AW Heinemann, Director, CROR, RIC
21 May 2015
Measuring What Matters in Rehabilitation Allen W. Heinemann, PhD, FACRM
1
Learning Objectives
1. Describe the history of rehabilitation outcome 2. 3.
4.
measurement Identify sentinel events in the development of rehabilitation outcome measures Describe opportunities to improve rehabilitation services through the routine collection, reporting and aggregating of details about rehabilitation services, processes and outcomes Discuss a research agenda related to rehabilitation outcomes improvement 2
Quebec Congress in AdaptationRehabilitation Research
1
AW Heinemann, Director, CROR, RIC
21 May 2015
In memoriam: David B. Gray • Developed the Participation and
• • • •
Environment components of the International Classification of Functioning, Disability and Health Deputy Director of the National Center for Medical Rehabilitation Research 1990 -5 Director of the National Institute on Disability and Rehabilitation Research, 1986-7 BA Lawrence University, 1966 MA Western Michigan University, 1970 PhD Behavior Genetics: University of Minnesota, 1974 3
The view from 30 meters and 30 years
Bubo scandiacus
Buteo jamaicensis 4
Quebec Congress in AdaptationRehabilitation Research
2
AW Heinemann, Director, CROR, RIC
21 May 2015
I. A brief and selective history of rehabilitation outcome measurement
5
Outcomes definitions
•
Rehabilitation outcomes – “Changes produced by rehabilitative services in the lives of service recipients and their environment” Fuhrer, 1987
•
Outcome measures – “Intended to quantify a patient’s performance or health status based on standardized evaluation protocols or close ended questions.” Jette, Halbert, Iverson, Miceli, Shah, 2009
Quebec Congress in AdaptationRehabilitation Research
3
AW Heinemann, Director, CROR, RIC
21 May 2015
A selective timeline of key outcome measurement events 1987 Marcus Fuhrer: Rehabilitation Outcomes: Analysis and Measurement 1987 Keith et al: Birth of the FIM and UDSmr 1993 Heinemann et al: Application of the Rasch model to functional status measurement 1994 Stineman et al: A Case-Mix Classification System for Medical Rehabilitation 1997 Fuhrer: Assessing Medical Rehabilitation Practices: The Promise of Outcomes Research 2001 Stucki et al. Emerging attention to clinically important change 2008 John Whyte: Coulter lecture – theoretical frameworks and intervention taxonomies 2005 Cella et al: PROMIS item banks
7
Types of rehabilitation outcome measures
• Patient performance (Timed Up and Go) – Ecological validity
• Clinician ratings of patient performance (FIM) – Require on-going rater training
• Patient-reported (PROMIS, AM-PAC) – Require some method to assure items “add-up” to a meaningful score – Contemporary methods include item response theory or Rasch model methods 8
Quebec Congress in AdaptationRehabilitation Research
4
AW Heinemann, Director, CROR, RIC
21 May 2015
Uses of outcome measures
• Establish a patient’s baseline status, need for services • Monitor a patient’s progress to determine the effectiveness • • • • • •
of an intervention Inform patients and family of progress in a quantifiable manner Justify reimbursement by payers Provide data for program evaluation Support accreditation decisions Define quality measures for provider selection Evaluate clinical trial benefits
9
Donabedian’s quality improvement model
The Donabedian Model of Patient Safety: Medical Teamwork and Patient Safety: The Evidencebased Relation. July 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/medteam/figure2.html
Quebec Congress in AdaptationRehabilitation Research
10
5
AW Heinemann, Director, CROR, RIC
21 May 2015
Rehabilitation + Outcome Measurement Citations: 1975 to 2015 (May)
11
Where were these 453 articles published? • • • • • • • • • •
Age and Ageing American J of Occupational Therapy American J of PM&R Aphasiology Archives of PM&R Brain Injury Canadian J Occupational Therapy/Revue Canadienne Ergotherapie Cochraine Database J Communication Disorders J Head Trauma Rehabilitation 12
Quebec Congress in AdaptationRehabilitation Research
6
AW Heinemann, Director, CROR, RIC
21 May 2015
II. Identify sentinel events in the development of rehabilitation outcome measures A. B. C. D.
Conceptual clarification Taxonomies Measurement technology Measurement resources for clinicians
13
A. Conceptual clarification Whyte’s 2007 Coulter Lecture • • •
Theoretical models and taxonomies are crucial in scientific development Rehabilitation theories are insufficiently developed Medical rehabilitation should develop a body of well-articulated theories
14
Quebec Congress in AdaptationRehabilitation Research
7
AW Heinemann, Director, CROR, RIC
21 May 2015
Messick reframes validity considerations • • • • • •
Content: relevance, representativeness, and technical of the measure to the construct Substantive: empirical evidence for the theoretical construct of interest Structural: fidelity of the scoring structure to the structure of the construct domain Generalizability: extent scores generalize across populations, settings, and tasks External: convergent, discriminant, and criterion-based evidence for the measure. How does this measure perform in comparison to other similar or different measures? Consequential: positive or negative, and intentional or unintentional consequences of use of the measure
15
B. International Classification of Functioning Disability and Health Body Functions & Structures
Activities & Participation
Environmental Factors
Functions
Capacity
Barriers
Structures
Performance
Facilitators
http://apps.who.int/classifications/icfbrowser/
Quebec Congress in AdaptationRehabilitation Research
16
8
AW Heinemann, Director, CROR, RIC
21 May 2015
Body functions and structures 1. 2. 3. 4. 5. 6. 7. 8.
Mental Functions Sensory Functions and Pain Voice and Speech Functions Functions of the Cardiovascular, Hematological, Immunological and Respiratory Systems Functions of the Digestive, Metabolic, and Endocrine Systems Genitourinary and Reproductive Functions Neuromusculoskeletal and Movement-related Functions Functions of the Skin and Related Structures
17
Activities and participation 1. 2. 3. 4. 5. 6. 7. 8. 9.
Learning and Applying Knowledge General Tasks and Demands Communication Mobility Self-care Domestic life Interpersonal Interactions and Relationships Major Life Areas Community, Social and Civic Life
18
Quebec Congress in AdaptationRehabilitation Research
9
AW Heinemann, Director, CROR, RIC
21 May 2015
Outcome measures across ICF domains •
Body function – Mini Mental Status Examination (performance) – Beck Depression Inventory (patient reported)
•
Activity and Participation – 10 Meter Walk Test (performance) – Functional Independence Measure (clinician rated) – Community Integration Questionnaire (patient reported)
•
Environmental factors – Community Health Environment Checklist (user rated) – Measure of the Quality of the Environment (patient reported)
19
C. Rehabilitation’s embrace of patientreported outcomes “Any report of status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else”
20
Quebec Congress in AdaptationRehabilitation Research
10
AW Heinemann, Director, CROR, RIC
21 May 2015
What do PROs measure? • • • • • •
Symptoms Health status Quality of life Satisfaction with services Medication use Perceived value of treatment
21
Why use PROs in clinical practice? •
Patient perspective is essential in comparative effectiveness and patient centered outcomes research
•
When making decisions, patients need to understand experiences of previous patients “like them” Clinicians and payers need to understand how patients experience interventions PROs predict whether patients comply with treatment and use services
Institute of Medicine
“Purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at individual and population levels”
Quebec Congress in AdaptationRehabilitation Research
22
11
AW Heinemann, Director, CROR, RIC
21 May 2015
PROs: Address goals of patient-centered outcomes research •
Patient-Centered Outcomes Research Institute – PCOR Definition
“Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”
– Methodology Report, Standard 4.1.3:
“Use patient-reported outcomes when patients or people at risk of a condition are the best sources of information.”
