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.     

Relationships among impairments in lower-extremity strength and power, functional limitations, and disability in older adults

BACKGROUND AND PURPOSE: During the aging process, older adults may experience a loss of strength and power, which then may lead to functional limitations and disability. The purpose of this study was to examine how impairments in lower-extremity strength and power are related to functional limitations and disability in community-dwelling older adults. SUBJECTS: Thirty older adults (age [X+/-SD], 77.3+/-7.0 years; 25 women and 5 men) with mild to moderate functional limitations participated in this study. METHODS: Lower-extremity strength, peak power, power at a low relative intensity, and power at a high relative intensity were measured with a pneumatic resistance leg press. Functional limitations and disability were assessed with the Short Physical Performance Battery (SPPB), the Six-Minute Walk Test (SMWT), and the Late Life Function and Disability Instrument (LLFDI). RESULTS: All measures of strength and power were related to functional limitations. Peak power demonstrated the strongest relationships with SMWT, the SPPB gait speed subscale, and the LLFDI functional limitation component. Power at a high relative intensity demonstrated the strongest relationships to the SPPB total score and the SPPB sit-to-stand subscale score. All measures of strength and power were indirectly related to the LLFDI disability component. DISCUSSION AND CONCLUSION: Older adults should focus on increasing and maintaining lower-extremity strength and power across a range of intensities in order to decrease functional limitations and disability.     

Associating the onset of motor impairments with disability progression in nursing home residents

OBJECTIVES: To evaluate the association between the onset of movement impairments and disability progression in nursing home residents. DESIGN: Retrospective cohort analysis of data from the State of New York Minimal Data Set, version 2.0, between November 1998 and October 1999. Participants were nursing home residents (n = 84,346) in the State of New York. Items defined as "functional limitation in range of motion" and "lack of voluntary movement" served as measures of movement impairments. Scores on the activities of daily living summary scale served as a measure of disability. Age, sex, measures of cognition, depression, and measures of medical stability served as adjustment variables. RESULTS: After adjusting for age, sex, cognition, depression, and measures of medical stability, the onset of either singular or combined movement impairments in voluntary movement or range of motion was associated with a concurrent step-wise loss in activities of daily living (P < 0.001). The progression in activities of daily living loss occurred regardless of location or limb type. CONCLUSION: This study directly links the onset of movement impairments with disability progression. These findings have important implications for physiatrists and other practitioners of geriatric rehabilitation.     

Incidence of functional limitation in older adults: the impact of gender,race, and chronic conditions

OBJECTIVES: To evaluate the relation of chronic conditions, gender, and race to the incidence of activities of daily living (ADLs) limitation in older adults. DESIGN: The 2-year cumulative incidence of functional limitation was estimated from survival analysis methods by using elders without baseline functional limitations. SETTING: Longitudinal Study of Aging (LSOA). Initial interviews: 1984; reinterviews: 1986, 1988, and 1990. PARTICIPANTS: A total of 4205 elderly subjects from the LSOA. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Dependent variables: self-reported moderate (1-2 ADLs) and severe (> or =3 ADLs) functional limitation. Independent variables: sociodemographics, self-reported chronic conditions, and prior levels of functional limitation. RESULTS: Gender and race predicted moderate functional limitation onset, after controlling for age and education. Arthritis, diabetes, prior cerebrovascular disease (CVD), incontinence, and impaired vision were significant predictors of moderate functional limitation onset after controlling for demographics. Differences in the prevalence of chronic conditions appear to explain why moderate functional limitation incidence rates are higher in older women and blacks. Gender, but not race, predicted onset of severe functional limitation, after controlling for age and education. Prior moderate functional limitation, CVD, and vision impairment predicted onset of severe functional limitation after controlling for demographics. CONCLUSION: Prevention of functional decline should target chronic conditions and moderate functional limitation in older adults.     

