Enhancing the conceptual clarity and utility of the international classification of functioning, disability & health: the potential of a new graphic representation.

PURPOSE: To present a new graphic representation of the international classification of functioning, disability and health (ICF), entitled the ICF-conceptual revision (ICF-CR). The ICF-CR aims to be clearer and more usable tool than the ICF graphic currently used by starting to address criticisms of the ICF raised in the literature, with a focus on positioning quality of life (QoL) in relation to the ICF's other components. METHOD: This is a conceptual paper based on a review of criticisms of the ICF and related literature published on human functioning. RESULTS: In addition to criticisms of the current graphic, four criticisms of the ICF are discussed in relation to the development of the ICF-CR, including: the lack of development of biopsychosocial theory, the lack of clarity between activities and participation, the language used, and the absence of QoL. General systems theory is used to help construct the new graphic in addressing these criticisms and to position QoL. CONCLUSIONS: The ICF-CR is designed to be a more responsive graphic of human functioning; one which enhances the clarity of principles integral to the ICF, including biopsychosocial theory and universalism. It is hoped the ICF-CR will promote continued discussion toward the goal of enhancing the ICF, both visually and conceptually.

Upper Extremity Motor Learning among Individuals with Parkinson's Disease: A Meta-Analysis Evaluating Movement Time in Simple Tasks.

Motor learning has been found to occur in the rehabilitation of individuals with Parkinson's disease (PD). Through repetitive structured practice of motor tasks, individuals show improved performance, confirming that motor learning has probably taken place. Although a number of studies have been completed evaluating motor learning in people with PD, the sample sizes were small and the improvements were variable. The purpose of this meta-analysis was to determine the ability of people with PD to learn motor tasks. Studies which measured movement time in upper extremity reaching tasks and met the inclusion criteria were included in the analysis. Results of the meta-analysis indicated that people with PD and neurologically healthy controls both demonstrated motor learning, characterized by a decrease in movement time during upper extremity movements. Movement time improvements were greater in the control group than in individuals with PD. These results support the findings that the practice of upper extremity reaching tasks is beneficial in reducing movement time in persons with PD and has important implications for rehabilitation.

Dual-task interference: the effects of verbal cognitive tasks on upright postural stability in Parkinson's disease.

Although dual-task interference has previously been demonstrated to have a significant effect on postural control among individuals with Parkinson's disease, the impact of speech complexity on postural control has not been demonstrated using quantitative biomechanical measures. The postural stability of twelve participants with idiopathic Parkinson's disease and twelve healthy age-matched controls was evaluated under three conditions: (1) without a secondary task, (2) performing a rote repetition task and (3) generating a monologue. Results suggested a significant effect of cognitive load on biomechanical parameters of postural stability. Although both groups increased their postural excursion, individuals with Parkinson's disease demonstrated significantly reduced excursion as compared with that of healthy age-matched controls. This suggests that participants with Parkinson's disease may be overconstraining their postural adjustments in order to focus attention on the cognitive tasks without losing their balance. Ironically, this overconstraint may place the participant at greater risk for a fall.

Predictive validity of the UPDRS postural stability score and the Functional Reach Test, when compared with ecologically valid reaching tasks.

Balance problems and falls are a common concern among individuals with Parkinson's disease (PD). Falls frequently occur during daily activities such as reaching into cupboards in the kitchen or bathroom. This study compared the correlation among two standard postural stability tests - the postural stability score on the Unified Parkinson's Disease Rating Scale (UPDRS) and the Functional Reach Test (FRT) - and ecologically valid reaching tasks that correspond to reaching at different cupboard heights among 20 individuals with PD and 20 age-matched controls. Both the FRT and the UPDRS postural stability tests are quick measures that can be performed during the clinical examination. The FRT, but not the postural stability score, demonstrated a significant correlation with the ecologically valid reaching tasks, among individuals with PD. Furthermore the FRT scores did not correlate with the UPDRS postural stability scores, indicating that these are measuring different aspects of balance. This study suggests that the FRT score may better predict the risk of postural instability encountered during daily activities among individuals with PD.

Plantar cutaneous sensory stimulation improves single-limb support time, and EMG activation patterns among individuals with Parkinson's disease.