23
How PROs can be used in clinical practice • • • • • • • •
Identifying goals for collecting PROs in clinical practice Selecting patients, setting, and timing for assessment Determining which questionnaires to use Choosing a mode for administering the PROs Reporting PRO results Interpreting scores Responding to issues identified by the PRO Evaluating the impact of PRO intervention on the practice
Quebec Congress in AdaptationRehabilitation Research
24
12
AW Heinemann, Director, CROR, RIC
21 May 2015
Standardized methods for measure development that allows CAT administration
(Reeve, 2006)
25
(Velozo, Seel, Magasi, Heinemann, & Romero, 2012)
PROs and computerized adaptive testing • •
Algorithm development uses psychometric framework of Item Response Theory CAT utilizes algorithms to estimate person ability and choose the next best item to administer using test specifications such as – Content coverage – Desired length – Precision
26
Quebec Congress in AdaptationRehabilitation Research
13
AW Heinemann, Director, CROR, RIC
21 May 2015
CAT advantages
• • • • •
Reduce patient burden without loss of precision Immediacy of feedback Communication on a common metric Dynamic tailoring of instrument difficulty to the level of patient Reduce clerical errors 27
Patient Reported Outcomes Measurement Information System
28
Quebec Congress in AdaptationRehabilitation Research
14
AW Heinemann, Director, CROR, RIC
21 May 2015
PROMIS domains
29
D. Resources to enhance clinician knowledge of measurement concepts • • • • •
Center on Outcome Measurement in Brain Injury (COMBI) Evidence-Based Review of Stroke Rehabilitation (EBRSR) StrokEDGE Spinal Cord Injury Rehabilitation Evidence (SCIRE) Rehabilitation Measures Database (RMD)
EBRSR: Evidence-Based Review of Stroke Rehabilitation 30
Quebec Congress in AdaptationRehabilitation Research
15
AW Heinemann, Director, CROR, RIC
21 May 2015
Rehabilitation Measures Database
31
Archives’ measurement “tear sheets” Additional collaborations: Rehabilitation Nursing American Journal of Occupational Therapy 32
Quebec Congress in AdaptationRehabilitation Research
16
AW Heinemann, Director, CROR, RIC
21 May 2015
Steps in selecting an outcome measure
Potter, Fulk, Salem, Sullivan, 2011
33
Considerations in outcome measure selection •
What to measure – Body structure, function, activity, participation, environmental factors
•
Purpose of measurement – Discriminative, predictive, evaluative
•
Types of measure – Condition-specific, generic
•
Patient and clinical factors – Patient ability, goals, clinic requirements
•
Psychometric considerations – Reliability, validity, diagnostic accuracy, responsiveness, sensitivity
•
Feasibility – Time, space, equipment, training, cost, burden, culture, language, proprietary restrictions
Quebec Congress in AdaptationRehabilitation Research
34
17
AW Heinemann, Director, CROR, RIC
21 May 2015
Goal: Improved patient care • • • • •
Standardized outcomes reported by all disciplines Assessment across settings Outcomes reported graphically to highlight trends over time Incorporates key patient reported factors into treatment planning Allows team conference to focus on trends and treatment modifications, not reporting
35
Facilitators of outcome measurement
• Individual facilitators – – – –
Belief in benefits of routine measurement Flexibility in selecting instruments to patients’ circumstances Evidence to negotiate with insurers regarding coverage Opportunity to use information for quality improvement
• External facilitators – – – –
Access to resources about a variety of measures Influential opinion leaders Accrediting organizations Information on selecting, administrating, scoring, and interpreting measures 36
Quebec Congress in AdaptationRehabilitation Research
18
AW Heinemann, Director, CROR, RIC
21 May 2015
Barriers to outcome measurement
• Individual barriers – – – –
Limited time to search, administer, score, interpret measures Limited knowledge on selection and interpretation criteria Limited resources to purchase, set-up, store equipment Belief that outcome measures are unnecessary, contrary to individualized services
• Organizational barriers – Perception that return on investment is insufficient – No policies promoting routine use of standardized outcome measures, limited compliance monitoring – Limited consensus or recommendations from professional organizations
37
III. Describe opportunities to improve rehabilitation services through the routine collection, reporting and aggregating of details about rehabilitation services, processes and outcomes
38
Quebec Congress in AdaptationRehabilitation Research
19
AW Heinemann, Director, CROR, RIC
21 May 2015
Example 1: Development of an outcomes dashboard for team conferences Funding provided by the Rehabilitation Institute of Chicago, Henry B. Betts Innovation Award
39
Project goal: Improve patient care with integrated information Current situation • Clinicians report patient status verbally: FIM, TUG, behavioral descriptions • Daily FIM ratings are collected but not used clinically; other ratings are in text notes • Patient voice is not documented using standard instruments • No objective measure of patient activity level • Can’t monitor trends over time
Quebec Congress in AdaptationRehabilitation Research
Vision • Clinicians have access to standardized outcomes data • Clinicians see progress in an easy-to-digest visual display • The patient’s voice is heard during team conferences • Accelerometers allow documentation of patient activity level • Team monitors patient trends over time
40
20
AW Heinemann, Director, CROR, RIC
21 May 2015
Project tasks
• Created an outcomes • • •
• Developed a procedure
dashboard that can be used in all levels of care Extracted nursing and PT-reported performance information from EMR Installed local version of NIH PROMIS Center Deployed accelerometers using Android phones to collect 3D movement
•
•
manual to support use of the Dashboard, PROMIS, and accelerometers Encouraged the clinical team to reconsider how they organize team conferences Compared team conference functioning with a floor not using the Dashboard
41
Outcomes dashboard available during team conferences OT
PT
Nurse
SLP
Psychologist
Physician
Care Manager
Researcher
Insurance Company
Patient
Family 42
Quebec Congress in AdaptationRehabilitation Research
21
AW Heinemann, Director, CROR, RIC
21 May 2015
Dashboard evaluation Percent of clinical team members rating each data source as at least somewhat useful in understanding patients’ progress
43
Qualitative feedback • • • •
“I’m excited at the potential impact that the dashboard can have on team communication surrounding patient progress and outcomes. It can also assist with educating patients and families about progress in a way that they can understand” OT “The visual representation of progress really allows the team to understand whether or not a patient is progressing and how quickly they are doing so” Clinician “The dashboard has great potential to improve communication and enhance understanding of patient performance and progress by all members of the team.” Physician “I think that this is great. The questions about my sleeping and the way I am feeling about things make me think. It is good to see that I am making progress because sometimes I feel like I am not.” Patient
44
Quebec Congress in AdaptationRehabilitation Research
22
AW Heinemann, Director, CROR, RIC
21 May 2015
Example 2: A quality improvement demonstration project for prosthetic clinics Funding provided by the National Institute on Disability and Rehabilitation Research Rehabilitation Engineering Research Center on Prosthetics and Orthotics
45
Continuous quality improvement •
CQI seeks to improve healthcare by – – – –
•
Factors to consider – – – –
•
Monitoring healthcare outcomes Engaging staff Maintaining a patient focus Understanding processes of care Patients Clinicians Organization Community
CQI requires the use of performance indicators – specify key desired outcomes – enable comparisons across facilities or over time within a facility – create the potential for benchmarking
Quebec Congress in AdaptationRehabilitation Research
46
23
AW Heinemann, Director, CROR, RIC
21 May 2015
Benefits of continuous quality improvement • • • • •
Improve patient satisfaction Reduce or eliminate problems within delivery systems Reduce costs while maintaining or improving quality Satisfy an existing need more effectively or efficiently Identify and meet new needs
47
ABC’s mission promotes CQI •
ABC’s Mission – To establish and promote the highest standards of organizational and clinical performance in the delivery of O&P services
•
Performance Management & Improvement Standards – A set of 10 standards promote tracking of the organization’s strengths and weaknesses in providing quality patient care
48
Quebec Congress in AdaptationRehabilitation Research
24
AW Heinemann, Director, CROR, RIC
21 May 2015
Project objectives
• Implement continuous quality improvement (CQI) • •
projects in several prosthetic clinics Evaluate the utility of the Orthotic and Prosthetic Users’ Survey as a CQI tool Describe challenges and strategies used by facilities in implementing CQI projects
49
49
Project methods
• Facilities: Five Midwest prosthetic clinics • Instrumentation: Orthotic and Prosthetic Users’ Survey • Procedures: Admission, device delivery, 2 month follow• •
up OPUS administration Variation: Facilities selected data collection methods Reporting: Investigators provided comparative outcomes information and consulted on quality improvement opportunities
50
Quebec Congress in AdaptationRehabilitation Research
25
AW Heinemann, Director, CROR, RIC
21 May 2015
Data collection forms and timing
• Initial visit – Orthotics Prosthetics Users Survey (OPUS)
Functional status Quality of life
– Health status – Clinician documentation (K levels, demographic details, goals)
• Device delivery – Functional status, quality of life, satisfaction with services and device
• Follow-Up at 2 months post-device delivery – Functional status, quality of life, satisfaction with services and device
51
Consultation process
• • • •
Review PRO results Discuss ways in which to improve clinical practice Develop draft action plans Monitor action plan implementation
52
Quebec Congress in AdaptationRehabilitation Research
26
AW Heinemann, Director, CROR, RIC
21 May 2015
Lower extremity functional status by etiology 62 60 58 56 54 52 50 48 46 44 42 40 38 36 34 32 30
Trauma n=16
Disease n=42
Intake
Congenital n=3
Delivery
Follow-Up
Higher scores represent greater function.
53
Quality improvement foci
• Facilities A and B – Identify trends for patients with declining functional status and satisfaction with service – Identify patients whose functional status or satisfaction with services decreases over time – Conduct follow-up calls using scripted open ended questions – Structure staff education to address identified needs – Collect follow-up data
• Facility C – QI Project planning on hold due to Medicare audits – Continue to collect surveys with goal of participating in QI project in the future
Quebec Congress in AdaptationRehabilitation Research
54
27
AW Heinemann, Director, CROR, RIC
21 May 2015
Challenges encountered
• Time limitations – “It’s difficult to get any patient to return surveys… Everyone is busy, whether they are high-income, low-income, have a disability, or don’t have a disability.” – “Time is the biggest barrier. We have limited staff who have multiple roles.”
• Tracking patient participation over the course of treatment – Electronic health record helps
• Obtaining follow-up data when patients do not return for •
appointments Patients not understanding the value in filling out the surveys 55
Strategies to collect quality data • • • • • •
“It is important to structure time for survey completion during a standard clinic visit.” “It would be very helpful if the survey was part of our EMR.” “We need to work on having our clinicians talk about the survey with patients and encourage the patient to begin filling it out while they are in the waiting room, and then while they are in the evaluation appointment.” “We offered a $50 gift card to the clinician who completed the most complete sets of surveys.” “We hand the delivery survey to the patient as they arrive. They bring it back at their follow-up appointment.” “Some of our patients live in the country and if they don’t want to come back in for a follow-up appointment, we don’t demand it. We have to rely 56 on them to mail the surveys in.”
Quebec Congress in AdaptationRehabilitation Research
28
AW Heinemann, Director, CROR, RIC
21 May 2015
Benefits of CQI activities
• Target the needs of patients and achieve accreditation requirements – “To have richer data to show whether the services we provide are actually improving patient’s function and participation.” – “We truly understand the value in gathering data about patients’ experience.”
