Search

BACKGROUND AND PURPOSE: Falls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries. PARTICIPANTS: The participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS). METHODS: Categories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data. RESULTS: Population estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, 'fallers' consistently had larger utilization costs than 'nonfallers' for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information. DISCUSSION AND CONCLUSION: Falls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people. [ABSTRACT FROM AUTHOR]

Purpose. To revise and improve the instructions, candidate items and response format for a tool to measure communicative participation. Method. Cognitive interviewing techniques, designed to study the process that respondents use to answer survey questions, were used to test a bank of candidate items for a measure of communicative participation. Twelve participants with spasmodic dysphonia (SD), a neurologic condition characterized by voice and speech changes, were asked to complete a sample questionnaire and then were interviewed regarding the clarity of instructions, candidate items and response format. Analysis of the interviews was conducted using qualitative techniques and resulted in a series of modifications to the measurement tool. Results. Problems identified related to candidate items included inadequate context, double-barreled or ambiguous items, redundancy, unclear or generally confusing items, infrequent situations, and cultural sensitivity. Participants preferred response options that asked them to rate interference rather than other dimensions such as satisfaction. Conclusions. Subtle differences in items and response options make key differences in how participants interpret and make decisions about their responses. Rich contextual information is needed in order to respond to items that sample communicative participation. Participants preferred response options that capture the barriers that they experience when participating in everyday communication situations. [ABSTRACT FROM AUTHOR]

The experiences of chronic pain among children and adolescents with cerebral palsy (CP) were examined in this survey-based study. Perspective of both the individual and the parent were solicited in a preliminary sample of 20 youths with CP, ages 6 to 17 years from a metropolitan area. Selected participants completed in-person, structured interviews that focused on quality of life with attention to pain experiences. Quantitative data were analyzed descriptively. Seventy percent of participants (n = 14) experienced recurrent chronic pain of moderate intensity on a daily or weekly basis. Greater than half of those participants (n = 9) reported that pain presented a problem for them and especially interfered with self-care and with sleep. Pain appears to be a problem for many youths with CP, and may create additional interference with routine activities of daily living and participation. Further exploration regarding pain experiences and the nature of pain interference is warranted in order to address development and maintenance of routine activities and participation by children and adolescents with CP. [ABSTRACT FROM AUTHOR]

This study explored the perceptions of occupational therapists regarding the impact and implications of the Patient Protection and Affordable Care Act (PPACA or ACA) on occupational therapy practice. Fifteen occupational therapists participated in an interview to answer open-ended questions related to their thoughts and perceptions regarding the impact and implications of the ACA on their practice. The participants were practicing in eight different states and worked in five different settings with clinical experience ranging from 3 to 38 years; their positions ranged from staff therapist to owner of a free-standing outpatient clinic. Qualitative content analysis was used to synthesize the interview transcripts. Results showed that therapists did not have sufficient knowledge on the various mandates and provisions of the ACA, or were uncertain about what implications the ACA would have on practice, with the ACA affecting some settings more than others. Data revealed the perceived impacts of the ACA on occupational therapy practice include greater attention on documenting outcome-focused care, external accountability pressures on productivity, conscientiousness about clients' insurance coverage, uncertainty about collaborative care delivery, and survival of small businesses. Findings suggest training regarding knowledge about and implications of different elements of the ACA is needed as well as practices needing to promote the services that occupational therapists can provide to improve cost-effectiveness and outcomes in collaborative care environments.

Aim: Using the World Health Organization International Classification of Functioning, Disability and Health (ICF), the aim of this study was to identify effective strategies for managing urinary and bowel complications resulting from spina bifida., Method: Charts of 210 children between 4- and 13-years-old with spina bifida were reviewed to quantify medical interventions and continence status. Standardized quality of life (QOL) questionnaires were administered to a subset of participants; child and parent interviews were carried out to examine the experience of living with bowel and bladder incontinence. Practitioners were also interviewed to understand their perspectives of intervention effectiveness., Results: Chart review indicated less than half of children were continent for bowel and bladder. More variability existed in bowel continence programs, and practitioners considered bowel continence more difficult to achieve than bladder continence. No significant associations were found between continence status and QOL measures. Interviews, however, reflected how managing continence at home and school more broadly affects QOL. Among practitioners, some focused primarily on optimizing physical health while others focused on activity and participation., Interpretation: While continence is a goal, programs used to achieve this are individualized and outcomes may be affected by differential treatment effects, environmental factors, and/or stigma experienced by children., (© 2016 Mac Keith Press.)

