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Rehabilitation clinicians strive to provide cost-effective, patient-centered care that optimizes outcomes. A barrier to this ideal is the lack of a universal system for describing, or specifying, rehabilitation interventions. Current methods of description vary across disciplines and settings, creating barriers to collaboration, and tend to focus mostly on functional deficits and anticipated outcomes, obscuring connections between clinician behaviors and changes in functioning. The Rehabilitation Treatment Specification System (RTSS) is the result of more than a decade of effort by a multidisciplinary group of rehabilitation clinicians and researchers to develop a theory-based framework to specify rehabilitation interventions. The RTSS describes interventions for treatment components, which consist of a target (functional change brought about as a direct result of treatment), ingredients (actions taken by clinicians to change the target), and a hypothesized mechanism of action, as stated in a treatment theory. The RTSS makes explicit the connections between functional change and clinician behavior, and recognizes the role of patient effort in treatment implementation. In so doing, the RTSS supports clinicians' efforts to work with their patients to set achievable goals, select appropriate treatments, adjust treatment plans as needed, encourage patient participation in the treatment process, communicate with team members, and translate research findings to clinical care. The RTSS may help both expert and novice clinicians articulate their clinical reasoning processes in ways that benefit treatment planning and clinical education, and may improve the design of clinical documentation systems, leading to more effective justification and reimbursement for services. Interested clinicians are invited to apply the RTSS in their local settings.

The field of rehabilitation remains captive to the black-box problem: our inability to characterize treatments in a systematic fashion across diagnoses, settings, and disciplines, so as to identify and disseminate the active ingredients of those treatments. In this article, we describe the Rehabilitation Treatment Specification System (RTSS), by which any treatment employed in rehabilitation may be characterized, and ultimately classified according to shared properties, via the 3 elements of treatment theory: targets, ingredients, and (hypothesized) mechanisms of action. We discuss important concepts in the RTSS such as the distinction between treatments and treatment components, which consist of 1 target and its associated ingredients; and the distinction between targets, which are the direct effects of treatment, and aims, which are downstream or distal effects. The RTSS includes 3 groups of mutually exclusive treatment components: Organ Functions, Skills and Habits, and Representations. The last of these comprises not only thoughts and feelings, but also internal representations underlying volitional action; the RTSS addresses the concept of volition (effort) as a critical element for many rehabilitation treatments. We have developed an algorithm for treatment specification which is illustrated and described in brief. The RTSS stands to benefit the field in numerous ways by supplying a coherent, theory-based framework encompassing all rehabilitation treatments. Using a common framework, researchers will be able to test systematically the effects of specific ingredients on specific targets; and their work will be more readily replicated and translated into clinical practice.

Despite significant advances in measuring the outcomes of rehabilitation interventions, little progress has been made in specifying the therapeutic ingredients and processes that cause the measured changes in patient functioning. The general approach to better clarifying the process of treatment has been to develop reporting checklists and guidelines that increase the amount of detail reported. However, without a framework instructing researchers in how to describe their treatment protocols in a manner useful to or even interpretable by others, requests for more detail will fail to improve our understanding of the therapeutic process. In this paper, we describe how the Rehabilitation Treatment Specification System (RTSS) provides a theoretical framework that can improve research intervention reporting and enable testing and refinement of a protocol’s underlying treatment theories. The RTSS framework provides guidance for researchers to explicitly state their hypothesized active ingredients and targets of treatment; as well as how the individual ingredients in their doses directly affect the treatment targets. We explain how theory-based treatment specification has advantages over checklist approaches for intervention design, reporting, replication, and synthesis of evidence in rehabilitation research. A complex rehabilitation intervention is used as a concrete example of the differences between an RTSS-based specification and the Template for Intervention Description and Replication (TIDieR) checklist. The RTSS’s potential to advance the rehabilitation field can be empirically tested through efforts to use the framework with existing and newly developed treatment protocols.

Most rehabilitation treatments are volitional in nature, meaning that they require the patient's active engagement and effort. Volitional treatments are particularly challenging to define in a standardized fashion, because the clinician is not in complete control of the patient's role in enacting these treatments. Current recommendations for describing treatments in research reports fail to distinguish between 2 fundamentally different aspects of treatment design: the selection of treatment ingredients to produce the desired functional change and the selection of ingredients that will ensure the patient's volitional performance. The Rehabilitation Treatment Specification System (RTSS) is a conceptual scheme for standardizing the way that rehabilitation treatments are defined by all disciplines across all areas of rehabilitation. The RTSS highlights the importance of volitional behavior in many treatment areas and provides specific guidance for how volitional treatments should be specified. In doing so, it suggests important crosscutting research questions about the nature of volitional behavior, factors that make it more or less likely to occur, and ingredients that are most effective in ensuring that patients perform desired treatment activities.

