Topics in Rehabilitation
Lecture 1: Introduction
Rehabilitation in the Netherlands
Rehabilitation medicine is aimed at the prevention, reduction and cure of (expected)
consequences of chronic physical impairments or functional limitation
Rehabilitation focuses on improving independent functioning in society. Consequently. It
focuses on issues like self-care, domestic life, communication, mobility, labor, education,
leisure activities, sports. The rehabilitation team consists of several professionals: physical
therapist, speech therapist, social worker, nurse etc.
Non-neurological group: Amputation, degenerative joint disease, hand trauma, low-back
pain, posttraumatic dystrophy (CRPS), cardio-pulmonary problems, burning, chronic pain,
poly-trauma, etc.
Neurological group: Stroke (CVA), neuromuscular disorders, multiple sclerosis (MS), spinal
cord injury (SCI), Parkinson’s disease, cerebral palsy (CP), developmental coordination
disorders (DCD).
Rehabilitation care can be provided in rehabilitation centers, hospitals, nursing home and.
Private centers. Children can also receive rehabilitation care at special schools (mytyl, tyltyl).
Rehabilitation research
Dutch organization for health research and development (ZonMw). ZonMw funds health
research and stimulates use of the knowledge developed to help improve health and
healthcare in the Netherlands. Two things are needed to improve health and healthcare in
the Netherlands: knowledge, and actual use of knowledge. With a range of grant
programmes, ZonMw stimulates the entire innovation cycle, from fundamental research to
the implementation of new treatments, preventive interventions and improvements to the
structure of healthcare
Critical appraisal
Critical appraisal = the process of systematically examining research evidence to assess its
results, validity and relevance before using it to inform a decision. Assess the usefulness and
validity of research findings with respect to a PICO question
P Patient, population or problem How would I describe a group
of patients similar to mine?
I Intervention, prognostic factor or exposure Which main intervention,
prognostic factor, or exposure
am I considering?
C Comparison to intervention What is the main alternative to
compare with the
intervention?
O Outcome you would like to measure or achieve What can I hope to accomplish
measure, improve or affect?
T What type of question are you asking? Therapy/Treatment, Diagnosis,
Prognosis, Harm/Etiology
T Type of study you want to find What would be the best study
design/methodology?
If you are looking for an effect for a specific intervention → look for a RCT
,Randomized control trial
- Random allocation of participants enables that groups are equivalent in terms of
both known and unknown confounding factors
- Be aware bias is still possible
- Verify if the randomization is concealed
- Assess blinding if relevant: participants, therapists, assessor
- Note: lack of blinding is less a problem with objective outcome measures than with
subjective
- Precise inclusion and exclusion criteria
- Usually: high internal validity but low external validity!
Observational design: cohort study
- Following up participants to observe who ‘develops’ the outcome of interest
- High risk for selection bias and confounding factors
- Long follow-up: risk of important losses to follow-up
- Appropriate design to analyze associations
- Problematic design when used to evaluate therapeutic interventions
Case-control studies
- Always retrospective in nature
- To investigate risk factors when the outcome of interest is rare
- Possibility of ‘recall bias’ for the cases if measures are subjective
- Difficulty to find comparable ‘controls’
Leading question for the CAT
1. Does this study address a clearly focused question?
a. Relevance of the question
b. Adding value of the study
c. Type of the research question
i. Questions about the effectiveness of treatment
ii. Question about diagnostic accuracy
iii. Questions about the prognostic value
iv. Questions about the frequency of events (Incidence, prevalence)
2. Did the study use valid methods to address this question?
a. Assess the study design: effectiveness of treatment, diagnostic, prognostic
and incidence & prevalence
b. Assess whether the study methods address the key potential sources of bias
i. Bias due to chance: random error → affects the precision of the
results
c. Bias due to the study methods: systematic bias → selection of participants,
data collection and data analysis and interpretation
3. What are the results?
a. Are they significant results?
b. Effect size
c. Check the level of uncertainty
d. Statistically and clinically significance
e. Check if potential conflict of interest have been identified.
