Validation of the NHANES ADL scale in a sample of patients with report of cervical pain: Factor analysis,item response theory analysis,and line item validity

Background.?Few functional outcomes scales have used Item Response Theory (IRT) for validation. IRT allows individual line item validations and offers substantial advantages over classic methods of scale validation or the simplest from of IRT known as Rasch. Rasch analysis reduces data to dichotomous variables thus decreasing the sensitivity of Likert-type data responses.

Purpose.?The purpose of this study was to create an outcome scale associated with the latent trait of functioning and disability, validated using IRT, in a population with report of cervical pain.

Methods.?Using the NHANES database, a recently created scale (NHANES ADL scale) was analysed using factor analysis, internal analyses of consistency, IRT, and comparison with internal measures of functioning and disability.

Results.?The newly created NHANES ADL scale demonstrated uni-dimensionality, was internally reliable, and was correlated to internal measures of functioning and disability. Additionally, the majority of the scale items demonstrate strong discrimination and suitable thresholds.

Discussion.?The NHANES ADL scale effectively measures physical, social, and emotional disability in patients with a cervical impairment, and may be an efficient measure of perceived limitations from working and generalized daily physical activity.

Conclusion.?The newly created NHANES ADL scale demonstrates internal consistency, unidimensionality, and line item validity. The NHANES ADL scale appears to be a useful instrument in measurement of functioning and disability in patients with report of cervical pain.     

Utilizing Rasch measurement models to develop a computer adaptive self-report of walking,climbing, and running

Purpose.?The purpose of this paper is to show how the Rasch model can be used to develop a computer adaptive self-report of walking, climbing, and running.

Method.?Our instrument development work on the walking/climbing/running construct of the ICF Activity Measure was used to show how to develop a computer adaptive test (CAT). Fit of the items to the Rasch model and validation of the item difficulty hierarchy was accomplished using Winsteps software. Standard error was used as a stopping rule for the CAT. Finally, person abilities were connected to items difficulties using Rasch analysis ‘maps’.

Results.?All but the walking one mile item fit the Rasch measurement model. A CAT was developed which selectively presented items based on the last calibrated person ability measure and was designed to stop when standard error decreased to a pre-set criterion. Finally, person ability measures were connected to the ability to perform specific walking/climbing/running activities using Rasch maps.

Conclusions.?Rasch measurement models can be useful in developing CAT measures for rehabilitation and disability. In addition to CATs reducing respondent burden, the connection of person measures to item difficulties may be important for the clinical interpretation of measures.     

Validation of the orthotics and prosthetics user survey upper extremity functional status module in people with unilateral upper limb amputation.

OBJECTIVE: To evaluate the measurement properties of the Upper Extremity Functional Status module of the Orthotics and Prosthetics User Survey (OPUS). DESIGN: Methodological research on an outcome measure administered by clinical interview. PATIENTS: A convenience sample of 61 adults who had unilateral upper limb amputations and completed rehabilitation at the Institute for Rehabilitation in Ljubljana, Slovenia, at least one year prior to interview. Thirty-four patients had undergone amputation of the dominant hand. Four patients did not use a prosthesis. METHODS: Rating scale analysis (Rasch model) was used to evaluate functioning of the rating scale categories, the validity of the measure by examining fit of items to the latent trait, and the hierarchy of item difficulties compared with expectations of the construct. RESULTS: Rasch analysis allowed us to improve the Upper Extremity Functional Status by rescoring to reduce the response categories from 5 to 4, and identifying 19 of 23 items that are useful to measure upper extremity function. The results allow us to have high confidence in the consistency of both person-ability and item-difficulty estimates. CONCLUSION: This revised Upper Extremity Functional Status is a promising instrument to measure the degree of manual functioning after a unilateral upper limb amputation.     

Adult acquired major upper limb amputation in Norway: prevalence,demographic features and amputation specific features. A population-based survey

Purpose.?To estimate the prevalence of adult acquired major upper limb amputation in Norway. To describe this amputee population regarding demographic features and amputation specific features. To compare our data to data collected internationally.