Parkinson's disease is a chronic neurological disorder that results in gait and posture impairment. There is increasing evidence that these motor impairments may be partially due to deficits within the sensory system. In this study, the effects of a facilitatory insole that provides increased plantar sensory stimulation, was evaluated during gait, in a group of individuals with Parkinson's disease in comparison with healthy age-matched controls. Spatial-temporal parameters of gait were evaluated using an instrumented carpet, and muscle activation patterns were evaluated using surface EMG. All participants were tested with both a facilitatory (ribbed) insole and a conventional (flat) insole while walking 20 feet. Results indicated that the use of the facilitatory insole produced a significant increase in single-limb support time. Additionally, the muscle activation sequence of the tibialis anterior was normalized by the facilitatory insole, at the time of initial ground contact. These changes may lead to an overall improvement in gait pattern and stability, and suggest that the use of this type of facilitatory insole may be a useful treatment strategy for improving the gait of individuals with Parkinson's disease. This also provides support for the role of facilitation of the sensory system in improving motor output in individuals with Parkinson's disease.

An evaluation of sensorimotor integration during locomotion toward a target in Parkinson's disease.

Recent research suggests that basal ganglia dysfunction may result in problems integrating concurrent vision and proprioception during movement. We evaluated dopaminergic system involvement in this sensorimotor process during locomotion within a large sample of Parkinson's disease (PD) patients while "On" and "Off" their dopaminergic medications (n=25), in conditions that selectively manipulated the availability of proprioception, vision or both. The present experiment focused on two main objectives: i) to examine the relative influence of visual and proprioceptive inputs on locomotion and target accuracy in patients with PD; and ii) to examine the influence of dopamine replacement therapy on sensorimotor integration while moving toward the target. All participants walked at a self-selected pace on a GAITRite carpet in two baseline conditions (light and dark), as well as four experimental darkness conditions: a) to a remembered target (i.e. proprioception only), b) to a remembered target with light on chest for body position awareness (proprioception plus), c) with vision of a lit target, also with light on chest (vision and proprioception), d) pushed in wheelchair to remembered target (no proprioception or vision). Final position was measured by 2-D radial error, and revealed a group by condition interaction, suggesting that PD patients "Off" their medications move to targets with less accuracy, but approach the accuracy of healthy participants when in the "On" state. Both PD and healthy improved their accuracy with availability of concurrent vision and proprioception (condition c). Interestingly, our results demonstrate that PD "Off" performed the task with greater difficulty than when "On" medication, but only when proprioception was the sole source of feedback. Since PD, whether medicated or unmedicated were even more affected when proprioception was removed (wheelchair), a memory-related explanation can be ruled out. Our results suggest that the basal ganglia are not specifically involved in visuoproprioceptive integration; however, assimilation of proprioceptive feedback to guide an ongoing movement may be a critical function of the basal ganglia.

The influence of external orthotic support on the adaptive gait characteristics of individuals with chronically unstable ankles.

External orthotic supports or braces are used clinically to treat individuals with chronically unstable ankles. Braces have efficacious effects on dynamic strength, passive tissue tension, and proprioception, but their effects on gait remains undetermined. The purpose of this study was to determine if overground locomotion, including walking up a step and a curb are influenced by orthotic device use. Twenty subjects, 10 with no previous injury and 10 with chronically unstable ankles, performed with no brace, a flexible brace and a semi-rigid brace while walking on a level surface, up a step and on a ramp. Differences were noted in kinematic and kinetic gait parameters between groups and between step and ramp conditions, suggesting that gait patterns vary between individuals who have had ankle sprain and those who have not. Few differences were noted between the brace and no brace conditions for both groups. Adding to the previously described efficacious benefits, we conclude that bracing does not alter selected gait parameters in individuals who have chronic ankle instability.

Association among neuromuscular and anatomic measures for patients with knee osteoarthritis.