Impact of tai chi on impairment, functional limitation, and disability among preclinically disabled older people: a randomized controlled trial

Day L, Hill KD, Jolley D, Cicuttini F, Flicker L, Segal L. Impact of tai chi on impairment, functional limitation, and disability among preclinically disabled older people: a randomized controlled trial.ObjectivesTo test the effect of tai chi on the progression of preclinical disability to manifest disability compared with seated flexibility exercise, and to examine whether tai chi mediates delayed disability by reducing impairments in musculoskeletal, cardiovascular, and neurologic systems, and related functional limitations.DesignMultisite parallel group individually randomized controlled trial.SettingGeneral community.ParticipantsPreclinically disabled community-dwelling people older than 70 years (n=503), without major medical conditions or moderate to severe cognitive impairment.InterventionModified Sun style tai chi exercise compared with seated flexibility exercise, both programs delivered in groups for 60 minutes twice weekly for 24 weeks.Main Outcome MeasuresDisability measured with the Late-Life Function and Disability Instrument. Secondary outcomes were impairments and functional limitations of the musculoskeletal, neurologic, and cardiovascular systems.ResultsThere was little change within or between the 2 groups. The mean change in the Disability Frequency Score was 0.3 and 0.1 points (100-point scale) for the intervention and control groups, respectively (adjusted difference ?.21; 95% confidence interval [CI] ?.99 to .56). The mean change in the Disability Limitation Score was ?0.1 and ?.04 points for the intervention and control groups, respectively (adjusted difference ?0.6; 95% CI ?2.31 to 1.11). There was little effect on impairments or functional limitations. A higher proportion of intervention participants ceased attending the exercise program (difference=17.9%, 95% CI 9.6–25.8). Multiple imputation of missing data did not change the results.ConclusionsModified Sun style tai chi did not have an impact on impairment, functional limitations, or disability in preclinically disabled older people when delivered for 24 weeks. Withdrawal from the exercise classes was high but did not explain the null result. Improved compliance, or a longer or more intensive program, may be required.     

Physical impairment and disability: relationship to performance of activities of daily living in community-dwelling older men

BACKGROUND AND PURPOSE: The decline of physical function of older adults, associated with loss of independent living status, is a major public health concern. The purpose of this study was to examine the relationship of physical impairment and disability to performance of activities of daily living (ADL) among community-dwelling older adults. SUBJECTS AND METHODS: Eighty-three community-dwelling older men who were referred to a comprehensive outpatient geriatric evaluation program (mean age=75.5 years, SD=7.0, range=64-97) were examined. Measurements of physical impairment (muscle force production, flexibility, and fitness) and physical disability (gait speed, stride length, risk for recurrent falls, and physical function) were recorded. RESULTS: A stepwise linear regression was used to determine the relationship of physical impairments and disability measures with ADL. The results indicated that walking speed, fall risk, and muscle force contributed independently to the characterization of the activities of daily living of the community-dwelling older men studied (adjusted R2=.68; F=56.81; df=3,80; P<.001). Using a principal components factor analysis, 4 domains were identified that explained 68.2% of the variance in performance of ADL: (1) mobility/fall risk=26.5%, (2) coordination=15%, (3) fitness=14.7%, and (4) flexibility=12.0%. DISCUSSION AND CONCLUSION: The identification of domains of physical function may be useful to physical therapists in the development of interventions targeted for physical impairments and disabilities that contribute to deficits in performance of ADL. Targeting interventions for physical impairments and disabilities related to function may improve the effectiveness of physical therapist interventions and reduce the loss of independence among community-dwelling older people.     

Impairment,disability, and the ICIDH model I: The relationship between impairment and disability

The conceptual scheme put forward in the International Classification of Impairments, Disabilities, and Handicaps suggests that impairment should be related to disability. This paper examines the proposition that disability should be related to impairment in terms of parts of the body involved, both in the physical requirements to carry out a given activity and as regards the site and types of functional limitation, by secondary analysis of data collected in a survey of disabled people in Great Britain. Factor analysis of data on functional limitations showed that these impairments could be considered in four groups representing manual dexterity, movements of the arm, strength, and lower limb function. These were found to be correlated with ability in self-care activities depending on the part of the body involved in the activity.     