BackgroundIt is unknown how impairments caused by multiple sclerosis (MS) affect upper limb capacity, performance, and community integration.ObjectiveThe aim of this study was to investigate the extent to which impairments explained the variance in activity level and participation level measures of the International Classification of Functioning, Disability and Health (ICF) and the extent to which upper limb capacity measures explained perceived performance on the activity level in people with MS and different dexterity levels.DesignThis was a cross-sectional study.MethodsA total of 105 people with MS (median Expanded Disability Status Scale=6.5) were assessed with measures on the ICF body functions and structures level (strength, active range of motion of the wrist, tactile sensitivity, tremor, spasticity, and pain), activity level (Nine-Hole Peg Test [NHPT], Action Research Arm Test, and Manual Ability Measure-36 [MAM-36]), and participation level (Community Integration Questionnaire). The sample was divided into low- and high-dexterity subgroups on the basis of the median score on the NHPT.ResultsIn the total group, muscle strength, tactile sensitivity of the thumb, and intention tremor explained 53% to 64% of the variance in activity level measures. In the low-dexterity subgroup, muscle strength and active range of motion explained 43% to 71% of the variance in activity level measures. In the high-dexterity subgroup, only 35% of the variance in the MAM-36 was explained by muscle strength. Capacity measures (NHPT and Action Research Arm Test) were moderately to highly associated with perceived performance (MAM-36) in the low-dexterity subgroup.LimitationsSome outcome measures showed ceiling effects in people with MS and a high dexterity level.ConclusionsUpper limb muscle strength is the most important impairment affecting capacity and perceived performance in daily life. Associations among outcome measures differ in people with MS and different dexterity levels.

BackgroundSelf-report measures of balance and multidimensional mobility assessments are common for people with a leg amputation, yet clinical assessment of balance ability remains less explored. The Berg Balance Scale (BBS), typically used for other populations with impaired balance, has been used for young people with a high level of functioning after traumatic amputation but rarely for older people after vascular amputation.ObjectiveThe study objective was to examine the psychometric properties of the BBS with Rasch rating scale analysis to determine the validity and utility of the BBS in assessing balance ability in adults who have a leg amputation and dwell in the community.DesignRating scale analysis was applied to BBS scores obtained from a single assessment.MethodsAdult volunteers (men and women) who had a leg amputation (any level and etiology) and dwelled in the community were recruited from a hospital-based community support group and a prosthetic clinic. Rating scale analysis of the BBS was used to assess unidimensionality, internal validity, goodness of fit, structural integrity, and person and item analyses.ResultsThe study participants were 40 people (26 men and 14 women; 57.8 [SD=9.7] years old) with leg amputations (24 transtibial, 13 transfemoral, and 3 bilateral) of mixed etiology (32 vascular and 8 nonvascular). The psychometric properties of the BBS confirmed that it measures the unidimensional construct of balance ability with adequate validity and with goodness of fit and structural integrity that meet the acceptability criteria. Person measures revealed that some participants scored near the top of the BBS, suggesting a ceiling effect; item measures revealed that participants with leg amputations had the most difficulty performing the following tasks: standing with 1 leg in front, turning 360 degrees, and placing alternate foot on a stool.LimitationsLimitations included a convenience sample and a lack of rater reliability testing.ConclusionsThe BBS cohered with the unidimensional construct of balance ability and had strong internal validity for use in a variety of people with leg amputations.

Lu W-S, Chen CC, Huang S-L, Hsieh C-L. Smallest real difference of 2 instrumental activities of daily living measures in patients with chronic stroke. Objective To estimate the smallest real difference (SRD) values of 2 instrumental activities of daily living measures (the Nottingham Extended Activities of Daily Living [NEADL] and the Frenchay Activities Index [FAI]) in patients with chronic stroke. Design Test-retest reliability study. Setting Physical rehabilitation units of 5 hospitals. Participants Chronic stroke patients (N=52; 37 men, 15 women) who were discharged from the hospital for more than 6 months. Interventions Not applicable. Main Outcome Measures Both measures were administered twice about 2 weeks apart to participants. The SRD was calculated on the basis of standard error of measurement: SRD=1.96 × √2 × Standard error of measurement. SRD% (the value of SRD divided by total score of a measure) was used to compare measurement errors across both measures. Reproducibility between successive measurements of the measures was investigated with intraclass correlation coefficients (ICCs). Results The SRD (SRD%) values of the NEADL and the FAI were 12.0 (21.1%) and 6.7 (14.9%), respectively. Test-retest reproducibility of both measures was high (ICC: NEADL=.89, FAI=.89). Conclusions Because of substantial SRD values of the NEADL and the FAI, prospective users should be cautious in using both measures to detect real change for a single subject.

