps in these domains are assessed on four-point Likert scales for severity. Problems perceived by the patient associated with these disabilities or handicaps are also assessed on four-point Likert scales for severity. High scores on perceived problems represent a patient's priorities. Information is gathered through a semi-structured interview with the patient; proxies and observations can be used as additional sources of information. Assessment can be performed at two levels. The first level is a global one, serving as a screening device. If disabilities or handicaps are identified, the second level provides for an in-depth assessment of those specific disabilities and handicaps as well as the related perceived problems. The method is designed to assist screening, goal-setting, and outcome evaluation of individual patients.