• Enhance patient-centered care – “To document our successes and to give patients a chance to specify where we can improve.” – “Patients would be valued by seeking their feedback, success and problems.” 57
Example 3: Feasibility of Obtaining Patient-Reported Outcomes after Rehabilitation Discharge Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness (NIDRR Award H133B040032111) Rehabilitation Research and Training Center on Improving Measurement of Medical Rehabilitation Outcomes (NIDRR Award H133B090024)
58
Quebec Congress in AdaptationRehabilitation Research
29
AW Heinemann, Director, CROR, RIC
21 May 2015
Project background and objectives
• Background
• Objectives
– Post-discharge information on participation is critical to improving rehabilitation services and patients’ quality of life – Telephone interviews are valuable, but costly – IRT/CAT methods may save resources, but feasibility is unknown
– Develop patient-reported outcome measure of participation – Implement participation measure CAT – Evaluate feasibility of CAT data collection using web and telephonic interface
59
Developing a measure of participation
• Conduct literature review • Conduct focus groups with
• •
consumers, caregivers, providers, payers, policy makers Develop items and rating scales to operationalize participation Conduct cognitive interviews with consumers and general public
• Revise and pilot test •
• •
participation instrument Collect and analyze population data from persons with and without disabilities (BRFSS) Refine instrument Evaluate instrument as part of routine postdischarge follow-up assessment 60
Quebec Congress in AdaptationRehabilitation Research
30
AW Heinemann, Director, CROR, RIC
21 May 2015
Focus group input from stakeholders Consumers “It means to make some sort of contribution in life” “Working and living” “It's important to socialize” “Just being able to do the things that you enjoy” Caregivers
“Just doing what you want to do” “Being able to go to the store, to school, being able to do all of the things that normal people do”
Providers
“It goes beyond just daily living activities” “What you want when you want with who you want” “You are seen as having something to give”
Payers
“Allowed to fail, take on challenge” “Lack of information can be as isolating as any physical barrier”
Policy Makers
“Just the stuff we do and take for granted” 61
What we heard: Participation enfranchisement Meaningful Engagement/ Being a Part of Personal & Societal Responsibilities
Choice & Control
Participation Values Having an Impact & Supporting Others
Access & Opportunity
Social Connection, Inclusion & Membership
• Hammel J, Magasi S, Heinemann AW, Whiteneck G, Bogner J, Rodriguez E. What does participation mean? An insider perspective from people with disabilities. Disability and Rehabilitation, 30:19,1445-1460. • Magasi S, Hammel J, Heinemann AW, Whiteneck G, Bogner J. Participation: A comparative analysis of multiple rehabilitation stakeholders’ perspectives. Journal of Rehabilitation Medicine, 41, 936-944, 2009. 62
Quebec Congress in AdaptationRehabilitation Research
31
AW Heinemann, Director, CROR, RIC
21 May 2015
Community Participation Indicators • • • •
Frequency of activity Importance of activity Evaluation of activity frequency 48 enfranchisement items – Control over participation – Involvement in life situations
63
Scoring decision: Consider importance of activities
• Avoid creating a “busy-ness” index • Personal preferences, opportunities, environmental • •
factors influence activity patterns Report descriptive information about activity patterns Evaluate “percent of important activities performed often enough” as an indicator of participation satisfaction
64
Quebec Congress in AdaptationRehabilitation Research
32
AW Heinemann, Director, CROR, RIC
21 May 2015
Rating scale analysis of enfranchisement items
• Control over participation • Involvement in life situations
65
People with more severe disabilities report less involvement in life situations
Known Groups Validity Evidence
66
Quebec Congress in AdaptationRehabilitation Research
33
AW Heinemann, Director, CROR, RIC
21 May 2015
Participation: Conclusions
• Participation as measured by activity frequency, evaluation and enfranchisement items is not a unidimensional construct – Activity frequency, importance and evaluation are distinct aspects – Individuals’ preferences and opportunities vary greatly – Personal preferences determine individual’s participation profile
• Involvement in and control over participation are distinct •
constructs that can be measured reliably Preliminary construct validity of involvement in and control over participation is promising
67
Feasibility of collecting post-discharge information using IRT/CAT
• Sample recruitment – Outcomes Management Systems and Analysis staff invited discharged adult inpatients to complete study instruments after a 1-month post-discharge telephone satisfaction survey.
• Data collection options – Secure web site – Interactive voice response (IVR) system – Questions administered using a CAT algorithm
• Data analysis – CAT data matched to de-identified inpatient data. 68
Quebec Congress in AdaptationRehabilitation Research
34
AW Heinemann, Director, CROR, RIC
21 May 2015
Timeline of events
Time estimated for survey completion
Week 0
Discharge
Week 4
OMSA calls patients for satisfaction survey, invites them to complete CPI
Week 5
Postcard mailed with information about CPI, log-in
Week 7
Reminder postcard mailed
Week 29
Log-in ID, password invalidated
Week 30
CPI data matched to inpatient data
69
Flow diagram of patient enrollment
70
Quebec Congress in AdaptationRehabilitation Research
35
AW Heinemann, Director, CROR, RIC
21 May 2015
Results •
674 patients agreed to complete the CAT-CPI. – Patients who agreed to complete the CAT-CPI were younger and reported slightly higher satisfaction with overall care than did those who did not participate.
•
34% actually completed the CAT-CPI – 61% selected telephonic administration – 39% selected internet administration.
•
Decreased odds of completing the CAT-CPI associated with – black and “other” race; stroke, brain injury, orthopedic and “other” impairments; being a Medicaid beneficiary, shorter LOS, and lower discharge FIM cognition measure
•
Increased odds of choosing telephonic administration associated with – younger age, retirement status, female gender, lower discharge FIM motor measure
71
Conclusions
• CAT administration by internet and telephone is feasible • • •
for collecting post-rehabilitation outcomes data Incentives required to assure sufficient level of patient follow-up Providing alternative ways of answering questions helps assure that a larger proportion of patients will respond Patient characteristics influence selection of phone vs. web-based option
72
Quebec Congress in AdaptationRehabilitation Research
36
AW Heinemann, Director, CROR, RIC
21 May 2015
IV. Research agenda
From 20 meters
73
Agenda • • • • • •
Promoting routine outcomes measurement in rehabilitation practice Selecting optimal measures across populations and settings Measuring what matters Measuring what’s feasible Appreciating policy priorities that influence outcome measurement Minimizing the unintended consequences of measurement
74
Quebec Congress in AdaptationRehabilitation Research
37
AW Heinemann, Director, CROR, RIC
21 May 2015
Promoting routine outcomes measurement in rehabilitation practice •
What are clinicians taught? – – – –
•
How do they acquire measurement knowledge? How does their training affect practice? How does their training affect the choice of outcome measures they use? How do different disciplines learn to use each others’ measures to guide care and place the focus on the patient?
How do clinicians access outcomes information? – Do they have access to Medline, CINAHL, PsychLit? – What sources of information do they use?
•
What are their training needs?
75
Selecting optimal measures across populations and settings • • •
How many measures are “enough”? How do we distinguish between the “good enough,” “better” and “optimal” measures within a domain? Institution specific measures – Prevent comparisons between institutions
• •
Challenges quantifying “change” when related but distinct instruments are used What criteria are clinicians using when they choose an instrument?
76
Quebec Congress in AdaptationRehabilitation Research
38
AW Heinemann, Director, CROR, RIC
21 May 2015
Measuring what matters •
Neglected areas of assessment – Longer term outcomes – Environmental factors
•
Cultural sensitivity and population specificity – – – –
Gender differences Racial / ethnic differences Impairment group differences Age differences
77
Appreciating policy priorities that influence outcome measurement • •
How will national and provincial health priorities affect what is measured? How will use of quality metrics affect what’s measured?
78
Quebec Congress in AdaptationRehabilitation Research
39
AW Heinemann, Director, CROR, RIC
21 May 2015
Minimizing the unintended consequences of measurement • •
Clinician and patient burden Risky uses of outcomes data – Using validated measures for a different population or setting than which it was evaluated – Measuring to impress – Provider compensation – Third-party payer reimbursements – Policy / political decisions – Marketing
79
At ground levelC • Utilize sensitive, reliable, appropriate instruments in CER studies • Evaluate methods to promote knowledge translation with clinical end users • Develop and evaluate quality measures for medical rehabilitation • Sustain efforts to evaluate promising interventions with carefully targeted endpoints operationalized by instruments that are reflective of and sensitive to clinical investigators’ goals 80
Quebec Congress in AdaptationRehabilitation Research
40
AW Heinemann, Director, CROR, RIC
21 May 2015
In conclusion • • •
Measure what matters Engage stakeholders in learning what matters Consider how measurement information will be utilized
81
Acknowledgments The Rehabilitation Research & Training Center on Improving Measurement of Medical Rehabilitation Outcomes Award H133B090024. This presentation does not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the US Federal Government.
Quebec Congress in AdaptationRehabilitation Research
41
Construire sa résilience au quotidien: une approche simple et peu coûteuse. Congrès québécois de recherche en adaptation-réadaptation Boucherville, le 21 mai 2015 Rachel Thibeault, Ph.D. erg.(c) Programme d’ergothérapie Faculté des sciences de la santé Université d’Ottawa
Qui suis-je? Une ergothérapeute qui accompagne des personnes et des collectivités vulnérables depuis 35 ans.
Qu’est-ce que la résilience? Propriété d’un individu à résister psychiquement aux épreuves de la vie. Mais le mot ‘résister’ s’avère trompeur.