Objective To evaluate the safety of preoperative enoxaparin in patients undergoing major gynecologic oncology surgery. Methods We identified a retrospective cohort group of patients undergoing major gynecologic oncology surgery from June 2002 to June 2004. Exclusion criteria included laparoscopic surgery, inferior vena cava filter, history of venous thromboembolism, and current anticoagulation for prior venous thromboembolism. All patients received prophylaxis with sequential pneumatic compression devices and early ambulation. We identified patients who received (preoperative and postoperative) enoxaparin (20–40 mg) and compared them to patients who received no additional prophylaxis other than pneumatic compression alone. Patient outcomes including estimated blood loss, blood transfusions, operative time, and length of hospital stay were collected. Statistical analysis was performed using the χ2 Wilcoxon rank sum tests. This study was approved by the institutional review board. Results We identified 122 patients who met our study criteria; there were 63 patients who received preoperative enoxaparin and 59 patients who received no additional prophylaxis. Both groups were similar in age, body mass index, race, comorbidities, cancer diagnosis, and surgical procedure. There was no significant difference between the enoxaparin group and the sequential pneumatic compression devices–only group regarding transfusion rates (29% and 27%; P = 0.86), operating time (150 and 140 minutes; P = 0.16), blood loss greater than 500 cc (35% and 37%; P = 0.79), and length of stay (5 vs 6 days). Conclusion The use of preoperative enoxaparin is not associated with increased blood loss, transfusion requirements, operative time, or hospital stay among patients having major gynecologic surgery.

Our aim was to compare perioperative patient controlled epidural analgesia (PCEA) versus patient controlled intravenous analgesia (PCA) after gynecologic oncology laparotomy.This was a prospective cohort study where perioperative pain management was decided through patient-centered discussion by anesthesia and surgical teams. The study was designed to accrue 224 patients, to test for equivalence in pain control on postoperative day 1, defined as less than a 10% difference in the proportion of patients with a visual analog scale pain score of2 (0-10 scale).Two hundred forty patients were enrolled, with 205 patients evaluable for outcomes: 98 received PCA, while 107 received a thoracic level PCEA. Utilization of PCEA was associated with longer anesthesia time pre-op (means: 60 vs. 44 min, p0.0001), as well as more likely use of pressors during surgery (78% vs. 57%, p=0.002). Pain control was comparable between groups on postoperative day 1 (mean VAS: 2.4 vs. 2.5, p=0.56), but patients with PCEA tended to require more supplemental pain medications. Time to first ambulation was longer in the PCEA patients (means: 49 vs. 36 h post-op, p=0.03), with no difference in time to tolerating regular diet (means: 89 vs. 77 h post-op, 0.17) and no difference in readiness for discharge (means: 144 vs. 145 h post-op, p=0.95).In this nonrandomized prospective study, selection of a PCEA for perioperative pain management did not improve pain management for patients undergoing gynecologic oncology surgery.

Objective. To investigate the test-retest reproducibility and smallest real difference (SRD) of 3 hand strength tests (grip, palmar pinch, and lateral pinch) and 2 dexterity tests (the Box and Block test [BBT] and the Nine Hole Peg test [NHPT]) in patients with stroke. Methods. The 5 tests were administered on 62 stroke patients in 2 sessions, 3 to 7 days apart. The intraclass correlation coefficient (ICC) was used to determine the level of reproducibility between measurements on 2 sessions. The SRD was used to determine the extent of measurement error because of chance variation in individual patients. SRD percentage (SRD relative to mean score) was used to compare test-retest reliability across tests. We analyzed the group as a whole, then in 2 subgroups (hand spasticity vs none). Results. The test-retest reproducibility of all 5 tests was high for all the patients, with ICCs ranging from 0.85 to 0.98. The SRDs for the more/less affected hand were: 2.9/4.7 kg for the grip test; 1.2/1.3 kg for the palmar pinch test; 1.4/1.0 kg for the lateral pinch test; 5.5/7.8 blocks/minute for the BBT; and 32.8/6.2 seconds for the NHPT. Unacceptably high SRD percentages (>30%) were found for the affected hand using the NHPT (54%), palmar pinch (35%), and lateral pinch (34%). When comparing these indices for participants with spasticity versus none for all 5 tests, the ICCs were lower and the SRD and SRD percentage were higher for the spasticity group. Conclusions. All 5 tests demonstrated satisfactory test-retest reproducibility for a diverse group of patients with stroke. However, all tests showed higher levels of measurement error when performed with the more affected hand and in patients with hypertonicity of that hand. Thus, baseline and postrehabilitation change scores using these common tests of strength and dexterity must be interpreted with some caution, especially in poorly controlled clinical trials. Repeated measures ought to be incorporated to examine reliability within a trial that includes participants with a hypertonic hand.

