Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial.

BACKGROUND: The Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was a cluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotion of the uptake of best practice recommendations for interventions targeting upper and lower extremity function, postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either the facilitated or passive KT intervention. The objective of the current study was to understand the factors influencing the implementation of the recommended treatments and KT interventions from the perspective of nurses, occupational therapists and physical therapists, and clinical managers following completion of the trial. METHODS: A qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understand the factors influencing the implementation of the recommended treatments and KT interventions. The Clinical Practice Guidelines Framework for Improvement guided the analysis. RESULTS: Thirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5 sites from the passive KT arm). The following factors influencing the implementation of the recommended treatments and KT interventions emerged: facilitation, agreement with the intervention - practical, familiarity with the recommended treatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes of facilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as an unintended outcome of the trial across both arms in addition to a facilitator to the implementation of the treatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in the passive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial. CONCLUSIONS: This is one of the first studies to examine the factors influencing the implementation of stroke recommendations and associated KT interventions within the context of a trial. Findings highlight the important role of self-selected facilitators to implementation efforts. Future research should seek to better understand the specific characteristics of facilitators that are associated with successful implementation and clinical outcomes, especially within the context of stroke rehabilitation.

Modeling health-related quality of life in people recovering from stroke.

BACKGROUND: The Wilson-Cleary (W-C) model of health-related quality of life (HRQL) has not been tested in stroke, and a better understanding of the components of HRQL during recovery would lead to a more integrated and person-centered approach to health management and outcome optimization for this vulnerable population. OBJECTIVE: To enhance our understanding for how QOL emerges from the sequelae of stroke during the recovery period, the aim was to empirically test a biopsychosocial conceptual model of HRQL for people recovering from stroke. METHODS: We present a multi-site longitudinal study of an inception cohort of 678 persons recruited at stroke onset and studied at key intervals over the first post-stroke year. As the most pronounced recovery after stroke occurs in the first 3 months, this time frame was chosen as the focus of this analysis. The measures for this study were chosen for their relevance to key constructs of stroke impact and for their optimal psychometric properties. Multiple measures for each of the W-C rubrics were available from instruments such as the Stroke Impact Scale, RAND-36, HUI, and EQ-5D, among others. A structural equation model (SEM) was fit using MPlus. To minimize potential bias arising from the missing data, multiple imputation was performed on the longitudinal data using SAS proc MI. RESULTS: Of the 678 subjects who entered the cohort, 618 were interviewed at 1 month post-stroke and 533 at 3 months (486 and 454 had data at 6 and 12 months, respectively). A 3-month model with paths from biological factors to symptoms and symptoms to function fits well (CFI:0.966, RMSEA:0.044), though one model with paths from function to health perception did not (CFI:0.934, RMSEA:0.058). Allowing additional paths across non-adjacent rubrics improved fit considerably (CFI:0.962, RMSEA:0.044). A final model included emotional well-being under the symptom rubric (CFI:0.955, RMSEA:0.047). Including social support as an environmental factor had little impact on the model. Total variance in health perception explained was 76.3 %. CONCLUSION: These results emphasize that to optimize overall HRQL during the crucial first 3 months of recovery, interventions need to continue to focus on comorbid health conditions and on reducing stroke impairments. A function-only focus too soon in the recovery process may not produce the desired impact to optimize HRQL.

Measuring psychological outcomes following pediatric intensive care unit hospitalization: psychometric analysis of the Children's Critical Illness Impact Scale.

