Responsiveness of the International Classification of Functioning, Disability And Health (ICF) Clinical Functioning Information Tool (ClinFIT) in Routine Clinical Practice in an Australian Inpatient Rehabilitation Setting.

OBJECTIVE: To examine the responsiveness of the International Classification of Functioning, Disability and Health (ICF) Clinical Functioning Information Tool (ClinFIT) in routine clinical practice in an Australian context. METHODS: A prospective observational study with consecutive recruitment of inpatients at a tertiary rehabilitation facility. The assessments were at admission (T0), discharge (T1) and 3-month postdischarge (T2), using the following questionnaires: ClinFIT, Functional Independence Measure (FIM) and European Quality of Life (EQ-5D-5L). Extension Indices (EI) were calculated for the ClinFIT set, and responsiveness measured as a change in scores over time. The association between FIM and ClinFIT scores was explored. RESULTS: Participants (n = 91, mean age 66.8±13.0 years, 52% male, 48% following stroke) reported ≥ 1 issue related to ClinFIT categories. ClinFIT total raw scores improved significantly across all health conditions compared with T0 (median (interquartile range): 196 (110, 228)) at both T1: 69 (37, 110); p < 0.001 and T2: 46.5 (20.8, 77); p < 0.001, with a medium effect size (r = 0.61 for both). There were significant changes in EI in the entire ClinFIT set from T0 to T1, and from T0 to T2 (p < 0.001 for both), with small to medium effect sizes. Analyses confirmed significant correlation in improvements between ClinFIT and FIM scores. CONCLUSION: ClinFIT is useful in evaluating patient functioning and can detect changes in functioning over time and across different health conditions.

A process evaluation of patient care needs using the Post-Stroke Checklist: A prospective study.

OBJECTIVE: To assess the utility of the modified Post-Stroke Checklist (mPSC) to identify impairments and care needs of patients with stroke (PwS) in an inpatient rehabilitation setting. METHODS: Prospective observational design with consecutive admission of PwS (n = 44) at a tertiary rehabilitation facility. The post-stroke checklist was administered at hospital discharge (T1) and 3 months post-discharge (T2). Furthermore, validated questionnaires assessed function and participation, including the Clinical Functioning Information Tool (ClinFIT) on admission (T0), T1 and T2. RESULTS: Participants' mean age was 67.7 years (standard deviation; SD) 14.6), 58% of participants were female, and the mean length of inpatient stay was 32.7 days (SD 22.4). At T1, 80% and at T2 only 60% of participants reported ≥1 stroke-related problem (mean 5.3 (SD 3.3) and 3.6 (SD 2.8), respectively). Half of participants were referred to physiotherapy/occupational therapy, and 36% to specialist clinics following discharge. The most prevalent problems included: life after stroke (62.2%), fatigue (55.6%), activities of daily living, and mobility (51.1% each). Compared with T1, at T2 there was an observed reduction in all mPSC items, except pain and incontinence. Participants showed improved function at T1 and T2 (Extension Index, ClinFIT set), from T0 to T1 and T0 to T2 (p<0.001, with large effect sizes). CONCLUSION: The mPSC is feasible to implement in an inpatient rehabilitation setting and community. It can identify relevant stroke-related problems, and hence facilitate targeted intervention.

Capacity-building in clinical skills of rehabilitation workforce in low- and middle-income countries.