Objectives: The home health care (HHC) setting is unique because it is both a household and a care-giving environment. As such, it may present a risk for adverse events that could affect the health and safety of HHC patients. This study assessed and characterized unsafe household conditions with implications for patient safety in the HHC setting. Methods: A convenience sample of HHC registered nurses (RNs) from New York State completed a self-administered survey, which addressed the type and frequency of hazardous conditions in the households of their current patients. These nurses were asked to report on potential hazards (biological, chemical, environmental and physical, and violence) observed in patients’ households. Results: A total of 738 RNs completed the survey. Hazardous household conditions were frequently reported including animal hair (n = 543, 74%), cigarette smoke (n = 534, 72%), excessive dust (n = 428, 58%), vermin (n = 328, 44%), and unsanitary conditions (n = 317, 43%). The threat of violence was also frequently reported. Hazardous conditions were significantly associated with a number of patient-related factors. Conclusions: Hazardous conditions identified in the households of HHC patients present a well-documented risk of injury/illness in the community setting and may also present occupational risk to caregivers. Many of these hazards are readily modifiable, although others may be less amenable to intervention. Additional studies are warranted in order to further assess and characterize the prevalence and risk factors for hazardous household conditions and to determine the relationship between these conditions and adverse patient safety events in the home care setting.

The purpose of this study is twofold: (1) to describe the hand strength, self-reported manual ability and health status in individuals with osteo- or rheumatoid arthritis, and (2) to evaluate the scale (psychometric) properties of the 36-item Manual Ability Measure (MAM) as it applied to this sample. We administered four self-report assessments to the participants and measured their grip and pinch strength. The results indicated that persons with arthritis had decreased grip and pinch strength, more functional limitations, compromised health status and restricted participation in everyday occupations when compared to the general population. Manual ability was not related to grip strength, but was significantly related to role restriction (i. e., SF-36 Role Physical domain). The study provides evidence that the MAM has adequate psychometric properties when used with patients with osteo- or rheumatoid arthritis.

Clinician feedback and thought processes about treatment classification and description will aid development of the rehabilitation treatment taxonomy (RTT) presented in this supplement. Here, we discuss comparisons between the proposed RTT and an inductive practice-based evidence (PBE) model used to describe rehabilitation treatments. Interviews with clinicians well versed with PBE highlight the complexity of rehabilitation treatments, and bring to light potential advantages and challenges of a deductive, theory-driven classification to uncover the black box of rehabilitation.

The purpose of this study was to develop an easy-to-use and psychometrically sound outcome instrument that is task-oriented and patient-centred. One hundred fifteen patients with a variety of hand impairments completed a rating scale of perceived manual ability (i.e., the Manual Ability Measure). The first 70 patients also completed two other questionnaires about physical health and psychological well-being. Rasch Analyses were conducted to transform the ordinal ratings into linear measures; Rasch statistics were used to evaluate its measurement properties at both scale and item levels. Eighty-three original items were reduced to 16 common tasks; Rasch reliabilities were good; the easy-to-difficult item hierarchy makes sense clinically. Moderate correlations were found between manual ability, physical function and general sense of well-being. The results of this preliminary study suggest that the MAM is a promising outcome measure that has adequate psychometric properties and can be used to complement other objective clinical measurements.

Objective: Falls are common among adults with leg amputations and associated with balance confidence. But subjective confidence is not equivalent with physical ability. This multivariate analyses of community-dwelling adults with leg amputations examined relationships among individual characteristics, falls, balance ability and balance confidence. Design: Cross-sectional study. Subjects/Patients: Community-dwelling adults with leg amputations recruited from a support group and prosthetic clinic. Methods: Subjects provided self-reported medical/fall history, prosthetic functional use, and Activities-specific Balance Confidence (ABC) questionnaire data. Balance ability was assessed with the Berg Balance Scale (BBS). Fall incidence was categorized as any fall (one or more) and recurrent falls (more than one). Multivariate logistic regression analyzed relationships within the two fall categories. Cross tabulations and ANOVA analyzed differences among subcategories. Results: Fifty-four subjects (mean age 56.8) with various etiologies, amputation levels, and balance abilities participated. 53.7% had any fall; 25.9% had recurrent falls. Models for both fall categories correctly classified fall history in > 70% of subjects with combinations of the variables ABC, BBS, body-mass-index, and amputation level. Conclusion: Falls occurred regardless of clinical characteristics. Total BBS and select item scores were independent determinants of fall history. Unlike other balance-impaired populations, adults with leg amputation and better balance ability had greater odds of falling.