Outcomes of the Bobath concept on upper limb recovery following stroke

OBJECTIVE: To determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations and participation restrictions after stroke. METHODS: Electronic databases were searched to identify relevant trials published between 1966 and 2003. Two reviewers independently assessed articles for the following inclusion criteria: population of adults with upper limb disability after stroke; stated use of the Bobath concept aimed at improving upper limb disability in isolation from other approaches; outcomes reflecting changes in upper limb impairment, activity limitation or participation restriction. RESULTS: Of the 688 articles initially identified, eight met the inclusion criteria. Five were randomized controlled trials, one used a single-group crossover design and two were single-case design studies. Five studies measured impairments including shoulder pain, tone, muscle strength and motor control. The Bobath concept was found to reduce shoulder pain better than cryotherapy, and to reduce tone compared to no intervention and compared to proprioceptive neuromuscular facilitation (PNF). However, no difference was detected for changes in tone between the Bobath concept and a functional approach. Differences did not reach significance for measures of muscle strength and motor control. Six studies measured activity limitations, none of these found the Bobath concept was superior to other therapy approaches. Two studies measured changes in participation restriction and both found equivocal results. CONCLUSIONS: Comparisons of the Bobath concept with other approaches do not demonstrate superiority of one approach over the other at improving upper limb impairment, activity or participation. However, study limitations relating to methodological quality, the outcome measures used and contextual factors investigated limit the ability to draw conclusions. Future research should use sensitive upper limb measures, trained Bobath therapists and homogeneous samples to identify the influence of patient factors on the response to therapy approaches.     

Muscle force and range of motion as predictors of function in older adults

BACKGROUND AND PURPOSE: Musculoskeletal impairments and functional limitations are linked to disability in older adults. The purposes of this study were to identify the extremity musculoskeletal impairments that best predict functional limitations in older adults and to assess the validity of measurements obtained for the Physical Performance Test (PPT) as a predictor of disability. SUBJECTS AND METHODS: Eighty-one older adults residing in independent and dependent care facilities were tested for extremity muscle force, range of motion, and function. Data were analyzed using multiple regression analysis to identify extremity impairments that predicted function scores and logistic regression analysis to determine whether PPT scores predicted subjects' living situation as dependent versus independent. RESULTS: Subject age, lower-extremity muscle force, and lower-extremity range of motion explained 77% of the variance in function as measured by the PPT. Results differed when analysis was done by subject living situation, with a higher percentage of the variance in function scores explained by musculoskeletal measures for the dependent living group as compared with the independent living group. CONCLUSION AND DISCUSSION: Extremity musculoskeletal impairments have a strong relationship to function, especially in older adults living in dependent care settings. The results of this study can be used to design interventions to address the musculoskeletal disorders most related to function in the older population.     

Functional recovery in cancer rehabilitation

OBJECTIVE: To assess the impact of inpatient rehabilitation on the motor and cognitive functional status of cancer patients, and to determine whether cancer diagnosis, rehabilitation impairment, physician-determined rehabilitation goals, and active cytotoxic treatment affect the magnitude of functional improvement. DESIGN AND SETTING: A retrospective, case series of patients with an oncology diagnosis undergoing inpatient rehabilitation at a rehabilitation hospital. PARTICIPANTS: A sample of 200 patients admitted for rehabilitation services due to disability resulting from impairments caused by cancer or its treatment. INTERVENTION: Comprehensive multidisciplinary inpatient rehabilitation. OUTCOME MEASURES: Function status was measured using the motor and cognitive measures of the Functional Independence Measure. RESULTS: All patients made significant gains in motor function regardless of diagnostic group, rehabilitation impairment group, rehabilitation goal group, and cytotoxic treatment status. The magnitude of motor function gain was not equivalent across all impairments and rehabilitation goals. Significant gains in cognitive function were made by all patients except those with intracranial neoplasms, central nervous system dysfunction, and palliative rehabilitation goals. CONCLUSION: Inpatient rehabilitation can improve both motor and cognitive function in patients with disability resulting from impairments caused by cancer or its treatment.     

