Correlation among physical impairments, pain, disability, and patient satisfaction in patients with chronic neck pain

OBJECTIVE: To investigate the correlations among pain, physical impairments, disability, and patient satisfaction in patients with chronic neck pain. DESIGN: A longitudinal cohort study with 6-month follow-up. SETTING: Institutional practice. PARTICIPANTS: Subjects (N=218) with chronic neck pain. INTERVENTIONS: Subjects were treated with different physiotherapy modalities. MAIN OUTCOME MEASURES: Data were obtained for self-reported disability, verbal numeric pain scale, patient satisfaction, and 2 measures of physical impairments during the initial visit, at 6 weeks, and finally at 6 months. RESULTS: The correlation among 4 sets of measurements varied. Moderate correlation was noted between disability and patient satisfaction ( r range, .50-.65), and between disability and pain ( r range, .55-.63). A fair relationship was found between pain and patient satisfaction ( r range, .43-.48), but only weak relationships were found between physical impairments and pain ( r range, -.08 to -.25). The correlations tended to increase in the follow-up assessments. CONCLUSIONS: No strong correlations were found among disability, patient satisfaction, pain, and physical impairments although the correlations tended to increase in the follow-up assessments. The findings support the suggestion that clinicians should address as many relevant aspects of a presenting clinical entity as possible in the management of chronic neck pain.     

Managing activity difficulties at home: a survey of Medicare beneficiaries

Dudgeon BJ, Hoffman JM, Ciol MA, Shumway-Cook A, Yorkston KM, Chan L. Managing activity difficulties at home: a survey of Medicare beneficiaries.

Objective

To describe assistance from helpers and use of assistive technology and environmental modification by community-dwelling people with difficulties in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Design

Cross-sectional study using the 2004 Medicare Current Beneficiary Survey.

Setting

Community.

Participants

Nationally representative sample of 14,500 Medicare beneficiaries (mean age, 71.5y; 55% female; 49% currently married; 68% living with others; 84% white).

Interventions

Not applicable.

Main Outcome Measures

Self-reported difficulty with ADLs and IADLs; uses of help, assistive technology, and/or environmental modification.

Results

Difficulties were reported most frequently for heavy housework, walking, and shopping; money management, shopping, and light housework were reported as activities most often needing a helper. Walking, bathing, and toileting were activities most often needing uses of assistive technology. Bathroom modifications were the most commonly reported environmental modification. Results from a logistic regression showed that advancing age was the primary factor associated with increasing use of helpers and assistive technology or both for difficult activities.

Conclusions

Uses of helpers, assistive technology, and environmental modification are common but vary by type of ADL and/or IADL and age. Focused studies regarding uses of help and access to assistive technology and environmental modification appear needed to support community living. Public education about methods and types of accommodations appears needed and may substitute for or augment guidance from care providers.     

Association of mobility limitations with health care satisfaction and use of preventive care: a survey of Medicare beneficiaries

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

Validation of the Reintegration to Normal Living Index in a population of community-dwelling people with mobility limitations

OBJECTIVE: To validate the Reintegration to Normal Living Index (RNLI) in a population of community-dwelling adults with mobility limitations. DESIGN: Cross-sectional survey. SETTING: Community. PARTICIPANTS: Six hundred four people between the ages of 18 and 80 years who had a mobility limitation, lived in the community, and had been discharged from rehabilitation for at least 1 year. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The RNLI. RESULTS: The RNLI is a reliable measure of community reintegration. A 2-factor structure emerged from a principal components analysis that indicates there are 2 subscales of the RNLI in a population with mobility impairments. CONCLUSIONS: The RNLI is a reliable and valid measure for studies of community integration among people living with long-term consequences of a chronic health condition.     

Obesity prevalence among a group of Chicago residents with disabilities

OBJECTIVE: To examine the prevalence of overweight, obesity, and extreme obesity in a predominantly minority group of adults with disabilities. DESIGN: Cross-sectional study using secondary data analysis. SETTING: Major university medical center. PARTICIPANTS: Adults with physical and cognitive disabilities (N = 306). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Direct measures of height and weight to classify subjects into 3 obesity categories: overweight (body mass index [BMI] range, 25-29.9 kg/m2), obese (BMI range, 30-39.9 kg/m2), and extreme obesity (BMI, > or = 40 kg/m2). RESULTS: People with disabilities, regardless of sex, race and ethnicity, or age, had significantly higher rates of overweight, obesity, and extreme obesity compared with people without disabilities. Extreme obesity (BMI, > or = 40 kg/m2) was approximately 4 times higher among people with disabilities than in the general population (odds ratio = 4.08; 95% confidence interval, 3.50-4.66). There were also substantial differences in obesity prevalence among people with disabilities, using actual measurement data, compared with self-reported data from previously published data sets. CONCLUSIONS: The disparity in excess body weight between people with and without disabilities, particularly in the category of extreme obesity, along with substantial differences in obesity prevalence between actual and self-reported data, show a critical need to better understand why these differences exist.     