OBJECTIVE: To investigate neuromuscular and anatomic factors involved in varus gonarthrosis by identifying measures associated with degenerative changes. DESIGN: Descriptive study. Individual measures that explained substantial portions of the variability in ratings of knee joint-degenerative changes in patients with knee medial compartment osteoarthritis. SETTING: Outpatient orthopedic clinic and biomechanics and muscular assessment laboratory. PATIENTS: Volunteer sample of 20 subjects (age range, 59 +/- 9 yr) with no history of neurologic disease. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: We assessed degenerative changes, varus alignment, standing balance, and knee proprioception. Weight-bearing radiographs were used to assess the extent of degenerative changes and the degree of varus alignment. Single-limb standing balance control was assessed through tests performed on a force platform. Knee proprioception was assessed with an isokinetic dynamometer, using a joint angle replication test. RESULTS: Forward-stepwise multiple linear regression indicated that the extent of degenerative changes could be best predicted from a linear combination of the independent variables, varus alignment, and standing balance (R =.80, F(2,17) = 14.81, p =.0002). Sixty-four percent of the variability in ratings of degenerative changes was explained by alignment and standing balance measures (37% by varus alignment, 27% by standing balance). Alignment and balance measures were poorly correlated (r =.12, p =.63), further suggesting that they provided different information about gonarthrosis. CONCLUSIONS: Although varus alignment is widely accepted as a clinically important factor in gonarthrosis, and is the focus of many treatment efforts, our results suggest that objective measures of standing balance are also important. As a result, the potential impact of rehabilitation to improve the control of standing balance should be further evaluated in this patient population.

Knee bracing after ACL reconstruction: effects on postural control and proprioception.

PURPOSE: To evaluate the effects an anterior cruciate ligament (ACL) brace has on various measures of knee proprioception and postural control. METHODS: Thirty subjects (mean age 27 +/- 11 yr) having undergone unilateral ACL reconstruction were tested with and without wearing their own custom-fit brace on their involved limb. Proprioception was assessed using joint angle replication tests completed on an isokinetic dynamometer. Postural control was assessed using a series of single-limb standing balance tests completed on a force platform. The balance tests included: 1) standing on the stable platform with eyes open, 2) standing on a foam mat placed over the platform with eyes open, 3) standing on the platform with eyes closed, and 4) standing on the platform after landing from a maximal single-limb forward hop. RESULTS: The brace provided a small but statistically significant improvement in proprioception (mean reduction in error scores between target and reproduced angles = 0.64 +/- 1.4 degrees, P = 0.02). For the postural control tests, there was a significant brace condition by test situation interaction (P = 0.02), with the brace providing a small but statistically significant improvement during the test completed on the stable platform with eyes open (mean reduction in center of pressure path length = 4.2 +/- 8.4 cm, P = 0.02) but not during the other more challenging test situations. Additional post hoc analyses indicated that the relationship between knee proprioception and postural control measures were low and not significant (r = 0.003 to 0.19, P > 0.32), consistent with the suggestion that changes in knee proprioception can occur in the absence of substantial changes in postural control. Also, standing balance tests that challenged the somatosensory contribution to postural control (i.e., those completed on foam, or with eyes closed) were significantly related to single-limb forward hop distances (r = -0.4, P < 0.05), whereas performance during the proprioception test was not (r = 0.1, P > 0.50). CONCLUSIONS: In general, bracing appears to improve performance during tasks characterized by relatively limited somatosensory input but not during tasks characterized by increased somatosenory input. The small magnitude of the improvements, coupled with their apparent lack of carry over to more difficult and functionally relevant tasks, questions the clinical benefit of the present effects of bracing.

Androgen regulates the level and subcellular distribution of the AU-rich ribonucleic acid-binding protein HuR both in vitro and in vivo.

HuR, a member of the ELAV family of AU-rich RNA-binding proteins, is present in a variety of tissues and is directly involved in stabilizing labile AU-rich messenger RNAS: We have found that treating the human HepG2 cell line with 10 nM dihydrotestosterone (DHT) for 48 h decreases the total level of HuR by 75%. DHT decreases both cytosolic and nuclear HuR levels in HepG2 cells, but increases HuR levels in polyribosomes by 325%. In BALB/c mice, HuR levels in the submaxillary salivary gland (SMG) and the kidney display a dramatic sexual dimorphism, but those in the spleen and thyroid do not. DHT (200 microg) causes total HuR levels in female SMG and kidney to fall progressively, whereas, conversely, orchiectomy of males causes HuR levels to rise in these two tissues by 800% and 200%, respectively. As an internal control we probed the same blots for AUF1, a destabilizing AU-binding protein, and confirmed our previous findings showing that the cytosolic p37 isoform of AUF1 shows the opposite responses of cytosolic HuR in the SMG, and that the level of AUF1 in the kidney does not respond to DHT. In polyribosomes from female mouse SMG, HuR levels doubled after 6 h of DHT, but decreased by 80% after 24- and 48-h DHT treatment. Thus, the total level of HuR is regulated in two different androgen-responsive systems, as is the shuttling of HuR between different subcellular compartments. As AUF1 is responsive to androgen in the mouse SMG, but not in the kidney, tissue-specific posttranscriptional regulation of AU-rich messenger RNA metabolism could be mediated in part by differential androgen-dependent regulation of HuR and AUF1.

Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control.

OBJECTIVE: To evaluate the effects of a functional knee brace specifically designed for patients with varus gonarthrosis on measures of proprioception and postural control. SUBJECTS: Fourteen men and six women (aged 59+/-9 yr) with measurable varus alignment and osteoarthritis of the knee medial compartment. METHODS: Proprioception was assessed in the sitting position using an isokinetic dynamometer and was quantified as the ability to replicate target knee-joint angles. Postural control was assessed with a force platform using tests of single-limb standing balance performed, while the patient was standing on a stable surface and standing on foam, and was quantified as the total length of the path of the centre of pressure. All tests were performed with and without the patient's own custom-fit valgus brace. RESULTS: Proprioception was significantly improved following application of the brace [mean difference=0.7 degrees, 95% confidence interval (CI)=0.2 to 1.1 degrees ). Postural control was not significantly affected by the use of the brace during the stable surface test (mean difference=2.6 cm, 95% CI=-4.3 to 9.5 cm) or the foam surface test (mean difference=0.9 cm, 95% CI=-7.5 to 9.4 cm). CONCLUSION: Although enhanced proprioception may be partially responsible for reported improvements with the use of a brace, the present findings call into question the functional importance of the small changes observed.

Inhibiting proteasomes in human HepG2 and LNCaP cells increases endogenous androgen receptor levels.

Treating HepG2 cells with MG132 for 4 h to inhibit proteasomal activity increased androgen receptor immunoreactivity in two major bands with molecular weights of 102 and 110 kDa by 77% each (P < 0. 05). MG132 treatment also increased the overall level of polyubiquitinated proteins between 66 and 220 kDa by 140% (P < 0.05). Antiubiquitin immunoreactivity comigrating with the androgen receptor bands was also increased by MG132 treatment. Two other proteasome inhibitors, lactacystin and epoxomycin, caused similar increases in the androgen receptor in HepG2 cells. Proteosome-inhibition studies conducted in LNCaP cells also showed that the two major androgen receptor bands with molecular weights of 102 and 110 kDa were increased by 85 and 115%, respectively (P < 0. 05 for both) by MG132 treatment. Overall levels of polyubiquitinated proteins with molecular weights between 66 and 220 kDa increased 365%. Ubiquitin immunoreactivity comigrating with the androgen receptor bands was also significantly increased. Thus inhibiting proteasomes in two human androgen-responsive cell lines increases endogenous androgen receptor levels as well as androgen receptor-associated ubiquitin-modified immunoreactivity. The regulation of steady-state levels of endogenous androgen receptor by proteasomal degradation could be involved in its rapid turnover in the absence of ligand and would provide a mechanism for limiting androgen responses. A PEST sequence similar to one in the vitamin D receptor is present in the hinge region of all known mammalian androgen receptors, suggesting that it may function in proteasome-mediated androgen receptor turnover.

The internalization and endosomal trafficking of the EGF receptor in response to EGF is delayed in the waved-2 mouse liver.

The EGF receptor in waved-2 mice contains a point mutation that renders it kinase-deficient. We investigated how the waved-2 mutation affects the internalization and endosomal trafficking of the receptor in vivo in response to EGF. When the waved-2 mice were injected with EGF, there was approximately 50% less tyrosine phosphorylation detected in whole-liver homogenate compared to wild-type background mice. Although EGF increased the EGF receptor levels in the early and late liver endosomal fractions of waved-2 mice, its trafficking was delayed compared to wild-type mice. Ubiquitination of the EGF receptor may affect its endosomal sorting. We found that a similar amount of EGF receptor was immunoprecipitated from the endosomal fractions of EGF-treated waved-2 and wild-type with anti-ubiquitin antibody. These results demonstrate that the waved-2 EGF receptor can become ubiquitinated and can be trafficked to the late endosomes, although it appears that its kinase deficiency delays this process.