4. Are these valid, important results applicable to my patient or population?
a. Who participated?
i. Characteristics of participants (age range, gender, illness stage)
, b. In which context? How long ago?
i. Academical/peripheral hospital
ii. Innovative/usual equipment
iii. Country, region
c. Cost-effectiveness?
Do not mix up reliability and internal validity
Reliability = precision, absence of random errors
Internal validity = accuracy, absence of systematic errors
Critical appraisal of primary evidence!
- Primary evidence: experimental and observational studies
- CAT assessment: use of (at least) 2 primary evidence
- No secondary evidence: systematic reviews, meta-analyses
- We expect you to:
o Appraise the results and the validity of the studies
o Try to appraise the relevance = this requires clinical experience
o Carefully conducted observational studies may provide more evidence than
poor RCTs
o Scales or checklists? No consensus on which is preferable
o Don’t use checklists to score articles with one number but to evaluate
shortcomings that may have influenced the results
o CAT assignment is not solely about responding to the question above but to
integrate them into the discussion of the results
Slidecast 1 Cerebral Palsy
Etiology, incidence/prevalence
- Most common pediatric neurological disorder (2-3/1000 live births)
- Premature babies have a higher risk for CP
- Diagnosis based on abnormal movement and posture
- Etiology: non-progressive brain injury
- Symptoms: change over time
- Umbrella term: large range of brain injuries and functional limitations
Background: diagnosis
- No definite test for CP
- Severe cases: diagnosis after birth
- Milder cases: wait until major brain maturation (5 years)
- Average age of diagnosis: around 2 years
Difficult diagnosis because:
- It may take years for clear signs to appear, many children with brain damage make a
recovery, levels of severity vary greatly, and signs of CP resemble other disorders
General background
There are different ways to classify CP according to
- Type of movement → spastic (‘stiff’ type of movement), dyskinetic (‘involuntary
movements’) and ataxic (‘shaky’ posture and movements)
- Anatomic/topographic distribution of symptoms → unilateral, bilateral
o There are clear differences in spastic unilateral (one side is affected) and in
spastic bilateral (both sides are affected)
, o In the ataxic/dyskinetic it is not useful to use unilateral or bilateral as a most
of the time the whole body is involved in different levels.
- Activity limitation → GMFCS, MACS and CFCS
Background: movement disorder & anatomy/topography
Spastic:
- Spastic unilateral CP (one side of body)
o Congenital hemiparesis
- Bilateral spastic CP (both sides of body)
o Diplegia, quadriplegia
Dyskinetic (variable topography)
- Dystonic (reduced activity and increased tone)
- Athetoid (increased activity and decreased tone)
Ataxic (variable topography)
- Low muscle tone and poor coordination
Background: activity limitation
What a child does in daily life (performance) → impact of impairments on activities
- Gross motor function = Gross motor classification system (GMFCS)
o 5 levels (I to V) of gross motor ability
▪ Fro totally independent (level I)
▪ To totally dependent (level V)
o 5 age bands:
▪ < 2 years / 2-3 years / 4-5 years / 6 to 12 years
- Bilateral functions of hands = Manual Ability Classification system (MACS)
- Communication = CFCS
Background: classification activity limitation
Classification system
- “Clinically meaningful distinctions” in function
- No detailed assessments of function
- Rate performance (“what she does”), not capacitiy (“what she can”)
- Enable to characterize function of participants in research
- Do not consider underlying components
- Not appropriate/sensitive to assess most treatments
- Enables to make gross predictions about the final level os mobility (from 2 years)
- Enables to set realistic goals for treatment(s).
Background: movements disorder & anatomy/topography & activity limitation
Most of the children will walk:
- About 60% of GMFCS I-II are independent walkers
- About 10 % of GMFCS III
- About 30% of GMFCS IV-V are wheelchair users
3 in 4 children have difficulty with hand function!