Presentation 3: Assessing disability in older adults: the effects of asking questions with and without health attribution

Objective: To determine the effects of using questions with and without health attribution on a self-reported disability instrument developed for use with older adults. Design: Cross-sectional. Setting: Community-based. Participants: 75 community-dwelling older adults from central and eastern Massachusetts. Interventions: Not applicable. Main Outcome Measures: We administered the disability component of the Late Life Function and Disability Instrument. To test whether altering attribution influenced scores, we administered the same 16 questions with attribution to specific health conditions. Results: A higher prevalence of disability was reported in the nonattributed compared with the health attribution (t=5.76, P<.001; 95% CI, 3.8-7.8). Item analyses indicated that participants were significantly more likely to report disability on the nonattributed version of 4 of the 16 disability items that required out-of-home travel. Conclusions: In this sample of older adults, estimates of disability were underestimated by questions that included specific attribution to health conditions. Factors other than health appear to influence self-report of disability related to participation in travel outside of the home.     

Determinants of utilization of physical rehabilitation services for persons with chronic and disabling conditions: an exploratory study

Elrod CS, DeJong G. Determinants of utilization of physical rehabilitation services for persons with chronic and disabling conditions: an exploratory study.

Objective

To determine which variables influence the receipt of physical rehabilitation services (ie, physical, occupational, speech therapy) for a population of people with chronic and disabling conditions.

Design

A convenience sample of 502 adults with cerebral palsy (CP), multiple sclerosis (MS), and spinal cord injury (SCI), drawn from diverse parts of the United States.

Setting

Respondents were surveyed in the general community.

Participants

Persons (91% under the age of 65y) with CP, MS, or SCI who responded to the 1999 component of a national longitudinal survey.

Interventions

Not applicable.

Main Outcome Measures

Self-reported need for physical rehabilitation services. Bivariate and multivariate analyses were used to examine variables that influenced utilization of services.

Results

Some 53% of respondents did not receive self-reported needed physical rehabilitation services. Respondents who had Medicaid were more likely than those with Medicare or private insurance to receive physical rehabilitation services. Respondents having a lower household income and poorer health were less likely to receive services.

Conclusions

Our findings indicate that health care funding sources provide widely disparate coverage for physical rehabilitation services to persons with 3 specific chronic and disabling conditions. Policy-makers and health plan administrators should re-evaluate their coverage of physical rehabilitation services designed to enhance quality of life and reduce the burden of lost independence.     

Health of community-dwelling adults with mobility limitations in the United States: incidence of secondary health conditions. Part II

Rasch EK, Magder L, Hochberg MC, Magaziner J, Altman BM. Health of community-dwelling adults with mobility limitations in the United States: incidence of secondary health conditions. Part II.

Objective

To compare incident health conditions that occurred over a 2-year period in nationally representative groups of adults with mobility, nonmobility, and no limitations.

Design

Data were collected prospectively from a probability subsample of households that represent the civilian, noninstitutionalized U.S. population.

Setting

Five rounds of household interviews were conducted over 2 years.

Participants

Data were analyzed on the same respondents from the 1996−1997 Medical Expenditure Panel Survey (MEPS) and the 1995 National Health Interview Survey Disability Supplement. Respondents were categorized into 3 groups for analysis; those with mobility limitations, nonmobility limitations, and no limitations. The analytic sample included 12,302 MEPS adults (≥18y).

Interventions

Not applicable.

Main Outcome Measures

Number, types, and 2-year incidence of self-reported health conditions compared across groups.

Results

The mean number of incident conditions (95% confidence intervals [CIs]) over the 2-year period was greatest in adults with mobility limitations (mean, 4.7; 95% CI, 4.4−4.9) compared with those with nonmobility limitations (mean, 3.9; 95% CI, 3.7−4.2) or no limitations (mean, 2.6; 95% CI, 2.5−2.7). Incident conditions affected most major body systems.

Conclusions

Because secondary conditions are potentially preventable, determining factors that influence their occurrence is an important public health issue requiring specific action.     

