Home-based Computer Assisted Arm Rehabilitation (hCAAR) robotic device for upper limb exercise after stroke: results of a feasibility study in home setting.

BACKGROUND: Home-based robotic technologies may offer the possibility of self-directed upper limb exercise after stroke as a means of increasing the intensity of rehabilitation treatment. The current literature has a paucity of robotic devices that have been tested in a home environment. The aim of this research project was to evaluate a robotic device Home-based Computer Assisted Arm Rehabilitation (hCAAR) that can be used independently at home by stroke survivors with upper limb weakness. METHODS: hCAAR device comprises of a joystick handle moved by the weak upper limb to perform tasks on the computer screen. The device provides assistance to the movements depending on users ability. Nineteen participants (stroke survivors with upper limb weakness) were recruited. Outcome measures performed at baseline (A0), at end of 8-weeks of hCAAR use (A1) and 1 month after end of hCAAR use (A2) were: Optotrak kinematic variables, Fugl Meyer Upper Extremity motor subscale (FM-UE), Action Research Arm Test (ARAT), Medical Research Council (MRC) and Modified Ashworth Scale (MAS), Chedoke Arm and Hand Activity Inventory (CAHAI) and ABILHAND. RESULTS: Two participants were unable to use hCAAR: one due to severe paresis and the other due to personal problems. The remaining 17 participants were able to use the device independently in their home setting. No serious adverse events were reported. The median usage time was 433 minutes (IQR 250 - 791 min). A statistically significant improvement was observed in the kinematic and clinical outcomes at A1. The median gain in the scores at A1 were by: movement time 19%, path length 15% and jerk 19%, FM-UE 1 point, total MAS 1.5 point, total MRC 2 points, ARAT 3 points, CAHAI 5.5 points and ABILHAND 3 points. Three participants showed clinically significant improvement in all the clinical outcomes. CONCLUSIONS: The hCAAR feasibility study is the first clinical study of its kind reported in the current literature; in this study, 17 participants used the robotic device independently for eight weeks in their own homes with minimal supervision from healthcare professionals. Statistically significant improvements were observed in the kinematic and clinical outcomes in the study.

Investigating the International Classification of Functioning, Disability, and Health (ICF) Framework to Capture User Needs in the Concept Stage of Rehabilitation Technology Development.

This study evaluates whether the International Classification of Functioning, Disability, and Health (ICF) framework provides a useful basis to ensure that key user needs are identified in the development of a home-based arm rehabilitation system for stroke patients. Using a qualitative approach, nine people with residual arm weakness after stroke and six healthcare professionals with expertise in stroke rehabilitation were enrolled in the user-centered design process. They were asked, through semi-structured interviews, to define the needs and specification for a potential home-based rehabilitation device to facilitate self-managed arm exercise. The topic list for the interviews was derived by brainstorming ideas within the clinical and engineering multidisciplinary research team based on previous experience and existing literature in user-centered design. Meaningful concepts were extracted from questions and responses of these interviews. These concepts obtained were matched to the categories within the ICF comprehensive core set for stroke using ICF linking rules. Most of the concepts extracted from the interviews matched to the existing ICF Core Set categories. Person factors like gender, age, interest, compliance, motivation, choice, and convenience that might determine device usability are yet to be categorized within the ICF comprehensive core set. The results suggest that the categories of the comprehensive ICF Core Set for stroke provide a useful basis for structuring interviews to identify most users needs. However some personal factors (related to end users and healthcare professionals) need to be considered in addition to the ICF categories.

Can the prognosis of polymyalgia rheumatica be predicted at disease onset? Results from a 5-year prospective study.