Movement disorders & topography are related to the underlying brain lesions. For the
spastic form the usual brain damage are located in the cortical regions, subcortical regions
Lecture 1: Introduction
Rehabilitation in the Netherlands
Rehabilitation medicine is aimed at the prevention, reduction and cure of (expected)
consequences of chronic physical impairments or functional limitation
Rehabilitation focuses on improving independent functioning in society. Consequently. It
focuses on issues like self-care, domestic life, communication, mobility, labor, education,
leisure activities, sports. The rehabilitation team consists of several professionals: physical
therapist, speech therapist, social worker, nurse etc.
Non-neurological group: Amputation, degenerative joint disease, hand trauma, low-back
pain, posttraumatic dystrophy (CRPS), cardio-pulmonary problems, burning, chronic pain,
poly-trauma, etc.
Neurological group: Stroke (CVA), neuromuscular disorders, multiple sclerosis (MS), spinal
cord injury (SCI), Parkinson’s disease, cerebral palsy (CP), developmental coordination
disorders (DCD).
Rehabilitation care can be provided in rehabilitation centers, hospitals, nursing home and.
Private centers. Children can also receive rehabilitation care at special schools (mytyl, tyltyl).
Rehabilitation research
Dutch organization for health research and development (ZonMw). ZonMw funds health
research and stimulates use of the knowledge developed to help improve health and
healthcare in the Netherlands. Two things are needed to improve health and healthcare in
the Netherlands: knowledge, and actual use of knowledge. With a range of grant
programmes, ZonMw stimulates the entire innovation cycle, from fundamental research to
the implementation of new treatments, preventive interventions and improvements to the
structure of healthcare
Critical appraisal
Critical appraisal = the process of systematically examining research evidence to assess its
results, validity and relevance before using it to inform a decision. Assess the usefulness and
validity of research findings with respect to a PICO question
P Patient, population or problem How would I describe a group
of patients similar to mine?
I Intervention, prognostic factor or exposure Which main intervention,
prognostic factor, or exposure
am I considering?
C Comparison to intervention What is the main alternative to
compare with the
intervention?
O Outcome you would like to measure or achieve What can I hope to accomplish
measure, improve or affect?
T What type of question are you asking? Therapy/Treatment, Diagnosis,
Prognosis, Harm/Etiology
T Type of study you want to find What would be the best study
design/methodology?
If you are looking for an effect for a specific intervention → look for a RCT
,Randomized control trial
- Random allocation of participants enables that groups are equivalent in terms of
both known and unknown confounding factors
- Be aware bias is still possible
- Verify if the randomization is concealed
- Assess blinding if relevant: participants, therapists, assessor
- Note: lack of blinding is less a problem with objective outcome measures than with
subjective
- Precise inclusion and exclusion criteria
- Usually: high internal validity but low external validity!
Observational design: cohort study
- Following up participants to observe who ‘develops’ the outcome of interest
- High risk for selection bias and confounding factors
- Long follow-up: risk of important losses to follow-up
- Appropriate design to analyze associations
- Problematic design when used to evaluate therapeutic interventions
Case-control studies
- Always retrospective in nature
- To investigate risk factors when the outcome of interest is rare
- Possibility of ‘recall bias’ for the cases if measures are subjective
- Difficulty to find comparable ‘controls’
Leading question for the CAT
1. Does this study address a clearly focused question?
a. Relevance of the question
b. Adding value of the study
c. Type of the research question
i. Questions about the effectiveness of treatment
ii. Question about diagnostic accuracy
iii. Questions about the prognostic value
iv. Questions about the frequency of events (Incidence, prevalence)
2. Did the study use valid methods to address this question?
a. Assess the study design: effectiveness of treatment, diagnostic, prognostic
and incidence & prevalence
b. Assess whether the study methods address the key potential sources of bias
i. Bias due to chance: random error → affects the precision of the
results
c. Bias due to the study methods: systematic bias → selection of participants,
data collection and data analysis and interpretation
3. What are the results?
a. Are they significant results?
b. Effect size
c. Check the level of uncertainty
d. Statistically and clinically significance
e. Check if potential conflict of interest have been identified.