Quatre scénarios posssibles: Résolution inadéquate
Résilience Croissance post-traumatique Anti-fragilité
Trois sources de données, en très résumé Psychologie classique Neurosciences
Recherches en ergothérapie
Le sens et la résilience selon les recherches en psychologie classique (Seligman, 2002, 2011) Pleasant life - je cherche le plaisir, j’évite la douleur et l’effort. Good life - je cultive mes talents et j’en tire de la satisfaction. Meaningful life - j’utilise mes talents pour redonner au monde.
Full life - j’utilise mes talents pour redonner au monde tout en goûtant à la vie.
6
La résilience revue par la neuroscience: Center for Investigating Healthy Minds (Ricard , Davidson, Lutz et al, 2004; 2005; 2007, 2011, 2012, 2013, 2014; Fredrickson, 2013; Lyubomirsky, 2013 )
Façonner des intentions altruistes positives. Donner forme à ces intentions- modalités cognitives, sensorielles, motrices.
Modifier notre structure neuronale.
Le rôle des ondes Gamma
‘Gamma waves play a vital role in cognitive functioning. Their propagation through the brain acts as a type of neuronal synchronizer, binding together distributed networks and focusing them towards an object of attention. Scientist have proposed that gamma waves are able to resolve the ‘binding problem’ of neuroscience – how sensory information processed in sensory-specific areas of the brain are unified into a single conscious experience. Their role in consciousness is so critical, that if gamma waves stop emitting from an area of the brain called the thalamus, conscious awareness is lost and the person slips into a deep coma.’ (Aiden, 2012)
Nouvelles evidences (Davidson, 2012)
Le système glymphatique (glymphatic clearance pathway) Les cellules gliales maintiennent un milieu sain pour les neurones. Elles jouent un rôle clef dans l’homéostasie, dans la production de myéline et dans le soutien et la protection du tissu nerveux. Elles approvisionnent les neurones en nutriments et en oxygène, éliminent les cellules mortes et combattent les pathogènes.
Elles comptent pour environ 90% des cellules du SNC. (Hooper et Pocock, 2014)
Le système glymphatique (glymphatic clearance pathway) Nedergaard (2013) a découvert le système glymphatique, un réseau de canaux cérébraux qui éliminent les toxines par le biais du liquide cérébrospinal, entre autres les dépôts protéiniques associés à certains troubles de l’humeur et à la maladie d’Alzheimer. Les activités de type contemplatif/méditatif stimulent le système glymphatique de façon statistiquement et cliniquement significative.
Faisons un parallèle
Si je désire améliorer ma forme physique, je vais travailler Ma force
Lever des poids
Mon endurance
Augmenter la durée
Ma souplesse
Faire des étirements
Mon équilibre
Faire des exercices
Ma vitalité
Bien me nourrir
Si je désire cultiver ma résilience, je vais cultiver (Seligman, 2012) La présence : minimum requis à chaque niveau de bien-être.
La compassion, l’amour, la tendresse La gratitude
Le pardon La justice
La tempérance (au sens d’équilibre)
Mais en choisissant quels exercices, quelles activités?
5 types Des exemples du bout du monde qui s’appliquent tout autant ici.
La centration Ephemia - Zambie Un activité souvent répétitive – parfois même en apparence inutile – comme une balade à pied vers nulle part pour se libérer de la fébrilité et favoriser une réceptivité et une disponibilité psychologiques (dopaminergiques).
La contemplation Ingrid et Annie – Afrique du Sud Des activités telles la prière, la méditation, l’observation tranquille qui créent l’expérience soutenue de la présence.
La création Lakech et Wagaye - Éthiopie Des activités qui comblent notre besoin de beauté et de créer, ne serait-ce que pour soi.
La contribution Doris et les bushwives– Sierra Leone
Des activités qui nous permettent de redonner, d’être des citoyens productifs et valorisés.
La communion Emmanuel - Nicaragua
Des activités qui renforcent nos liens d’appartenance – nous relient au Vivant.
Une surprise: parlons de malbouffe!
La notion de « malactivité » Mâcher du « qat » en Éthiopie Spider solitaire pour moi La vôtre?
Les gens résilients gèrent leur temps et leurs activités comme nous, nous gérons notre alimentation.
L’étonnant pouvoir que nous avons sur notre résilience
30-40 % génétique
50-60% activités intentionnelles 10% circonstances de la vie Adapté de Lyubomirsky, 2013
Quels sont les impacts de ces activités intentionnelles?
26
Fredrickson, B. L., Grewen, K. M., Coffey, K. A., Algoe, S. B., Firestine, A. M., Arevalo, J. M. G., Ma, J., & Cole, S. W. (2013). A functional genomic perspective on human well-being. Proceedings of the National Academy of Sciences, 110, 13684-13689.
27
Quelques extraits…
"Philosophers have long distinguished two basic forms of well-being: a 'hedonic' form representing an individual's pleasurable experiences, and a deeper 'eudaimonic,' form that results from striving toward meaning and a noble purpose beyond simple selfgratification. It's the difference, between enjoying a good meal and feeling connected to a larger community through a service project.
Trois mesures bien-être psychologique
réponse inflammatoire réponse immunitaire
29
‘While
both offer a sense of satisfaction, each is experienced very differently in the body's cells.’
30
"At the cellular level, our bodies appear to respond better to a different kind of well-being, one based on a sense of connectedness and purpose."
31
Que conclure? Nous avons surtout besoin d’activités à caractère eudémonique. Nous pouvons tolérer quelques activités à caractère hédonique , de préférence des expériences plutôt que des biens.
En 2 mots: les gens résilients cultivent des stratégies gagnantes sur 3 fronts à la fois: 1. les activités intentionnelles 2. les attitudes positives 3. la gestion efficace de l’émotion
En une diapo, nos outils pour cultiver la résilience Les éléments constitutifs
Les activités
La présence
Centration
La gratitude
Contemplation
Le pardon
Communion
La justice La compassion, l’amour, la tendresse
Création Contribution
avec une saine régulation émotionnelle associée
Une analogie incontournable
Un cadeau en terminant… Mon choix me permettra-t-il D’être authentique? Intégrité De grandir? Défi De redonner? Question de sens et d’appartenance D’avoir du plaisir?
Bonne route, en pleine conscience!
Bibliographie Aiden, (2012). http://dharmaineverywave.com/tag/happiness/ Alvord, M. K., Grados, J. J. (2005). Enhancing Resilience in Children: A Proactive Approach. Professional Psychology: Research and Practice, 36(3), 238-245. Anaut , M. (2003). La résilience: Surmonter les traumatismes. Paris : Nathan/VUEF. (voir www.nathan-u.com). Anderson, T. (2005). Occupational therapy in treating children with developmental delays who have been abused or neglected: A case study. Australian Occupational Therapy Journal, 52, 75-77. Bernstein, G. A., Layne, A. E., Egan, E. A., Tennison, D. M. (2005). School-Based Interventions for Anxious Children. Journal of the American Academy of Child and Adolescent Psychiatry, 44(11), 1118-1126. Blanche, E. I. (2007).The Expression of Creativity Through Occupation. Journal of Occupational Science, 14(1), 21-29. Bradshaw, B. G., Richardson, G. E., Kulkarni, K. (2007). Thriving with Diabetes: an Introduction to the Resiliency Approach for Diabetes Educators. Diabetes Educator, 33(4), 643-9. Bradshaw, B. G., Richardson, G. E., Kumpfer, K., Carlson, J., Stanchfield, J., Overall, J., et al. (2007). Determining the Efficacy of a Resiliency Training Approach in Adults with Type 2 Diabetes. Diabetes Educator, 33(4), 650-9. Brandon, S. E., Silke, A. P. (2007). Near- and Long-term Psychological Effects of Exposure to Terrorist Attacks. In Bongar Bruce, Brown Lisa M, Beutler Larry E, Breckenridge James N, Zimbardo Philip G (Eds), Psychology of terrorism (pp. 175-193). New York, NY, US: Oxford University Press.