Objective: Knowing the prevalence of obesity and orthopedic comorbidities associated. Design: Cross sectional descriptive study. Setting: Public elementary school in El Remolino Zacatecas, Mexico. Participants: Students of a rural elementary school who were between 6 and 11 years old. Interventions: Not applicable. Main Outcome Measures: Sex, gender, height, weight, body mass index (BMI) adjusted with latest parameters of the International Obesity Task Force (IOFT), postural alterations in foot, knees, and spine. We applied the Mann-Witney U test in order to relation normal weight, overweight and obesity with flat foot, knee alterations (genu varum and genu valgum) and spine curvature disorders (lordosis and kyphosis). Level of Evidence: 1. Results: Of the total child populations studied (76) we found 42 children with normal weight (55.3%), 18 overweight (23.7%), 8 obese (10.5%), and 8 with morbid obesity (10.5%). Spine curvature alterations: a significant correlation (p1⁄40.001) was found between elevated (above 25kg/m) BMI and the presence of kyphosis or lordosis. In knees we found a very significant correlation (p1⁄40.001) between children with BMI above 27 kg/m and the presence of one knee orthopedic alteration. Finally we did not find such a significant relation between the presence of overweight or obesity and flat foot (p1⁄40.038) thus the majority of children with it were obese (7 out of 13). Conclusions: Childhood overweight and obesity have a global prevalence of 10% and 3% respectively; Mexico is first place worldwide with a combined prevalence of overweight and obesity of 26% in children population. There is a wide spectrum of orthopedic alterations aggravated by obesity. In this research data we correlated a narrow relation between obesity and knee and spine curvature alterations. It is necessary to conduct new clinical investigations to understand the severity of this association in order to establish early diagnostic and treatment guidelines.

Background: There has been limited research on upper limb dysfunction in people with multiple sclerosis (PwMS). Objective: The objective of this paper is to study unilateral and bilateral upper limb dysfunction at different International Classification of Functioning (ICF) levels according to overall disability in PwMS. Methods: A total of 105 PwMS (16 with EDSS6.5 (severe non-ambulant)) were recruited from two rehabilitation centers and assessed in a cross-sectional study. Results: The whole sample showed a diminished sensory function (median (first/third interquartile)) score of 3 (2/3) on the Monofilament Test and a reduced strength 91 (76/100) points on the Motricity Index (Body-Function level). Sensory dysfunction did not increase with higher EDSS while strength decreased from 100 (86/100) in the mild subgroups to 91 (80/100) points in the severe subgroup. All showed diminished dexterity, scoring 0.28 peg/s (0.17/0.35) on the Nine-Hole Peg Test (NHPT) (activity level). Score was better for the mild (0.38 (0.35/0.46)) peg/s compared to the severe subgroup (0.28 (0.17/0.35)). Sixty-eight percent, 44% and 75% of PwMS showed bilateral disorders in sensation, strength and dexterity, respectively. The Community Integration Questionnaire (participation level) showed a 35% reduction in home activities, even among PwMS with EDSSConclusion: This study showed uni-/bilateral upper limb abnormalities at all ICF levels increasing with the overall disability.

OBJECTIVE. To examine the responsiveness of the Manual Ability Measure–36 (MAM–36) compared with a clinician-administered functional assessment. METHOD. The MAM–36 was administered to 46 patients (Cohort A, n = 20; Cohort B, n = 26) with various upper-extremity conditions. All patients received occupational therapy intervention for 2–37 wk and were retested at discharge. Additionally, the Smith Hand Function Test (SHFT), including task performance speeds and grip strength measurements, was administered to Cohort B at intake and discharge. RESULTS. Manual ability improved significantly at discharge in all patients. Patients also showed significant improvement on the SHFT. The correlation between gain in MAM–36 and gain in grip strength was moderate. The standardized response mean for the MAM–36 was 1.18. CONCLUSION. The MAM–36 was responsive to changes in hand function in patients receiving occupational therapy services. MAM–36 results correlated positively with improvements in task performance speeds and grip strength.

This study was designed to examine the effect of two copying strategies on children's recall of the Rey-Osterrieth Complex Figure (ROCF). The study included 75 children with learning disabilities (LD) and 75 typical children (NC). Children were assigned to either a three-step strategy (condition A), a seven-step strategy (condition B), or a no-strategy condition (condition C), with 25 children in the LD and NC groups in each condition. Children copied the ROCF and then drew it from memory immediately after. The results showed that the NC group performed better than the LD group on recall accuracy, and the groups receiving a strategy performed better than groups without a strategy. For recall organization, children in conditions A and B did better than children in condition C. However, there was no significant difference between the NC and the LD groups in condition A. For recall style, more drawings were “configurational” when a strategy was provided for both the LD and NC groups. This study confirmed that breaking down the steps of a complex task may facilitate its learning.

