1. No category

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
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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
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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
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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
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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
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5
AW Heinemann, Director, CROR, RIC
21 May 2015
Rehabilitation + Outcome Measurement
Citations: 1975 to 2015 (May)
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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
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Quebec Congress in AdaptationRehabilitation Research
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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
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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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
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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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
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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
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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
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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
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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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
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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
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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
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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
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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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
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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
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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
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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
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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)
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Quebec Congress in AdaptationRehabilitation Research
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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
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Quebec Congress in AdaptationRehabilitation Research
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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”
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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.
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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Quebec Congress in AdaptationRehabilitation Research
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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.
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Quebec Congress in AdaptationRehabilitation Research
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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
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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
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Quebec Congress in AdaptationRehabilitation Research
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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!
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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
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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
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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
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Questions et commentaires?
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