Use of the International Classification of Functioning, Disability and Health (ICF) in patients with traumatic brain injury.

INTRODUCTION: Many tools exist for assessing the functioning of a patient with traumatic brain injury. Possible benefits of the ICF in TBI rehabilitation are currently under discussion. GOAL: The study explored to what extend the ICF is useful to organize existing clinical information and to retrospectively evaluate the effect of interventions in patients with TBI. METHOD: A retrospective patient record study was conducted. Medical records of 100 patients admitted to the Slovenian University Rehabilitation Institute from 2007-2009 were linked to the ICF. RESULTS: The majority of the functional problems at the level of body functions corresponded to mental and movement-related functions. Within the list of activities and participation, the patients experienced more difficulties in tasks that require intellectual effort, communicational ability, mobility and self-care. The ICF detected substantial improvement after rehabilitation regarding body functions and activities related to mobility and self-care and little improvement regarding mental functions and related activities. Some important environmental factors were also identified. CONCLUSIONS: The translation of the information about functioning into the ICF format provided a well-structured functional profile of the selected group of patients in a language-independent format. ICF also clearly outlined the environmental factors important for the recovery and functioning.

Influence of foot orthoses on plantar pressures, foot pain and walking ability of rheumatoid arthritis patients--a randomised controlled study.

PURPOSE: To compare the effectiveness of functional foot orthoses and unshaped (flat) orthotic material on plantar pressure redistribution, forefoot pain reduction and walking ability in rheumatoid arthritis (RA) patients. METHODS: Forty patients with RA were randomised to receive unshaped material (UM) (n = 20) or functional foot orthoses (n = 20). Plantar pressure measurement was performed with an F-scan system. Foot pain was assessed by the pain subscale of the Foot Function Index. Walking ability was assessed by the 6-min walking test. Investigations were performed at baseline, 1 week after the patient received shoes with orthoses and 6 months later. RESULTS: Plantar pressures were significantly higher at painful than at non-painful foot areas. No differences in plantar pressure redistribution were found between the groups. Notable reduction of pain and improvement of activity (walking ability) was observed in both groups. Foot pain has moderate impact on the walking ability of RA patients. CONCLUSIONS: The study showed no clear advantage of functional foot orthoses over UM.

Rehabilitation medicine in countries of Central/Eastern Europe.

PURPOSE: To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges. METHODS: Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries. RESULTS: CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content. CONCLUSION: The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.

Need for rehabilitation teamwork training in Europe.

Teamwork is the cornerstone of rehabilitation medicine. Rehabilitation workers in European countries are well educated in their own disciplines and attain appropriate professional knowledge; however, they lack educational opportunities for acquiring skills and attitudes necessary for effective teamwork, mainly communication, cooperation, and leadership. Consequently, teamwork is compromised and rehabilitation effectiveness reduced. Therefore, training in these components of professional competence needs scaling up in order to increase their impact on rehabilitation care.

Return to work after lower limb amputation.

PURPOSE: To review the literature on return to work after lower limb amputation. METHOD: A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED. RESULTS: Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network). CONCLUSIONS: Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.

Partial hand amputation and work.

PURPOSE: To determine whether or not subjects who had had a partial hand amputation were able to return to the same job and whether or not they used their silicone finger prosthesis for work. METHOD: Medical records of all the patients who had undergone a traumatic partial hand amputation and who had been treated in the Upper Limb Prosthetic Clinic at the Institute for Rehabilitation in Ljubljana were reviewed. Questionnaires were sent to 112 patients. Forty-eight questionnaires which were returned and had been correctly answered were analysed. RESULTS: The study found that less than half the patients who had had a partial hand amputation were able to do the same work as before the amputation. Less than one-third wore their silicone prosthesis at work regularly. The subjects who did not have manual jobs and who had an amputation of only one or two fingers were able to keep the same job more easily after the amputation. Only a few subjects found their silicone prosthesis useful at work. CONCLUSION: It can be concluded that partial hand amputation may present a great problem in keeping the same job after amputation. An aesthetic (cosmetic) silicone prosthesis is helpful particularly for subjects with higher education whose work involves personal contacts and for whom aesthetics is important. They use the prosthesis for certain activities, such as typing.

Cross-cultural validity of functional independence measure items in stroke: a study using Rasch analysis.

OBJECTIVE: To analyse cross-cultural validity of the Functional Independence Measure (FIM) in patients with stroke using the Rasch model. SETTINGS: Thirty-one rehabilitation facilities within 6 different countries in Europe. PARTICIPANTS: A total of 2546 in-patients at admission, median age 63 years. METHODS: Data from the FIM were evaluated with the Rasch model, using the Rasch analysis package RUMM2020. A detailed analysis of scoring functions of the 7 categories of the FIM items was undertaken prior to testing fit to the model. Categories were re-scored where necessary. Analysis of Differential Item Functioning was undertaken in pooled data for each of the FIM motor and social-cognitive scales, respectively. RESULTS: Disordered thresholds were found on most items when using 7 categories. Fit to the Rasch model varied between countries. Differential Item Functioning was found by country for most items. Adequate fit to the Rasch model was achieved when items were treated as unique for each country and after a few country-specific items were removed. CONCLUSION: Clinical collected data from FIM for patients with stroke cannot be pooled in its raw form, or compared across countries. Comparisons can be made after adjusting for country-specific Differential Item Functioning, though the adjustments for Differential Item Functioning and rating scales may not generalize to other samples.