Background: Many persons post-stroke continue to have difficulty using their more involved upper extremity and home programs may be poorly adhered to limiting the amount of practice an individual receives. More information on the experience of traditional home program and the acceptability of a novel home intervention was sought., Objective: To qualitatively describe 1) upper extremity use at home, 2) previous home exercise or activity programs, and 3) the acceptability of a novel upper extremity home program, NeuroGame Therapy (NGT), that combines surface electromyography (sEMG) biofeedback and a commercial computer game., Methods: A purposeful sample of ten persons with moderate to severe upper extremity motor impairment used the NGT intervention in their home for four weeks and completed nested (pre and post) one-on-one interviews. Written transcripts from the interviews were coded and themes were identified to address stated objectives., Results: Participants reported that while use of their upper extremity in daily activities was recommended it occurred infrequently. Most participants described previous home programs as being non-specific, were often not carried out as recommended or were self-modified. Participants found NGT to be engaging and motivating, but reported minimal changes in the functional uses of their upper extremity., Conclusion: These findings suggest that after stroke upper extremity use may be infrequent and home program approaches could be re-examined. NGT was reported to be an acceptable home intervention, but it will require further development and study to understand its value and role in post-stroke rehabilitation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to explore the experiences of patients with aphasia, their family members, and physicians related to communication during medical interactions., Method: Face-to-face, semistructured interviews were conducted with 18 participants—6 patients with aphasia, 6 family members involved in patient care, and 6 practicing physicians. A qualitative description approach was used to collect and summarize narratives from participants' perspectives and experiences. Participants were asked about experiences with communication during medical interactions in which the family member accompanied the patient. Interviews were audio- and/or video-recorded, transcribed, and then coded to identify main themes., Results: Patients and family members generally described their communication experiences as positive, yet all participants discussed challenges and frustrations. Three themes emerged: (a) patients and family members work as a team, (b) patients and family members want physicians to "just try" to communicate with the patient, and (c) physicians want to interact with patients but may not know how., Conclusions: Participants discussed the need for successful accommodation, or changing how one communicates, to help facilitate the patients' increased understanding and ability to express themselves. Over- and underaccommodation with communication were commonly reported as problems. Speech-language pathologists have a role to play in helping to improve communication during medical interactions. Implications for current speech-language pathologist practice and future directions of research are discussed.

Background: Stroke survivors experience sensory impairments that significantly limit upper-limb functional use. Lack of clear research-based guidelines about their management exacerbates the uncertainty in occupational therapists' decision making to support these clients., Purpose: This study explores occupational therapists' clinical decision making regarding upper-limb, post-stroke sensory impairments that can ultimately inform approaches to support therapists working with such clients., Method: Twelve therapists participated in a qualitative descriptive study. Transcripts of semi-structured interviews were analyzed using content analysis., Findings: Three overarching categories were identified: deciding on the focus of interventions (describing intervention choices), it all depends (outlining factors considered when choosing interventions), and managing uncertainty in decision making (describing uncertainty and actions taken to resolve it)., Implications: Providing training about post-stroke sensory impairment and decision making may improve therapists' decision making and ultimately improve client outcomes. Further research is needed to understand the impact of uncertainty on occupational therapy decision making and resulting care practices.

Purpose: The purpose of this study was to explore the perceived environmental supports and barriers to daily functioning for people with low vision due to diabetic retinopathy and the adaptive strategies used by these individuals to improve person-environment fit., Method: The researchers used a qualitative descriptive approach with eight participants with low vision as a result of diabetic retinopathy. Data collection methods included semi-structured interviews, observation of participants' home environments and focus group discussions., Results: Participants described aspects of the physical environment, the social environment and psychological adjustment as important in adapting to vision loss and diabetes. Four themes emerged from the data analysis: "It's a Complicated Life", "The World Isn't Accessible", "Making it Work" and "Learning to be Blind"., Conclusions: Physical and social environmental influences on functioning are complex. Adaptation to vision loss is an ongoing process that may be aided by peer interactions and more community-based rehabilitation. To best rehabilitate people with low vision due to diabetic retinopathy, the influence of both the physical and social environment along with psychological adaptation need to be considered. Periodic rehabilitation, interventions taking place in community settings and the formal inclusion of peers in the rehabilitation process may be indicated. Implications for Rehabilitation Consideration of the social as well as the physical environment is essential in the rehabilitation of people with low vision due to diabetic retinopathy. Adaptation to vision loss by those with diabetic retinopathy is complicated by the fact that diabetes is a systemic disease that affects multiple body systems. Psychological adaptation to vision loss is characterized by cycles of grieving and acceptance, which affects readiness for rehabilitation. Alternative approaches to rehabilitation may be indicated for people with low vision due to diabetic retinopathy, including periodic intervention over time and the inclusion of peers in the rehabilitation process.