For people with lower-limb loss, impaired balance is common and limits prosthetic function within the community. This cross-sectional study (1) analyzed relationships among prosthetic use for mobility, balance ability and confidence, and amputation-related variables and (2) determined multivariate models to identify level of prosthetic use. Subjects included 46 community-dwelling adults (mean age 56.2 yr) with limb loss (91.3% unilateral) of varied levels (52.2% transtibial) and etiologies (69.6% vascular). A three-variable linear regression model including balance ability, balance confidence, and years since amputation explained 63.7% of variance in the Houghton scale of prosthetic use score. A logistic regression model including the 14-task Berg Balance Scale, balance confidence, years since amputation, age, and number of comorbidities correctly differentiated between people who had reached a satisfactory level of prosthetic use or not 89.1% of the time. The first three variables demonstrated moderate accuracy with positive likelihood ratios from 2.34 to 4.35. The regression model was further reduced to correctly classify 87.0% of cases with three balance ability tasks (retrieving objects from floor, turning to look behind, and placing alternate foot on stool), balance confidence, and numbers of comorbidities. Logistic models that include balance ability, balance confidence, and numbers of comorbidities can identify level of prosthetic use in people with lower-limb loss. Increased balance confidence and ability when retrieving objects from floor, turning to look behind, and placing alternate foot on stool were most indicative of successful prosthetic use for mobility.

Occupational therapists often treat children with constructional difficulties. Constructional deficits have been extensively researched in the rehabilitation and neuropsychological literature on adults with brain damage. Little research has been conducted, however, on children's constructional disabilities. This paper provides a literature review on (1) how constructional functions are assessed in adults with brain damage and in typical and atypical children; (2) the development of constructional abilities in typical children; and (3) the similarities and differences in performance "errors" made by adults with brain damage and by typical and atypical children. It is hoped that the knowledge gained from these areas can help occupational therapists to better assess and treat children with constructional difficulties. Clinical implications and principles for intervention are suggested.

Objective To develop and validate the Taiwanese Manual Ability Measure for Burns (T-MAM for Burns), a task-oriented functional evaluation tool to assess self-reported manual ability in burn patients. Design A longitudinal study. Participants A sample of 45 burn patients from burn rehabilitation centers with varying degrees of hand involvement. Methods The preliminary testing version was formed by adding burn specific items to the Taiwanese version of the Manual Ability Measure. A field test was then conducted for item reduction and psychometric properties testing. Results Out of 55 initial items, 20 were selected into the final version of the T-MAM for Burns. Psychometric analyses indicated that it was reliable (test–retest ICC = .99), with adequate concurrent validity with various other hand function tests (r = −.79 with the short form Disabilities of the Arm, Shoulder, and Hand, or, the QuickDASH) and discriminative validity (significant difference (t = 2.99, P = .005) between groups with unilateral vs. bilateral hand burns), and responsive (ES = .24 and .44 at one- and 3-month evaluations). Conclusion This study shows that the T-MAM for Burns has great potential to be a functional outcome measure for burn rehabilitation. Additional research with a larger sample should be conducted to further confirm its validity and reliability.

The aims of this study were to identify factors or barriers in therapists' decisions to acquire and use new technology devices (NTDs) and to examine rating differences across therapy disciplines.Literature review, key informant interviews, and focus group sessions were conducted to define a conceptual framework of acceptance/resistance of NTDs and to develop survey items. The survey was subsequently mailed to therapists.The survey responses showed that billability of services, having a sufficient caseload using a device, and initial cost were the most important factors in acquisition decisions; that patient acceptance, suitability for the setting, and logistics were the most important factors in use decisions; and that negative patient outcomes, problems with reimbursement, and perceived lack of patient interest were the most significant barriers to their use. Patient safety, motivation, and cognition were the most important patient considerations in the therapist's decision to use NTDs with a particular patient, whereas lack of progress, unavailability of the participants post discharge, and requiring too much patient effort were the most significant barriers to the use of NTDs with particular patients. Some rating variations existed across disciplines.This study confirmed that rehabilitation therapists consider clinical and practical factors, as well as the match between the patient and the device, when making acquisition and use decisions of NTDs. Research and education implications were discussed.

Chen CC, Bode RK. Psychometric validation of the Manual Ability Measure-36 (MAM-36) in patients with neurologic and musculoskeletal disorders. Arch Phys Med Re- habil 2010;91:414-20. Objectives: To evaluate the psychometric properties of the Manual Ability Measure-36 (MAM-36), a new hand function outcome measure, and to examine differences in manual abil- ities and item parameters in patients with neurologic and mus- culoskeletal conditions. Design: Convenience sample from 2 time periods, cross-sectional. Setting: Outpatient rehabilitation units and private hand clinics. Participants: Patients (N337; mean age, 50.314.9y) with a variety of neurologic and musculoskeletal (orthopedic) diagnoses. Most of these individuals were community dwell- ing, and all had residual functional limitations in the hand(s). Interventions: Not applicable. Main Outcome Measures: Rasch analysis was performed on MAM-36 data to evaluate both scale structure and psycho- metric properties, which include rating distribution, step mea- sures, item fit, separation, and dimensionality. A t test was performed to examine the differences in manual abilities in patients with the 2 conditions. Uniform differential item func- tioning (DIF) between neurologic and musculoskeletal groups was examined. (DIF occurs when subgroup members within the sample with the same level of the underlying trait being measured respond differently to an individual item.) Manual ability estimates were recalibrated with step and common item anchoring; they were compared with those derived from the original analysis. Results: The 36 items measured a single construct with no misfitting items. The scale was used as intended. The items can reliably separate the participants into 5 ability strata. Neuro- logic patients had a significantly lower mean manual ability than musculoskeletal patients. Fourteen items exhibited DIF. However, DIF had no effect on either scale quality or calibra- tion of manual ability. We decided that a single rating scale is appropriate for both groups. Conclusions: This study showed that the MAM-36 has more than adequate psychometric properties and can be used as a