OBJECTIVE: Critically ill children are at risk for psychological sequelae following pediatric intensive care unit hospitalization. This article reports on the psychometric testing of the first self-report measure of psychological distress for 6-12-yr-old children post-pediatric intensive care unit hospitalization: The Children's Critical Illness Impact Scale. This 23-item scale takes approximately 15 mins for children to complete. DESIGN: Psychometric testing based on Classic Test Theory and guidelines for health measurement scale development. SETTING: The pediatric intensive care units of four Canadian pediatric hospitals and the ear, nose, and throat clinic of one participating hospital. PATIENTS: A total of 172 children (pediatric intensive care unit group, n = 84; ear, nose, and throat group, n = 88) aged 6-12 yrs and their parents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed the factor structure, internal consistency, and test-retest reliability of the Children's Critical Illness Impact Scale and conducted contrasted group comparisons and convergent and concurrent validation testing. Fit indices and internal consistency were best for a three-factor solution, suggesting three dimensions of psychological distress: 1) worries about getting sick again, 2) feeling things have changed, and 3) feeling anxious and fearful about hospitalization. As expected, Children's Critical Illness Impact Scale scores were positively correlated with child anxiety and medical fear scores. The ear, nose, and throat group scores were higher than expected. Higher Children's Critical Illness Impact Scale scores in older children may reflect a better understanding of the situation and its complexity and meaning, and younger children's tendency to provide more positive self-evaluation. CONCLUSIONS: The Children's Critical Illness Impact Scale is a promising new self-report measure of psychological distress with demonstrated reliability and validation testing in 6-12-yr-old children post-pediatric intensive care unit hospitalization. This new measure has potential to advance the evidence base for pediatric intensive care unit and post-pediatric intensive care unit health promotion interventions.

Combining both generic and disease-specific properties: development of the McGill COPD quality of life questionnaire.

UNLABELLED: Presently, a generic and a disease-specific questionnaire are often co-administered to capture the different domains of quality of life in chronic obstructive pulmonary disease (COPD) subjects. A health-related-quality of life (HRQL) questionnaire in COPD combining both generic and disease-specific properties is needed. OBJECTIVE: To develop a new, hybrid-HRQL questionnaire, the McGill-COPD-questionnaire, with qualities of both generic and disease-specific instruments. Using pre-defined criteria, we selected items from the SF-36 to complement the items from a COPD-specific-module to create the new hybrid-HRQL-questionnaire. Domains were identified via confirmatory factor analysis. The McGill COPD questionnaire is available in English and French; it assesses three domains: symptoms, physical-function and feelings, has 29 items: 17 from the COPD-specific-module and 12 from the SF-36. The symptom sub-scale has 6 items, all from the COPD-specific-module; the feelings sub-scale has 10 items, 5 each from COPD-specific-module and SF-36 and the physical-function sub-scale has 13 items, 6 from COPD-specific-module and 7 from SF-36. The McGill COPD questionnaire was developed using a novel method of combining items from the SF-36 and a COPD-specific-module. Thus, this new questionnaire has items from a generic-questionnaire and a disease-specific-module and, hence, is promising to be a stand alone quality-of-life questionnaire for COPD subjects.

Study protocol of the YOU CALL--WE CALL TRIAL: impact of a multimodal support intervention after a "mild" stroke.

BACKGROUND: More than 60% of new strokes each year are "mild" in severity and this proportion is expected to rise in the years to come. Within our current health care system those with "mild" stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving with regard to specific concerns that arise. Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization.The purpose of this study is to assess the effectiveness, for individuals who experience a first "mild" stroke, of a sustainable, low cost, multimodal support intervention (comprising information, education and telephone support)--"WE CALL" compared to a passive intervention (providing the name and phone number of a resource person available if they feel the need to)--"YOU CALL", on two primary outcomes: unplanned-use of health services for negative events and quality of life. METHOD/DESIGN: We will recruit 384 adults who meet inclusion criteria for a first mild stroke across six Canadian sites. Baseline measures will be taken within the first month after stroke onset. Participants will be stratified according to comorbidity level and randomised to one of two groups: YOU CALL or WE CALL. Both interventions will be offered over a six months period. Primary outcomes include unplanned use of heath services for negative event (frequency calendar) and quality of life (EQ-5D and Quality of Life Index). Secondary outcomes include participation level (LIFE-H), depression (Beck Depression Inventory II) and use of health services for health promotion or prevention (frequency calendar). Blind assessors will gather data at mid-intervention, end of intervention and one year follow up. DISCUSSION: If effective, this multimodal intervention could be delivered in both urban and rural environments. For example, existing infrastructure such as regional stroke centers and existing secondary stroke prevention clinics, make this intervention, if effective, deliverable and sustainable. TRIAL REGISTRATION: ISRCTN95662526.

A longitudinal view of apathy and its impact after stroke.