Promoting physical activity among women with mobility impairments: a randomized controlled trial to assess a home- and community-based intervention

OBJECTIVE: To assess the effectiveness of an intervention to promote physical activity and fitness in physically disabled women. DESIGN: Randomized controlled trial. SETTING: Home or community. PARTICIPANTS: Seventy-five adult women with mobility limitations. INTERVENTION: Incorporated behavioral techniques, social support, and education to promote exercise. MAIN OUTCOME MEASURES: Fitness measures included weight, body mass index, resting blood pressure and heart rate, time to complete a mobility course, and heart rate during and blood pressure after navigating the course. Also collected self-reported experience of secondary conditions and weekly self-reports of physical activity. RESULTS: We found no significant fitness differences between groups, except for peak heart rate. However, paired t tests of the physical activity data revealed the experimental group significantly increased its total weekly physical activity minutes (P=.04), and the increase in weekly cardiovascular activity approached significance (P=.06). CONCLUSIONS: The experimental group did not experience better fitness or fewer secondary conditions than the controls. However, the experimental group's physical activity data indicate that this group significantly increased its activity over 6 months. Thus, although this study did not detect health changes, it showed that mobility-impaired women can adopt and maintain a physical activity program.     

Distal symmetrical polyneuropathy: a definition for clinical research. A report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

The objective of this report was to develop a case definition of "distal symmetrical polyneuropathy" to standardize and facilitate clinical research and epidemiologic studies. A formalized consensus process was employed to reach agreement after a systematic review and classification of evidence from the literature. The literature indicates that symptoms alone have relatively poor diagnostic accuracy in predicting the presence of polyneuropathy; signs are better predictors of polyneuropathy than symptoms; and single abnormalities on examination are less sensitive than multiple abnormalities in predicting the presence of polyneuropathy. The combination of neuropathic symptoms, signs, and electrodiagnostic findings provides the most accurate diagnosis of distal symmetrical polyneuropathy. A set of case definitions was rank ordered by likelihood of disease. The highest likelihood of polyneuropathy (useful for clinical trials) occurs with a combination of multiple symptoms, multiple signs, and abnormal electrodiagnostic studies. A modest likelihood of polyneuropathy (useful for field or epidemiologic studies) occurs with a combination of multiple symptoms and multiple signs when the results of electrodiagnostic studies are not available. A lower likelihood of polyneuropathy occurs when electrodiagnostic studies and signs are discordant. For research purposes, the best approach to defining distal symmetrical polyneuropathy is a set of case definitions rank ordered by estimated likelihood of disease. The inclusion of this formalized case definition in clinical and epidemiologic research studies will ensure greater consistency of case selection.     

Decreased neck muscle strength is highly associated with pain in cervical dystonia patients treated with botulinum toxin injections

OBJECTIVES: To compare the isometric neck muscle strength of cervical dystonia patients treated with botulinum toxin injections with that of healthy control subjects and to evaluate the association between neck strength, neck pain, and disability in these patients. DESIGN: Clinical cross-sectional study. SETTING: Outpatient rehabilitation and neurology clinics in a Finnish hospital. PARTICIPANTS: Twenty-three patients with cervical dystonia with botulinum toxin-treated neck muscles and 23 healthy control subjects. INTERVENTIONS: Not applicable.Main outcome measures Isometric neck strength was measured by a special neck strength measurement system. Disability was measured by the Neck Disability Index, and pain and symptoms of cervical dystonia by a visual analog scale. RESULTS: Isometric neck strength in all directions measured was significantly lower (25%-44%) in the cervical dystonia patients than in the healthy controls. Neck pain levels reported during the strength tests (r range, -.36 to -.70) and neck pain experienced during the preceding week (r range, -.52 to -.63) were inversely associated with isometric strength results. The difference between sides in rotation strength was 35% in the patient group (P<.001), whereas no significant difference between sides was found in the healthy controls. Fifty-one percent of the patients reported moderate or severe disability. Pain, stiffness, and incorrect position of the head were the most prominent symptoms. CONCLUSIONS: Cervical dystonia patients with botulinum toxin-treated neck muscles showed significantly lower maximal neck strength than healthy controls. The patients also had a statistically significant difference between sides in neck rotation strength. Thus, strength measures may be useful to detect disturbance in the function of the neck muscles.     

