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Klinimetrie bij het stellen van de functionele prognose na een CVA: hulp of last? Dr. G. Kwakkel.

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Presentation on theme: "Klinimetrie bij het stellen van de functionele prognose na een CVA: hulp of last? Dr. G. Kwakkel."— Presentation transcript:

1 Klinimetrie bij het stellen van de functionele prognose na een CVA: hulp of last? Dr. G. Kwakkel

2 Identify patient’s problem Define a meaningful question Determine the prognosis Select most appropriate therapy Evaluate efficacy

3 Doel van het (klinisch) meten  om te onderscheiden (diagnostiseren en/of klassificeren) Kirshner & Guyatt, J. Chron. Dis 1985; 38: 27  om te voorspellen  om (verandering) te evalueren

4 home at 6 months ? outcome of ADL ? needs further help ? clinical decision making patients future

5 home at 6 months? outcome of ADL ? needs further help?  pattern recognition  hypothetico-deductive reasoning?  problem solving ?  intuition ? patients future

6 determinant Outcome of what? (1) Prediction of what?

7 Health Condition ( disorder/disease ) Interaction of Concepts ICF 2001 Environmental Factors Personal Factors Body function&structure (Impairment ) Activities(Limitation)Participation(Restriction) ??

8 Neuro-physiology Neuroradiology Clinical neurology Neuro-psychology Demographic factors determinant Functional outcome (e.g., dexterity, walking ability, (I)ADL- independency Which construct (at level of activity) do we exactly like to predict?

9 Basic ADL Arm- handvaardigheid Barthel Index ARAT ? Loopvaardigheid Functional Ambulation Categories

10 Construct validity of BI (N=89) weeks Correlation coefficient (r s )

11 Construct validity of BI (N=89) weeks Correlation coefficient (r s )

12 Neuro-physiology Neuroradiology Clinical neurology Neuro-psychology Demographic factors determinant Functional outcome of basic ADLs (2) Which determinants are valid?

13 I. Key methodological criteria for prognostic research internal validity  reliable and valid measurements  inception cohort  appropriate end-points of observation  control of patient drop-out statistical validity  control for statistical significance  adequate estimation of sample-size  control for multicollinearity Kwakkel et al, Age & Ageing 1996;25:

14 Factor x 2 Factor x 1 Outcome Y (explained variance) r y.x2 r y.x1 r x1.x2

15 Predictive value of volume of stroke according to MRI scan for outcome of ADL-independency at 6 months post stroke Schiemanck et al, Stroke. 2006;37:

16 Copyright ©2006 American Heart Association Schiemanck, S. K. et al. Stroke 2006;37: Receiver operating curves of model 1 (clinical) and model 2 (clinical imaging) (N=75) Model 1 (AUC=0.83) = age and IBI Model 2 (AUC =0.87) = Model 1 + volume MRI Schiemanck et al, Stroke. 2006;37:

17 II. Key methodological criteria for prognostic research external validity  specification of inclusion and exclusion criteria  description of additional treatment effects during period of observation  cross-validation of the prediction model Kwakkel et al, Age & Ageing 1996;25:

18 Internal validity 78 Statistical validity external validity 13 (  8) 0

19 Valid predictors for ADL (and walking ability)  admission ADL (i.e., assessment specific)  urinary (in)continence  age*  previous stroke (and other disabling co-morbidity)  consciousness at onset  severity of paresis  sitting balance  orientation in time and place  level of social support  inattention  depression

20 Possible negative predictors for ADL  homonymous hemianopia  conjugate deviation of the eyes  fatigue  dyspraxia  dysphasia  ??