Testosterone and dihydrotestosterone regulate AUF1 isoforms in a tissue-specific fashion in the mouse.

The sex difference in the metabolism of certain mRNAs in the murine submaxillary gland (SMG) prompted us to determine whether androgens regulate the expression of any of the four isoforms of AUF1, proteins that bind differentially to AU-rich RNA. We found that cytosol from female SMGs contains two major isoforms (p45 and p40), whereas cytosol from male SMGs contains a prominent p37 and a weaker p42. Injecting female mice with testosterone decreases p45 levels by 81% after 7 days (P < 0.05, n = 4), whereas p42 and p37 increase 74 and 449% at 7 days (P < 0.05, n = 4, for both). Orchiectomy, conversely, decreases p37 levels in the male SMG by 91% (P < 0.006) while increasing p45 5-fold and p40 2.5-fold (P < 0.05, n = 5 for both). Both male and female kidney cytosol contains a prominent p37 and a faint band of approximately 42 kDa, but neither shows a significant change when circulating androgen levels are altered. Dihydrotestosterone (DHT) changes the pattern of AUF1 isoforms in female SMG cytosol more rapidly than does testosterone. Nuclear extracts from female SMG contain predominantly p45, and DHT decreases its level slightly (35%, P < 0.05 at 24 h). Polysomal extracts from female SMG contain p45 and p42, and DHT increases p45 levels 58% (P < 0.02, n = 6) at 24 h. In certain nonreproductive tissues, androgens may differentially regulate AUF1 isoform levels to modulate the metabolism of AU-rich mRNAs posttranscriptionally.

Biomechanical analysis of four supports for the subluxed hemiparetic shoulder.

External support systems, such as slings and lapboards, may reduce shoulder subluxation in individuals with hemiplegia. However there is controversy among occupational therapists concerning the most appropriate method to support the affected arm. The purpose of the present paper is to report the biomechanical analysis of four support systems; two shoulder support systems, a Bobath axillary roll, and a laptray. Two dimensional static biomechanical analyses determine the mechanical characteristics of each of these four support systems. The results of the analyses demonstrate the magnitude of the shoulder loading and the effectiveness of the various components of each of the systems. The effect of changing some of the characteristics of the slings is demonstrated. Slings with straps over the unaffected shoulder provide continuous support for the flaccid extremity. The Bobath axillary roll may introduce an unwanted lateral force. Lapboards must be maintained at an appropriate distance from the subluxed shoulder to be effective. This theoretical analysis of supports systems will provide therapists information to help them understand effective supports for subluxation.

Assessment and intervention with clients with apraxia: contributions from the literature.

Individuals with praxis problems encounter difficulties engaging in occupation, and the occupational therapists who work with these clients are challenged to provide intervention that enables occupational performance. This extensive review of the current literature provides clinicians with information regarding the relevant descriptions and suggested mechanisms of apraxia. Errors noted in performance, different classification systems and the implications of the current knowledge will be discussed. The paper concludes by providing information for clinicians regarding occupational therapy evaluation and intervention strategies for praxis problems.

Eccentric/concentric ratios at selected velocities for the invertor and evertor muscles of the chronically unstable ankle.

OBJECTIVE: The use of muscle balancing by the clinician to determine return to activity or discharge of a patient is not a well understood measure. Because of the lack of information on the poorly understood concept of eccentric/concentric (E/C) ratios at the ankle, the purpose was to determine the E/C ratios for the invertor and evertor muscles at various velocities in healthy and chronically unstable ankles. METHODS: Ten subjects with healthy ankles and 14 with chronically unstable ankles performed five maximal effort reciprocal eccentric/contraction contractions on an isokinetic dynamometer at four velocities (60, 120, 180, and 240 degrees/s) and for each physiological movement of inversion and eversion. Data were analysed using a two way mixed model analysis of variance with repeated measures, with Tukey's test used for post hoc analysis. RESULTS: Although the chronically unstable ankle was significantly weaker (p < 0.05) eccentrically and concentrically for inversion and eversion, the main effect of the E/C ratios for the ankle was not significant for either joint motion. The main effect of velocity was significant (p < 0.05) for each joint motion, but no significant interaction effects were observed. As velocity increased, the E/C ratio increased, except at 180 and 240 degrees/s for either ankle group. CONCLUSIONS: Chronic ankle instability and muscle weakness co-exist. Adequate E/C ratios in the chronically unstable ankle may exist in the absence of normal strength values.

