Three-dimensional, task-specific robot therapy of the arm after stroke: a multicentre, parallel-group randomised trial.

BACKGROUND: Arm hemiparesis secondary to stroke is common and disabling. We aimed to assess whether robotic training of an affected arm with ARMin--an exoskeleton robot that allows task-specific training in three dimensions-reduces motor impairment more effectively than does conventional therapy. METHODS: In a prospective, multicentre, parallel-group randomised trial, we enrolled patients who had had motor impairment for more than 6 months and moderate-to-severe arm paresis after a cerebrovascular accident who met our eligibility criteria from four centres in Switzerland. Eligible patients were randomly assigned (1:1) to receive robotic or conventional therapy using a centre-stratified randomisation procedure. For both groups, therapy was given for at least 45 min three times a week for 8 weeks (total 24 sessions). The primary outcome was change in score on the arm (upper extremity) section of the Fugl-Meyer assessment (FMA-UE). Assessors tested patients immediately before therapy, after 4 weeks of therapy, at the end of therapy, and 16 weeks and 34 weeks after start of therapy. Assessors were masked to treatment allocation, but patients, therapists, and data analysts were unmasked. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT00719433. FINDINGS: Between May 4, 2009, and Sept 3, 2012, 143 individuals were tested for eligibility, of whom 77 were eligible and agreed to participate. 38 patients assigned to robotic therapy and 35 assigned to conventional therapy were included in analyses. Patients assigned to robotic therapy had significantly greater improvements in motor function in the affected arm over the course of the study as measured by FMA-UE than did those assigned to conventional therapy (F=4.1, p=0.041; mean difference in score 0.78 points, 95% CI 0.03-1.53). No serious adverse events related to the study occurred. INTERPRETATION: Neurorehabilitation therapy including task-oriented training with an exoskeleton robot can enhance improvement of motor function in a chronically impaired paretic arm after stroke more effectively than conventional therapy. However, the absolute difference between effects of robotic and conventional therapy in our study was small and of weak significance, which leaves the clinical relevance in question. FUNDING: Swiss National Science Foundation and Bangerter-Rhyner Stiftung.

Impact of a film portrayal of a police officer with spinal cord injury on attitudes towards disability: a media effects experiment.

PURPOSE: The portrayal of disabled people in the media can influence the public's perception of disability in both positive and negative ways. In this article, an experimental before and after design is used to determine the effects of a short film on the attitudes of non-disabled and disabled persons concerning employment and productivity of persons with disabilities. METHOD: Three questions were posed to 480 study participants prior to and following a short film featuring a police officer with paraplegia. Linear mixed models were used to assess the effects of time point and disability status on the responses. RESULTS: The non-disabled participants' ratings of eligibility for employment of a paraplegic man and estimates of the employment rate of disabled people were significantly enhanced following the film. Nevertheless, the film had no significant effects on the ratings given by participants with disabilities in terms of eligibility, employment rate or productivity. CONCLUSIONS: This investigation highlights the potentially important influence of media portrayal and coverage of people with disabilities on attitudes of the public concerning disability. IMPLICATIONS FOR REHABILITATION: Restrictions in participation may result from an interaction of persons with impairments with an environment that is dominated by negative attitudes towards disability The portrayal of disabled people in the media can influence the public's attitudes towards disability in both positive and negative ways In this experimental study, attitudes of the general public were significantly improved following viewing a short film featuring a positive media portrayal of a police officer with paraplegia.

Explaining the disability paradox: a cross-sectional analysis of the Swiss general population.