OBJECTIVE. To examine the relationships between self-reported and performance-based hand function. METHOD. Thirty participants with hand function limitations completed the Manual Ability Measure (MAM–36) and the Upper Extremity Performance Test for the Elderly (TEMPA). Participants were categorized into two groups: (1) Dominant Hand Affected and (2) Nondominant Hand Affected. Correlations between the two assessments were examined. The speed of task execution and TEMPA scores were compared between the two groups. RESULTS. A significant correlation was found between the MAM–36 and TEMPA Total Functional Rating (ρ = 0.79, p < .05). Significant differences were found in the speed of execution of unilateral tasks and the Unilateral Functional Ratings between the two groups. CONCLUSION. The MAM–36 is a promising assessment tool for measuring a client's perceived hand function. However, a performance-based assessment can supplement information about the quality and speed of hand-task performance.

Chen CC, Kasven N, Karpatkin HI, Sylvester A. Hand strength and perceived manual ability among patients with multiple sclerosis. Objectives To describe hand function among patients with multiple sclerosis (MS) and to examine the relationship between strength and self-reported abilities. Design Cross-sectional study using a convenience sample. Setting Outpatient department at a rehabilitation center. Participants Forty-four community-dwelling adults with MS (mean age, 49±9y; range, 34−68y) who were monitored by rehabilitation practitioners. Interventions Not applicable. Main Outcome Measures Grip and pinch (tip, lateral, palmar) strengths and Manual Ability Measure (MAM-36). Results When compared with the 50- to 54-year-old female norms, the pinch and grip strengths of the sample were lower. MAM-36 correlated moderately with right pinch (tip, lateral, palmar) strengths ( r range, .51−.59; P Conclusions Manual ability seems to be more associated with pinch than grip strengths, probably because finger strength and dexterity are both needed to perform many hand tasks.

Objectives To explore the factor structure of the Kessler Foundation Neglect Assessment Process (KF-NAP), and evaluate the prevalence and clinical significance of spatial neglect among stroke survivors. Design Inception cohort. Setting Inpatient rehabilitation facility (IRF). Participants Participants (N=121) with unilateral brain damage from their first stroke were assessed within 72 hours of admission to an IRF, and 108 were assessed again within 72 hours before IRF discharge. Interventions Usual and standard IRF care. Main Outcome Measures During each assessment session, occupational therapists measured patients' functions with the KF-NAP, FIM, and Barthel Index (BI). Results The KF-NAP showed excellent internal consistency with a single-factor structure. The exploratory factor analysis revealed the KF-NAP to be unique from both the FIM and BI even though all 3 scales were correlated. Symptoms of spatial neglect (KF-NAP>0) were present in 67.8% of the participants at admission and 47.2% at discharge. Participants showing the disorder at IRF admission were hospitalized longer than those showing no symptoms. Among those presenting with symptoms, the regression analysis showed that the KF-NAP scores at admission negatively predicted FIM scores at discharge, after controlling for age, FIM at admission, and length of stay. Conclusions The KF-NAP uniquely quantifies symptoms of spatial neglect by measuring functional difficulties that are not captured by the FIM or BI. Using the KF-NAP to measure spatial neglect, we found the disorder persistent after inpatient rehabilitation, and replicated previous findings showing that spatial neglect adversely affects rehabilitation outcome even after prolonged IRF care.

To investigate the measurement properties of the WeeFIM instrument and examine the developmental differences in motor item difficulty in a pediatric inpatient rehabilitation sample.Database approach, retrospective study, using 814 WeeFIM records from 12 facilities. Rasch rating scale analysis was used for all analyses. Data for the complete sample were used to evaluate the dimensionality and item fit of the WeeFIM instrument. Patients were then divided into three age groups,3 yrs of age (toddlers), 3-7 yrs of age (preschoolers and kindergartners), and7 yrs of age (school-age children), and their data were used to compare the order of motor items by level of difficulty within and across different age groups.Principal component analysis of the WeeFIM suggests distinct motor and cognitive scales. Within the motor scale, bowel and bladder items misfit, suggesting they measure a distinct aspect of function. The order of motor item difficulty, an indicator of construct validity, varies across age groups, suggesting that motor tasks present different challenges to children at different developmental stages: toileting is the most difficult, whereas locomotion is the easiest motor item for toddlers. For children3 yrs of age, eating is easiest and stair climbing is most difficult, followed by tub transfer and bathing.Similar to the adult FIMtrade mark instrument, the WeeFIM instrument has two distinct dimensions. The motor items form a unidimensional construct with acceptable measurement properties. Developmental differences in motor task mastery among children with disabilities are assumed but rarely tested. As evidenced by the age-specific item hierarchies found in this study, developmental differences among children with disabilities mimic that of children without disabilities.