Bibliographie Brennan, M. A. (2008). Conceptualizing Resiliency : An Interactional Perspective for Community and Youth Development. Child Care in Practice, 14(1), 55-64. Butler, L. D, Morland, L.A., Leskin, G.A. (2007). Psychological Resilience in the Face of Terrorism. In Bongar Bruce, Brown Lisa M, Beutler Larry E, Breckenridge James N, Zimbardo Philip G (Eds), Psychology of terrorism (pp. 400-417). New York, NY, US: Oxford University Press. Crust, L. (2008). A Review and Conceptual Re-examination of Mental Toughness: Implications for Future Researchers. Personality and Individual Differences, 45(7), 576-583. Cyrulnik, B. (2001). Les vilains petits canards. Paris : Odile Jacob. Cyrulnik, B. (2003). Ces enfants qui tiennent le coup (2e ed.) Paris : Hommes et perspectives. Cyrulnik, B. (2005). Vivre devant soi: être résilient et après?. Revigny-sur-Ornain : Éditions du Journal des psychologues. Davidson, R. J. (2000). Affective Style, Psychopathology, and Resilience: Brain Mechanisms and Plasticity. American Psychologist, 55(11), 1196-1214. Davidson, R. J.; Kabat-Zinn, J.; Schumacher, J.; Rosenkranz, M.; Muller, D.; Santorelli, S.; Urbanowski, F.; Harrington, A.; Bonus, K.; Sheridan, J. F. (2003). "Alterations in Brain and Immune Function Produced by Mindfulness Meditation". Psychosomatic Medicine 65 (4): 564–570. doi:10.1097/01.PSY.0000077505.67574.E3. PMID 12883106. edit Davidson, R.; Lutz, A. (2008). "Buddha's Brain: Neuroplasticity and Meditation [In the Spotlight]". IEEE Signal Processing Magazine 25 (1): 176–174. Bibcode:2008ISPM...25..176D. doi:10.1109/MSP.2008.4431873. PMC 2944261. PMID 20871742. edit
Bibliographie Davidson, R.& Begley, S. (2012). The emotional life of your brain. Hudson Street Press: New York Farrell, L. J. & Barrett P. M. (2007). Prevention of Childhood Emotion Disorders: Reducing the Burden of Suffering Associated with Anxiety and Depression. Child and Adolescent Mental Health, 12(2), 58-65. Fernandez, E. (2004). Effective Interventions to Promote Child and Family Wellness: A Study of Outcomes of Intervention Through Children’s Family Centres. Child and family social work, 9(1), 91-104. Frankl, V. (1988). Découvrir un sens à sa vie avec la logothérapie (traduction de Man’s search for meaning). Montréal: actualisation. Fredrickson, B. L., Grewen, K. M., Coffey, K. A., Algoe, S. B., Firestine, A. M., Arevalo, J. M. G., Ma, J., & Cole, S. W. (2013). A functional genomic perspective on human well-being. Proceedings of the National Academy of Sciences, 110, 13684-13689. Gillham, J., Reivich, K. (2007). Cultivating Optimism in Childhood and Adolescence. In Monat Alan, Lazarus Richard S, Reevy Gretchen (Eds), The Praeger handbook on stress and coping (vol.2)(pp. 309-326). Westport, CT, US: Praeger Publishers/Greenwood Publishing Group. Gillham, J. E., Reivich, K. J., Freres, D. R., Chaplin, T. M., Shatte, A. J., Samuels, B., et al. (2007). School-based Prevention of Depressive Symptoms: A Randomized Controlled Study of the Effectiveness and Specificity of the Penn Resiliency Program. Journal of Consulting and Clinical Psychology, 75(1), 9-19.
Bibliographie Gilligan, R. (2008). Promoting resilience in young people in long-term care--the relevance of roles and relationships in the domains of recreation and work. Journal of Social Work Practice, 22(1), 37-50. Gist, R. (2007). Promoting Resilience and Recovery in First Responders. In Bongar Bruce, Brown Lisa M, Beutler Larry E, Breckenridge James N, Zimbardo Philip G (Eds) Psychology of terrorism (pp. 418-433). New York, NY, US: Oxford University Press. Hooper, C. & Pocock, J.M. (2014). http://www.abcam.com/neuroscience/the-functions-of-glia-inthe-cns Jackson, D., Firtko, A., Edenborough, M. (2007). Personal Resilience as a Strategy for Surviving and Thriving in the Face of Workplace Adversity: A Literature Review. Journal of Advanced Nursing, 60(1), 1-9. Kordich Hall, D. (2000). Fostering Optimism in Young Children. Interaction (The national magazine of the Canadian Childcare Federation), Layous, K., Chancellor, J., & Lyubomirsky, S. (2014). Positive activities as protective factors against mental health conditions. Journal of Abnormal Psychology, 123, 3-12. Lutz, A.; Brefczynski-Lewis, J.; Johnstone, T.; Davidson, R. J. (2008). Baune, Bernhard, ed. "Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative Expertise". PLoS ONE 3 (3): e1897. Bibcode:2008PLoSO...3.1897L. doi:10.1371/journal.pone.0001897. PMC 2267490. PMID 18365029. edit Lutz, A.; Slagter, H. A.; Dunne, J. D.; Davidson, R. J. (2008). "Attention regulation and monitoring in meditation". Trends in Cognitive Sciences 12 (4): 163–169. doi:10.1016/j.tics.2008.01.005. PMC 2693206. PMID 18329323. editLyubomirsky S. (2011). Hedonic adaptation to positive and negative experiences. In Folkman S. (Ed.), Oxford handbook of stress, health, and coping (pp. 200–224). New York, NY: Oxford University Press.
Bibliographie Lyubomirsky, S., & Layous, K. (2013). How do simple positive activities increase well-being? Current Directions in Psychological Science, 22, 57-62. Lyons, D.M., Parker, K.J. (2007). Stress Inoculation-induced Indications of Resilience in Monkeys. Journal of Traumatic Stress, 20(4), 423-433. Masten, A. S. (2001). Ordinary Magic: Resilience Process in Development. American Psychologist, 56(3), 227-238. Masten, A. S. (2007). Resilience in Developing Systems: Progress and Promise as the Fourth Wave Rises. Development and Psychopathology, 19(3), 921-927. Masten, A. S. & Obradovic, J. (2006). Competence and Resilience in Development. Annals of the New York Academy of sciences, 1094(1), 13-27. Mental Health Association of Australia (2005). Resiliency Resource Centre, révisé le 15-022007, de http://www.embracethefuture.org.au/resiliency/index.htm Miller, A. (1990). For Your Own Good: Hidden Cruelty in Child-rearing and the Roots of Violence (3rd ed.). New-York, NY: The Noonday Press. Miller, A. (1993). Breaking Down the Wall of Silence : The Liberating Experience of Facing Painful Truth. New York, NY: Penguin Books USA inc. Miller, E. D. (2003). Reconceptualizing the Role of Resiliency in Coping and Therapy. Journal of Loss & Trauma, 8(4), 239-246. Nedergaard M (2013 Jun 01). Is there a cerebral lymphatic system? Stroke. 44, S93-5 Nedergaard M (2013 Jun 28). Neuroscience. Garbage truck of the brain. Science. 340, 152930
Bibliographie Nelson, S. K., Fuller, J. A. K., Choi, I., & Lyubomirsky, S. (2014). Beyond self-protection: Selfaffirmation benefits hedonic and eudaimonic well-being. Pers Soc Psychol Bull. 2014 Apr 29;40(8):998-1011 Olivier, K. G., Collin, P., Burns, J., Nicolas, J. (2006). Building Resilience in Young People Through Meaningful Participation. Australian e-Journal for the Advancement of Mental Health, 5(1), 1-7. Perkins, D. F., Jones, K. R. (2004). Risk Behaviours and Resiliency Within Physically Abused Adolescents. Child Abuse and Neglect, 28(5), 547-563. Phillips, G. (2008). Resilience in Practice Interventions. Child Care in Practice, 14(1), 45-54. Phipps, S. (2007). Adaptative Style in Children with Cancer: Implications for a Positive Psychology Approach. Journal of pediatric psychology, 32(9), 1055-1066. Plog BADashnaw MLHitomi EPeng WLiao YLou NDeane R Nedergaard M (2015 Jan 14). Biomarkers of Traumatic Injury Are Transported from Brain to Blood via the Glymphatic System. J Neurosci. 35, 518-26 Resiliency Canada (2006). De http://www.resiliencycanada.ca/ Richardson, G. E. (2002). The Metatheory of Resilience and Resiliency. Journal of Clinical Psychology, 58(3), 307-321. Ricard, M. (2004). Plaidoyer pour le bonheur. Paris : Pocket. Robertson, C., Finlay, L. (2007). Making a Difference, Teamwork and Coping: The Meaning of Practice in Acute Physical Settings. British Journal of Occupational Therapy, 70(2), 73-80. Rutter, M. (2006). Implications of Resilience Concepts for Scientific Understanding. Annals of the New York Academy of sciences, 1094(1), 1-12.
Bibliographie Rutter, M. (2007). Resilience, Competence, and Coping. Child Abuse and Neglect, 31(3), 205-209. Schaefer, C. E., Kaduson, H. (2008). Contemporary Play Therapy: Theory, Research and Practice. New York: Guilford Press. Seligman, M. (2002). Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. New York: The Free Press. Seligman, M. (2011). Flourish: A Visionary New Understanding of Happiness and Wellbeing. New York: Free Press Shaw, J. A. (2006). (2006). Commentary on “Seven Institutionalized Children and Their Adaptation in Late Adulthood: The Children of Duplessis”: Les Enfants de Duplessis: Perspectives on Trauma and Resiliency. Psychiatry, 69(4), 328-332. Siu, O., Chow, S. L., Phillips, D.R., Lin, L. (2006). An Exploratory Study of Resilience Among Hong Kong Employees: Ways to Happiness. In Ng Yew-Kwang, Ho Lok Sang (Eds) Happiness and public policy: Theory, case studies and implications. (pp. 209-220). New York, NY: Palgrave Macmillan. Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., Bernard, J. (2008). The Brief Resilience Scale: Assessing the Ability to Bounce Back. International Journal of Behavioral Medicine, 15(3), 194-200. Sokodol, A. E. & al. (2007). Positive Childhood Experiences: Resilience and Recovery From Personality Disorder in Early Adulthood. Journal of Clinical Psychiatry, 68 (7), 1102-1108. Southwick, S. M., Morgan, C. A., Vythilingam, M. & Charney, D. (2006). Mentors Enhance Resilience in At-Risk Children and Adolescents. Psychoanalytic Inquiry, 26, 577-584.