OBJECTIVE: Despite the prevalence of disability in low-and middle-income countries, the clinical skills of the rehabilitation workforce are not well described. We report health professionals' perspectives on clinical skills in austere settings and identify context-specific gaps in workforce capacity. METHODS: A cross-sectional pilot survey (Pakistan, Morocco, Nigeria, Malaysia) of health professionals' working in rehabilitation in hospital and community settings. A situational-analysis survey captured assessment of clinical skills required in various rehabilitation settings. Responses were coded in a line-by-line process, and linked to categories in domains of the International Classification of Functioning, Disability and Health (ICF). RESULTS: Respondents (n = 532) from Pakistan 248, Nigeria 159, Morocco 93 and Malaysia 32 included the following: physiotherapists (52.8%), nurses (8.8%), speech (5.3%) and occupational therapists (8.5%), rehabilitation physicians (3.8%), other doctors (5.5%) and prosthetist/orthotists (1.5%). The 10 commonly used clinical skills reported were prescription of: physical activity, medications, transfer-techniques, daily-living activities, patient/carer education, diagnosis/screening, behaviour/cognitive interventions, comprehensive patient-care, referrals, assessments and collaboration. There was significant overlap in skills listed irrespective of profession. Most responses linked with ICF categories in activities/participation and personal factors. CONCLUSION: The core skills identified reflect general rehabilitation practice and a task-shifting approach, to address shortages of health workers in low-and middle-income countries.

Challenges and barriers for implementation of the World Health Organization Global Disability Action Plan in low- and middle- income countries.

OBJECTIVE: To identify potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Nigeria and compare these with other low- and middle-income countries. METHODS: A rehabilitation team from the Royal Melbourne Hospital, Parkville, Australia, conducted intensive workshops at medical/academic institutions in Nigeria for healthcare professionals from various local Physical Medicine and Rehabilitation facilities. A modified Delphi method identified challenges for person with disability, using 3 GDAP objectives. Findings were compared with similar exercises in Madagascar, Pakistan and Mongolia. RESULTS: Despite differences in the healthcare system and practice, the challenges reported in Nigeria were similar to those in other 3 low- and middle-income countries, at both macro (governmental/policymakers) and micro levels (community/social/individual). Common challenges identified were: limited knowledge of disability services, limited Physical Medicine and Rehabilitation workforce, guidelines and accreditation standards; coordination amongst healthcare sectors; social issues; data and research; legislation and political commitment. Common potential facilitators included: need for strong leadership; advocacy of disability-inclusive development; investment in infrastructure/human resources; coordination/partnerships in healthcare sector; and research. CONCLUSION: Disability care is an emerging priority in low- and middle-income countries to address the needs of people with disability. The challenges identified in Nigeria are common to most low- and middle-income countries. The GDAP framework can facilitate access and strengthen Physical Medicine and Rehabilitation services.

World Health Organisation Global Disability Action Plan 2014-2021: Challenges and perspectives for physical medicine and rehabilitation in Pakistan.

OBJECTIVE: To provide an update on disability and outline potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Pakistan. METHODS: A 6-day workshop at the Armed Forces Institute of Rehabilitation Medicine, Islamabad facilitated by rehabilitation staff from Royal Melbourne Hospital, Australia. Local healthcare professionals (n = 33) from medical rehabilitation facilities identified challenges in service provision, education and attitudes/approaches to people with disabilities, using consensus agreement for objectives listed in the GDAP. RESULTS: Respondents agreed on the following challenges in implementing the GDAP: shortage of skilled work-force, fragmented healthcare system, poor coordination between acute and subacute healthcare sectors, limited health services infrastructure and funding, lack of disability data, poor legislation, lack of guidelines and accreditation standards, limited awareness/knowledge of disability, socio-cultural perceptions and geo-topographical issues. The main facilitators included: need for governing/leadership bodies, engagement of healthcare professionals and institutions using a multi-sectoral approach, new partnerships and strategic collaboration, provision of financial and technical assistance, future policy direction, research and development. CONCLUSION: The barriers to implementing the GDAP identified here highlight the emerging priorities and challenges in the development of rehabilitation medicine and GDAP implementation in a developing country. The GDAP summary actions were useful planning tools to improve access and strengthen rehabilitation services.

An enriched environmental programme during inpatient neuro-rehabilitation: A randomized controlled trial.