Raised paraspinal muscle activity reduces rate of stature recovery after loaded exercise in individuals with chronic low back pain

OBJECTIVES: To further the understanding of stature recovery in subjects with and without chronic low back pain (CLBP) and to determine the relations among stature recovery, paraspinal muscle activity, and perceived pain and disability. DESIGN: A case-control study in which stature loss and recovery were assessed in subjects with and without CLBP after a 20-minute loaded walking task (10% of body mass). Group differences in pain, disability, and paraspinal muscle activity were also assessed. SETTING: A university laboratory. PARTICIPANTS: Twenty subjects with CLBP were matched (age, sex, body mass, physical activity level) with 20 controls who were recruited through notices in the university, general community, and local Primary Care Trust. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stature changes and integrated electromyograms of the paraspinal muscles during a loading and unloading period were assessed. RESULTS: Stature changes after loading did not differ between groups ( P <.05). Subjects with CLBP recovered significantly less stature during unloading than did the controls ( P <.05). Paraspinal muscle activity correlated negatively with stature recovery ( P <.05). Relations among stature recovery, pain, and disability were shown ( P <.05). CONCLUSIONS: The elevated paraspinal muscle activity exhibited by the CLBP group increased compression on the intervertebral disks and diminished their ability to recover the height lost through loaded exercise. Further research is required to establish whether a change in paraspinal muscle activity is associated with corresponding changes in stature recovery, and if this has any clinical implications by reducing pain and disability.     

Evaluating diagnosis-based risk-adjustment methods in a population with spinal cord dysfunction

OBJECTIVE: To examine performance of models in predicting health care utilization for individuals with spinal cord dysfunction. DESIGN: Regression models compared 2 diagnosis-based risk-adjustment methods, the adjusted clinical groups (ACGs) and diagnostic cost groups (DCGs). To improve prediction, we added to our model: (1) spinal cord dysfunction-specific diagnostic information, (2) limitations in self-care function, and (3) both 1 and 2. SETTING: Models were replicated in 3 populations. PARTICIPANTS: Samples from 3 populations: (1) 40% of veterans using Veterans Health Administration services in fiscal year 1997 (FY97) (N=1,046,803), (2) veteran sample with spinal cord dysfunction identified by codes from the International Statistical Classification of Diseases, 9th Revision, Clinical Modifications (N=7666), and (3) veteran sample identified in Veterans Affairs Spinal Cord Dysfunction Registry (N=5888). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Inpatient, outpatient, and total days of care in FY97. RESULTS: The DCG models (R(2) range,.22-.38) performed better than ACG models (R(2) range,.04-.34) for all outcomes. Spinal cord dysfunction-specific diagnostic information improved prediction more in the ACG model than in the DCG model (R(2) range for ACG,.14-.34; R(2) range for DCG,.24-.38). Information on self-care function slightly improved performance (R(2) range increased from 0 to.04). CONCLUSIONS: The DCG risk-adjustment models predicted health care utilization better than ACG models. ACG model prediction was improved by adding information.     

Study of the Independence IBOT 3000 Mobility System: an innovative power mobility device, during use in community environments

OBJECTIVE: To test the safe and effective use of a new mobility device, the Independence IBOT 3000 Mobility System, by people with a disability. DESIGN: A prospective, balanced, open-label evaluation that used participants as their own controls. SETTING: Home and community environments. PARTICIPANTS: Twenty subjects who use a mobility device. INTERVENTIONS: Subjects used the test device for up to 2 weeks in their home and community environments. MAIN OUTCOME MEASURE: Safety was determined by comparing the number of reported adverse events, including falls, in the test device compared with their own device. Effectiveness was measured by comparing scores from the Community Drive Test in the test device versus their own chair. RESULTS: No adverse event requiring medical attention was reported for either device and a similar number of device falls were reported for each device. The scored driving test results found that the test device was shown to statistically improve (P <.001) the subjects independent functional mobility skills in a community environment. Ten of 20 subjects were able climb stairs independently; the remaining 10 subjects were able to climb stairs with the assistance of only 1 person. CONCLUSIONS: People who are properly assessed, and participate and successfully complete the training, will benefit through increased independence in community mobility activities.     

Disparities in antihypertensive medication adherence in persons with disabilities and without disabilities: results of a Korean population-based study

Park JH, Park JH, Lee SY, Kim SY, Shin Y, Kim SY. Disparities in antihypertensive medication adherence in persons with disabilities and without disabilities: results of a Korean population-based study.

Objective

To determine disparities in antihypertensive medication adherence between persons with disabilities and those without disabilities in South Korea.

Design

The study compared antihypertensive medication adherence between persons with disabilities and those without disabilities using medical claims data of the National Health Insurance (NHI).