Bibliographie Spreitzer, G., Sutcliffe, K., Dutton, J., Sonenshein, S., Grant, A. M. (2005). A Socially Smbedded Model of Thriving at Work. Organization Science, 16(5), 537-549. Stallard, P., Simpson, N., Anderson, S., Carter, T., Osborn, C., Bush, S. (2008). An Evaluation of the FRIENDS Programme: A Cognitive Behaviour Therapy Intervention to Promote Emotional Resilience. Archives of Disease in Childhood, 90(10), 1016-1019. Suniya, L. (2003). Resilience and vulnerability: Adaptation in the context of childhood adversity. U of Cambridge Press Tugade, M. M., Barbara, L. F. (2004). Resilient Individuals Use Positive Emotions to Bounce Back From Negative Emotional Experiences. Journal of Personality and Social Psychology, 86(2), 320-333. Youssef, C. M., Luthans F. (2007). Positive Organizational Behavior in the Workplace : The Impact of Hope, Optimism, and Resiliency. Journal of management, 33(5), 774-800. Waaktaar, T., Christie, H. J., Borge, A. I. H., Torgersen, S. (2004). Building youths' resilience within a psychiatric outpatient setting: Results from a pilot clinical intervention project. Psychological Reports, 94(1), 363-370. Wallace, A. B. (2007). Contemplative Science : Where Buddhism and Neuroscience Converge. New-York, NY: Columbia University Press. Zimmerman, M. A., Bingenheimer, J. B. & Notaro, P. C. (2002). Natural Mentors and Adolescent Resiliency: A study With Urban Youth. American Journal of Community Psychology, 30(2), 221-243.
Fay B. Horak PhD, PT Professor of Neurology Portland VA and OHSU Balance Disorders Laboratories
Objective Measures of Balance and Gait for Rehabilitation
Objectives • Understand how system impairments underlie balance and gait dysfunction • Discover technology that allows clinicians to measure objective balance and gait impairments • Learn how continuous monitoring of mobility may reveal more impairments
Body-Worn Sensors: Mobility Lab
Laboratory: Balance Systems
Clinic: BESTest MiniBESTest
Systems Underlying Postural Control
BESTest Horak, Frank, and Wrisley Physical Therapy 89(5):484-98, 2009
Scores: 2 Normal 1 Abnormal 0 Absent
MiniBESTest for Dynamic Balance Franchignoni, Godi, Nardone, Horak, J Rehab Med 2010
14 items 42 pt MAX
Anticipatory
Sit to Stand
Reactions
Step Fwd
Sensory
Gait
EO Stance
Change Speed Head Turns
Rise to Toes
Step Bkwd
EC on Foam
Pivot Turns Obstacle
One Leg
Step Sideway
EO on Incline
TUG with Cognitive
MiniBESTest has great Clinimetrics 4 Systems
Psychometricss
Clinical
• Anticipatory • Reactive • Sensory • Gait • No Ceiling Effects 2% • No Redundancy • Min Detec Change 3.5 • Min Clinical Diff 4 • Fast (10 Min) • Reliable .96 • Fall Risk • Sensitive to Rehab
30
60
25
55
20
50
15
45
10
40
5
35
0
30
miniBEST mild PD Leddy et al J Neurolog Physical Therapy, 2011 Godi et al Phys Therapy 2012 Ryan et al Parkinsons Disease 2012 Sachi et al Thys Therapy 2014 Franchignoni et al, 2015
Berg
But NOT Objective!
In a Clinic
OPALS by APDM APDM.com
Long-Term Monitoring
Synchronized, wireless sensors OHSU and Dr. Horak have a significant financial interest in APDM, a company that may have a commercial interest in the results of this research and technology. This potential conflict of interest has been reviewed and managed by OHSU and the Integrity Program Oversight Council.
Body-worn Inertial Sensors:
Activity vs Movement Monitors
sensors
Inertial
Activity Monitors
Movement Monitors
• Accelerometers • Quantity of Movement Sedentary or Active • Pedometer • Consumer devices
• Accelerometers +Gyroscopes + Magnetometer • Quality of Movement- kinematics • Impairments • Medical Devices
Right Shank (Pitch) Trunk (Yaw)
Angular Velocity (deg/s)
400 300 200 100 0 -100 -200 0
2
4
6
10 Time (s)
12
14
Compensatory Stepping
DBS in STN impairs postural preparation but not compensatory step stepping # APAs
Latency
St George et al, in press
Improvement of stepping responses with practice in elderly control and PD subjects Peterson and Horak In preparation
0,25
PD_On (11)
PD_On (11)
3,00
Con (11) 0,20
Number of Steps
COM movement (m)
Con (11)
0,15 0,10 0,05
2,50 2,00 1,50 1,00 0,50
0,00
1
2
3
Day 1
4
5
6
7
Day 2
0,00 1
2
3
Day 1
4
5
6
7
Day 2
Validating IPush with inertial sensors El Gohary et al, in prep
R=.74
Significant difference (p<.01) in: Latency (ms): PD = 304, MS = 380, CT = 263 Step Length (cm): PD = 32, MS = 48, CT = 45
N= 50 MS, 50 Controls, 20 PD
Stepping PD = 3 to 4 small steps MS = 2 larger steps CT = one step
Important to test several systems for postural control (quickly) SwaySensory
What type of balance problem do you have?
Anticipatory Postural Adjustment
Postural Response Gait and Turning
Instrumented Stand and Walk test (ISAW)
Stand
Step Initiation
Walk and turn Right Shank (Pitch) Trunk (Yaw)
+
+
Angular Velocity (deg/s)
400 300 200 100 0 -100 -200 0
2
4
6
10 Time (s)
12
14
16
Instrumented Stand and Walk Test (ISAW)
APA with Inertial Sensors: Experimental Validity
Mancini M., et al., 2009
APAs don’t get larger with wide stance in patients with PD WIDE
NARROW
Control This may be the reason why stance width decreases with progression of PD! Parkinson’s Disease
Rocchi et al J of Neurosurgery 2012
Postural Sway can be measured with Accelerometers • Inertial Sensor
Sway area (stability
achieved by the postural control system) •
Sway velocity
(amount of regulatory activity associated with this level of stability) •
Sway jerkiness (derivative
• of acceleration, reflecting the amount of corrections)
Force Plate Mancini et al, 2009
Hufschmidt A et al., 1980 Maki BE et al., 1991
* * *
Surface Rotation Size Peterka, Wrisley, Statler, Horak, Frontiers in Neurootology, 2011
*
Vestibular ADL Scale
Vestibular Weight
Unilateral vestibular loss who weight remaining vestibular show best ADL
Vestibular Weight
deg
Instrumented postural sway may be more sensitive to rehabilitation than clinical measures 150 145
70
140 135 130
Pre1
Pre2
POST
Medio-lateral range 0.4
65
Pre1
Pre2
POST
Sit-to-Stand Peak speed 100
0.35 90 0.3
SWAY 85
m/s 2
degree/s
0.25
Turning Peak Speed
King, L.A. and Horak, F.B. Physical Therapy 2009
180
King, LA et al Parkinson’s Disease, 2013
0.2
0.15
80
75
0.1
0.05
Pre1
175 170
Pre2
POST
70
Pre1
Treadmill Agility
Pre2
POST
StrideVelocit 80
King, LA et al J of Neurological PD, 2012
Mobility impairments in patients with normal gait speed
Objective measures are more sensitive than clinical tests to mild impairment and more specific for disease
Zampieri et al, JNNR 2010 Spain, et al, Gait and Posture 2012
Instrumented gait for FALL RISKVerghese J Geronotol A 2009 Gait Measure
Median
All Falls Risk Ratio/p-V
Injurious Falls Risk Ratio p-V
Speed
95 cm/s
1.-08 / .003
1.05 / .25
Swing Time Variability
5.17% (sd/mean x 100)
1.007 / <.001
1.11 < .001
Stride Length
1123.5 cm
1.095 / .003
1.0 / .67
Stride Length Variability
3.6% (SD/mean x 100)
1.09 / <.001
1.13 / <.001
Double Support
26%
1.2 <.001
1.03 / .79
4 Balance Domains in a 1-minute test
ISAW ISWAY
ISTEP
Sway
Gait Initiation
Sway area Sway jerkiness Sway frequency Sway velocity
Size of APA Duration of APA Step Velocity First Step length
Over 40 metrics
10 metrics
ITUG Gait Spatio-temporal RoM Velocities Asymmetries Variability
Turning Duration # of steps in turn Last step time Over 5 metrics
Over 35 metrics
Responsiveness of balance and gait (ISAW) to levodopa
• • • •
Gait speed improved Gait arm/trunk improved Balance worse Gait timing no change
Curtze, et al Movement Disorders In Press
Turning is most sensitive to severity of PD
Turning, Speed and Stability related to Quality of Life
Do you want to know about your patient’s mobility at home?
• • • • • • •
More realistic Natural environments More dual-tasks How sedentary or active Fluctuations/variability Better predictor of falls Need to come back for “tune-up”
Characterizing Turning in the home with inertial sensors
Continuous monitoring of turning predicts future falls better than gait speed!
Mancini, et al
Turn velocity differs in daily life but not in prescribed turns Prescribed Turning Test 90° turn
180° turn
90° turn
Start Mancini et al Neurorehabilitation in press
Quantity of activity is similar in PD and controls, but quality of turning is different QUALITY
VARIABILITY
QUANTITY
Mancini et al Neurorehabilitation in press
Variability of turning predicts prospective falls
Mancini et al J of Gerontology, Med Sci Submitted
Does targeting balance training to specific ‘ impairments help? Elizabeth WangHsu, 2015 Thesis Drexel University
Can we target cognitive function to improve mobility?