Purpose: To study the experiences of adults who use augmentative and alternative communication (AAC) systems and methods when interacting with medical providers, specifically primary care providers., Method: Individual face-to-face interviews were conducted with 12 participants, four of whom also participated in an online focus group. Diagnoses of the participants included cerebral palsy, undifferentiated developmental disability, head and neck cancer, amyotrophic lateral sclerosis and primary lateral sclerosis. Transcripts from the interviews and the focus group were analyzed to create a list of codes. From these codes themes that captured particular concepts discussed were identified., Results: Participants described multiple frustrations in communicating with medical care providers. Themes that arose included: planning and preparing for the appointment, time barriers, inappropriate assumptions, relationship building and establishing rapport, medical decision making and implementing the plan. All but one participant reported bringing a caregiver with them to their appointments and this person, whether a family member, friend or paid aide, had a substantial role throughout the appointment., Conclusions: The participants' stories highlight important barriers they experience when communicating with medical providers. These barriers bring attention to the need for education for physicians, caregivers and patients with communication disabilities, along with increased research to improve patient-provider communication., Implications for Rehabilitation: Patients with communication disabilities face multiple barriers to communicating with medical care providers. Patients, caregivers, and medical care providers all play a role in effective and ineffective communication during appointments. Education for medical care providers, caregivers, and patients with communication disabilities, along with increased research is needed to improve patient-provider communication.

Purpose: To assess the content, format, and comprehension of the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric physical function related to mobility items for children who use wheelchairs (WCs)., Methods: During a cognitive interview, 14 children, aged 8 to 12 years, who use WCs, verbalized their thoughts when answering PROMIS items. The questionnaire appraisal system was used to code summarized text from the interviews., Results: The children requested items be more specific and include options for reporting adaptive ways of performing and participating. How they would answer the item depended on the situation and specific environmental supports and constraints they may have experienced., Conclusions: As rehabilitation professionals develop and use self-reported outcome measures, they should explore what is important to children who use WCs regarding their views on physical functioning, the influences of the environment, and variability in the use of devices to assist with functional mobility.

Objective: Pain is an important component of health and function, and chronic pain can be a problem in its own right. The purpose of this report is to review the considerations surrounding pain measurement in the NIH Toolbox, as well as to describe the measurement tools that were adopted for inclusion in the NIH Toolbox assessment battery., Methods: Instruments to measure pain in the NIH Toolbox were selected on the basis of scholarly input from a diverse group of experts, as well as review of existing instruments, which include verbal rating scales, numerical rating scales, and graphical scales., Results: Brief self-report measures of pain intensity and pain interference were selected for inclusion in the core NIH Toolbox for use with adults. A 0 to 10 numerical rating scale was recommended for measuring pain intensity, and a 6-item Patient Reported Outcome Measurement Information System (PROMIS) short form for measuring pain interference. The 8-item PROMIS Pediatric Pain Interference measure was recommended as a supplemental measure. No specific measure was recommended for measuring pain intensity in children., Conclusions: Core and supplemental measures were recommended for the NIH Toolbox. Additional measures were reviewed for investigators who seek tools for measuring pain intensity in pediatric samples.

Background: Assistive technology (AT) is one strategy to mitigate or eliminate barriers to independence for individuals with disabilities, including those with spina bifida (SB). However, little is known about current use and costs of AT for people with SB, including the cost burden to medical insurance payees., Objective: The aim of this study was to evaluate frequency of AT purchases and their associated costs for individuals with SB covered by the Washington State Medicaid program. Additionally, we sought to compare Medicaid reimbursement for AT to the overall Medicaid reimbursement for all medical care for these individuals., Methods: Data included all electronic claims and eligibility records of persons covered by the Medicaid program over a 4-year period (2001-2004) who had at least one service with a coded diagnosis of SB. Procedure codes were reviewed and grouped into the following AT categories: manual wheelchairs, powered wheelchairs, wheelchair cushions and seats, wheelchair accessories and repairs, wheelchair rental, ambulatory aids, orthotic and prosthetic devices, positioning aids, bathroom equipment, beds and bed accessories, and communication and hearing aids. Age group analyses were conducted after dividing patients into 3 age groups (0-15, 16-25, and 26+). Further subgroup analyses were done for individuals with dual or capitated medical coverage compared with those who had fee-for-service Medicaid-only coverage., Results: A total of 984 individuals with at least one diagnosis of SB during the 4-year study period were identified. On average, approximately one third of individuals made claims for some type of AT per year; the majority of these AT claims (87%) were for mobility-related AT. Average annual Medicaid cost of AT was $494 per enrollee and AT accounted for 3.3% of all Medicaid costs for these individuals. AT-related costs were highest for those aged 0-15 years and lowest for those aged 16-25 years. Persons with only fee-for-service Medicaid coverage had more than twice the annualized Medicaid AT-related expenditures compared to those with additional coverage or who were covered under a Medicaid capitation plan., Conclusions: Medicaid reimbursement for AT, as classified in this study, is a relatively low percentage of overall medical costs for individuals with SB. Because of the small percentage of non-mobility-related AT paid for in this study, we believe there may be a substantial unmet need for AT in this population and/or that individuals with SB may have significant AT-related out-of-pocket expenses. Given its large potential impact and relatively low cost burden to Medicaid, AT is a "good buy" and coverage for AT should be expanded., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background and Purpose: Falls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries., Participants: The participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS)., Methods: Categories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data., Results: Population estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, "fallers" consistently had larger utilization costs than "nonfallers" for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information., Discussion and Conclusion: Falls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people.