Setting

We obtained data from claims submitted to the NHI, which covers almost the entire Korean population. Persons who were prescribed antihypertensive medication during the calendar year 2004 were identified.

Participants

The study comprised data from persons with disabilities (n=85,098) and persons without disabilities (n=2,368,636).

Interventions

Not applicable.

Main Outcome Measures

A cumulative medication adherence (CMA) greater than or equal to 80% was defined as an appropriate medication adherence. Multiple logistic regression was used to identify differences in antihypertensive medication adherence between persons with disabilities and without disabilities. Estimates were adjusted for demographic characteristics (sex, age), type of medical insurance, insurance contribution a month as a proxy for household income, residential area, and clinical characteristics (medication duration, comorbid conditions).

Results

People with disabilities had lower CMAs than those without (median CMA, 83.6% vs 85.7%; appropriate medication adherence, 54.5% vs 57.5%). Results of the multiple logistic regression adjusting other factors indicated that people with disabilities had decreased probabilities of appropriate adherence.

Conclusions

Medication adherence is reduced by various types of disability and impairment such as those involving mobility and communication. Much effort should be made to investigate how and why these disparities take place and develop health policies to remove these disparities if they exist.     

Responsiveness of the Michigan Hand Outcomes Questionnaire--Dutch language version in patients with rheumatoid arthritis

van der Giesen FJ, Nelissen RG, Arendzen JH, de Jong Z, Wolterbeek R, Vliet Vlieland TP. Responsiveness of the Michigan Hand Outcomes Questionnaire-Dutch language version in patients with rheumatoid arthritis.

Objective

To investigate the responsiveness of the Michigan Hand Outcomes Questionnaire (MHQ) in patients with rheumatoid arthritis (RA) who were treated in a multidisciplinary hand clinic.

Design

Observational study comparing the responsiveness of the MHQ with that of various other outcome measures for hand function.

Setting

Multidisciplinary hand clinic within a tertiary referral center for rheumatologic care.

Participants

Twenty-eight patients with problems in hand function due to RA were assessed before and 3 months after conservative and/or surgical treatment.

Interventions

Not applicable.

Main Outcome Measures

Assessments included, apart from a previously validated Dutch language version of the MHQ, a visual analog scale for pain, grip strength, the Sequential Occupational Dexterity Assessment, the Arthritis Impact Measurement Scales (AIMS) hand and finger function scale, and each patient's rating of subjective change in hand function. Measurements of responsiveness included the standardized response mean (SRM), effect size, and responsiveness ratio. In addition, the Spearman rank correlations (ρ) between the change scores of the MHQ and those of other measures of hand function were calculated.

Results

The mean MHQ total score improved significantly between baseline (mean ± standard deviation, 48.3±12.2) and follow-up (mean, 54.7±16.9) (change score, −7.2; 95% confidence interval, −11.1 to −3.3). The SRM, effect size, and responsiveness ratio of the MHQ total score were −0.72, −0.52, and −1.99, respectively. Significant associations were found between the changes of the MHQ total score and each patient's rating of subjective change in hand function (ρ=.64, P=.001) and the change score of the AIMS hand function scale (ρ=−.24, P=.260).

Conclusions

The MHQ proved to be a responsive measure of hand function in patients with RA who were treated in connection with a multidisciplinary hand clinic.     

The segway personal transporter as an alternative mobility device for people with disabilities: a pilot study

Sawatzky B, Denison I, Langrish S, Richardson S, Hiller K, Slobogean B. The Segway Personal Transporter as an alternative mobility device for people with disabilities: a pilot study.

Objectives

To determine the functional measures that best correlate with the skill levels of people with disabilities who operate a Segway Personal Transporter, and—using a qualitative analysis—to explore subjects’ experience with the Segway.

Design

A prospective study encompassing 3 training sessions with the Segway to correlate subjects’ functional ability (eg, cognition, balance, mobility, muscle strength) with their skill level on the device.

Setting

A provincial adult rehabilitation center.

Participants

Twenty-three subjects (age range, 19−65y) with a wide range of disabilities (eg, multiple sclerosis, spinal cord injury, amputation) who could walk at least 6m with or without assistance.

Interventions

Not applicable.

Main Outcome Measures

Segway Task Assessment, Berg Balance Scale, and Timed Up & Go test.

Results

No correlation was found because all participants successfully completed the final Segway Task Assessment, regardless of scores on functional assessments.

Conclusions

The Segway is a useful device for a broad range of populations with functional disabilities. Subjects found the Segway easy to use and were excited about its potential as an assistive device for use in their communities.