OBJECTIVES. Relatively little is known about the treatment effectiveness and functional outcomes of pediatric rehabilitation therapies. This study was conducted to gain knowledge of the type and quantity of inpatient rehabilitation services provided to children who received acute inpatient rehabilitation and compare functional gains by age and diagnosis. METHOD. A retrospective cohort design was used. Records of rehabilitation therapies and functional assessments of 814 pediatric patients who received inpatient rehabilitation during 1996, 1997, and 1998 were collected. The admission and discharge item ratings of the WeeFIM® instrument were first transformed into inter-val-level measures of self-care, mobility, and cognition. Parametric analyses were used to compare functional gains across impairment groups and to examine the relationship between amount of treatment and functional gains. RESULTS. Occupational therapy and physical therapy were the primary rehabilitation services received by patients across impairment groups (98% and 99%, respectively). A large proportion of children with traumatic brain injuries also received speech therapy (97%) and psychology services (60%). Across domains (selfcare, mobility, cognition), the largest gains were made by children who were older than 7 years and had traumatic injuries. Functional gains were significantly related to the amount of discipline-specific treatment received, after controlling for age, impairment, and functional status at admission. CONCLUSION. Rehabilitation therapy provision in pediatric inpatient rehabilitation varies greatly depending on children’s age and the nature of the impairment. Systematic reporting of type and quantity of rehabilitation therapies along with functional assessments before and after hospitalization would allow researchers to track functional changes and study the determinants of functional improvement.

Chen CC, Heinemann AW, Granger CV, Linn RT. Functional gains and therapy intensity during subacute rehabilitation: a study of 20 facilities. Arch Phys Med Rehabil 2002;83:1514-23. Objectives: To document patient, program characteristics, and therapy service provision in subacute rehabilitation across 3 types of facilities that provide subacute rehabilitation, to examine the determinants of therapy intensity, and to evaluate the contribution of rehabilitation services to functional gains. Design: A retrospective study linking administrative billing data and patients' functional assessment records. Setting: Twenty facilities part of the Uniform Data System for Medical Rehabilitation (UDSMR) subacute database Participants: A total of 1976 billing records of patients with stroke, orthopedic, and debility impairments, discharged in 1996 and 1997, were retrieved and linked with the FIM™ instrument ratings from UDSMR subacute database. Interventions: Not applicable. Main Outcomes Measures: Total therapy intensity and Rasch-transformed FIM domain gains (ie, gains in self-care, mobility, cognition). Results: Therapy intensity was mostly determined by impairment and facility type, although variances explained by the predictors were small. Patients in all 3 impairment groups made functional gains; gains were related weakly, although significantly, to therapy intensity and rehabilitation duration after controlling for other variables. Conclusions: The provision of rehabilitation therapies varied across facilities. Skilled nursing facilities with subacute rehabilitation units tended to provide more therapies than subacute units in acute or rehabilitation hospitals. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objectives: To examine patterns of amputation (all levels) among veterans who were identified as at-risk and to examine factors that predict greater risks for a major (below-knee, above-knee) amputation. Design: Database approach, secondary data analysis. Setting: Veterans Affairs medical centers (VAMCs). Participants: 451,824 were selected if they had diagnoses of diabetes mellitus or peripheral vascular disease, and were at-risk for lower-extremity amputation. These patients were followed for 4 years (1997–2000) to determine the occurrence of amputation. Interventions: Not applicable. Main Outcome Measures: Differences in frequency and level of amputation were assessed among 132 VAMCs with different Preservation of Amputation Care and Treatment (PACT) rankings. Regression techniques were used to identify factors associated with increased risk. Results: Over the 4-year period, 10,258 patients had at least 1 amputation (2.3%). Highly ranked VAMCs had greater amputation rates and performed more above-knee amputations than less well ranked VAMCs. Factors that increase risk for a major amputation include race, skin ulcers, gangrene, and prior amputation. Conclusion: High-PACT VAMCs are often located in an urban setting, affiliated with academic medical programs, and have higher volume of patients. Higher amputation rate at high-PACT facilities may reflect a movement toward centers of excellence for prevention of and treatment for lower-extremity amputations.