Objective: To describe assistance from helpers and use of assistive technology and environmental modification by community-dwelling people with difficulties in activities of daily living (ADLs) and instrumental activities of daily living (IADLs)., Design: Cross-sectional study using the 2004 Medicare Current Beneficiary Survey., Setting: Community., Participants: Nationally representative sample of 14,500 Medicare beneficiaries (mean age, 71.5 y; 55% female; 49% currently married; 68% living with others; 84% white)., Interventions: Not applicable., Main Outcome Measures: Self-reported difficulty with ADLs and IADLs; uses of help, assistive technology, and/or environmental modification., Results: Difficulties were reported most frequently for heavy housework, walking, and shopping; money management, shopping, and light housework were reported as activities most often needing a helper. Walking, bathing, and toileting were activities most often needing uses of assistive technology. Bathroom modifications were the most commonly reported environmental modification. Results from a logistic regression showed that advancing age was the primary factor associated with increasing use of helpers and assistive technology or both for difficult activities., Conclusions: Uses of helpers, assistive technology, and environmental modification are common but vary by type of ADL and/or IADL and age. Focused studies regarding uses of help and access to assistive technology and environmental modification appear needed to support community living. Public education about methods and types of accommodations appears needed and may substitute for or augment guidance from care providers.

Objective: To assess, using a longitudinal definition, the impact of disability on a broad range of objective health care quality indicators., Design: Longitudinal cohort study following up with patients over several years. The first 2 interviews, 1 year apart, were used to determine each patient's disability status in activities of daily living (ADLs). Assessment of the health care indicators commenced after the second interview and continued throughout the survey period (an additional 1-3y)., Setting: National survey., Participants: Participants (N=29,074) of the Medicare Current Beneficiary Survey (1992-2001) with no, increasing, decreasing, and stable ADL disability., Interventions: Not applicable., Main Outcome Measure: The incidence of 5 avoidable outcomes, receipt of 3 preventive care measures, and adherence to 32 diagnostically based indicators assessing the quality of treatment for acute myocardial infarction [AMI], angina, breast cancer, cerebrovascular accident, transient ischemic attack, cholelithiasis, chronic obstructive pulmonary disease [COPD], congestive heart failure, depression, gastrointestinal bleeding, diabetes, and hypertension., Results: For most indicators, less than 75% of eligible patients received necessary care, regardless of disability status. For 5 indicators, less than 50% of patients received appropriate treatment. In a logistic regression analysis that controlled for patient age, sex, race, and income, disability status was a significant factor in 7 quality measures (AMI, breast cancer, COPD, diabetes, angina, pneumonia, annual visits)., Conclusions: Using a longitudinal definition of disability and objective health quality indicators, we found that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories. However, the impact of disability status varies depending on the indicator measured. In this cohort of patients, the changing nature of a person's disability seems to have less impact than whether they ever have had any functional deficits.

Objectives: To examine racial and ethnic disparities in mobility limitation, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) in older adults enrolled in Medicare., Design: Longitudinal national survey., Participants: Community-dwelling respondents in the Medicare Current Beneficiaries Survey from 1992 to 2004 (10,180-16,788 respondents per year)., Measurements: Disability-related outcomes included mobility limitation, difficulty in six ADLs and six IADLs. Explanatory variables included age, sex, racial or ethnic group, living situation, and income level., Results: From 1992 to 2004, proportions of Medicare beneficiaries with mobility limitations were stable across racial and ethnic groups, improving slightly for ADLs and IADLs. Blacks reported more limitations in all three disability-related measures. In a longitudinal analysis, the probability of developing mobility limitation was consistently higher for blacks, followed by white Hispanics, white non-Hispanics, and Asians, after adjusting for age, sex, socioeconomic status, and living situation. For ADL and IADL difficulties, the number of reported difficulties increased with age for all ethnic and racial groups. At approximately age 75, Asians and white Hispanics reported difficulties with much higher numbers of ADLs and IADLs than the other groups., Conclusion: Across all ethnic and racial groups, self-reported disability has declined in the past decade, but even after adjusting for age, sex, socioeconomic status, and living situation, racial and ethnic disparities in disability outcomes persist. Race and ethnicity may influence the reporting of disability, potentially affecting measures of prevalence. Further research is needed to understand whether these differences are a result of perceptions related to disablement or true differences in disability between racial and ethnic groups.