21 Variables not related to outcome of ADL  gender  ethnic origin  side of stroke Kwakkel et al., Age & Ageing, 1996: 25:

22 Individual recovery patterns of Barthel Index (n=13) weeks BI-score weeks

23 Mean recovery pattern of Barthel Index prediction outcome

24 Regression model statistics for outcome of BI  Intercept  Initial BI  Sitting balance  Soc. Support  age *  Model Nh  Pooled R-square Eigenvalue CI

25 Final regression model for outcome of Barthel Index at 6 months post stroke BI = (0.51 * IBI) + (20.93 * SB) + (10.35 * SS)  BI= (Initial) Barthel Index (ranging from 0-100)  SB=initial sitting balance (yes/no on the TCT)  SS= Social Support (yes/no: having a partner able to support)

26 Increment in explained variance for outcome of BI score (N=102) model retesting Explained variance (%)

27 Effects of initial BI on outcome at 6 months post stroke (N=89) Adjusted R 2 =0.50 (Initial BI)

28 Barthel Index stairs bowel grooming bladder feeding transfer toilet use mobility dressing bathing Coefficient of Scalability: 0.72 (week 26) < CS <0.85 (week3) Rest. Neurology & Neuroscience 2004;22:

29 Copyright ©2006 American Heart Association van Hartingsveld, F. et al. Stroke 2006;37: Logit item step difficulties ({beta}I) of the Rasch homogeneous 8-item Barthel scale Van Hartingsveld et al, Stroke. 2006;37: Logit item step difficulties (I) of the Rasch homogeneous 8- item Barthel scale (N=559) feeding transfer step 1 groom dress step 1 toilet mobility step 2 dress step 2 stairs bathing easy difficult

30 Take home message: Barthel Index gemeten in de eerste 2 weken na een CVA is een robuuste determinant voor het uiteindelijk te verwachten herstel op de BI na 6 maanden. Een klinimetrische testuitslag krijgt pas een prognostische (meer)waarde wanneer men deze relateert aan het moment waarop het CVA heeft plaatsgevonden. Functionele prognostiek is pas mogelijk wanneer men eveneens kennis heeft over de psychometrische eigenschappen van gebruikte meetinstrumenten.

31 Mijn dank voor uw aandacht!

32 Clinical assessments increase the transparency in making client-related decisions within a team of professionals working together as a stroke team. Advantage of clinimetrics (2):

33 Increment in explained variance for outcome of BI, FAC and ARA score (N=102)

34 consensus in clinimetrics: What do we measure systematically? How do we measure systematically? Who is measuring what? When do we measure the stroke patient? Steps to follow for getting relation coordination

35 % herstel HospitalRehabilitation centre Home/ Nursing house

36 % herstel ? HospitalRehabilitation centre Home/ Nursing house

37 % herstel ? ‘learning from making functional prognosis’ HospitalRehabilitation centre Home/ Nursing house

38 Clinimetrics (ICF 2001) pathologyimpairment disability handicap  OCSP  Stroke type  Number of strokes  Epilepsy  HSP, GHS  SHS  MI-score  FM-motor score  Ashworth Scale  Thumb-Finding Test  Letter cancellation task, line-bisection task  MMSE  Scan. Stroke Scale  Trunk Control Test  Berg-Balance Scale  Timed-Balance test  Timed-Get-up & Go- Test  FAC, 10-meter walking test  ARA, Frenchay Arm  Barthel Index  FAI, EADL  SIP-68  NHP-part 1  Post-stroke Depression  Carer Strain Index  Satisfaction Questionnaires activitiesparticipation

39 Construct validiteit van de BI (N=89) weeks Pearson correlation coefficients with Barthel Index

40 Clinimetrics objectivity communicatio n reliability validity hierarchy responsiveness CONSENSUS

41  From perspective of a health care professional: Assessment contribute to set realistic and therapeutically attainable treatment goals (i.e., improves objectivity). Advantage of clinimetrics:  From perspective of a (stroke) team: Clinical assessments increase the transparency in making client-related decisions within a team of professionals working together as a stroke team (i.e., improves communication).

42 Multidisciplinary guidelines for stroke financed by the Dutch Heart Foundation Stroke Guidelines

43  Praktijkrichtlijn  Samenvattingskaart  Deskundigheidsbevorderingspakket  Verantwoording en toelichting

44 Samenvattingskaart

45 Conclusion  Not only differences in heterogeneity in stroke patients are responsible for lack of accuracy in predicting functional outcome, but also the methodological shortcomings in published prognostic research Kwakkel et al., Age & Ageing, 1996: 25:


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