Long-term outcome of multiple joint procedures in haemophilia.

In elderly people with haemophilia (PWH), surgery of more than one joint of the lower extremities might be needed. Multiple joint procedures (MJP) were introduced in 1995, defined as any combination of Total Knee or Total Hip Arthroplasty or Ankle Arthrodesis during one in-hospital stay. The expectation is that by means of such procedures this specific population is able to physically function better for an extended period of time. Thus, they will participate in their society in an optimal way. In this study, we tried to describe an outcome after MJP, including pre- and post-operative pain and range of motion (ROM), and recommend measurement tools. 22 of 37 PWH who underwent MJP between 1995 and 2012 were available for assessment. Pain (WFH score) and range of motion were compared pre and postoperatively. Current outcome was described by VAS per joint, nocturnal and overall pain, MACTAR, Hemophilia Activity List, SF36, and EQ-5D. Mean age at surgery was 50, 3 years (SD 8, 3); mean follow-up 12 years (1-18 years). Pain (VAS) decreased post-surgery (Median 1 - 1, 5), but moderate pain remained. Extension of knees slightly increased, but both knee flexion and ankle plantar and dorsal flexion decreased. PWH reported the ability to stand longer but also pointed at specific problems, e.g. riding a bike (MACTAR). The HAL showed limited activities (functional domains), especially in the 'complex lower extremity' (22, 8/100). The SF36 and EQ-5D showed a mix of physical problems of our population, while experiencing moderate pain and reasonable physical functioning. This led us to the conclusion that adequate follow-up is needed: ROM of all joints, VAS of all joints as well as nocturnal and overall pain, HAL, SF36 and EQ5D. Performance based activities and participation need further attention.

Do children participate in the activities they prefer? A comparison of children and youth with and without physical disabilities.

OBJECTIVE: To assess the discrepancy between the leisure activities children prefer and the leisure activities they actually participate in, for children with and without a physical disability, and to explore how in both groups this is related to age and gender. DESIGN: Cross-sectional comparison. SUBJECTS: Children with and without physical disabilities that were recruited from schools for special education and regular schools in the Netherlands. MAIN MEASURES: The Children's Assessment of Participation and Enjoyment (CAPE) and the Preferences for Activities of Children (PAC). A discrepancy score was calculated representing high preference but no participation in the activity in the past four months. RESULTS: A total of 141 children (6-18 years) with a physical disability (mean age 12.5, 43% girls, 57% boys) and 156 children without physical disabilities (mean age 11.5, 55% girls,45% boys) were included in the study. There was no significant difference in discrepancy scores between children with and without physical disabilities (informal activities 9.8 ± 5.0 vs. 9.8 ± 4.6, formal activities 6.4 ± 3.4 vs. 6.6 ± 2.8). Discrepancy between preference and performance varied by age and gender for children without disabilities but not for children with disabilities. CONCLUSIONS: Both groups are equally able to participate in the activities they prefer. Age and gender had a significant effect on the discrepancy scores for children and adolescents without physical disabilities but not for children with physical disabilities.

Parents' experiences with physical and occupational therapy for their young child with cerebral palsy: a mixed studies review.

Understanding the experiences of parents with their child's intervention might help meet the needs of parents and, subsequently get them engaged in their child's intervention. As parents' early beliefs regarding their child's intervention has consequences for treatment participation, it is important to understand these parental perspectives. The aim of this mixed studies review was to give an overview of the experiences and related factors of parents of young children (0-5 years of age) with cerebral palsy in relation to the physical and/or occupational therapy of their child in a rehabilitation setting. The literature was searched systematically for qualitative and quantitative studies published between January 1990 and July 2011. Inclusion criteria were (1) the study population consisted of parents of children with cerebral palsy, with at least 25% of children under the age of five; (2) children had received physical and/or occupational therapy in a rehabilitation setting; and (3) the experiences of the parents with their child's therapy were addressed. Data were synthesized with the framework synthesis method resulting in a conceptual framework describing the factors that are related to the parents' experiences with their child's interventions. A total of 13 studies (eight qualitative and five quantitative) were included and evaluated. Parents expressed various aspects in context, process and outcomes when asked about their experiences with their child's intervention. They had different needs over time and needed time to build a collaborative relationship with their child's therapists. The proposed framework acknowledges the various aspects in context, process and outcomes that parents reported when asked about their experiences. Knowing this, the importance of the broader context of the child in a family should be acknowledged; realizing the impact that the demands of daily life, supports and resources provided to parents, attitudes in the community and culture have on parental experiences.