Purpose: This study examined satisfaction with communicative participation as reported by adults with multiple sclerosis (MS)., Method: Eight community-dwelling adults with MS participated in semi-structured interviews. They were asked to discuss their satisfaction with their communication in a variety of situations. Interviews were analyzed using a constant comparative method of qualitative description., Results: Themes derived included: Comfort, consisting of Ease and Confidence; Success of the Outcome, including Function is Achieved and A Connection is Made; and Personal Meaning of Participation, including Personal Preferences, Comparison with the Past, and Thinking about One's Own Communication., Conclusions: Participants described multiple facets of satisfaction with communicative participation. Some of the dimensions were similar to those in existing assessment instruments such as levels of ease or difficulty with performance. Participants did not talk about frequency of activities as a key part of their satisfaction. Implications for identifying intervention targets and treatment outcome measurements are provided., Learning Outcomes: The reader should be able to: 1) define communicative participation and identify key elements of this construct; 2) identify the issues that were most relevant to satisfaction with communicative participation with participants with MS; and 3) identify reasons for greater emphasis on the subjective viewpoint of people with communication disorders in measurement of treatment outcomes.

Objective: To examine the association between satisfaction with health care, the use of preventive health care, and mobility limitation., Design: Cross-sectional analysis of survey data., Setting: Community., Participants: A total of 12,769 people, age greater than 65, who participated in the 2001 Medicare Current Beneficiary Survey., Interventions: Not applicable., Main Outcome Measures: Self-report of mobility limitation, satisfaction, and use of preventive health care (immunizations, cancer screening). Sampling weights were used in all analyses, including logistic regression for survey data, to calculate estimates for a Medicare population of 31 million., Results: After controlling for sociodemographic characteristics, Medicare beneficiaries with mobility limitations were significantly more dissatisfied with their health care compared with beneficiaries without mobility limitations. Receipt of preventive care did not differ for those with and without mobility limitation on some preventive services., Conclusions: Mobility limitation is highly associated with dissatisfaction with health care among older adult beneficiaries. Although Medicare beneficiaries may receive similar rates of preventive care, those with mobility limitation may have more difficulty accessing services and be more dissatisfied with their health care in general.

Lymphedema is a chronic medical condition caused by lymphatic insufficiency that can lead to extreme swelling and susceptibility to infection. Physical and psychosocial effects of the condition can have a significant impact on an individual's life and level of participation. Research about experiences of individuals living with lymphedema has focused primarily on women with breast cancer, yet individuals with non-cancer-related lymphedema are a distinct group. In this study, the authors used qualitative description to explore the experience of 7 individuals living with advanced and complicated cases of lymphedema who had been treated in an inpatient setting. Findings reveal the extensive impact lymphedema has on those who live with it. Participants spoke of difficulty finding a correct diagnosis and effective treatment, the importance of their inpatient experiences, and the challenges of daily self-management. The authors make recommendations to increase lymphedema awareness, promote inpatient treatment programs, and create effective self-management techniques.

Purpose: To assess the adequacy of self-report instruments in speech-language pathology for measuring a construct called communicative participation., Method: Six instruments were evaluated relative to (a) the construct measured, (b) the relevance of individual items to communicative participation, and (c) their psychometric properties., Results: No instrument exclusively measured communicative participation. Twenty-six percent (n = 34) of all items (N = 132) across the reviewed instruments were consistent with communicative participation. The majority (76%) of the 34 items were associated with general communication, while the remaining 24% of the items were associated with communication at work, during leisure, or for establishing relationships. Instruments varied relative to psychometric properties., Conclusions: No existing self-report instruments in speech-language pathology were found to be solely dedicated to measuring communicative participation. Developing an instrument for measuring communicative participation is essential for meeting the requirements of our scope of practice.

Understanding the use of weights in the analysis of data from multistage surveys. Large national surveys are powerful tools with which to examine a variety of important rehabilitation-related issues and are currently the only feasible method to study disability trends over time. Because it is impractical to draw simple random samples from the entire United States, national surveys, such as the Medicare Current Beneficiary Survey (MCBS), select random samples of subgroups of a population. Thus, respondents may have unequal probabilities of being included in the survey, and weighting must be used in the analysis before the results may be generalized to the entire United States. Surveys such as the MCBS are rich sources of data for rehabilitation medicine, and it can be expected that more research will be conducted using these data sources. Statistical analysis of these data should account for the sampling scheme used in data collection. We review the principles involved in the design of multistage samples, the calculation of weights, and their use in the data analysis, focusing on their importance in the estimation of population values. Our objective is to help readers to understand and interpret results of research articles using this methodology. Examples using the MCBS data are provided to clarify the concepts presented in the article.