OBJECTIVE: To assess the effectiveness of an enriched environmental activities programme in an inpatient tertiary neuro-rehabilitation unit. METHODS: A total of 103 participants were randomized to an intervention group (n = 52) undertaking an enriched environmental activities programme or a control group (n = 51) receiving usual ward activity. PRIMARY OUTCOME MEASURE: Depression, Anxiety Stress Scale (DASS). Other measures included: Neurological Impairment Scale; Multidimensional Health Locus of Control, Rosenberg Self-Esteem Scale, Montreal Cognitive Assessment (MoCA); Functional Independence Measure (FIM), and Euro-Quality of Life-5D. Questionnaire assessments were performed at admission, discharge and 3-months post-discharge. RESULTS: Mean age of subjects was 62.5 years (standard deviation 18.5), 63% were male; 53 had stroke and the remainder had other neurological conditions. Compared with controls, the intervention group showed significant improvement at discharge in: DASS: "total", "depression", and "stress" subscales (p < 0.05 for all, with small effect sizes (η2) = 0.04-0.05); MoCA (p = 0.048, η2 = 0.04) and FIM motor (total and "self-care", "mobility" subscales (p < 0.05 for all, with moderate effect sizes, η2 = 0.0-0.08). At 3-month follow-up, significant differences were maintained in most secondary outcomes in the intervention group. Cognitive function and activities improved most in participants with stroke. CONCLUSION: An enriched environmental programme can produce significant improvements in functional and cognitive ability in inpatient neurological cohorts compared with routine ward activity programmes.

Factors associated with long-term functional and psychological outcomes in persons with moderate to severe traumatic brain injury.

OBJECTIVE: To examine factors impacting long-term functional and psychological outcomes in persons with moderate-severe traumatic brain injury. METHODS: A prospective cross-sectional study (n = 103) assessed the long-term (up to 5 years) impact of traumatic brain injury on participants' current activity and restriction in participation using validated questionnaires. RESULTS: Participants' median age was 49.5 years (interquartile range (IQR) 20.4-23.8), the majority were male (77%), and 49% had some form of previous rehabilitation. The common causes of traumatic brain injury were falls (42%) and motor vehicle accidents (27%). Traumatic brain injury-related symptoms were: pain/headache (47%), dizziness (36%), bladder/bowel impairment (34%), and sensory-perceptual deficits (34%). Participants reported minimal change in their physical function and cognition (Functional Assessment Measure: motor (median 102, IQR 93-111) and cognition (median 89, IQR 78-95)). Participants were well-adjusted to community-living; however, they reported high levels of depression. Factors significantly associated with poorer current level of functioning/well-being included: older age (≥ 60 years), presence of traumatic brain injury-related symptoms, a lack of previous rehabilitation and those classified in "severe disability categories" at admission. Caregivers reported high levels of strain and burden (55%). CONCLUSION: Cognitive and psychosocial problems are more commonly reported than physical disability in the longer-term. A greater focus on participation and ageing with disability in these persons is needed.

Implementation of a technology-assisted programme to intensify upper limb rehabilitation in neurologically impaired participants: A prospective study.

OBJECTIVE: To evaluate the implementation of a technology-assisted programme to intensify upper limb rehabilitation after stroke and other neurological conditions in an Australian community cohort. METHODS: A "Hand Hub" was established in a tertiary hospital. Intervention was delivered via individual or group sessions for a period of up to 6 weeks, in addition to the patients' regular therapy. Patients were assessed before and after the programme using validated measures. RESULTS: A total of 92 participants completed both assessments (mean age 57 years (standard deviation 17 years), 58% male and 88% with stroke). Post-intervention, participants showed significant improvement in arm function and strength (p < 0.001, effect sizes (r) = 0.5-0.7), streamlined Wolf Motor Function Test score (p < 0.05, r = 0.2-0.4), improved muscle tone on the Modified Ashworth Scale (p < 0.001, r = 0.4), Functional Independence Measure (locomotion, mobility and psychosocial subscales (p < 0.05, r = 0.2-0.3). Quality of life (EQ-5D) and overall health also improved significantly (p < 0.01 for all, r = 0.3-0.6). CONCLUSION: The "Hand Hub" programme is feasible and showed promising results for upper limb function in persons with neurological disorders. The findings need to be further confirmed in a larger study sample, with a longer follow-up.