OBJECTIVE: To identify the features of PMR that may predict the duration of steroid therapy, the occurrence of relapses and the late development of GCA. METHODS: Prospective cohort study of 176 patients with PMR, followed up for 5 years. Baseline factors associated with the duration of steroids therapy were identified using Cox regression. Predictors of relapse and the late development of GCA were identified using binary logistic regression. RESULTS: A total of 176 patients with PMR were included, of whom 124 stopped steroids within 5 years. The probability of stopping steroids within 5 years was independently reduced by an elevated plasma viscosity (PV) [hazard ratio (HR) = 0.49; 95% CI 0.29, 0.82 for a PV > or = 2.00 mPa s compared with a PV < or = 1.80 mPa s; overall P = 0.024] and by starting treatment at >15 mg prednisolone (HR = 0.63; 95% CI 0.41, 0.97; P = 0.036). Either of these independently reduced the chances of stopping steroids within a given time interval between 27 and 51%. No significant predictors of relapse were identified. Predictors of late GCA on univariable analysis were female sex [odds ratio (OR) = 8.16; 95% CI 1.06, 63.13; P = 0.044], HLA-DRB1*0101 or -*0401 alleles (OR = 4.95; 95% CI 1.05, 23.34; P = 0.043), PV > or = 2.00 mPa s compared with PV < or = 1.80 mPa s (OR = 10.64; 95% CI 1.28, 88.38; P = 0.029) and initial prednisolone dose >15 mg (OR = 4.53; 95% CI 1.61, 12.79; P = 0.004). CONCLUSION: A higher PV in PMR increases the risk of prolonged steroid therapy and late GCA. Female sex and particular HLA alleles may increase the risk of late GCA. Starting patients on >15 mg prednisolone is associated with a prolonged steroid duration.

Head-torso-hand coordination in children with and without developmental coordination disorder.

AIM: This study investigated the nature of coordination and control problems in children with developmental coordination disorder (DCD). METHOD: Seven adults (two males, five females, age range 20-28 y; mean 23 y, SD 2 y 8 mo) and eight children with DCD (six males, two females, age range 7-9 y; mean 8 y, SD 8 mo), and 10 without DCD (seven males, three females, age range 7-9 y; mean 8 y, SD 7 mo) sat in a swivel chair and looked at or pointed to targets. Optoelectronic apparatus recorded head, torso, and hand movements, and the spatial and temporal characteristics of the movements were computed. RESULTS: Head movement times were longer (p<0.05) in children with DCD than in the comparison group, even in the looking task, suggesting that these children experience problems at the lowest level of coordination (the coupling of synergistic muscle groups within a single degree of freedom). Increasing the task demands with the pointing condition affected the performance of children with DCD to a much greater extent than the other groups, most noticeably in key feedforward kinematic landmarks. Temporal coordination data indicated that all three groups attempted to produce similar movement patterns to each other, but that the children with DCD were much less successful than age-matched children in the comparison group. INTERPRETATION: Children with DCD have difficulty coordinating and controlling single degree-of-freedom movements; this problem makes more complex tasks disproportionately difficult for them. Quantitative analysis of kinematics provides key insights into the nature of the problems faced by children with DCD.

The coordination of upper and lower arm rotation.

We tested the hypothesis that the upper and lower arm act as a coordinative structure coupled through a higher order control system. Five healthy participants moved their hand between two targets in ten conditions via internal/external rotation of the shoulder. In eight conditions, the task required concurrent rotation of the lower arm (180 degrees pronation/supination). Movements were stereotypical within a condition but plotting the upper and lower arm angle against each other produced an asymmetrical pattern. With internal rotation, the upper arm reached peak angular velocity slower than the lower arm but this was reversed with external rotation. In two conditions, participants were asked to move faster and slower than their normal speed. The peak speed, time to peak speed and duration were predictable for the different tasks. Internal and external asymmetries decreased with faster movements. In addition a decrease in upper arm amplitude (from 90 degrees to 30 degrees) removed the asymmetry. The asymmetry was unaffected by initial posture but was exaggerated when external rotation was paired with pronation rather than supination, and internal rotation combined with supination (versus pronation). However, the presence of the same fundamental pattern suggests that the asymmetry is not due to biomechanical factors but might arise because of the difficulties involved in visually monitoring the hand when it is close to the body. The results support the idea that functional coupling can occur between upper and lower arm rotations and thus provides further evidence for a higher order control system which is responsible for coordination of arm segment movement.