Objective: With physical disabilities, persons often experience secondary pain that adds to restrictions in activity and participation. We investigated pain-management strategies used by those with physical disabilities., Method: Qualitative phenomenological inquiry was used in multiple interviews with (N= 28) adults with physical disabilities (9 with amputation, 7 with cerebral palsy, and 12 with spinal cord injury) and subsequent thematic analysis., Results: Among those with physical disabilities, a distinction is made between usual and unexpected pains. Usual pain is experienced consistently or as a consequence of not getting adequate rest, exercise, or stress-free time. Managing usual pain involves uses of prevention (e.g., exercise/fitness) and/or pragmatic actions through scheduling and pacing daily activities and taking interim retreats. Unexpected pain is experienced periodically and requires an immediate response and change of activity. To manage, persons describe making efforts to create a mind and body disassociation, activating safety nets to support function and alleviate pain, and making decisions to persevere with activity and participation., Conclusion: Advising those with physical disabilities to do proactive planning for both usual and unexpected pain may help them to use varied pain-management strategies to enhance function and minimize negative impacts on participation.

Purpose: To examine the prevalence and characteristics of community-dwelling Medicare beneficiaries reporting a communication disability and the relationship between that disability and dissatisfaction with medical care., Method: A total of 12,769 Medicare Current Beneficiary Survey respondents age 65 and older in 2001 were categorized by level of communication disability. Sampling weights were used to make inferences about the entire Medicare population., Results: Over 16 million beneficiaries reported a communication disability. Hearing problems were most commonly reported (41.99%). The association between dissatisfaction and communication disability was statistically significant (p

Objective: To design and validate a methodology that identifies secondary conditions using International Classification of Disease, 9th Revision (ICD-9) codes., Design: Secondary conditions were identified through a literature search and a survey of Washington State physiatrists. These conditions were translated into ICD-9 codes and this list was then validated against a national sample of Medicare survey respondents with differing levels of mobility and activities of daily living (ADL) disability., Setting: National survey., Participants: Participants (N=9731) in the 1999 Medicare Current Beneficiary Survey with no, mild, moderate, and severe mobility and ADL disability., Interventions: Not applicable., Main Outcome Measure: Percentage of survey respondents with a secondary condition. The secondary conditions were grouped into 4 categories: medical, psychosocial, musculoskeletal, and dysphagia related (problems associated with difficulty in swallowing)., Results: Our literature search and survey of 26 physiatrists identified 64 secondary conditions, including depression, decubitus ulcers, and deconditioning. Overall, 70.4% of all survey respondents were treated for a secondary condition. We found a significant relation between increasing mobility as well as ADL disability and increasing numbers of secondary conditions (chi 2 test for trend, P <.001). This relation existed for all categories of secondary conditions: medical (chi 2 test for trend, P <.001), psychosocial (chi 2 test for trend, P <.001), musculoskeletal (chi 2 test for trend, P <.001), and dysphagia related (chi 2 test for trend, P <.001)., Conclusions: We created a valid ICD-9-based methodology that identified secondary conditions in Medicare survey respondents and discriminated between people with different degrees of disability. This methodology will be useful for health services researchers who study the frequency and impact of secondary conditions.

Purpose: Advances in genetics indicate a need for occupational therapists to develop literacy and skills in genetics as it relates to lifestyle and occupation. The purpose of this study is to identify genetics content areas taught, instructional methods used, and the importance of teaching genetics at the entry-level in occupational therapy curricula., Method: A questionnaire was sent to all entry-level occupational therapy educational programs (N=157). Structured mailing and follow-up were used., Results: The response rate was 63.9%. Most respondents (47%) rate teaching genetics as "moderately important." Genetics content is predominately taught at the introductory or knowledge level rather than at the integration and application level. Respondents indicate a lack of time and space for genetics content and of faculty interest and expertise., Discussion: As occupational therapy practice evolves to include new genetics, curriculum change will need to be implemented. Development of teaching materials and methods addressing genetics is recommended.