Method.?Population-based cross-sectional study on adult upper limb amputees with acquired limb loss through or proximal to the radio-carpal joint. Patients were found in the databases of the two companies in Norway that make upper limb prostheses and in the medical records of three of the largest Norwegian hospitals. Data were collected by postal questionnaires.

Results.?We estimated a population prevalence of 11.6 per 100,000 adults (n == 416). Our survey was not 100%% comprehensive and the estimate is conservative. The amputees were predominantly men with traumatic, unilateral, distal amputations at a young age. There were significant gender- and amputation level differences in cause. Most amputees had used prostheses. About four in ten were in paid employment.

Conclusions.?Our findings are mainly consistent with earlier studies from other countries. Implications of our findings related to the planning of future health care for these patients are outlined, including suggestion of regional multidisciplinary rehabilitation emphasising occupational rehabilitation and focus on preventive measures. Potential areas of follow-up are suggested.     

An application of computerised adaptive testing for measuring health status in patients with knee osteoarthritis

Purpose.?The aim of this study was to explore the potential of computerised adaptive testing (CAT) for measuring health status in knee osteoarthritis.

Method.?Three hundred and fifty-one patients with knee osteoarthritis (OA) answered 118 questions from a range of widely used questionnaires. Three dimensions relevant to knee OA were identified by expert opinion as ‘pain, mental and emotional status’; ‘self-care and household activities’ and ‘mobility and social activities’. Confirmatory factor analysis (CFA) was used to test the relationship between the items and their dimensions. After CFA, these dimensions were subjected to Rasch analysis to calibrate the items onto an interval scale. A CAT was developed for each dimension, and the results checked against simulated applications from 10,000 simulees.

Results.?After CFA and Rasch analysis, 14, 22 and 23 items remained in the first, second and third dimensions, respectively. Items were mostly free of differential item functioning for age, gender and duration of disease. Reliability exceeded 0.87 for each dimension. The health status levels generated using item banks and those obtained from the simulated CAT application were highly correlated (i.e. >0.91 for each dimension). On average, 8, 10 and 10 items were used to estimate the health status levels using the CAT for the first, second and third dimensions respectively.

Conclusions.?Using a combination approach of CFA and Rasch analysis, this study has shown that it is possible to calibrate items onto a single metric in a way that can be used to provide the basis of a CAT application.     

Validity,reliability and predictive accuracy of the Driving Awareness Questionnaire

Purpose.?To examine the psychometric properties of the Driving Awareness Questionnaire (DriveAware) and to compare this rating of awareness of driving ability with the rating made in the context of an on-road assessment.

Method.?A prospective design was employed to examine the psychometric properties of DriveAware using Rasch analysis. Participants (n = 91) with varying diagnoses were recruited from two driving rehabilitation centres in Sydney, Australia. They completed DriveAware in the context of a standard driving assessment. Awareness of driving ability determined by DriveAware was compared with awareness determined in the on-road assessment.

Results.?Rasch analysis provided good evidence for construct validity and inter-rater reliability and some evidence for internal reliability of DriveAware. The item hierarchy was logical and goodness-of-fit statistics for four of five items were within an acceptable range. The test had a moderate reliability index (0.73). Measurement precision could be improved by including more items to assess drivers with little awareness. When compared with the on-road measure of awareness, the best DriveAware cut-off score yielded sensitivity of 84% and specificity of 94%.

Conclusion.?This short and easy-to-administer test could provide a useful tool with sound psychometric properties to measure awareness of driving ability.     

Systematic review of the effectiveness of mirror therapy in upper extremity function

Purpose.?This review gives an overview of the current state of research regarding the effectiveness of mirror therapy in upper extremity function.

Method.?A systematic literature search was performed to identify studies concerning mirror therapy in upper extremity. The included journal articles were reviewed according to a structured diagram and the methodological quality was assessed.

Results.?Fifteen studies were identified and reviewed. Five different patient categories were studied: two studies focussed on mirror therapy after an amputation of the upper limb, five studies focussed on mirror therapy after stroke, five studies focussed on mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one study on mirror therapy with complex regional pain syndrome type 2 (CRPS2) and two studies focussed on mirror therapy after hand surgery other than amputation.