Impairment and activity limitation associated with epiphyseal dysplasia in children

OBJECTIVES: To develop a profile of impairment and activity limitation among children with epiphyseal dysplasia (ED) and to identify the relationship between these 2 domains. DESIGN: Cross-sectional study. SETTING: Acute, pediatric academic and health sciences center. PARTICIPANTS: Eleven subjects with multiple epiphyseal dysplasia (MED) and 17 subjects with spondyloepiphyseal dysplasia (SED), with a mean age of 12.9 years. INTERVENTIONS: Not applicable.Main outcome measures Anthropometric indexes of growth and nutrition, joint range of motion (ROM) and alignment, muscle strength, pain, and activity limitation. RESULTS: Subjects with SED had significantly shorter stature than the reference population (P<.01). Seventy-three percent of participants with MED and 77% of those with SED were above average or overweight for their height (P<.01). Both groups presented with moderate to severe joint ROM impairment, with greater lower-extremity involvement. Subjects with SED had worse outcomes with respect to overall ROM and alignment impairments (P<.01), particularly in their upper extremities (P<.01), than subjects with MED. Significant overall muscle weakness was noted in all subjects (z=-1.81; P<.01). Ninety-four percent of subjects with SED reported pain with activity, compared with 64% of those with MED (P=.04), although pain intensity did not differ between groups. Fifty percent of subjects had undergone orthopedic surgery. Mild activity limitation was reported by all subjects (mean score, 87.7+/-18.83). Significant correlations were identified between height for age and strength (r=.50) and pain and activity limitation (r=-.50). CONCLUSIONS: Despite moderate to severe impairments, all subjects reported surprisingly mild activity limitation. A positive correlation was identified between pain and activity limitation. This study also identified and described patterns of muscle weakness, pain, and nutritional concerns not previously reported in the ED literature.     

Application of the HOAC II: an episode of care for a patient with low back pain

BACKGROUND AND PURPOSE: The HOAC II is a patient management algorithm designed, in part, to provide a conceptual framework for patient management for any type of patient seen by physical therapists. This case report illustrates how the HOAC II can be used in clinical practice. CASE DESCRIPTION: The patient was a 47-year-old woman with low back pain. The report describes the patient's examination, evaluation, diagnosis, prognosis, intervention, and outcomes within the context of the HOAC II. OUTCOME: The patient had measurable improvements in impairments, functional limitation, and disability following an intervention designed to resolve her impairments and functional limitations. DISCUSSION: This case report illustrates how the HOAC II can be used to assist in the management of a patient from admission to discharge. The report also demonstrates how use of a disablement model can add clarity to patient care.     

Excess physical limitations among adults with diabetes in the U.S. population, 1997-1999

OBJECTIVE: To estimate the prevalence of physical limitations associated with diabetes among U.S. adults > or =18 years of age. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional analysis of the association between diabetes status and physical limitations using the 1997-1999 National Health Interview Survey (NHIS). Physical limitation was defined from self-reported degree of difficulty with nine tasks. RESULTS: People with diabetes had a higher proportion of any physical limitation than did people without diabetes overall (66 vs. 29%, P < 0.001), for both men (59 vs. 24%, P < 0.001) and women (72 vs. 34%, P < 0.001). Compared with those without diabetes, a higher proportion of people with diabetes had some physical limitation among all age groups, and the difference declined (all P < 0.001) with increasing age (46 vs. 18% for 18-44 years, 63 vs. 35% for 45-64 years, 74 vs. 53% for 65-74 years, and 85 vs. 70% for those 75 years and older). After controlling for demographic characteristics and several other confounders, the odds ratio of physical limitation among adults with diabetes versus those without diabetes was 1.9 (95% CI: 1.8-2.1). CONCLUSIONS: People with diabetes are much more likely to have a physical limitation than those without diabetes. Interventions are needed in this population to reduce progression from impairment to physical limitation and from physical limitation to disability, especially because the prevalence of diabetes is projected to increase dramatically in the next several decades.     