Agility
Agility-Cogniitve
Executive function
King and Horak Physical Therapy 2011; 2013
Executive Inhibition is related to FoG Cohen, Nutt and Horak, 2013
Stroop Conflict 120 250
Rho = .84
*
Response time (s)
100
200
Stroop Score (s)
**
150
100
50
80 60 40
20
0 6
8
10
12
14
16
Score on Freezing of Gait Questionnaire (FoG-Q)
18
0
HC
FOG-
FOG+
Stroop: Name the Colors! Blue Green Purple Green
Impairment of cognitive inhibition could contribute to FoG • In gait, lifting of the stepping leg must be delayed until the postural weight shift is complete. • Failure to release inhibition of the stepping program and to inhibit the postural preparation may lead to FoG. • Is the response inhibition circuit impaired in FoG?
Posture/Locomotor Network Prefrontal preSMA
Hypothesis: FoG is due to abnormal connections STN/ between MedialPPN PPN Frontal Cortex and Midbrain PPN is atrophied Locomotor but more active Centers (PPN) and during imagined walking in Freezers STN Snijders et al., 2011
Fougere et al, NeuroImage 50:1589, 2010
Missing white matter of the Right Locomotor (Response Inhibition) Network in Freezers Fling and Horak, Brain 2013
** R
*
0,14
L
PPN Tract Laterality Index
0,12 0,1 0,08 0,06
Response Inhibition Circuit: Right STN-PreSMA Healthy
0,04 0,02
Coxon, et al, J Neurosci 2012
0
-0,02 -0,04 -0,06
HC
FOG-
Asymmetry of white matter from PPN to medial frontal relates to Executive Inhibition in FoG+ Flankers Accuracy
Stroop Conflict 250
r = 0.61 p = 0.02
HC FoG-
0,95
200
Accuracy (% correct)
Stroop Conflict (s)
FoG+
1
150
100
0,9 0,85 HC FoGFoG+
0,8 0,75
50
r = -0.67 p = 0.004
0,7 -0,4
-0,2 0 0,2 PPN Tract Laterality Index
0,4
0 -0,4
-0,2
0
0,2
PPN Tract Laterality Index
0,4
Fling et al. Brain 2013
A systems approach to balance can identify specific impairments for rehabilitation to target
Objective measures of impairments are more sensitive to mild impairments than clinical measures of function
Continuous monitoring of mobility adds value
Cognitive impairments contribute to mobility disability
Balance Disorders Lab OHSU Dan Peterson
Brett Fling
Carolin Curtz
Laurie King Martina Mancini
Patty CarlsonKuhta
Grant support: NIA, NINDS, VA Merit, Kinetics Foundation, MRF, MS Society, OHSU
www.posture.sk
Les lésions professionnelles à l’épaule chez les travailleurs : bilan des connaissances portant sur l’évaluation clinique, la réadaptation et le retour au travail
Jean-Sébastien Roy, Ph.D., pht Professeur adjoint, Faculté de médecine, Université Laval Chercheur, Centre interdisciplinaire de recherche en réadaptation et en intégration sociale
François Desmeules, Ph.D., pht Professeur adjoint, École de réadaptation, Université de Montréal Chercheur, Centre de recherche de l’Hôpital Maisonneuve-Rosemont
Congrès québécois de recherche en adaptationréadaptation 22 mai 2015
Équipe de recherche Autres chercheurs principaux • Pierre Frémont, MD, Ph.D.: Université Laval et CRCHUL • Clermont Dionne, erg., Ph.D.: Université Laval et URESP • Joy C. MacDermid, pht, Ph.D.: McMaster University Collaborateurs • Nicola Hagemeister, Ph.D.: Université de Montréal et CRCHUM • Nathalie J. Bureau, MD: Université de Montréal et CRCHUM • Martin Lamontagne, MD: Université de Montréal et CRCHUM Professionnels de recherche • Caroline Braën Boucher et Jennifer Boudreault Étudiants et stagiaires • C. St-Pierre, P. Touliopoulos, A. Desjardins-Charbonneau
www.ulaval.ca
2
Les lésions professionnelles à l’épaule chez les travailleurs : bilan des connaissances portant sur l’évaluation clinique, la réadaptation et le retour au travail • Problèmes MSK: 2e raison de consultation • Prévalence: 48,3 personnes sur 100 • Travailleurs au Québec: • 60 000 cas indemnisés (7 500 cas / an) entre 2000-2007 • Coûts annuels entre 2007-2011: 393 204 738$ • Impliquent 2X plus de jours d’absence au travail que les atteintes lombaires • Rétablissement complet après une nouvelle consultation • 50% après 6 mois • 60% après 1 an • Atteintes de la coiffe des rotateurs: diagnostic le plus fréquent • 50 à 85% de toutes les atteintes à l’épaule • Prévalence augmente avec l'âge www.ulaval.ca
3
Les lésions professionnelles à l’épaule chez les travailleurs : bilan des connaissances portant sur l’évaluation clinique, la réadaptation et le retour au travail
• Milieux cliniques: Aucune approche standardisée et validée pour: • Diagnostic et évaluation clinique des travailleurs • Suivis médical et de réadaptation à entreprendre • Prise de décision face au retour au travail • Milieux cliniques utilisent différentes méthodes dévaluation et d’intervention • Ne reposent pas toujours sur données probantes • Lacunes possibles pour: • Diagnostics et évaluations cliniques, traitements et indicateurs de la pertinence d’un retour au travail www.ulaval.ca
4
Les lésions professionnelles à l’épaule chez les travailleurs : bilan des connaissances portant sur l’évaluation clinique, la réadaptation et le retour au travail • Aucune synthèse accessible aux cliniciens pour intégrer les données probantes • Réalisation d’un bilan des connaissances couvrant l’ensembles des trois volets suivants: • Évaluation clinique • Interventions médicales et en réadaptation • Retour au travail
www.ulaval.ca
5
Objectif principal • Type d’étude: Bilan des connaissances • Revues systématiques et méta-analyses
• Buts: Résumer les données probantes et concevoir des recommandations cliniques concernant: • Évaluation clinique • Interventions médicales et de réadaptation • Retour au travail
• Population: Travailleurs (ou adultes) souffrant d’une atteinte de la coiffe des rotateurs
www.ulaval.ca
6
Objectifs spécifiques A. Évaluation clinique • Propriétés psychométriques et diagnostiques • Tests diagnostiques • Imagerie médicale et tests physiques • Sensibilité / spécificité
• Outils d’évaluation clinique • Outils de mesure clinique, tests de performance et questionnaires • Validité, fidélité, sensibilité au changement
Leonardo da Vinci, Anatomical studies of the shoulder, 1510
www.ulaval.ca
7
Objectifs spécifiques B. Interventions médicales et de réadaptation • Efficacité des interventions médicales • Approches chirurgicales • Médications • Infiltrations • Efficacité de la réadaptation • Interventions actives • exercices et thérapie manuelle • Interventions passives • Modalités physiques: courants, US, laser
www.ulaval.ca
8
Objectifs spécifiques
C. Retour au travail • Efficacité des interventions en milieu de travail • Facteurs liés à l’absentéisme et au RT
Modern Times, Charlie Chaplin, 1936
www.ulaval.ca
9
Méthodologie générale • Population – Atteinte de la coiffe des rotateurs • Tendinopathies de la coiffe des rotateurs • Tendinose des tendons de la coiffe des rotateurs • Syndrome d’abutement de l’épaule / Conflit sous-acromial • Bursite sous-acromiale / sous-deltoïdienne • Tendinopathie de la longue portion du biceps • Rupture partielle de la coiffe des rotateurs • Rupture transfixiante de la coiffe des rotateurs
www.ulaval.ca
10
Méthodologie générale • Approche utilisant la pratique basée sur les données probantes (Guyatt et coll. 1992)
• Définition d’une question de recherche • Recherche systématique dans la littérature • PubMed, CINHAL, Embase, Cochrane Library, PedDRO
• Analyse critique • Grille spécifique à la question de recherche
• Synthèse • Revue systématique +/- méta-analyse
• Formulations de recommandations • Selon niveau d’évidence www.ulaval.ca
11
Objectif 1 – Évaluation clinique Objectif : Résumer les évidences sur les propriétés psychométriques et diagnostiques des : § Tests diagnostiques § Tests physiques et imagerie médicale
§ Outils d’évaluation clinique § Outils de mesure clinique, tests de performance et questionnaires
www.ulaval.ca
Objectif 1 – Tests diagnostics / physique (n=26) Test de Hawkins Kennedy
Test de Neer
Syndrome d’abutement de l’épaule: • Exclure ce diagnostic : test de HawkinsKennedy (sensibilité : 0,86 [0,65-1,00]) • Confirmer ce diagnostic : test de l’arc de mouvement douloureux (spécificité : 0,82 [95%IC 0,53-1,00])
Arc de mouvement
www.ulaval.ca
Objectif 1 – Tests diagnostics / physique Arc de mouvement
Rupture transfixiante – Infra et supra • Exclure ce diagnostic : test de l’arc de mouvement douloureux (sensibilité : 0.87 [95%IC 0,34-1,00]) • Confirmer ce diagnostic : le test External rotation lag sign (spécificité : 0.98 [95%IC 0,89-1,00]) Rupture transfixiante - Sous-scapulaire • Exclure ou confirmer ce diagnostic : le test Internal rotation lag sign (sensibilité : 0,62 [0,25-1,00], spécificité : 0,87 [0,58-1,00])
Drop arm
www.ulaval.ca
Extermal Rotation Lag Sign
Objectif 1 – Tests diagnostics / physique Recommandations cliniques • Aucun test avec sensibilité et spécificité > 0,80 • Équivalence diagnostique de tous les tests évalués (intervalles crédibles) • Potentiel des combinaisons de tests physiques et de variables cliniques • Sensibilité et spécificité satisfaisantes • Se rapproche davantage du contexte clinique • Futures recherches devraient évaluer combinaison tests/variables
www.ulaval.ca
Objectif 1 – Tests diagnostics / imagerie (n=80) US
IRM
Rupture transfixiante • Sensibilité et spécificité élevées (>0.90) de US, IRM et arthro-IRM
Arthro-IRM
www.ulaval.ca
Objectif 1 – Tests diagnostics / imagerie
Recommandations cliniques • Pertinence de l’imagerie: • Vérifier la présence d’une rupture transfixiante chez des patients suspectés d’en souffrir sur la base des tests cliniques • Surtout si échec traitements conservateurs • En aiguë chez patients présentant une forte suspicion clinique de rupture transfixiante • US devrait être priorisée en raison du coût moindre • Si US ne permet pas d’établir un diagnostic définitif et cohérent: IRM, puis l’arthro-IRM sont conseillées. www.ulaval.ca