BACKGROUND AND PURPOSE: Stroke survivors are often described as apathetic. Because apathy may be a barrier to participation in promising therapies, more needs to be learned about apathy symptoms after stroke. The specific objective was to estimate the extent to which apathy changes with time over the first year after stroke and the impact of apathy on recovery. METHODS: The Apathy Assessed cohort was formed from stroke survivors participating in a longitudinal study of health-related quality of life after stroke. A family caregiver completed an apathy questionnaire by telephone at 1, 3, 6, and 12 months after stroke (n=408). Group-based trajectory modeling and ordinal regression were used to identify distinctive groups of individuals with similar trajectories of apathy over the first year after stroke and predictors of apathy trajectory. RESULTS: Both 3- and 5-group trajectory models fit the data. We used the 5-group model because of the potential to further explore the apathy construct. The largest group (50%) had low apathy and 33% had minor apathy that remained stable throughout the first year after stroke. A small proportion (3%) of the study sample had high apathy that remained high. Two other groups of almost equal size (7%) showed worsening and improving apathy. Poor cognitive status, low functional status, and high comorbidity predicted higher apathy. High apathy had a significant negative effect on physical function, participation, health perception, and physical health over the first 12 months after stroke. CONCLUSION: Some degree of apathy was prevalent and persistent after stroke and was predicted by older age, poor cognitive status, and low functional status after stroke. Even a minor level of apathy had an important and statistically significant impact on stroke outcomes.

A measure of physical functioning to define stroke recovery at 3 months: preliminary results.

OBJECTIVE: To develop a physical functioning measure through Rasch analysis conceptualized using the International Classification of Functioning, Disability and Health (ICF). DESIGN: Observational cohort study. SETTING: Acute-hospital and community-based study. PARTICIPANTS: Subjects (N=235) hospitalized with postacute stroke and reassessed in the community at 3-months (mean age, 71.6+/-12.9 y). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Functional assessments 3 months poststroke included self-report and observational indices and tests commonly used to evaluate stroke survivors. Sociodemographic information was also collected. Rasch analysis assisted in combining the items across ICF components to develop the measure. Items were retained based on fit to the model and relationship to the construct; reliability and validity were assessed. RESULTS: The best 44 items formed the Physical Functioning Measure at 3 months (F3m) measure of functioning evaluating limb movement, balance, activities of daily living, and participation. All Rasch model assumptions were met. Both item and person reliably (.96) indicated a stable hierarchy, while precision varied from .51 to 1.2 logits. Early evidence for construct validity is adequate. CONCLUSIONS: The F3m combines patient reported and observed ratings of performance items into a single measure quantifying functioning with good preliminary psychometric properties that with further testing can assist in directing and evaluating interventions and recovery.

Psychometric Testing of the CHAMPS Questionnaire in French Canadians with COPD.

Physical activity is an important health behaviour in reducing morbidity and mortality in individuals with chronic obstructive pulmonary disease (COPD). Accurate measurement of the characteristics of physical activity is essential to understanding the impact of COPD on physical activity. In a previous article, we reported on the cross-cultural adaptation of the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire to produce a Canadian French version. The CHAMPS yields four summary scores: two caloric expenditure scores (moderate-intensity activities and all activities) and two frequency scores (moderate-intensity activities and all activities). The objective of this study was to evaluate test-retest reliability and convergent construct validity, in both English and French versions of the CHAMPS, in individuals with COPD. Test-retest reliability was assessed by administering the CHAMPS at two visits (2-3 weeks apart), to 19 English-speaking and 18 French-speaking participants. Validity was assessed in 56 English-speaking and 74 French-speaking participants, who completed the CHAMPS, Short Form- (SF-) 36, and St. George's Respiratory Questionnaire (SGRQ) at a single visit. Results from reliability testing indicated that intraclass correlation coefficients (ICCs) generally met the threshold for good reliability (ICC > 0.6), with frequency scores showing greater stability than caloric expenditure scores. Validity testing yielded moderate correlations (r = 0.4-0.5) of the CHAMPS with the SF-36 domains and summary score capturing constructs of physical function, and with the SGRQ activity domain and total score. CHAMPS frequency scores for moderate-intensity activities correlated more strongly than other scores, with physical aspects of the SF-36 and SGRQ. The English and French versions of the CHAMPS did not show any substantial differences in reliability (frequency scores) or validity (frequency and caloric expenditure scores). Findings from this study support the reliability and validity of the CHAMPS. In particular, frequency scores for moderate-intensity activities can provide useful information on physical activity levels in individuals with COPD. This trial is registered with NCT00169897. ISRCTN registration number: IRSCTN32824512.