Muscle impairments and behavioral factors mediate functional limitations and disability following stroke

BACKGROUND AND PURPOSE: Stroke remains the leading cause of disability in the United States. The purposes of this study were to examine whether quantitative measures of muscle strength and power in the involved lower extremity predict functional limitations and to evaluate the contributions of behavioral factors to mediating disability and quality of life in people who have survived a stroke. SUBJECTS AND METHODS: A cross-sectional study design was used, and measurements of muscle impairment, lower-body function, disability, quality of life, and behavioral factors were obtained for 31 community-dwelling volunteers who had experienced a single ischemic stroke in the past 6 to 24 months. RESULTS: Stepwise regression models including impairment and behavioral measures were strong predictors of function, disability, and quality of life. Involved-extremity muscle strength and power and self-efficacy were independently associated with function, whereas depression and self-efficacy were strong predictors of disability and quality of life. DISCUSSION AND CONCLUSION: The findings warrant future studies to determine whether interventions that address muscle strength and power, depressive symptoms, and low self-efficacy effectively improve function, reduce disability, and enhance quality of life in people who have survived a stroke.     

Diabetes and incidence of functional disability in older women.

OBJECTIVE: To examine the relationship between diabetes and the incidence of functional disability and to determine the predictors of functional disability among older women with diabetes. RESEARCH DESIGN AND METHODS: We analyzed data from 8,344 women enrolled in the Study of Osteoporotic Fractures, a prospective cohort of women aged > or =65 years. Diabetes (n = 527, 6.3% prevalence) and comorbidities (coronary heart disease, stroke, arthritis, depression, and visual impairment) were assessed by questionnaire and physical examination. Incident disability, defined as onset of inability to do one or more major functional tasks (walking 0.25 mile, climbing 10 steps, performing household chores, shopping, and cooking meals), was assessed by questionnaire over 12 years. RESULTS: The yearly incidence of any functional disability was 9.8% among women with diabetes and 4.8% among women without diabetes. The age-adjusted hazard rate ratio (HRR) of disability for specific tasks associated with diabetes ranged from 2.12 (1.82-2.48) for doing housework to 2.50 (2.05-3.04) for walking two to three blocks. After adjustment for potential confounders at baseline (BMI, physical activity, estrogen use, baseline functional status, visual impairment, and marital status) and comorbidities (heart disease, stroke, depression, and arthritis), diabetes remained associated with a 42% increased risk of any incident disability and a 53-98% increased risk of disability for specific tasks. Among women with diabetes, older age, higher BMI, coronary heart disease, arthritis, physical inactivity, and severe visual impairment at baseline were each independently associated with disability. CONCLUSIONS: Diabetes is associated with an increased incidence of functional disability, which is likely to further erode health status and quality of life.     

Validity,invariance and responsiveness of a self-report measure of functional limitations and disability in multiple sclerosis

Objective.?This study examined the structural and external aspects of score validity for the abbreviated Late Life-Function and Disability Inventory (LL-FDI) as well as its longitudinal measurement invariance and responsiveness in individuals with multiple sclerosis (MS).

Methods.?The sample included 292 individuals with MS who completed a battery of questionnaires on two occasions separated by 6 months. The battery included the abbreviated LL-FDI along with measures of mobility disability; neurological impairments; symptoms of fatigue, anxiety, depression and pain; health status; and quality of life. The data were analysed using Analysis of Moment Structures (AMOS) and Statistical Package for the Social Sciences (SPSS), versions 16.0.