Objectif 1 – Évaluation clinique (n = 107) • 34 études pour l’amplitude articulaire, 49 pour la force musculaire de l’épaule et 24 pour le mouvement et la position de la scapula • Résultats • Mesure de l’amplitude articulaire : le goniomètre et l’inclinomètre sont fidèles • Mesure de la force musculaire : les dynamomètres manuel et stationnaire sont fidèles • Sensibilité au changement de ces outils non déterminée
www.ulaval.ca
Objectif 1 – Évaluation clinique Recommandations cliniques • Mesure de la force isométrique : favoriser le dynamomètre manuel plutôt que le bilan musculaire manuel qui est non valide • Mesures linéaires de la scapula devraient seulement être utilisées pour caractériser la position scapulaire
www.ulaval.ca
Objectif 1 – Questionnaires (n=120)
Recommandations cliniques • Excellente fidélité et sensibilité au changement, validité démontrée. À intégrer à l’évaluation clinique • Outils d’évaluation pour lesquels les sensibilités au changement les plus élevées ont été démontrées • Disability of the Arm, Shoulder and Hand (DASH) est accessible en 40 langues dont le français • American Shoulder and Elbow Surgeon Score (ASES) et le Upper Limb Functional Index (ULFI) peuvent être privilégiés pour la réévaluation de patient (non disponible en français) • Western Ontario Rotator Cuff index (WORC) est particulièrement sensible au changement www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation Interventions pour le traitement des tendinopathies de la coiffe des rotateurs • Interventions médicales • AINS oraux • Infiltrations de corticostéroïdes • Chirurgie
• Interventions en réadaptation • Exercices • Thérapie manuelle • Ultrasons • TENS • Taping • Laser • Ondes de choc extracorporelles
Populations à l’étude: adultes et non seulement des travailleurs www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation
§ Efficacité des anti-inflammatoires non-stéroïdens oraux (AINS): 12 essais cliniques randomisés inclus dans une revue systématique avec métaanalyse
www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Résultats et recommandations cliniques pour les AINS : § Réduction de la douleur à court terme § Efficacité indéterminée pour l’amélioration de la fonction § Équivalence des deux classes d’AINS (COX NS et COX-2) pour le traitement de la douleur et gain de l’amplitude articulaire. § L’incidence des effets secondaires gastro-intestinaux semblable à court terme pour les deux classes § Efficacité à long terme non abordée dans les études incluses § Pour la prise à long terme d’AINS, prendre en considération le manque d’études quant aux effets potentiellement délétères
www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité des injections de corticostéroïdes : § Deux méta-analyses incluses et analysées § Résultats et recommandations cliniques : § Faible effet pour le soulagement de la douleur ou l’amélioration de la fonction ( vs placebo). Effet non maintenu à moyen et long terme § Efficacité non supérieur des injections par rapport à la prise d’AINS oraux (douleur et fonction) § Dans ce contexte, les injections ne devraient pas être la modalité initiale de traitement www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité de la chirurgie: § 15 essais cliniques randomisés inclus dans une revue systématique: § Résultats et recommandations cliniques : § Efficacité semblable des exercices thérapeutiques et de l’acromioplastie § Efficacité démontrée de l’arthroscopie et de la chirurgie ouverte § Possible avantage de l’arthroscopie quant à l’amélioration à court terme de l’amplitude articulaire www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité d’un programme d’exercices thérapeutiques chez des travailleurs : § 10 essais cliniques randomisés inclus dans une revue systématique § Résultats et recommandations cliniques : § Évidences modérées de l’efficacité pour la diminution de la douleur, l’amélioration de la fonction et le retour au travail § Résultats similaires de la chirurgie et des exercices thérapeutiques (douleur et fonction) chez des travailleurs § Études nécessaires pour déterminer le type, la durée ou l’intensité des exercices à réaliser pour un effet de traitement optimal www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité de la thérapie manuelle: § 21 études incluses dans une revue systématique avec méta-analyses
§ Résultats et recommandations cliniques : § Évidences faibles à modérées d’un faible effet de traitement (seule ou conjointement à des exercices) (douleur et fonction) § Études (de bonne qualité méthodologique) nécessaires pour confirmer cette tendance www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité du laser : § 13 essais cliniques randomisés inclus dans une revue systématique avec méta-analyse § Résultats et recommandations cliniques : § Évidences faibles quant à l’efficacité du laser (faible intensité) pour le soulagement de la douleur à court terme § Le laser n’est pas supérieur à un programme d’exercices. § Aucun bénéfice lors de l’ajout de laser à d’autres modalités (exercices ou ultrasons) (douleur et fonction) www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité du taping : § 9 études incluses dans une revue systématique avec méta-analyse § Résultats et recommandations cliniques : § Évidences insuffisantes pour conclure sur l’efficacité du kinesiotaping (KT) ou du taping non-élastique (TNE) (+ études nécessaires) § Capacité du TNE à améliorer l’amplitude articulaire active § Efficacité du KT pour l’amélioration de l’amplitude articulaire sans douleur www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation Autres modalités non démontrées efficaces pour le traitement des tendinopathies de la coiffe:
§ Ultrasons thérapeutiques et la thérapie par ondes de choc ne sont pas efficaces (niveau d’évidence faible à modéré) § Aucune recommandation possible pour le TENS § + d’études nécessaires
www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation Interventions pour le traitement des ruptures transfixiantes de la coiffe des rotateurs § Efficacité des interventions conservatrices (exercices) : § Bilan de 2 revues systématiques et synthèse des résultats § Résultats et recommandations cliniques : § Évidences faibles soutenant la chirurgie plutôt que traitement conservateur pour les patients jeunes et actifs § Évidences contradictoires quant à la supériorité de la réparation de coiffe par rapport aux exercices thérapeutiques § Des études sont nécessaires pour confirmer l’efficacité des traitements conservateurs et chirurgicaux www.ulaval.ca
Objectif 2 – Efficacité des interventions médicales et de réadaptation § Efficacité de la chirurgie : § Bilan de 8 revues systématiques et 3 essais cliniques randomisés § Résultats et recommandations cliniques : § Équivalence de la réparation de coiffe par voie ouverte, semi-ouverte ou par arthroscopie (douleur, fonction et amplitude articulaire) § Équivalence de la réparation de coiffe par simple rang ou par double rang, mais taux de récidive possiblement moins élevé pour le double rang
www.ulaval.ca
Objectif 3 – Retour au travail Objectifs : résumer les évidences sur : • L’efficacité des interventions en milieu de travail • Les facteurs pronostiques associés à l’absentéisme et au retour au travail Chez les patients présentant des douleurs à l’épaule spécifiquement
Modern Times, Charlie Chaplin, 1936
www.ulaval.ca
Objectif 3 –Interventions en milieu de travail (N = 11) Résultats et recommandations cliniques • Exercices en milieu de travail semblent efficaces pour la réduction de la douleur • Bénéfices possibles (faibles évidences) d’une approche multimodale au travail (conseils, exercices, modifications et adaptation des tâches au travail) par rapport à une approche usuelle clinique • Évidences divergentes quant l’amélioration de la fonction, l’absentéisme, le retour au travail et le présentéisme • Évidences contradictoires quant à l’efficacité de modifications ergonomiques de postes de travail et de l’organisation du travail (études nécessaires) www.ulaval.ca
Objectif 3 –Facteurs pronostiques de l’absentéisme et du retour au travail (n = 8) • Évidences insuffisantes pour déterminer les facteurs associés à l’absentéisme ou au retour au travail • Principaux facteurs identifiés dans la revue : • Origine de l’atteinte (non traumatique associée à un plus grand risque d’arrêt de travail et de délais du retour au travail) • Niveau de scolarité plus élevé (plus de 12 ans) associé à un retour au travail plus rapide • Travailleurs plus âgés moins susceptibles de retourner au travail • Travail plus exigeant physiquement serait associé à de plus longues périodes d’absence au travail • Nécessité davantage d’études de bonne qualité avec des travailleurs présentant des atteinte de la coiffe des rotateurs
www.ulaval.ca
Retombées et avenues de recherche • Retombées: • Rapport complet publié sous peu par les IRSST et le REPAR • Présentations et articles scientifiques • Guide de pratique? • Objectif 1: • Évaluer les qualités de la combinaison de tests physiques et de variables cliniques – plus près de la réalité • Sensibilité au changement des outils cliniques • Objectif 2: Pour certaines modalités, évidences faibles • Objectif 3: Tout reste à faire
www.ulaval.ca
36
Questions et commentaires?
www.ulaval.ca
37