Determinants of health-related quality of life after aneurysmal subarachnoid hemorrhage: a systematic review.

BACKGROUND AND PURPOSE: Many persons with subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm recover to functional independence but nevertheless experience reduced quality of life (QoL). The aim of this study was to summarize the evidence on determinants of reduced QoL in this diagnostic group. METHODS: Databases PubMed, PsychINFO, and CINAHL were used to identify empirical studies reporting on quantitative relationships between possible determinants and QoL in persons with aneurysmal SAH and published in English. Determinants were classified using the International Classification of Functioning, Disability and Health (ICF). RESULTS: Twenty studies met the inclusion criteria for this review, in which 13 different HRQoL questionnaires were used. Determinants related to Body Structure & Function (clinical condition at admission, fatigue, and disturbed mood), Activity limitations (physical disability and cognitive complaints), and Personal factors (female gender, higher age, neuroticism, and passive coping) are consistently related to worse HRQoL after aneurysmal SAH. Treatment characteristics were not consistently related to HRQoL. CONCLUSION: This study identified a broad range of determinants of HRQoL after aneurysmal SAH. The findings provide clues to tailor multidisciplinary rehabilitation programs. Further research is needed on participation, psychological characteristics, and environmental factors as determinants of HRQoL after SAH.

Predicting leisure participation of school-aged children with cerebral palsy: longitudinal evidence of child, family and environmental factors.

OBJECTIVE: This longitudinal study aims to determine which child, family and environmental variables measured at 2 years of age predict leisure participation in formal and informal activities in school aged children with cerebral palsy (CP). METHODS: Parents of 46 children with CP (mean age at baseline: 2 years 6 months, SD 0 years 1 month; at follow-up 6 years 7 months, SD 0 years 9 months; n = 26 boys, n = 20 girls; Gross Motor Classification System I = 30%, II = 7%, III = 28%, IV = 24%, V = 11%) completed the Children's Assessment of Participation and Enjoyment indicating their child's participation. Multivariate regression models were used to identify early predictors of participation. RESULTS: Movement ability was a significant child-related predictor for formal activities (R(2) 17%, P < 0.05). Movement ability and social skills were most predictive (R(2) 62%, P < 0.00) for informal activities. The feeling of being restricted in family participation was the single most predictive factor for formal and informal activities at family level (R(2) 12%, P < 0.05, R(2) 25%, P < 0.05). Type of daycare was the only environmental variable that was predictive, and only for informal activities (R(2) 16%, P < 0.05). In the overall model movement ability was most predictive for leisure participation in formal activities (R(2) 17%, P < 0.05). Movement ability and social skills are the most important predictors for informal leisure participation (R(2) 62%, P < 0.01). CONCLUSIONS: Several variables are found to be related to formal and informal participation at age 6. Movement ability and social skills at age 2 are most predictive of leisure participation when the child is 6 years old.

Associations between psychological factors and quality of life ratings in persons with spinal cord injury: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: To review the literature on relationships between psychological factors and quality of life (QOL) of persons with spinal cord injury (SCI). SETTING: NA. METHODS: A systematic literature search was conducted in several online databases (PubMed, Embase and PsychInfo). Articles were included if they provided quantitative information on associations between QOL-related dependent variables and psychological factors as independent variables in an SCI population. The search was limited to empirical studies published in English. The methodological quality of the included articles was assessed. RESULTS: A total of 48 studies were included. Total locus of control, sense of coherence, self-worth, hope, purpose in life and positive affect were consistently associated with greater QOL. Negative affect and posttraumatic cognitions were consistently associated with lower QOL. Inconsistent evidence was found for subscales of locus of control, the role of attribution of blame, spirituality, personality, appraisals, passive coping and emotion-focused coping. No evidence was found for an association between active problem-focused coping styles and QOL. CONCLUSION: Many psychological factors were strongly and consistently related to QOL, but for some others no or inconsistent evidence was found. Further research should (1) use larger study groups, preferably in longitudinal designs, (2) improve terminological precision and avoid conceptual overlap between determinants and outcomes, (3) increase uniformity of questionnaires and (4) reexamine concepts that have been abandoned prematurely, such as personality and social comparison.

Exploring the relation between learning style and cognitive impairment in patients with acquired brain injury.