4. Are these valid, important results applicable to my patient or population?
a. Who participated?
i. Characteristics of participants (age range, gender, illness stage)
, b. In which context? How long ago?
i. Academical/peripheral hospital
ii. Innovative/usual equipment
iii. Country, region
c. Cost-effectiveness?
Do not mix up reliability and internal validity
Reliability = precision, absence of random errors
Internal validity = accuracy, absence of systematic errors
Critical appraisal of primary evidence!
- Primary evidence: experimental and observational studies
- CAT assessment: use of (at least) 2 primary evidence
- No secondary evidence: systematic reviews, meta-analyses
- We expect you to:
o Appraise the results and the validity of the studies
o Try to appraise the relevance = this requires clinical experience
o Carefully conducted observational studies may provide more evidence than
poor RCTs
o Scales or checklists? No consensus on which is preferable
o Don’t use checklists to score articles with one number but to evaluate
shortcomings that may have influenced the results
o CAT assignment is not solely about responding to the question above but to
integrate them into the discussion of the results
Slidecast 1 Cerebral Palsy
Etiology, incidence/prevalence
- Most common pediatric neurological disorder (2-3/1000 live births)
- Premature babies have a higher risk for CP
- Diagnosis based on abnormal movement and posture
- Etiology: non-progressive brain injury
- Symptoms: change over time
- Umbrella term: large range of brain injuries and functional limitations
Background: diagnosis
- No definite test for CP
- Severe cases: diagnosis after birth
- Milder cases: wait until major brain maturation (5 years)
- Average age of diagnosis: around 2 years
Difficult diagnosis because:
- It may take years for clear signs to appear, many children with brain damage make a
recovery, levels of severity vary greatly, and signs of CP resemble other disorders
General background
There are different ways to classify CP according to
- Type of movement → spastic (‘stiff’ type of movement), dyskinetic (‘involuntary
movements’) and ataxic (‘shaky’ posture and movements)
- Anatomic/topographic distribution of symptoms → unilateral, bilateral
o There are clear differences in spastic unilateral (one side is affected) and in
spastic bilateral (both sides are affected)
, o In the ataxic/dyskinetic it is not useful to use unilateral or bilateral as a most
of the time the whole body is involved in different levels.
- Activity limitation → GMFCS, MACS and CFCS
Background: movement disorder & anatomy/topography
Spastic:
- Spastic unilateral CP (one side of body)
o Congenital hemiparesis
- Bilateral spastic CP (both sides of body)
o Diplegia, quadriplegia
Dyskinetic (variable topography)
- Dystonic (reduced activity and increased tone)
- Athetoid (increased activity and decreased tone)
Ataxic (variable topography)
- Low muscle tone and poor coordination
Background: activity limitation
What a child does in daily life (performance) → impact of impairments on activities
- Gross motor function = Gross motor classification system (GMFCS)
o 5 levels (I to V) of gross motor ability
▪ Fro totally independent (level I)
▪ To totally dependent (level V)
o 5 age bands:
▪ < 2 years / 2-3 years / 4-5 years / 6 to 12 years
- Bilateral functions of hands = Manual Ability Classification system (MACS)
- Communication = CFCS
Background: classification activity limitation
Classification system
- “Clinically meaningful distinctions” in function
- No detailed assessments of function
- Rate performance (“what she does”), not capacitiy (“what she can”)
- Enable to characterize function of participants in research
- Do not consider underlying components
- Not appropriate/sensitive to assess most treatments
- Enables to make gross predictions about the final level os mobility (from 2 years)
- Enables to set realistic goals for treatment(s).
Background: movements disorder & anatomy/topography & activity limitation
Most of the children will walk:
- About 60% of GMFCS I-II are independent walkers
- About 10 % of GMFCS III
- About 30% of GMFCS IV-V are wheelchair users
3 in 4 children have difficulty with hand function!
Movement disorders & topography are related to the underlying brain lesions. For the
spastic form the usual brain damage are located in the cortical regions, subcortical regions