Impact of research-based synopses delivered as daily e-mail: a prospective observational study.

We conducted a prospective observational study to (1) determine usage and construct validity of a method to gauge the cognitive impact of information derived from daily e-mail, and (2) describe self-reported impacts of research-based synopses (InfoPOEMs) delivered as e-mail. Ratings of InfoPOEMs using an Impact assessment scale provided (a) data on usage of the impact assessment method, (b) reports of impact by InfoPOEM and by doctor and (c) data for analysis of construct validity of the scale. PARTICIPANTS were family physicians or general practitioners who rated at least five InfoPOEMs delivered on e-mail. For each InfoPOEM rated, 0.1 continuing education credit was awarded by the College of Family Physicians of Canada. Use of the impact assessment scale linked to a daily InfoPOEM was sustained during the 150-day study period. 1,007 participants submitted 61,493 reports of 'cognitive impact' by rating on average 61 InfoPOEMs (range 5-111). 'I learned something new' was most frequently reported. 'I was frustrated as there was not enough information or nothing useful' was the most frequently reported negative type of impact. The proportion of reports of 'No Impact' varied substantially across individual InfoPOEMs. Impact patterns suggested an 8 or 9-factor solution. Our Impact assessment method facilitates knowledge transfer by promoting two-way exchange between providers of health information and family doctors. Providers of health information can use this method to better understand the impact of research-based synopses. Sustaining current practice and increasing knowledge about new developments in medicine are important outcomes arising from research-based synopses delivered as e-mail, in addition to practice change.

Bridging the gap: the effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of stroke.

OBJECTIVES: to test the hypothesis as to whether persons newly discharged into the community following an acute stroke and assigned a stroke case manager would experience, compared to usual post-hospital care, better health-related quality of life (HRQL), fewer emergency room visits and less non-elective hospitalisations. DESIGN: a stratified, balanced, evaluator-blinded, randomised clinical trial. SETTING: five university-affiliated acute-care hospitals in Montreal, Quebec, Canada. PARTICIPANTS: persons (n = 190) returning home directly from the acute-care hospital following a first or recurrent stroke with a need for health care supervision post-discharge because of low function, co-morbidity, or isolation. INTERVENTION: for 6 weeks following hospital discharge a nurse stroke care manager maintained contact with patients through home visits and telephone calls designed to coordinate care with the person's personal physician and link the stroke survivor into community-based stroke services. MEASUREMENTS: the primary outcome was the Physical Component Summary (PCS) of the Short-Form (SF)-36 survey. A secondary outcome was utilisation of health services. Also measured was the impact of stroke on functioning. Measurements were made at hospital discharge (baseline), following the 6-week intervention and at 6-months post-stroke. RESULTS: the average age of the participants was 70 years. Discharge was achieved on average 12 days post-stroke and most participants had had a stroke of moderate severity. There were no differences between groups on the primary outcome measure, health services utilisation, or any of the secondary outcome measures. CONCLUSION: for this population, there was no evidence that this type of passive case management inferred any added benefit in terms of improvement in health-related quality of life or reduction in health services utilisation and stroke impact, than usual post-discharge management.

A measure of early physical functioning (EPF) post-stroke.

OBJECTIVE: To develop a comprehensive measure of Early Physical Functioning (EPF) post-stroke quantified through Rasch analysis and conceptualized using the International Classification of Functioning Disability and Health (ICF). DESIGN: An observational cohort study. SUBJECTS: A cohort of 262 subjects (mean age 71.6 (standard deviation 12.5) years) hospitalized post-acute stroke. METHODS: Functional assessments were made within 3 days of stroke with items from valid and reliable indices commonly utilized to evaluate stroke survivors. Information on important variables was also collected. Principal component and Rasch analysis confirmed the factor structure, and dimensionality of the measure. Rasch analysis combined items across ICF components to develop the measure. Items were deleted iteratively, those retained fit the model and were related to the construct; reliability and validity were assessed. RESULTS: A 38-item unidimensional measure of the EPF met all Rasch model requirements. The item difficulty matched the person ability (mean person measure: -0.31; standard error 0.37 logits), reliability of the person-item-hierarchy was excellent at 0.97. Initial validity was adequate. CONCLUSION: The 38-item EPF measure was developed. It expands the range of assessment post acute stroke; it covers a broad spectrum of difficulty with good initial psychometric properties that, once revalidated, can assist in planning and evaluating early interventions.