Transition from sitting to standing after trans-femoral amputation.

Standing up is an important and common daily activity. It is essential for independence and a prerequisite for walking. Many elderly and many subjects with impairments have problems with transition from sitting to standing. The aim of the present study was to determine whether there was any difference between the characteristics of standing up in trans-femoral amputees and healthy subjects. Five young trans-femoral amputees and five healthy subjects were included in the study. They were asked to stand up. The body motion was recorded using an Optotrak contactless optical system. The force and moment vectors exerted on the seat were recorded by a JR3 six-axis robot wrist sensor. The force under the feet was recorded by two AMTI force plates. The trans-femoral amputees were found to stand up more slowly than the healthy subjects. The angles of the hip, knee, and ankle joints on the amputated side were different from the angles on the healthy side or in the healthy subjects. There was also a great difference in loading between the healthy and the prosthetic foot. It can be concluded that there are differences in standing up between the trans-femoral amputees and the healthy subjects. These differences may indicate a reason for problems many elderly trans-femoral amputees face when standing up.

Influence of foot pain on walking ability of diabetic patients.

OBJECTIVE: To assess foot pain and its correlation with walking ability in diabetic patients. SUBJECTS: Two groups of type 2 diabetic patients (30 with symptomatic neuropathy and 30 without symptomatic neuropathy) and 30 healthy volunteers were studied. METHODS: Pain was assessed by the pain sub-scale of the Foot Function Index. Internal consistency for the pain sub-scale was tested. Walking ability was assessed by the 6-minute walking test. RESULTS: The pain was worse in diabetic patients, the pain sub-scale scores differed between the groups (p < 0.05). High internal consistency was found for the pain sub-scale of the Foot Function Index. Results of the 6-minute walking test differed among the 3 groups: healthy volunteers performed best, and diabetic patients with symptomatic neuropathy worst (p < 0.001). Foot pain correlated moderately with the result of walking test (r = -0.449, p < 0.001). CONCLUSION: The pain sub-scale of the Foot Function Index is suitable for the assessment of pain in diabetic patients. Patients with severe foot pain have more difficulties when walking long distances than patients with less severe or without any pain.

Comparison of clinical test and questionnaires for the evaluation of upper limb prosthetic use in children.

PURPOSE: The aim of the present study was to find out if there was a correlation between an observational clinical test and a questionnaire for the evaluation of upper limb prosthetic use in children and to determine which one was better and easier to use in clinical practice. METHOD: Twenty children who were patients of the children's prosthetic clinic at the Rehabilitation Institute in Ljubljana, Slovenia, and had a functional prosthesis were included in the study. The age appropriate subtest of the University of New Brunswick Test of Prosthetic Function (the UNB test) was assessed by an occupational therapist. Parents completed either the Child Amputee Prosthetics Project-Functional Status Inventory for Preschool children (CAPP-FSIP) or the Child Amputee Prosthetics Project-Functional Status Inventory (CAPP-FSI), depending on which was appropriate for the child's age. Information was limited to the upper extremity items. RESULTS: We found a significant correlation between UNB spontaneity and skill score (r = 0.956, p = 0.000) and also between the parental CAPP score and UNB test (UNB spontaneity--CAPP activities r = 0.634, p = 0.003; UNB spontaneity--CAPP prosthetic use r = 0.542, p = 0.014, UNB skill--CAPP activities r = 0.559, p = 0.010, UNB skill--CAPP prosthetic use r = 0.597, p = 0.005). CONCLUSIONS: We concluded that both instruments can be used for assessing upper limb prosthetic use in children but neither is an optimal choice.

Driving ability following upper limb amputation.

BACKGROUND: In the existing literature, there is scarce information about subjects with upper limb amputation and driving. OBJECTIVES: The aim of this study was to find out how frequently subjects following upper limb amputation have problems when driving; most frequently proposed adaptations and, when possible, factors that influence driving ability. STUDY DESIGN: Retrospective clinical study. METHODS: Medical records were reviewed of all subjects following upper limb amputation who had been amputated in the last 5 years and those with congenital upper limb deficiency who in the last 5 years turned 17. RESULTS: Out of 37 subjects, 7 did not attend the clinic for assessment of driving abilities. They were significantly older at the time of the amputation (p < 0.001). To the remaining 30 who attended driving assessment, zero to four car adaptations (two on average) were proposed. There were no correlations between the number of suggested car adaptations and the age at the time of the amputation, amputation level, education and severity of phantom limb pain. Type of prosthesis also did not influence the number of car adaptations. CONCLUSIONS: Most people following upper limb amputation need at least one car adaptation for safe driving.

Use of the International Classification of Functioning, Disability, and Health in traumatic brain injury rehabilitation: linking issues and general perspectives.