Conclusions.?Most of the evidence for mirror therapy is from studies with weak methodological quality. The present review showed a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS, whereas the effectiveness in other patient groups has yet to be determined.     

Are neck pain scales and questionnaires compatible with the international classification of functioning,disability and health? A systematic review

Purpose.?To identify neck-pain-specific questionnaires and scales that measure functioning and disability and assess whether their contents are comparable to the international classification of functioning, disability and health (ICF).

Methods.?A systematic search was conducted in LILACS, MEDLINE, CINAHL, and SPORTSDISCUS databases, identifying questionnaires and scales used to assess neck-related functioning and disability from 1966 to November 2007. Each item of each scale or questionnaire was extracted and classified according to the ICF categories.

Results.?The databases yielded a total of 888 articles, of which seven questionnaires were identified and included in the review. A total of 74 items were analyzed, 27 linked to body function, 46 to activities and participation, 1 to environmental factors, and 5 to non-classified items. While the pain disability index tends to focus on limitations to body functions, the functional rating index and the Copenhagen neck functional disability scale appear to be limited to measuring activity. Three questionnaires (the neck Bournemouth Questionnaire, the neck disability index, and the neck pain and disability scale) have demonstrated a well-balanced distribution of items across the ICF components.

Conclusion.?Most identified questionnaires reflect limitations or restrictions in one component only. These results provide valuable information on the content quality of these questionnaires for health-care providers and researchers.     

Effect of bilateral reaching on affected arm motor control in stroke – with and without loading on unaffected arm

Purpose.?To investigate the effect of bilateral reaching, with/without inertial loading on the unaffected arm, on hemiparetic arm motor control in stroke.

Methods.?Twenty unilateral stroke patients were recruited. A three-dimensional optical motion capture system was used to measure the movement trajectory of the hemiparetic arm while performing three tasks: affected limb reaching forward; two-limb reaching forward; and two-limb reaching forward with inertia loading of 25% upper limb weight on the unaffected limb, respectively. Kinematical parameters were utilized to quantify the reaching performance of the affected arm.

Results.?No matter whether loading was applied on the unaffected arm or not, the bilateral reaching task did not significantly facilitate smoother and faster movement. Furthermore, during bilateral reaching task with/without loading on the unaffected arm, stroke patients showed slower movement, lower maximal movement velocity, feedback control dominant and discontinuous movements in the affected arm than the same task with unilateral reaching. Subjects showed the greatest active upper extremity range of motion in proximal joints during the bilateral reaching task without unaffected arm loading. The amount of trunk movement also increased during bilateral reaching either with or without loading on the unaffected arm. Patients with moderate upper extremity motor impairment performed more discontinuous movements and less active elbow range of motion during bilateral reaching tasks; however, those with mild upper extremity motor impairment performed smoother movements and demonstrated greater active elbow range of motion during bilateral reaching tasks.

Conclusions.?Bilateral reaching tasks with/without loading on the unaffected arm could be considered as adding challenges during motor control training. Training with bilateral arm movements may be considered as a treatment strategy, and can be incorporated in stroke rehabilitation to facilitate greater arm active movement and improve motor control performance in the affected arm.     

Using the manual ability classification system in young adults with cerebral palsy and normal intelligence

Purpose.?The study aimed to establish whether the manual ability classification system (MACS), a valid classification system for manual ability in children with cerebral palsy (CP), is applicable in young adults with CP and normal intelligence.

Subjects.?The participants (n?=?83) were young adults with CP and normal intelligence and had a mean age of 19.9 years.

Method.?In this study, inter observer reliability of the MACS was determined. We investigated relationships between the MACS level and patient characteristics (such as the gross motor function classification system (GMFCS) level, limb distribution of the spastic paresis and educational level) and with functional activities of the upper extremity (assessed with the Melbourne assessment, the Abilhand questionnaire and the domain self-care of the functional independence measure (FIM)). Furthermore, with a linear regression analysis it was determined whether the MACS is a significant determinant of activity limitations and participation restrictions.