Development of a measure of functioning for stroke recovery: the functional recovery measure.

PURPOSE: To develop a parsimonious measure of functioning for persons after stroke. METHOD: A sub-set of 206 community-dwelling subjects with a first stroke from a larger cohort was interviewed within 9 months using 39 items from five indices assessing functioning. Information was collected on influencing variables: age, stroke type and severity, and previous health. Two statistical methods, factor analysis and Rasch analysis, confirmed the item structure, hierarchy and dimensionality of the measure. Statistics confirmed fit to the model; internal consistency was also assessed. Items were deleted iteratively based on fit and relationship to the construct. RESULTS: The subjects were predominately male (63%) aged on average 68-years-old. A 12-item unidimensional functioning measure was developed. All items and persons fit the Rasch model with stable item-person reliability indices of 0.98 and 0.91, respectively. Item precision (standard errors) ranged from 0.14-0.37 logits. Gaps in measurement occurred at the extremes of the measure and there was a small ceiling effect. CONCLUSIONS: A 12-item measure captured the concept of functioning that could be used as a prototype to quantify recovery post-stroke. These items could form the basis for a measure of functioning.

Quality of stroke rehabilitation clinical practice guidelines.

BACKGROUND AND PURPOSE: Clinical practice guidelines (CPGs) are systematically developed statements that assist practitioners to provide appropriate evidence-based care. The purpose of this study was to evaluate the quality of currently published CPGs for stroke care and to examine the reliability and validity of the appraisal of guidelines, research and evaluation (AGREE) instrument. METHODS: Multiple databases and Internet resources were searched for stroke care CPGs. Guidelines included were published in English or French from 1998 to 2004 and developed by a group process. Four appraisers evaluated each CPG using the AGREE instrument. The AGREE consists of 23 items, ranked on a 4-point Likert scale, that is organized into six domains. A standardized score is calculated separately for each domain and ranges from 0 to 100. RESULTS: Eight guidelines were identified. The AGREE quality scores were high for the 'scope and purpose' domain (mean +/- SE = 71.2 +/- 5.48, intra-class correlation (ICC) = 0.66), and 'clarity and presentation' (mean +/- SE = 70.6 +/- 4.43, ICC = 0.66). There was wide variation in ratings of 'rigour of development' (mean +/- SE = 60.7 +/- 7.1, ICC = 0.75) and 'stakeholder involvement' (mean +/- SE = 52.6 +/- 7.14, ICC = 0.89). The 'editorial independence' (mean +/- SE = 38.1 +/- 8.72, ICC = 0.88) and 'applicability' (mean +/- SE = 35.1 +/- 4.93, ICC = 0.75) had the lowest scores. CONCLUSIONS: There is considerable variability in quality of stroke care guidelines but stroke guidelines score higher on the AGREE rigour of development domain than CPGs from other medical fields. The Scottish Intercollegiate Guideline Network, Veterans Affairs/Department of Defence, Royal College of Physicians, and the New Zealand Guidelines Group consistently scored the highest across the domains. Stroke rehabilitation clinicians should consider these results in selecting a guideline. CPG development groups can improve their AGREE scores by considering the cost of implementing their CPGs, pilot testing their CPGs, recording conflict of interest of development panel members and providing tools supporting application of their CPGs.

Facilitated interprofessional implementation of a physical rehabilitation guideline for stroke in inpatient settings: process evaluation of a cluster randomized trial.