Treatment of malignant pheochromocytomas with 131-I metaiodobenzylguanidine and chemotherapy.

Malignant pheochromocytomas have exhibited partial responses to treatments with 131-I metaiodobenzylguanidine (MIBG) and with chemotherapy. The authors combined these two therapeutic methods to determine if beneficial effects from each would be additive. Patients with documented malignant pheochromocytomas were recruited with the intent of administering 131-I MIBG in three substantial amounts of radioactivity at 3-month intervals followed by a year of chemotherapy in which cyclophosphamide, dacarbazine, and vincristine were to be given in 21-day cycles. Six patients entered the protocol. After the 131-I MIBG treatments, three patients manifested declines in the presence of tumor (smaller tumor volume or abnormalities on bone and 131-I MIBG scans) and the function of tumor (decreased rate of normetanephrine excretion as the major index). Two patients completed at least 9 months of chemotherapy and showed further reductions in the presence and function of tumors and were classified as having partial responses. Progressive disease afflicted three of the other four subjects. Even though toxicity was minimal from 131-I MIBG, it was sufficient to force reduction in the dosages or duration of chemotherapy. A combination of 131-I MIBG treatments and chemotherapy produced additive effects in reducing malignant pheochromocytomas. Toxicity moderately curtailed the proposed chemotherapy protocol.

Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee.

OBJECTIVE: To determine whether elderly individuals with chronic pain as a result of osteoarthritis of the hip and/or knee would report adaptations to their activities, or occupational adaptations, as a coping response to pain and, if so, to describe these adaptations and their relation to chronic pain, functional difficulty, depression, social support, and life satisfaction. DESIGN: Thirty elderly individuals completed rating scales and a structured questionnaire designed to measure occupational adaptation and the importance of activity. SETTING: Participants were community-dwelling elderly individuals and were interviewed in their homes or in a research office setting. PATIENTS: Consecutive orthopedic surgeon, family physician, or Arthritis Society patients, whose names were provided with the patient's consent, to the researcher. RESULTS: Individuals reported two approaches to occupational adaptation: they changed how they performed personal activities of daily living that they rated as most important and they stopped performing a number of avocational activities that they rated as less important. Statistically significant correlations were found among occupational adaptation, pain, depression, and difficulty with functioning. These variables were inversely related to life satisfaction. CONCLUSIONS: This sample of elderly individuals with chronic pain described occupational adaptations, or adaptations to "doing," as a means of coping with their chronic pain. There appeared to be a relation among pain, functional difficulty, depression, social support, and occupational adaptation. Additional research to increase the understanding of occupational adaptation as a means of coping with chronic pain is warranted.

Intraoperative dynamic MRI: localization of sites of brain tumor recurrence after high-dose radiotherapy.

In patients with malignant astrocytomas or metastatic brain disease treated with high-dose radiotherapy, conventional imaging methods may not adequately distinguish recurrent tumor from radiation change. We used a fast spoiled gradient refocusing technique in the open-configuration intraoperative MR system to assess the rate of regional enhancement of the treated tumor bed and to localize specific sites for pathologic sampling to determine whether gadolinium uptake correlated with histologic data. Twenty-four patients were studied. Fourteen of 15 patients with areas of early enhancement had recurrent tumor present in histologic samples, and 8 of the remaining 9 patients had only reactive changes. Dynamic MRI was predictive of recurrent tumor (P < .0005, Fisher exact test and P < .002, Student t test). We conclude that dynamic MRI in the open-bore magnet is a promising method for localizing potential sites of active tumor growth in patients treated for malignant astrocytomas and metastatic brain lesions.