BACKGROUND: Disability can be broken down into difficulties in different components of functioning such as impairments and limitations in activities and participation (A&P). Previous studies have produced the seemingly surprising result that persons with severe impairments tend to report high quality of life (QoL) including perceived health regardless of their condition; the so-called "disability paradox". We aim to study the role of contextual factors (i.e. the personal and environmental situation) in explaining the disability paradox. METHODS: The Swiss Health Survey provides information on the perceived health of 18,760 participants from the general population. We construct a conditional independence graph applying random forests and stability selection in order to represent the structure of impairment, A&P limitation, contextual factors, and perceived health. RESULTS: We find that impairment and A&P limitations are not directly related but only via a cluster of contextual factors. Similarly, impairment and perceived health are not directly related. On the other hand, perceived health is directly connected with A&P limitations. We hypothesize that contextual factors have a moderating and/or mediating effect on the relationship of impairment, A&P limitations, and perceived health. CONCLUSION: The disability paradox seems to dissolve when contextual factors are put into consideration. Contextual factors may be responsible for some persons with impairments developing A&P limitations and others not. In turn, persons with impairments may only then perceive bad health when they experience A&P limitation. Political interventions at the level of the environment may reduce the number of persons who perceive bad health.

Functioning and disability in people living with spinal cord injury in high- and low-resourced countries: a comparative analysis of 14 countries.

OBJECTIVES: We examined whether persons with spinal cord injury (SCI) from countries with differential resources and resource distribution differ in the level and structure of functioning and disability. METHODS: We analysed cross-sectional data of 1,048 persons with SCI from 14 countries based on the International Classification of Functioning, Disability and Health (ICF). We used penalized logistic regression to identify ICF categories distinguishing lower- and higher-resourced countries. Hierarchical linear models were employed to predict the number of problems in functioning. The association structure of ICF categories was compared between higher- and lower-resourced countries using graphical models. RESULTS: A total of 96 ICF categories separated lower- and higher-resourced countries. Differences were not univocal. Lower resources and unequal distribution were predictive of more functional problems in persons with higher age or tetraplegia. In the graphical models, few associations between ICF categories persisted across countries. CONCLUSION: Higher-resourced countries do not score higher in all ICF categories. Countries' economic resources and their distribution are significant predictors of disability in vulnerable groups such as tetraplegics and the elderly. Functioning is multi-dimensional and structures of association suggest that country-specific pathways towards disability exist.

Visual perception and appraisal of persons with impairments: a randomised controlled field experiment using photo elicitation.

PURPOSE: Visual cues from persons with impairments may trigger stereotypical generalisations that lead to prejudice and discrimination. The main objective of this pilot study is to examine whether visual stimuli of impairment activate latent prejudice against disability and whether this connection can be counteracted with priming strategies. METHODS: In a field experiment, participants were asked to rate photographs showing models with mental impairments, wheelchair users with paraplegia, and persons without any visible impairment. Participants should appraise the models with regard to several features (e.g. communicativeness, intelligence). One hundred participants rated 12 photo models yielding a total of 1183 observations. One group of participants was primed with a cover story introducing visual perception of impairment as the study's gist, while controls received neutral information. RESULTS: Photo models with mental impairments were rated lowest and models without visible impairment highest. In participants who did not have prior contacts with persons with impairments, priming led to a levelling of scores of models with and without impairment. Prior contacts with persons with impairments created similar effects as the priming. Unexpectedly, a pattern of converse double discrimination to the disadvantage of men with mental impairments was revealed. CONCLUSION: Signs of stereotypical processing of visual cues of impairment have been found in participants of the Swiss general population. Personal contact with persons with impairments as well as priming participants seems to reduce stereotyping.

Cross-cultural validity of four quality of life scales in persons with spinal cord injury.