Objectives: To identify common pain descriptors used by people with physical disability-related pain and to suggest words that are likely to prompt responses in clinical interviews and assessments., Design: Open-ended interviews were coded and then contrasted with responses to a pain questionnaire, obtained through mail or interview surveys., Setting: Rehabilitation research program., Participants: Twenty-eight people with physical disability-related pain in a series (n=54) of in-depth interviews and 1053 participants with disabilities who responded to mailed questionnaires or structured interviews about pain and its impact (459 with acquired lower-limb amputation, 471 with spinal cord injury, 123 with cerebral palsy)., Interventions: Not applicable., Main Outcome Measures: Pain interview descriptions and McGill Pain Questionnaire (MPQ)., Results: Different pain experiences were reflected in narrative descriptions and self-report questionnaire responses. We report the common terms, but across diagnoses use of terms does not appear to clearly differentiate distinct pain phenomenon. Narrative interviews support the use of several MPQ pain descriptors. However, discrete descriptors are recommended when assessing adults with physical disability., Conclusions: We identified pain descriptors that appear to be most useful in assessing daily life and participation experiences with physical disability-related pain. These may be clinically useful, but caution is advised when doing diagnostic workups based solely on sensory and affective pain descriptions.

Objectives: To obtain an insider's view about disability-related pain to help rehabilitation clinicians understand the experience and to show how people with disability manage daily living and encounters with other people., Design: Qualitative methods by using open-ended interviews and thematic analysis., Setting: Rehabilitation research program., Participants: Nine adults with chronic physical disability and pain were recruited from study groups. The 9 included people with spinal cord injury, acquired amputation, or cerebral palsy., Intervention: Interview protocol., Main Outcome Measure: Phenomenologic analysis of interviews based on codewords derived from interview topics and themes., Results: Study participants described pain as a part of daily living that influenced many lifestyle decisions. They characterized pain as plural, meaning that it has multiple locations, distinctive descriptions, and different implications. They also were concerned about pain being a mystery, having unclear causes and consequences. Typically they described pain as a personal venture, with little or dissatisfying communication about pain with family, friends, or health care providers., Conclusions: Understanding pain associated with physical disability can help guide rehabilitation practitioners in their pain assessments, interventions, and related research. Our findings suggest that some people with disability-related pain may benefit from reassurance and specific planning for expected and unexpected pain episodes., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: The purpose of this study was to examine educational participation and accommodations for children with spinal cord injury (SCI) or disease in primary, secondary, and postsecondary educational settings., Method: Written surveys were developed for students with SCI and their teachers. Fifty-three participants had SCI onset before age 18 years, were at least 4 years old and enrolled in a school program, and had residual motor disability without cognitive-behavioral impairments., Results: Nearly all participants were enrolled full time in regular education classrooms. Seventy-five percent of primary-level participants and 32% of secondary-level participants were qualified for special education and related services, receiving teacher aide assistance as well as occupational and physical therapy services. Most participants were graduating from high school and pursing postsecondary education. Classroom performance and grades were reported as average or above average, but curriculum modifications were commonly made, and many participants required human assistance and assistive technology in functional and classroom tasks. Access barriers were often reported by participants using wheelchairs, and those using augmentative writing aids were not fluent with these devices., Conclusion: Accommodations in schools for students with SCI appear to support completion and advancement to higher levels of education, but these accommodations appear to be geared toward participation rather than levels of performance and productivity that may be realistic for work and other community settings.

Objective: To examine educational achievement and vocational success of children with SCI., Design: Surveys administered to students and teachers, and content analysis of school records., Setting: Regional pediatric rehabilitation program., Participants: Participants were selected from 144 children with SCI treated from 1979 through 1992; 98 met inclusion criteria of onset of SCI before the age of 18 years, older than 3 years, residual paresis, and no cognitive impairment; 29% were lost to follow-up, and 53 of the 70 contacted were enrolled., Main Outcome Measures: School completion rates, absenteeism, grades, ratings of participation; education and living situations after high school; history of paid employment., Results: The 53 responders were: 33 boys, 20 girls; 25 with paraplegia (47%), 28 with tetraplegia (53%); mean length of disability = 9.4 years; 12 primary students (23%), 19 secondary students (36%), and 22 postsecondary participants (41%). Students and teachers rated student participation and performance as average or above compared to peers; 84% of secondary students planned to attend college after graduation. Only 33% of high school students over age 15 had been employed. Ninety-one percent of postsecondary subjects had graduated from high school. Seven (32%) had graduated from college or a vocational program, 11 (50%) were enrolled in college full- or part-time, and 4 others (18%) were neither in school nor employed. Current employment rates were 71% of college graduates, 36% of those in college, and 0% of those who had never enrolled. Level of SCI was not related to employment., Conclusions: Students with SCI demonstrate adequate participation and performance in educational settings, but may benefit from more vocational counseling and opportunities for paid employment.