The way a patient prefers to approach or choose a learning situation represents the patient's learning style. The objective of this chart review study was to explore the relation between learning style and cognitive impairment in patients with acquired brain injury (ABI). We used data from files of 92 adult patients with ABI referred to inpatient rehabilitation, who completed the Adapted Learning Style Inventory (A-LSI) and at least one of the following neuropsychological tests: Trail Making Test, Rey Auditory Verbal Learning Test, WAIS-III Digit Span, Rey-Osterrieth Complex Figure Test-Copy, Stroop Color-Word Test, or the Brixton Spatial Anticipation Test. The A-LSI yielded the following distribution of learning styles: 4 doers, 48 observers, 2 deciders and 38 thinkers. No significant correlation coefficients were found between the neuropsychological tests and the A-LSI. Furthermore, Chi-square tests revealed no significant associations between learning style (observer, thinker) and cognitive impairment. The results of this exploratory study suggest that learning style and cognitive impairment are independent in patients with ABI.

In-hospital rehabilitation after multiple joint procedures of the lower extremities in haemophilia patients: clinical guidelines for physical therapists.

This project aimed to develop guidelines for use during in-hospital rehabilitation after combinations of multiple joint procedures (MJP) of the lower extremities in persons with haemophilia (PWH). MJP are defined as surgical procedures on the ankles, knees and hips, performed in any combination, staged, or during a single session. MJP that we studied included total knee arthroplasty, total hip arthroplasty and ankle arthrodesis. Literature on rheumatoid arthritis demonstrated promising functional results, fewer hospitalization days and days lost from work. However, the complication rate is higher and rehabilitation needs optimal conditions. Since 1995, at the Van Creveldkliniek, 54 PWH have undergone MJP. During the rehabilitation in our hospital performed by experienced physical therapists, regular guidelines seemed useless. Guidelines will guarantee an optimal physical recovery and maximum benefit from this enormous investment. This will lead to an optimal functional capability and optimal quality of life for this elderly group of PWH. There are no existing guidelines for MJP, in haemophilia, revealed through a review of the literature. Therefore, a working group was formed to develop and implement such guidelines and the procedure is explained. The total group of PWH who underwent MJP is described, subdivided into combinations of joints. For these subgroups, the number of days in hospital, complications and profile at discharge, as well as a guideline on the clinical rehabilitation, are given. It contains a general part and a part for each specific subgroup.

Development of non-verbal intellectual capacity in school-age children with cerebral palsy.

BACKGROUND: Children with cerebral palsy (CP) are at greater risk for a limited intellectual development than typically developing children. Little information is available which children with CP are most at risk. This study aimed to describe the development of non-verbal intellectual capacity of school-age children with CP and to examine the association between the development of non-verbal intellectual capacity and the severity of CP. METHODS: A longitudinal analysis in a cohort study was performed with a clinic-based sample of children with CP. Forty-two children were assessed at 5, 6 and 7 years of age, and 49 children were assessed at 7, 8 and 9 years of age. Non-verbal intellectual capacity was assessed by Raven's Coloured Progressive Matrices (RCPM). Severity of CP was classified by the Gross Motor Function Classification System, type of motor impairment and limb distribution. manova for repeated measurements was used to analyse time effects and time × group effects on both RCPM raw scores and RCPM intelligence quotient scores. RESULTS: The development of non-verbal intellectual capacity was characterised by a statistically significant increase in RCPM raw scores but no significant change in RCPM intelligence quotient scores. The development of RCPM raw scores was significantly associated with the severity of CP. Children with higher levels of gross motor functioning and children with spastic CP showed greater increase in raw scores than children with lower levels of gross motor functioning and children with dyskinetic CP. CONCLUSIONS: Children with CP aged between 5 and 9 years show different developmental trajectories for non-verbal intellectual capacity, which are associated with the severity of CP. The development of non-verbal intellectual capacity in children with less severe CP seems to resemble that of typically developing children, while children with more severe CP show a limited intellectual development compared to typically developing children.

Short-term changes in parents' resolution regarding their young child's diagnosis of cerebral palsy.