Safety and efficacy of co-careldopa as an add-on therapy to occupational and physical therapy in patients after stroke (DARS): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Dopamine is a key modulator of striatal function and learning and might improve motor recovery after stroke. Previous small trials of dopamine agonists after stroke provide equivocal evidence of effectiveness on improving motor recovery. We aimed to assess the safety and efficacy of co-careldopa plus routine occupational and physical therapy during early rehabilitation after stroke. METHODS: This double-blind, multicentre, randomised controlled trial of co-careldopa versus placebo in addition to routine NHS occupational and physical therapy was done at 51 UK NHS acute inpatient stroke rehabilitation services. We recruited patients with new or recurrent clinically diagnosed ischaemic or haemorrhagic (excluding subarachnoid haemorrhage) stroke 5-42 days before randomisation, who were unable to walk 10 m or more, had a score of less than 7 points on the Rivermead Mobility Index, were expected to need rehabilitation, and were able to access rehabilitation after discharge from hospital. Participants were assigned (1:1) using stratified random blocks to receive 6 weeks of oral co-careldopa or matched placebo in addition to routine NHS physiotherapy and occupational therapy. The initial two doses of co-careldopa were 62·5 mg (50 mg of levodopa and 12·5 mg of carbidopa) and the remaining doses were 125 mg (100 mg of levodopa and 25 mg of carbidopa). Participants were required to take a single oral tablet 45-60 min before physiotherapy or occupational therapy session. The primary outcome was ability to walk independently, defined as a Rivermead Mobility Index score of 7 or more, at 8 weeks. Primary and safety analyses were done in the intention-to-treat population. The trial is registered on the ISRCTN registry, number ISRCTN99643613. FINDINGS: Between May 30, 2011, and March 28, 2014, of 1574 patients found eligible, 593 (mean age 68·5 years) were randomly assigned to either the co-careldopa group (n=308) or to the placebo group (n=285), on an average 18 days after stroke onset. Primary outcome data were available for all 593 patients. We found no evidence that the ability to walk independently improved with co-careldopa (125 [41%] of 308 patients) compared with placebo (127 [45%] of 285 patients; odds ratio 0·78 [95% CI 0·53-1·15]) at 8 weeks. Mortality at 12 months did not differ between the two groups (22 [7%] vs 17 [6%]). Serious adverse events were largely similar between groups. Vomiting during therapy sessions, after taking the study drug, was the most frequent adverse event and was more frequent in the co-careldopa group than the placebo group (19 [6·2%] vs 9 [3·2%]). INTERPRETATION: Co-careldopa in addition to routine occupational and physical therapy does not seem to improve walking after stroke. Further research might identify subgroups of patients with stroke who could benefit from dopaminergic therapy at different doses or times after stroke with more intensive motor therapy. FUNDING: Medical Research Council.

Associated reactions after stroke: a randomized controlled trial of the effect of botulinum toxin type A.

OBJECTIVE: To measure the impact of botulinum toxin A on associated reactions in patients following stroke. DESIGN: Randomized placebo-controlled trial. PATIENTS: Forty patients with spasticity in their paretic arm (median time since stroke: 2.7 years) were randomized to botulinum toxin A (Dysport; 1000 mouse units (MU) divided between elbow, wrist and finger flexors) or placebo. METHODS: Associated reactions were measured using hand dynamometry. The effort used was measured using maximum voluntary grip in the unaffected arm. Measurements were recorded at 2 pre-treatment and 3 post-intervention times. Activities that patients felt caused associated reactions and activities that were affected by associated reactions were recorded. RESULTS: Peak associated reactions force was reduced at week 6 with botulinum toxin A compared with placebo (mean group difference 19.0 N; 95% confidence interval (CI): 7.2, 30.9; p < 0.01) and week 2 (p = 0.005), with the effect wearing off by week 12 (p = 0.09). Thirty-one patients noted associated reactions on a regular basis and 24 said that these movements interfered with daily activities. Ten of 12 patients receiving botulinum toxin A and 2 of 12 receiving placebo reported reduction in interference with daily activities (p = 0.02). CONCLUSION: Botulinum toxin A reduces associated reactions and may be a useful adjunct to other rehabilitation interventions. The impact of associated reactions on daily activities may also be reduced.