BACKGROUND: The Stroke Canada Optimization of Rehabilitation by Evidence-Implementation Trial (SCORE-IT) showed that a facilitated knowledge translation (KT) approach to implementing a stroke rehabilitation guideline was more likely than passive strategies to improve functional walking capacity, but not gross manual dexterity, among patients in rehabilitation hospitals. This paper presents the results of a planned process evaluation designed to assess whether the type and number of recommended treatments implemented by stroke teams in each group would help to explain the results related to patient outcomes. METHODS: As part of a cluster randomized trial, 20 rehabilitation units were stratified by language and allocated to a facilitated or passive KT intervention group. Sites in the facilitated group received the guideline with treatment protocols and funding for a part-time nurse and therapist facilitator who attended a 2-day training workshop and promoted guideline implementation for 16 months. Sites in the passive group received the guideline excluding treatment protocols. As part of a process evaluation, nurses, and occupational and physical therapists, blinded to study hypotheses, were asked to record their implementation of 18 recommended treatments targeting motor function, postural control and mobility using individualized patient checklists after treatment sessions for 2 weeks pre- and post-intervention. The percentage of patients receiving each treatment pre- and post-intervention and between groups was compared after adjusting for clustering and covariates in a random-effects logistic regression analysis. RESULTS: Data on treatment implementation from nine and eight sites in the facilitated and passive KT group, respectively, were available for analysis. The facilitated KT intervention was associated with improved implementation of sit-to-stand (p = 0.028) and walking (p = 0.043) training while the passive KT intervention was associated with improved implementation of standing balance training (p = 0.037), after adjusting for clustering at patient and provider levels and covariates. CONCLUSIONS: Despite multiple strategies and resources, the facilitated KT intervention was unsuccessful in improving integration of 18 treatments concurrently. The facilitated approach may not have adequately addressed barriers to integrating numerous treatments simultaneously and complex treatments that were unfamiliar to providers. TRIAL REGISTRATION: Unique identifier- NCT00359593.

The significance and impact of a faculty teaching award: disparate perceptions of department chairs and award recipients.

Teaching awards are commonly regarded as an incentive to encourage pedagogic excellence. Inasmuch as their effectiveness depends on how they are perceived by faculty, the authors investigated the impact of a teaching award in the Faculty of Medicine (Faculty Honor List for Educational Excellence) on the attitudes of award recipients and departmental chairs. A questionnaire was designed to sample opinion on the extent to which the Honor List program was publicized, whether the award contributed to recognition and/or stature in the academic unit, and whether it was personally valued by recipients. The questionnaire was sent to all 23 departmental chairs and to all 43 faculty members who had received the award between 1998 and 2002; 78% of the chairs and 77% of the recipients responded. The results revealed marked discrepancies between the perceptions of chairs and recipients. Chairs, although uncertain of the effect on quality of teaching, largely regarded the award as prestigious and well publicized within their departments. A notably smaller percentage of award recipients shared these views. Nonetheless, 93% of recipients valued the award highly, and 45% of recipients indicated that the award inspired them to enhance the quality of their teaching.

Long-term caregiving after stroke: the impact on caregivers' quality of life.

This study examined the health-related quality of life (HRQL) and overall quality of life (QOL) of family caregivers of stroke survivors to determine changes over time and to identify QOL predictors. Caregivers were interviewed after 1.5 and 2 years of caregiving. The scores on the mental subscales were significantly lower than on the age- and sex-matched population norms. The most important predictors of QOL were the stroke survivor's behavioral disturbances and reintegration into normal patterns of living. Caregivers who reported fewer stroke-survivor behavioral disturbances and well-adjusted reintegration also reported a higher personal QOL. These results highlight the impact of a stroke on the caregiver's HRQL and QOL, even after 2 years, and the importance of interventions for caregivers.

Psychometric testing of the McGill Ingestive Skills Assessment.

The goal of this study was to determine the psychometric properties of the McGill Ingestive Skills Assessment. Interrater and intrarater reliability and score stability were tested using repeated administration of this test. The Functional Independence Measure and Modified Mini-Mental State Examination, as well as patient characteristics, were used to determine the validity of the assessment. One hundred and two persons with ingestive skill loss of neurologic origin were evaluated. Intraclass correlations for interrater, intrarater reliability and stability reached or surpassed 0.80 for most subscales. In validity testing, significant relationships were found between McGill Ingestive scores and Functional Independence Measure and Mini-Mental scores, as well as with patient characteristics. It is concluded that the McGill Ingestive Skills Assessment approaches or meets levels of reliability necessary for assessing patients and is valid for adults with neurogenic feeding difficulties residing in tertiary care facilities.