Results.?Confirmatory factor analysis supported the structural validity and longitudinal measurement invariance of the disability and functional limitations components of the abbreviated LL-FDI. MANOVA and bivariate correlations supported the external aspects of score validity based on differences in mean scores as a function of clinical MS course (relapsing vs. progressive) and level of mobility disability (mild vs. moderate mobility disability) and associations with measures of neurological impairments, symptoms, health status and QOL, respectively. ANOVA established the responsiveness (i.e., sensitivity for reflecting clinically important differences in health status across time) of the functional limitations and disability components of the abbreviated LL-FDI for detecting changes in mobility disability across 6-months.

Conclusion.?Such findings provide a new option for the measurement of functional limitations and disability using the abbreviated LL-FDI in persons with MS.     

Temporary working disability among younger patients with back pain and its interaction with severity of pain,functional capacity,social factors and personality styles

The relationships between sick absenteeism and clinical measures were studied for a group of younger patients with chronic back pain (mean years of age for women and men were 41.7 and 42.2, respectively) who were sent to a rehabilitation programme. The duration of sick absenteeism during the last year as well as the momentary status of working ability were correlated with different clinical variables and personality styles. At the beginning of the rehabilitation program, the measure of functional capacity (FFbH-R, Kohlmann u. Raspe, 1996) showed the strongest correlation with temporary working disability (r = -.46) and duration of sick absenteeism during the last year (r = -.44). The severity of pain showed a lower but significant correlation with temporary working disability (r =.24) and duration of sick absenteeism (r =.25). In contrast, depression, vitality and age did not show significant correlations with temporary working disability at the beginning of the rehabilitation. In addition, some of the personality styles from the PSSI (Kuhl u. Kazén, 1997) showed significant correlations with temporary working disability and duration of sick absenteeism. When entering the variables into regression analyses, the measure of functional capacity was the most important predictor of sick absenteeism. Severity of pain, depression, vitality and age did not significantly add to the variance accounted for. In contrast, distinct personality styles from the PSSI significantly contributed to an additional proportion of variance in sick absenteeism and temporary working disability. At the end of the rehabilitation program, there were stable relationships between temporary working disability and functional capacity (r = -.45) as well as severity of pain (r =.39). In, correlations between temporary working disability and depression (r =.30) and vitality (r = -.19) were significant. This was due to the stronger improvement during therapy among patients who were able to work compared to patients who were not.     

Comorbidities and impairments explaining the association between diabetes and lower extremity disability: The Women's Health and Aging Study

OBJECTIVE: To elucidate the role of diabetes-related impairments and comorbidities in the association between diabetes and physical disability, this study examined the association between diabetes and lower extremity function in a sample of disabled older women. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 1,002 women (aged >or=65 years) enrolled in the Women's Health and Aging Study (one-third most disabled of the total community-dwelling population). Diabetes and other medical conditions were ascertained by standard criteria that used multiple sources of information. Functional status was assessed using self-reported and objective performance measures. RESULTS: Women with diabetes were significantly more likely to have cardiovascular diseases, peripheral nerve dysfunction, visual impairment, obesity, and depression. After adjustment for age, women with diabetes had a greater prevalence of mobility disability (odds ratio [OR] 1.85, 95% CI 1.12-3.06), activities of daily living disability (1.61, 1.06-2.43), and severe walking limitation (2.34, 1.56-3.50), and their summary mobility performance score (0-12 scale based on balance, gait speed, chair stands) was 1.4 points lower than in nondiabetic women (P < 0.001). Peripheral artery disease, peripheral nerve dysfunction, and depression were the main individual contributing factors; however, none of these conditions alone fully explained the association between diabetes and disability. Conversely, only after adjusting for all potential mediators was the relationship between diabetes and disability reduced to a large degree. CONCLUSIONS: Even among physically impaired older women, diabetes is associated with a major burden of disability. A wide range of impairments and comorbidities explains the diabetes-disability relationship, suggesting that the mechanism for such an association is multifactorial.