Working with a brain injury: personal experiences of returning to work following a mild or moderate brain injury.

OBJECTIVE: Most brain injuries occur in people of working age. Individuals with mild or moderate injuries may have unrecognized problems affecting return to work. Previous studies have focused on factors that predict return to work after brain injury. There is limited information about the experiences of individuals returning to work. DESIGN: Individual interviews explored the work-related expectations and experiences of workers who had sustained mild to moderate brain injury. A sampling frame ensured a spread of participants by age, injury severity and work type. METHODS: Thirty-three interviews were conducted 4-6 months post-injury. Most participants had returned to work. Interviews were transcribed verbatim for thematic analysis. RESULTS: Key emerging issues for participants were the invisibility of their injury, continuing symptoms affecting their ability to do their job and lack of advice and guidance on returning to work. Return to work support systems were considered to be poorly coordinated and managed. CONCLUSION: It is important that healthcare professionals anticipate the vocational rehabilitation needs of patients who have sustained mild to moderate brain injury. These patients may require additional coordinated interventions and specific person-centred information to ensure a successful and, most importantly, a sustained return to work.

Restoring mobility: theories, technologies and effective treatments.

Movement impairment affects the independence and lifestyle of a significant number of people worldwide. A MDT approach towards the problem is needed for optimal restoration of mobility. Educating vulnerable people on preventive strategies and safe techniques after a fall is imperative. Use of appropriate orthosis, assistive technology, physiotherapy and surgical interventions should be timely and evidence based. Assessment of the patient is critical to ensure successful outcomes of technological interventions. Novel technologies such as targeted reinnervation prosthesis and implantable technologies, although at a very early stage in their development, have huge potential to help people with movement impairments due to disorders of neuromuscular control or limb loss.

Intrathecal phenol: an old treatment revisited.

PURPOSE: Severe bilateral leg spasticity can cause severe symptoms and reduced quality of life in affected individuals. It is often unresponsive to treatment. The objective of this study was to review the effectiveness of intrathecal phenol in the treatment of severe bilateral leg spasticity. METHOD: A retrospective case notes review of patients treated with intrathecal phenol by a rehabilitation service was performed. A simple rating scale based on comments in the case notes was used to identify changes in spasticity and treatment goals. RESULTS: Forty patients were identified as having been treated with intrathecal phenol over a 10-year period. All patients had improvements in their spasticity, 34 of which were rated as substantial or excellent. All patients (in whom the effect was documented), except one, had short-term improvement in the goals for treatment, 31 having substantial or excellent improvement. The effect was long lasting in many of the patients. Seven patients required repeat injections with similar outcomes. Seven patients experienced temporary side-effects. CONCLUSION: Intrathecal phenol is a useful alternative in treating selected patients with chronic severe bilateral leg spasticity that is unresponsive to other treatments.

The Cerebral Palsy Kinematic Assessment Tool (CPKAT): feasibility testing of a new portable tool for the objective evaluation of upper limb kinematics in children with cerebral palsy in the non-laboratory setting.