OBJECTIVE: This study aimed to describe changes in parents' resolution regarding their young child's diagnosis of cerebral palsy over a period of 1 year, and to describe the changes in strategies of resolution. METHODS: In this longitudinal study, 38 parents of children with cerebral palsy (mean age 18.4 months, SD = 1.1 at baseline) were followed with the Reaction to Diagnosis Interview, assessing their personal reactions to their child's diagnosis (i.e. resolution status). Changes at main and subclassification level of the Reaction to Diagnosis Interview were investigated using a binominal test. RESULTS: Twenty-nine parents (76%) were found to be stable with respect to their main resolution status (i.e. 'resolved' or 'unresolved'), while 24% of the parents either had changed from 'unresolved' to 'resolved' or in the opposite way. Furthermore, of the 28 parents who were classified as 'resolved' at both times, 15 (54%) had changed at subclassification level with respect to the specific strategies used. CONCLUSION: Resolution at a main level of parental reactions to their child's diagnosis was predominantly stable. Most parents were classified as 'resolved' at both baseline and follow-up assessment. However, more detailed analyses at subclassification level showed that most parents with a 'resolved' main status showed changing patterns of resolution strategies to their child's diagnosis, suggesting that resolution is an ongoing process.

Promoting the use of outcome measures by an educational programme for physiotherapists in stroke rehabilitation: a pilot randomized controlled trial.

OBJECTIVE: To determine the influence of tutor expertise on the uptake of a physiotherapists' educational programme intended to promote the use of outcome measures in the management of patients with stroke. DESIGN: Pilot randomized controlled trial. METHODS: Thirty physiotherapists involved in stroke management were randomized into two groups and participated in five tutor-guided educational sessions (the Physiotherapists' Educational Programme on Clinimetrics in Stroke, PEPCiS). Groups differed from each other with respect to tutors: one experienced and one inexperienced in stroke care. Primary outcome was 'actual use' (the frequencies of data of seven recommended outcome measures in the patient records of the participating physiotherapists). RESULTS: The actual use of instruments shifted from a median of 3 to 6 in the expert tutor group and from 3 to 4 in the non-expert tutor group (P = 0.07). Physiotherapists educated by the expert tutor used a broader variety of instruments and appreciated the educational programme, their own knowledge gain and all three scales of tutor style aspects significantly more than their colleagues of the non-expert tutor group (all P<0.05). Univariate analysis on the entire set of data revealed eight factors, including tutors' performance, that were associated with a change score of the use of two or more outcome measures by individual physiotherapists after the educational programme. CONCLUSION: In this pilot trial it was not proven that tutor expertise in stroke care influences the actual use of outcome measures, but it warrants a future study with sufficient power to investigate the influence of the tutor.

[Falls: incidence and risk factors after stroke. A systematic literature review]. / Vallen: incidentie en risicofactoren bij patiënten met een beroerte. Een systematisch literatuuronderzoek.

Falls are common after stroke. This article presents a literature review of the incidence and risk factors of falls and the consequences for professionals working with stroke patients. It is important to consider the specific problems after stroke. Depression and cognitive impairments were found to be risk factors for fall incidents after stroke. In the relevant literature many different risk factors and circumstances are described. When patients move from bed to chair, walk to the bathroom and the first few days after the patient is discharged to another setting, - all these circumstances showed high percentages of falling. A fall during hospital stay is a significant risk factor for future fall incidents. A reliable index to measure the fall risk is not (yet) available. But scores on the Barthel Index and the Timed-Up-and-Go test can be used as fall risk indicators. Fear of falling is an important complication after a fall and therefore it is recommended prior to discharge to inquire about the patient's self efficacy in maintaining balance. Few intervention studies use the number of falls as an outcome measure. Exercising balance following a mass training protocol seems to diminish the risk of falling.

Efficient screening of cognitive dysfunction in stroke patients: comparison between the CAMCOG and the R-CAMCOG, Mini Mental State Examination and Functional Independence Measure-cognition score.

BACKGROUND: The CAMCOG is a valid screening instrument for cognitive dysfunction in stroke patients but too time-consuming to be used by physicians in acute or post-acute care settings. The aim of this study was to identify a shorter cognitive screening test or combination of tests that yields the same results as the CAMCOG. METHODS: A total of 169 stroke patients completed the CAMCOG and the abbreviated Rotterdam-CAMCOG (R-CAMCOG), Mini Mental State Examination (MMSE) and the cognitive part of the Functional Independence Measure (FIM cognition) after admission to clinical rehabilitation and 1 year after stroke. The CAMCOG score was used as criterion standard for validity. RESULTS: Spearman correlations with the CAMCOG were very strong for the R-CAMCOG (both 0.92), strong for the MMSE (0.66 and 0.69) and moderate to weak for the FIM cognition (0.35 and 0.27). Stepwise linear regression analyses showed that, at admission, the R-CAMCOG explained 83% of the variance in the CAMCOG. The MMSE and R-CAMCOG together explained 87%. At 1 year after stroke the correlations and explained variances were similar. CONCLUSION: The recently constructed R-CAMCOG appears an efficient alternative for the CAMCOG as a screening tool for cognitive dysfunction of stroke patients.