Cross-Cultural Adaptation of the CHAMPS Questionnaire in French Canadians with COPD.

Physical activity is difficult to measure in individuals with COPD. The Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire demonstrated strong clinometric properties when used with the elderly and with those affected by chronic disease. Study objectives were to translate, culturally adapt the CHAMPS into French, and reexamine its test-retest reliability and construct validity in French and English Canadians with COPD. This paper presents the cross-cultural adaptation of the CHAMPS; results of its clinometric testing will be described in another article. The CHAMPS examines the degree of physical activity performed in a typical week through two summary scales, caloric expenditure and activity frequency. The CHAMPS was only in English; thus, a cross-cultural adaptation was needed to translate the CHAMPS into French for use in French Canadians with COPD. Cross-cultural adaptation consisted of forward and back translation, with expert review at each stage of translation: minor inconsistencies were uncovered and rectified. Five French participants with COPD completed the finalized Canadian French CHAMPS and participated in cognitive debriefing; no problematic items were identified. A structured and stepwise, cross-cultural adaptation process produced the Canadian French CHAMPS, with items of equivalent meaning to the English version, for use in French Canadians with COPD.

The structural equation modeling technique did not show a response shift, contrary to the results of the then test and the individualized approaches.

BACKGROUND AND OBJECTIVE: Persons experiencing changes in their physical health may change their values and rerate the importance of basic elements of health-related quality of life (HRQL), a process known as response shift. Developing an estimator of HRQL that differentiates between objective change and response shift is essential for the interpretation of the results. The purpose of the present article was to contrast three methodologic approaches for evaluating response shift to develop a proposed set of HRQL measurement recommendations under circumstances where response shift is expected to occur. METHODS: The three approaches compared were a structural equation modeling (SEM) technique, the then test, and an individualized approach. The data collection procedures for these methods were incorporated into a poststroke randomized controlled trial. RESULTS: The SEM did not show a response shift, contrary to the results of the then test and the individualized approaches. We discuss factors that effect the selection of a methodologic approach including feasibility, subjects' memory and more advanced cognitive tasks, and whether response shift was evaluated at the group or individual level. CONCLUSION: The evaluation of response shift is an integral part of HRQL evaluations, and further comparisons between methodologic approaches are needed.

The effect of a task-oriented walking intervention on improving balance self-efficacy poststroke: a randomized, controlled trial.

OBJECTIVES: To evaluate the efficacy of a task-oriented walking intervention in improving balance self-efficacy in persons with stroke and to determine whether effects were task-specific, influenced by baseline level of self-efficacy and associated with changes in walking and balance capacity. DESIGN: Secondary analysis of a two-center, observer-blinded, randomized, controlled trial. SETTING: General community. PARTICIPANTS: Ninety-one individuals with a residual walking deficit within 1 year of a first or recurrent stroke. INTERVENTION: Task-oriented interventions targeting walking or upper extremity (UE) function were provided three times a week for 6 weeks. MEASUREMENTS: Activities-specific Balance Confidence Scale, Six-Minute Walk Test, 5-m walk, Berg Balance Scale, and Timed "Up and Go" administered at baseline and postintervention. RESULTS: The walking intervention was associated with a significantly greater average proportional change in balance self-efficacy than the UE intervention. Treatment effects were largest in persons with low self-efficacy at baseline and for activities relating to tasks practiced. In the walking group, change in balance self-efficacy correlated with change in functional walking capacity (correlation coefficient=0.45, 95% confidence interval=0.16-0.68). Results of multivariable modeling suggested effect modification by the baseline level of depressive symptoms and a prognostic influence of age, sex, comorbidity, time poststroke, and functional mobility on change in self-efficacy. CONCLUSION: Task-oriented walking retraining enhances balance self-efficacy in community-dwelling individuals with chronic stroke. Benefits may be partially the result of improvement in walking capacity. The influence of baseline level of self-efficacy, depressive symptoms, and prognostic variables on treatment effects are of clinical importance and must be verified in future studies.