BACKGROUND: Quality of life (QoL) in persons with spinal cord injury (SCI) has been found to differ across countries. However, comparability of measurement results between countries depends on the cross-cultural validity of the applied instruments. The study examined the metric quality and cross-cultural validity of the Satisfaction with Life Scale (SWLS), the Life Satisfaction Questionnaire (LISAT-9), the Personal Well-Being Index (PWI) and the 5-item World Health Organization Quality of Life Assessment (WHOQoL-5) across six countries in a sample of persons with spinal cord injury (SCI). METHODS: A cross-sectional multi-centre study was conducted and the data of 243 out-patients with SCI from study centers in Australia, Brazil, Canada, Israel, South Africa, and the United States were analyzed using Rasch-based methods. RESULTS: The analyses showed high reliability for all 4 instruments (person reliability index .78-.92). Unidimensionality of measurement was supported for the WHOQoL-5 (Chi2 = 16.43, df = 10, p = .088), partially supported for the PWI (Chi2 = 15.62, df = 16, p = .480), but rejected for the LISAT-9 (Chi2 = 50.60, df = 18, p = .000) and the SWLS (Chi2 = 78.54, df = 10, p = .000) based on overall and item-wise Chi2 tests, principal components analyses and independent t-tests. The response scales showed the expected ordering for the WHOQoL-5 and the PWI, but not for the other two instruments. Using differential item functioning (DIF) analyses potential cross-country bias was found in two items of the SWLS and the WHOQoL-5, three items of the LISAT-9 and four items of the PWI. However, applying Rasch-based statistical methods, especially subtest analyses, it was possible to identify optimal strategies to enhance the metric properties and the cross-country equivalence of the instruments post-hoc. Following the post-hoc procedures the WHOQOL-5 and the PWI worked in a consistent and expected way in all countries. CONCLUSIONS: QoL assessment using the summary scores of the WHOQOL-5 and the PWI appeared cross-culturally valid in persons with SCI. In contrast, summary scores of the LISAT-9 and the SWLS have to be interpreted with caution. The findings of the current study can be especially helpful to select instruments for international research projects in SCI.

Dimension reduction in human functioning and disability outcomes research: graphical models versus principal components analysis.

PURPOSE: The complexity of rehabilitation outcomes in terms of functioning and disability leads to the need for dimension reduction in relation to specific research or clinical problems. Several statistical procedures are at hand. This article examines whether and to what extent principal component analysis (PCA) and graphical models differ in the dimension reduction of data based on the International Classification of Functioning, Disability and Health (ICF). METHODS: Using a data set of 1048 persons with spinal cord injury from 14 different countries as a case in point, this article compares the solutions in dimension reduction generated with a graphical model based on least average shrinkage selection operator (LASSO) regression on one hand and with a PCA on the other. RESULTS: Some factors extracted with the PCA properly match the clusters found with the graphical model, while in others less commonality can be found. In general, overlap ranges from 9 to 100% with 75% on average. Many of the discovered clusters or factors, i.e. dimensions, are compatible with the ICF structure, particularly in activity and participation. CONCLUSION: Functioning is a multidimensional, complex and dynamic outcome. We recommend being careful with dimension reduction based on statistical procedures alone. Theoretical considerations and clinical significance should always guide statistics. Stability of emergent dimensions that are compatible with theoretical or clinical considerations is a most important point. At least two different statistical procedures for dimension reduction, for instance PCA and LASSO regression, should be applied to conservatively select those dimensions that stay stable with both procedures.

Understanding human functioning using graphical models.

BACKGROUND: Functioning and disability are universal human experiences. However, our current understanding of functioning from a comprehensive perspective is limited. The development of the International Classification of Functioning, Disability and Health (ICF) on the one hand and recent developments in graphical modeling on the other hand might be combined and open the door to a more comprehensive understanding of human functioning. The objective of our paper therefore is to explore how graphical models can be used in the study of ICF data for a range of applications. METHODS: We show the applicability of graphical models on ICF data for different tasks: Visualization of the dependence structure of the data set, dimension reduction and comparison of subpopulations. Moreover, we further developed and applied recent findings in causal inference using graphical models to estimate bounds on intervention effects in an observational study with many variables and without knowing the underlying causal structure. RESULTS: In each field, graphical models could be applied giving results of high face-validity. In particular, graphical models could be used for visualization of functioning in patients with spinal cord injury. The resulting graph consisted of several connected components which can be used for dimension reduction. Moreover, we found that the differences in the dependence structures between subpopulations were relevant and could be systematically analyzed using graphical models. Finally, when estimating bounds on causal effects of ICF categories on general health perceptions among patients with chronic health conditions, we found that the five ICF categories that showed the strongest effect were plausible. CONCLUSIONS: Graphical Models are a flexible tool and lend themselves for a wide range of applications. In particular, studies involving ICF data seem to be suited for analysis using graphical models.