PURPOSE: Efficacy of treatment to improve upper-limb activity of children with cerebral palsy (CP) is typically evaluated outside clinical/laboratory environments through functional outcome measures (e.g. ABILHAND kids). This study evaluates CPKAT, a new portable laptop-based tool designed to objectively measure upper-limb kinematics in children with CP. METHODS: Seven children with unilateral CP (2 females; mean age 10 years 2 months (SD 2 years 3 months), median age 9 years 6 months, range 6 years 5 months, MACS II-IV) were evaluated on copying, tracking and tracing tasks at their homes using CPKAT. CPKAT recorded parameters relating to spatiotemporal hand movement: path length, movement time, smoothness, path accuracy and root mean square error. The Wilcoxon signed ranks test explored whether CPKAT could detect differences between the affected and less-affected limb. RESULTS: CPKAT detected intra-limb differences for movement time and smoothness (aiming), and path length (tracing). No intra-limb tracking differences were found, as hypothesised. These findings are consistent with other studies showing that movements of the impaired upper limb in unilateral CP are slower and less smooth. CONCLUSION: CPKAT provides a potential solution for home-based assessment of upper limb kinematics in children with CP to supplement other measures and assess functional intervention outcomes. Further validation is required. Implications for Rehabilitation This paper demonstrates the feasibility of evaluating upper limb kinematics in home using CPKAT, a portable laptop-based evaluation tool. We found that CPKAT is easy to set-up and use in home environments and yields useful kinematic measures of upper limb function. CPKAT can complement less responsive patient reported or subjectively evaluated functional measures for a more complete evaluation of children with cerebral palsy. Thus, CPKAT can help guide a multi-disciplinary team to more effective intervention and rehabilitation for children with cerebral palsy.

Using item response theory to explore the psychometric properties of extended matching questions examination in undergraduate medical education.

BACKGROUND: As assessment has been shown to direct learning, it is critical that the examinations developed to test clinical competence in medical undergraduates are valid and reliable. The use of extended matching questions (EMQ) has been advocated to overcome some of the criticisms of using multiple-choice questions to test factual and applied knowledge. METHODS: We analysed the results from the Extended Matching Questions Examination taken by 4th year undergraduate medical students in the academic year 2001 to 2002. Rasch analysis was used to examine whether the set of questions used in the examination mapped on to a unidimensional scale, the degree of difficulty of questions within and between the various medical and surgical specialties and the pattern of responses within individual questions to assess the impact of the distractor options. RESULTS: Analysis of a subset of items and of the full examination demonstrated internal construct validity and the absence of bias on the majority of questions. Three main patterns of response selection were identified. CONCLUSION: Modern psychometric methods based upon the work of Rasch provide a useful approach to the calibration and analysis of EMQ undergraduate medical assessments. The approach allows for a formal test of the unidimensionality of the questions and thus the validity of the summed score. Given the metric calibration which follows fit to the model, it also allows for the establishment of items banks to facilitate continuity and equity in exam standards.

Measuring movement irregularity in the upper motor neurone syndrome using normalised average rectified jerk.

Movement irregularity is a feature of the upper motor neurone (UMN) syndrome which is difficult to measure. Average rectified jerk (ARJ) has been proposed as a measure of this movement irregularity, but ARJ depends upon the duration of movement. Since movements may be slower in UMN patients, duration dependence compromises ARJ as a measure of irregularity. A normalisation technique is proposed that generates a measure of movement irregularity which is independent of movement duration: normalised average rectified jerk (NARJ). This paper presents a validation of NARJ in the UMN syndrome. Nine control subjects, nine left hemiparetic stroke patients and nine right hemiparetic stroke patients were studied. Test movements comprised elbow extension/flexion in the horizontal plane; these were recorded with an electro-goniometer and accelerometer. The effectiveness of the normalisation technique has been demonstrated using trajectories of various durations; some of these were artificially generated from participants' trajectories, in order to preserve the movement profile. The variability of NARJ and ARJ have been compared in a sample of control subjects. NARJ has been criterion validated by correlation with expert subjective rating of irregularity in a heterogeneous set of trajectories. Construct validity has been tested by discrimination between movements of control subjects, left hemiparetic stroke patients and right hemiparetic stroke patients. When comparing trajectories of identical profile but two-fold difference in movement duration, NARJ differed only 2.6% whereas ARJ differed 706%. NARJ was less reproducible in healthy participants than ARJ: median non-parametric coefficients of variation for repeated movements were 55% and 41%, respectively. Spearman rank correlation coefficient for NARJ and expert rating was 0.92 (p<0.01). NARJ measurements on right hemiparetic patients differ significantly from those made on the control group (p<0.02); corresponding ARJ measurements do not attain statistical significance. NARJ is a valid measure of movement irregularity in the UMN syndrome.