Effects of training and albuterol on pain and fatigue in facioscapulohumeral muscular dystrophy.

BACKGROUND: We recently reported a randomised controlled trial on the efficacy of strength training and the beta2-adrenergic agonist albuterol in patients with facioscapulohumeral muscular dystrophy (FSHD). Strength training and albuterol appeared safe interventions with limited positive effect on muscle strength and volume. We concurrently explored the prevalence and the characteristics of pain and fatigue in the participating FSHD patients, because these are probably underreported but clinically relevant symptoms in this disorder. Next, we studied the effects of albuterol and strength training on pain, experienced fatigue, health-related functional status and psychological distress. METHODS: Sixty-five patients were randomised to strength training of elbow flexors and ankle dorsiflexors or non-training. After 26 weeks, albuterol (sustained-release, 8 mg bid) was added in a randomised, double-blind, placebo-controlled design. Outcomes comprised self-reported pain, experienced fatigue, functional status and psychological distress obtained with validated questionnaires at 52 weeks. RESULTS: Eighty percent of patients reported chronic persistent or periodic, multifocal pains. Thirty-four percent of the participants were severely fatigued. Strength training and albuterol failed to have a significant effect on all outcomes. CONCLUSIONS: Pain and fatigue are important features in FSHD. Strength training and albuterol do not have a positive or negative effect on pain, experienced fatigue, functional status and psychological distress.

Mental status and health-related quality of life in an elderly population 15 years after limited cerebral ischaemia.

BACKGROUND: Stroke has a major impact on survivors. Our study was designed to describe the mental status and health-related quality of life (HRQoL) in long-term survivors of TIA or minor ischaemic stroke (MIS) and evaluate associations of mental and physical factors with HR-QoL. METHODS: A random sample of the 10-year survivors of the Dutch TIA Trial (DTT) and the dutch participants of the European Atrial Fibrillation Trial (EAFT) were interviewed by postal questionnaire (n = 468) and at home (n = 198). Demographic data, mental health status (depression (CES-D), cognition (CAMCOG)), and health perception (SF-36 and Euroqol) were measured. RESULTS: 198 long-term survivors were included; mean age was 72.5 (SD 8.7 years), 22% was depressed (CES-D > or = 16) and 15% had cognitive dysfunction (CAMCOG < 80). The overall HR-QoL did not differ much from the norm population. Physical disability, occurrence of a major stroke and comorbidity of locomotion or the heart were independently associated with a low health perception. CONCLUSIONS: Despite varying amounts of disability, the majority of long-term survivors of a TIA or MIS rated their quality of life as rather good. Physical factors, rather than mental status were independently related to a decrease in perceived health.

Identification of risk factors related to perceived unmet demands in patients with chronic stroke.

PURPOSE: To investigate the prevalence of unmet demands concerning autonomy and participation and to identify risk factors related to these unmet demands in patients with chronic stroke. METHOD: A cross-sectional study of 147 patients three years after stroke. We assessed perceived unmet care demands in relation to problems of participation and autonomy measured by the Impact on Participation and Autonomy Questionnaire (IPAQ). Socio-demographic and health characteristics were analysed as potential risk factors for the prevalence of unmet demands, using multivariate regression analysis. RESULTS: A total of 33% of the patients perceived at least one unmet demand in one of the IPAQ subdomains. Risk factors significantly related to the presence of unmet demands were younger age, motor impairment, fatigue and depressive symptoms. Findings indicate that the model including these factors was fairly accurate in identifying patients having unmet demands and those not having unmet demands. CONCLUSIONS: Unmet care demands were present in a substantial proportion of the stroke patients. The risk factors identified are helpful for clinicians and health care providers to recognize patients who are at risk of perceiving unmet care demands and to optimize care to patients with chronic stroke.

Comparing contents of functional outcome measures in stroke rehabilitation using the International Classification of Functioning, Disability and Health.