Selective dorsal rhizotomy (SDR) followed by intensive postoperative therapy is commonly performed to reduce spasticity in carefully selected children with cerebral palsy. Reduction in spasticity and improvement in range and quality of movements are frequently reported. Functional gains have also been indicated but have not often been examined in a systematic manner. Twenty-nine children with spastic diplegia or quadriplegia received SDR and postoperative physical and occupational therapy. Upper-limb movement, self-care, and functional mobility were evaluated prospectively through preoperative, 6-month, and 12-month follow-up examinations. Significant improvements in the Pediatric Evaluation of Disability Inventory scores for functional mobility and self-care domains were observed for children with spastic diplegia, but not spastic quadriplegia. Children's scores in upper-limb reach and coordination tasks did not consistently improve. When attributing improvements in self-care and mobility independence to SDR and specialized therapy, continued development, new goals, and positive beliefs about progress should also be considered as factors influencing outcome.

Recruitment of occupational therapy students requires both expansion and broadening of ethnic, cultural, age, sex, and geographic distribution. Information used to guide recruitment activities can be limited, quickly outdated, and regionally nonspecific. Applicants to all entry-level programs in the Northwest were surveyed to assess trends that could influence recruitment practices. One hundred thirty-five (82.8%) of the 163 applicants surveyed responded to a questionnaire that probed for sources of exposure to occupational therapy, career goals, and educational preferences. Applicants indicated having an initial interest in allied health or education fields, yet only 36% began college with occupational therapy education in mind. Volunteer or work experience in specific practice settings was identified by approximately 80% of the applicants as an influence in seeking an education in occupational therapy. Career influences, goals, and educational program preferences did not differ among applicants based on age, residential background, grades, or previous degree. An absence of applicants of ethnic minority allows limited application of findings to these targeted groups.

One hundred consecutive children with juvenile rheumatoid arthritis (JRA) were evaluated for shoulder dysfunction. Shoulder arthritis was virtually absent in all 45 children with pauciarticular onset JRA. Twenty of 40 children (50%) with polyarticular JRA and 12 of 15 (80%) with systemic onset JRA had shoulder involvement characterized by pain or restricted passive range of motion (PROM). Ninety-five percent of those with shoulder arthritis had bilateral involvement. Children with systemic onset were likely to have shoulder disease within 2.5 years of onset and to have more severely limited PROM. Children with polyarticular onset developed shoulder arthritis any time during the course of their disease. With either type of onset, internal rotation was the most commonly and severely limited motion, followed by abduction. Clinicians treating children with JRA should carefully monitor pain and examine both rotational and planar components of shoulder motion.

Carpal tunnel syndrome (CTS) is unusual in childhood, and familial occurrence has been reported infrequently. A case of CTS in a seven-year-old boy, associated with abnormal thickening of the transverse carpal ligament and aplasia of the median nerve distal to this ligament, is described. Clinical, electrodiagnostic, and surgical findings are presented: all were consistent with absence of the median nerve distal to the transverse carpal ligament. Family history of CTS was positive in a pattern consistent with autosomal dominant transmission in three generations. Thickening of the transverse carpal ligament has been described, although infrequently, in childhood and familial CTS. Aplasia of the median nerve distally has not been reported in association with this anatomic abnormality. Case reports of familial CTS are reviewed, and other congenital anomalies which should be considered in the differential diagnosis of CTS in children and adults are discussed.

Right hemisphere brain-damaged stroke patients demonstrate a variety of neurologic deficits which seem to impair their ability to regain self-care independence. Visual perceptual and visual search disorders have been implicated with persistent functional deficits. The objective of this study was to measure the extent to which defects of optokinetic nystagmus (OKN), an ocular movement reflex, may be associated with inability to regain independent function. Eighteen right hemisphere brain-damaged stroke patients suffering similar sensory-motor deficits were followed up from admission as they underwent self-care training in a comprehensive stroke rehabilitation center. Ten subjects demonstrated unilateral absence of OKN and eight subjects demonstrated bilaterally intact responses upon admission. Upper extremity (UE) dressing independence was used as an indicator of functional skill level at admission, during treatment, and at discharge. Subjects with unilateral loss of OKN were significantly less independent at admission and at discharge when compared to subjects with intact OKN. Although both groups of patients made statistically significant gains in UE dressing, those with defective OKN had a 40% greater inpatient length of stay and were more likely to be discharged to a nursing home or needed care by a significant other after rehabilitation.

Survival from head and neck cancer is not uncommon. However, treatment is often radical and may compromise the patient's appearance, function, and quality of life. The most common modalities of treatment, employed either singly or in combination, are chemotherapy, radiation, and surgery. Each treatment modality involves unique complications and compromises, many of which are amenable to rehabilitation techniques. A role of the occupational therapist on a cancer rehabilitation team is described and an overview of the therapeutic procedures for the evaluation and treatment of common problems recognized in these patients is presented. The material is derived both from clinical experience of the rehabilitation team and from a literature review employed in developing the rehabilitation program.