Clinicians' perspectives on decision making in lower limb amputee rehabilitation.

OBJECTIVE: Decision making within amputee rehabilitation includes the assessment of whether a patient is suitable for a prosthesis and if so, what components to provide. This study seeks to increase understanding about clinicians' perspectives on what factors influence these decisions. METHOD: One-to-one semi-structured interviews were completed with 23 experienced clinicians at their place of work at 4 UK amputee rehabilitation centres. Thematic analysis using a theoretical, semantic approach was used to identify key themes from the data. RESULTS: Four key themes were identified: estimating outcome; difficulties predicting outcome; patient choice and barriers to prescribing. There was variation in the importance placed on each theme between individual clinicians and services, with factors such as budget and risk aversion acting as barriers to prescribing. Only one of the 4 centres used formal prescribing guidelines. CONCLUSION: The results highlight the difficulties clinicians experience in estimating outcome and suggest inequity of prosthetic provision in the UK, with variation in the provision of high cost items. The development of national prescription guidelines is suggested to improve equality of prosthetic provision.

The nature of arm movement in children with cerebral palsy when using computer-generated exercise games.

PURPOSE: To compare upper limb kinematics of children with spastic cerebral palsy (CP) using a passive rehabilitation joystick with those of adults and able-bodied children, to better understand the design requirements of computer-based rehabilitation devices. METHOD: A blocked comparative study involving seven children with spastic CP, nine able-bodied adults and nine able-bodied children, using a joystick system to play a computer game whilst the kinematics of their upper limb were recorded. The translational kinematics of the joystick's end point and the participant's shoulder movement (protraction/retraction) and elbow rotational kinematics (flexion/extension) were analysed for each group. RESULTS: Children with spastic CP matched their able-bodied peers in the time taken to complete the computer task, but this was due to a failure to adhere to the task instructions of travelling along a prescribed straight line when moving between targets. The spastic CP group took longer to initiate the first movement, which showed jerkier trajectories and demonstrated qualitatively different movement patterns when using the joystick, with shoulder movements that were significantly of greater magnitude than the able-bodied participants. CONCLUSIONS: Children with spastic CP generate large shoulder and hence trunk movements when using a joystick to undertake computer-generated arm exercises. This finding has implications for the development and use of assistive technologies to encourage exercise and the instructions given to users of such systems. IMPLICATIONS FOR REHABILITATION: A kinematic analysis of upper limb function of children with CP when using joystick devices is presented. Children with CP may use upper body movements to compensate for limitations in voluntary shoulder and elbow movements when undertaking computer games designed to encourage the practice of arm movement. The design of rehabilitative computer exercise systems should consider movement of the torso/shoulder as it may have implications for the quality of therapy in the rehabilitation of the upper limb in children with CP.

Effort test performance in clinical acute brain injury, community brain injury, and epilepsy populations.

Effort tests have become commonplace within medico-legal and forensic contexts and their use is rising within clinical settings. It is recognized that some patients may fail effort tests due to cognitive impairment and not because of poor effort. However, investigation of the base rate of failure among clinical populations other than dementia is limited. Forty-seven clinical participants were recruited and comprised three subgroups: acute brain injury (N = 11), community brain injury (N = 20), and intractable epilepsy (N = 16). Base rates of failure on the Word Memory Test (WMT; Green, 2003 ) and six other less well-validated measures were investigated. A significant minority of patients failed effort tests according to standard cutoff scores, particularly patients with severe traumatic brain injury and marked frontal-executive features. The WMT was able to identify failures associated with significant cognitive impairment through the application of profile analysis and/or lowered cutoff levels. Implications for clinical assessment, effort test interpretation, and future research are discussed.

The DARS (Dopamine Augmented Rehabilitation in Stroke) trial: protocol for a randomised controlled trial of Co-careldopa treatment in addition to routine NHS occupational and physical therapy after stroke.