PURPOSE: To examine the content of outcome measures that are frequently used in stroke rehabilitation and focus on activities and participation, by linking them to the International Classification of Functioning, Disability and Health (ICF). Method. Constructs of the following instruments were linked to the ICF: Barthel Index, Berg Balance Scale, Chedoke McMaster Stroke Assessment Scale, Euroqol-5D, Functional Independence Measure, Frenchay Activities Index, Nottingham Health Profile, Rankin Scale, Rivermead Motor Assessment, Rivermead Mobility Index, Stroke Adapted Sickness Impact Profile 30, Medical Outcomes Study Short Form 36, Stroke Impact Scale, Stroke Specific Quality of Life Scale and Timed Up and Go test. Results. It proved possible to link most constructs to the ICF. Most constructs fitted into the activities and participation component, with mobility being the category most frequently covered in the instruments. Although instruments were selected on the basis of their focus on activities and participation, 27% of the constructs addressed categories of body functions. Approximately 10% of the constructs could not be linked. CONCLUSIONS: The ICF is a useful tool to examine and compare contents of instruments in stroke rehabilitation. This content comparison should enable clinicians and researchers to choose the measure that best matches the area of their interest.

Functional status and use of healthcare facilities in long-term survivors of transient ischaemic attack or minor ischaemic stroke.

BACKGROUND: Stroke may have a major effect on survivors and on the healthcare system. AIMS: To study the functional status and use of healthcare facilities in long-term survivors of a transient ischaemic attack (TIA) or minor ischaemic stroke (MIS) and evaluate associations with baseline and follow-up characteristics. METHODS: Follow-up of patients who had participated in the Dutch TIA Trial or the European Atrial Fibrillation Trial was extended to a mean period of 15.6 years. Patients were interviewed through a postal questionnaire (n = 468) and a sample of this group was also interviewed at home (n = 198). Demographic data, information on comorbidity, functional status (Barthel Index, Frenchay Activities Index and modified Rankin Scale) and use of healthcare facilities were recorded. RESULTS: About one third of the survivors interviewed at home experienced any residual disability and 26% were moderately to severely handicapped. Factors associated with poor functional status were advanced age and the presence of any infarct on a baseline computed tomography scan, the recurrence of a new major stroke or the presence of comorbidity of locomotion. One third of survivors used any kind of professional care, which was predominantly related to the functional status at follow-up. CONCLUSIONS: Recurrent stroke and the presence of comorbidity of locomotion are important determinants of long-term disability of survivors of a TIA or an MIS, which, in turn, is strongly associated with the long-term use of professional care. The need for measuring comorbidity with regard to functional status is recommended in research on stroke outcome.

Responsiveness of functional health status measures frequently used in stroke research.

PURPOSE: To compare the responsiveness of several functional health status measures frequently used in stroke research, namely the Barthel Index (BI), Functional Independence Measure (FIM), Frenchay Activities Index (FAI) and Stroke-Adapted Sickness Impact Profile 30 (SA-SIP 30). METHOD: Patients with a first-ever supratentorial stroke admitted for inpatient rehabilitation were included. Complete datasets for 163 patients were available for analysis. Floor/ceiling effects and responsiveness, quantified by effect sizes, were studied for the periods between rehabilitation admission and six months post stroke (subacute phase) and between six and 12 months post stroke (chronic phase). RESULTS: Effect sizes in the subacute phase were similar and were classified as large for the BI, FIM total and FIM motor score. The FIM cognitive score showed a considerable ceiling effect and had the smallest effect size in the subacute phase. In the chronic phase, the FAI and SA-SIP 30 detected the most changes and had moderate effect sizes. CONCLUSIONS: BI, FIM total and FIM motor score, FAI and SA-SIP 30 were responsive measures. We recommend the use of the BI in the subacute phase and the use of the FAI and SA-SIP 30 in the chronic phase, especially for the stroke rehabilitation population.

Shoe adaptation after amputation of the II - V phalangeal bones of the foot.

In The Netherlands, about 50% of all amputations of the lower limb are toes and forefoot amputations. Traumata of toes and mid-foot are rare. Preservation of the foot is the primary goal for treatment. Crush injuries of the foot may be associated with prolonged morbidity. This case study presents an insole solution for the solitary first phalangeal bone after amputation of the phalangeal bones II - V. The normal adaptation for forefoot amputations is stiffening of the sole of the shoe and a rocker bar to improve the toe off phase with load reduction of the forefoot. Because the patient had to do excessive stair climbing during work another solution was chosen. As a foot orthosis, a metal soleplate was made in order to have free movement during loading and toe-off during walking. The soleplate gives safety and provides self-adjusting properties after toe off. This enables the shoe technician to make a shoe without a rocker bar or an extra stiff insole. The 0.5 mm custom-made spring-steel plate is also used as a protective in industrial safety shoes. To improve shoe adaptation more research and case reports have to be published in order to inform doctors and shoe technicians about everyday solutions to partial foot amputations.