OBJECTIVE: The aims of this study were to summarize the possible benefits of using the International Classification of Functioning, Disability, and Health (ICF) in rehabilitation after traumatic brain injury and to explore the technical aspects of linking existing medical records to the ICF in such cases. DESIGN: A literature review was conducted using PubMed, Cochrane Collaboration, and Trip. Medical records of 100 patients admitted to University Rehabilitation Institute of Slovenia in 2007-2009 were linked to the ICF. RESULTS: Fourteen relevant articles were identified from 2002 to 2010, suggesting that in patients with traumatic brain injury, the ICF can contribute to evaluation of disabilities, identification of treatment goals and intervention targets, and categorizing important environmental factors. Linking existing medical records to the ICF proved successful although time-consuming. Identified challenges included need for frequent use of ``unspecified'' qualifier, different scope of reports from different specialists, and mapping of either one Functional Independence Measure to more ICF codes or vice versa. CONCLUSIONS: Despite some criticism, the literature suggests that the ICF is useful as a model of health and disability and the basis for the development of practical instruments for description and assessment of functioning of persons with traumatic brain injury. Although challenging, time-consuming, and subject to limitations, linking existing medical records to the ICF can provide a clear functional profile of a patient or group with the additional advantage of being able to describe contextual factors.

Measuring patterns of disability using the International Classification of Functioning, Disability and Health in the post-acute stroke rehabilitation setting.

OBJECTIVE: To determine whether the International Classification of Functioning, Disability and Health (ICF) model is adequate for assessing disability patterns in stroke survivors in the sub-acute rehabilitation setting in terms of potential changes in functional profiles over time. METHODS: Functional profiles of 197 stroke patients were assessed using the ICF Checklist and the Functional Independence Measure (FIMTM) at admission and discharge from rehabilitation hospital. The ICF Checklist was applied based on medical documentation and rehabilitation team meetings. Descriptive analyses were performed to identify changes in ICF categories and qualifiers from admission to discharge, and correlations between different improvement measures were calculated. RESULTS: Mean rehabilitation duration was 60 days; patients' mean age was 60 years, with mean FIM-score 75 at admission. Mean FIM-score improvement at discharge was 12.5. Within Body Functions, changes in at least 10% of patients were found regarding 13 categories; no categories within Body Structures, 24 within Activities and Participation, and 2 within Environmental Factors. Changes were mostly due to improvement in qualifiers, except for within Environmental Factors, where they were due to use of additional categories. Correlations between improvements in Body Functions and Activities and Participation (regarding capacity and performance), as well as between capacity and performance within Activities and Participation, were approximately 0.4. CONCLUSION: Rating ICF categories with qualifiers enables the detection of changes in functional profiles of stroke patients who underwent an inpatient rehabilitation programme. :

The International Classification of Functioning, Disability and Health (ICF) in vocational rehabilitation and disability assessment in Slovenia: state of law and users' perspective.

OBJECTIVE: This study illustrates the use of the ICF in vocational rehabilitation and disability assessment in Slovenia. METHOD: A review of the Slovenian law about vocational rehabilitation was performed. A survey was developed and group and individual interviews were conducted with professionals involved in vocational rehabilitation who use the ICF. RESULTS: The vast majority of the respondents believe that ICF helps to create a common language for multidisciplinary communication. The main advantages of the ICF identified by the respondents are that it provides a holistic view of the person, assesses complexities of functioning, provides a unified language and offers a quick and easy insight into functioning. The disadvantages of ICF are complicated terminology and subjectivity of the assessor. A difficulty encountered by the users is that by law, only body functions of the ICF are assessed. Additional qualitative analysis of the users' understanding of ICF and its purpose revealed heterogeneity. Significant differences between public and private organisations were found. CONCLUSION: ICF is a promising tool for use in vocational rehabilitation and disability assessment in Slovenia. A major challenge is the lack of interface between ICF and policies on vocational rehabilitation in Slovenia.

Functioning and disability in stroke.

PURPOSE: To describe functioning and disability in patients with stroke according to the model endorsed by the International Classification of Functioning Disability and Health (ICF) in a rehabilitation hospital. METHODS: Adult patients with stroke were consecutively enrolled. The Functional Independence Measure (FIM) and the WHO Disability Assessment Schedule II (WHO-DAS II) were administered in individual sessions. ICF checklist was applied on the basis of medical documentation and rehabilitation team meetings. Descriptive analyses were performed to report on FIM and WHO-DAS II scores. ICF categories reported as a problem by more than 20% of patients were described in detail. RESULTS: Patients (197 in total) were mainly men, aged about 60, with average FIM score of 75. Within ICF Body Functions component 32 categories were applied in at least 20% of the patients, 5 within Body Structures, 27 within Activities and Participation and 7 within Environmental Factors. CONCLUSIONS: ICF represents a new integrative tool to help professionals dealing with stroke. The checklist captures the various sequels of stroke in terms of impairments, activity limitations and participation restrictions. It shows the extensive need for rehabilitation, whereby it facilitates consideration of the patient' needs.