BACKGROUND: Stroke has a huge impact, leaving more than a third of affected people with lasting disability and rehabilitation remains a cornerstone treatment in the National Health Service (NHS). Recovery of mobility and arm function post-stroke occurs through re-learning to use the affected body parts and/or learning to compensate with the lesser affected side. Promising evidence suggests that the addition of Co-careldopa to physical therapy and occupational therapy may improve the recovery of arm and leg movement and lead to improved function. METHODS/DESIGN: Dopamine Augmented Rehabilitation in Stroke (DARS) is a multi-centre double-blind, randomised, placebo, controlled clinical trial of Co-careldopa in addition to routine NHS occupational therapy and physical therapy as part of early stroke rehabilitation. Participants will be randomised on a 1:1 basis to either Co-careldopa or placebo. The primary objective of the trial is to determine whether the addition of six weeks of Co-careldopa treatment to rehabilitation therapy can improve the proportion of patients who can walk independently eight weeks post-randomisation. DISCUSSION: The DARS trial will provide evidence as to whether Co-careldopa, in addition to routine NHS occupational and physical therapy, leads to a greater recovery of motor function, a reduction in carer dependency and advance rehabilitation treatments for people with stroke. TRIAL REGISTRATION: ISRCTN99643613 assigned on 4 December 2009.

Can simple clinical tests predict walking ability after prosthetic rehabilitation?

OBJECTIVE: To investigate whether simple clinical measures can predict walking ability after lower limb prosthetic rehabilitation. DESIGN: Prospective observational study. SUBJECTS: Ninety five adults who were assessed as suitable for lower limb prosthetic rehabilitation by the multidisciplinary team. METHODS: Information regarding baseline clinical factors (amputation details, comorbidities, physical ability, mood and cognitive ability) was collected prior to provision of the prosthesis. Backward step linear regression was used to identify factors predictive of performance on the Timed Up and Go test following rehabilitation. RESULTS: Seventy one participants were able to complete this walking test and were included in the final analysis. The backward step regression model had an adjusted R2 of 0.588 and comprised 6 factors: age (p = 0.002), gender (p = 0.027), level of amputation (p = 0.000), presence of contracture (p = 0.088), ability to stand on one leg (p = 0.062) and Trail Making Tests A + B (p = 0.047), a test of cognitive flexibility. Cause of amputation (dysvascular or non-dysvascular) was not an independent predictor of walking outcome. CONCLUSION: These results indicate that simple clinical assessments completed prior to prosthetic provision can be used to predict mobility outcome. These findings need to be validated in a larger population across other amputee rehabilitation services and if confirmed could easily be incorporated into routine clinical practice.

Development of a framework to define the functional goals and outcomes of botulinum toxin A spasticity treatment relevant to the child and family living with cerebral palsy using the International Classification of Functioning, Disability and Health for Children and Youth.

OBJECTIVE: To define a sub-set of functional goals and outcomes relevant to children and families living with cerebral palsy following treatment with botulinum toxin type A using the International Classification of Functioning, Disability and Health for Children and Youth. METHODS: We identified treatment goals and treatment outcomes from medical case records in 2102 assessments of 239 children with cerebral palsy treated with botulinum toxin between 1994 and 2009. Goals were set through assessment and discussion by experienced clinicians, therapists, parents and children. RESULTS: There were 61 separate goals, mapping to 40 categories, falling mostly within Body Functions: b710 Mobility of joint functions (414 times); b770 Gait pattern functions (374 times); b7351 Tone of muscles of one limb (117 times). A total of 93 separate treatment outcomes were identified, mapping to 51 categories. Two of the 3 most common outcomes correspond to the 2 most common goals (gait pattern and mobility of joint functions). CONCLUSION: The International Classification of Functioning, Disability and Health for Children and Youth provides a useful framework to categorize the reasons for using botulinum toxin in children and focuses the clinical consultation not only on impairments but also functional outcomes.