Results.?The reliability was good (intraclass correlation coefficient 0.83). The Spearman correlation coefficients with GMFCS level, limb distribution of the spastic paresis and educational level were 0.53, 0.46, and 0.26, respectively. MACS level correlated moderately with outcome measures of functional activities (correlations ranging from??0.38 to??0.55). MACS level is, in addition to the GMFCS level, an important determinant for limitations in activities and restrictions in participation.

Conclusion.?We conclude that the MACS is a feasible method to classify manual ability in young adults with CP and normal intelligence with a good manual ability.     

Design and quality of ICF-compatible data items for national disability support services

Purpose.?To examine the structure, distribution and interrelationships of International Classification of Functioning, Disability and Health (ICF)-compatible items in Australia's national data collection about disability support services.

Method.?Rasch analyses were carried out on 93,000 records relating to people aged 15 to 64 years, receiving disability support services in Australia in 2003. The range of disabilities and services received was diverse. ‘Support needs’, in all nine life areas based on the ICF Activities and Participation domains, are recorded in the national data collection in one of the following three categories: ‘needs no help/supervision in this life area’; ‘sometimes needs help/supervision’; or ‘always needs help/supervision or unable to do activity’.

Results:?The results of the analysis demonstrate the value of the ‘support needs’ questions. The three categories of need for support were distinct and widely separated; the ICF domains were also found to be distinct. The results also showed that ‘support needs’ in one subset of ICF Activities and Participation domains could not be used to predict values in another subset.

Conclusions.?The two-dimensional question about ‘support needs’ offers promise as a general data capture tool for indicating ‘extent’ of disability. Caution should be exercised in the omission of any ICF Activities and Participation life areas for measurement in diverse populations.     

Barriers,activities and participation: Incorporating ICF into service planning datasets

Purpose.?Guided by the World Health Organization's International Classification of Functioning, Disability and Health (ICF), a measure of activity and participation (MAP) was developed and incorporated into the National Physical and Sensory Disability Database in Ireland. The aims of this article are to investigate and explore the relationship between the barriers, participation restriction and functioning levels experienced by people with disabilities.

Method.?Seven thousand five hundred and sixty-two personal interviews with people meeting specific eligibility criteria for registering onto the database were conducted across four health service executive regions in Ireland.

Results.?Overall, differences in barriers, participation restriction and activity limitations experienced by people with different types of disabilities were found to be significant. Furthermore, low functioning and experience of barriers were indicators of participation restriction.

Conclusions.?This article has shown that elements of the ICF have been successfully operationalised in a service planning tool through the development of the MAP. This provides a more holistic view of disability and will enable the impact of service interventions to be measured over time.     

Assessing and comparing the outcome measures for the rehabilitation of adults with communication disorders in randomised controlled trials: an International Classification of Functioning,Disability and Health approach

Purpose.?To identify the assessment instruments and relevant outcome measures used in randomised clinical trials (RCTs) relating to interventions for adults with communication disorders, and then examine and compare the domains of the outcome measures using the International Classification of Functioning, Disability and Health (ICF) as a reference tool.

Method.?Published RCTs with primary focus on the effectiveness of rehabilitation for adults with communication disorders were systematically reviewed. Identified RCTs were examined for all the assessments used as outcome measures. Distinctions were made between the use of standardised assessment tools and non-standardised empirical measures. The key concepts examined by the outcome measures were then linked to the ICF using the established ICF linking rules.

Results.?The systematic review included 24 RCTs in which 11 trials used non-standardised empirical assessment as the outcome measure, and 18 trials included standardised instruments as the outcome measure. It is clear that all the identified items and meaningful concepts from the assessment used in the included studies can be linked to the ICF categories. Of the 108 linked level-two ICF categories, 53%% were linked to ‘body functions’, 36%% to ‘activity and participation’ and 9%% to ‘environmental factors’.

Conclusions.?A wide range of outcome measures have been used in RCTs of interventions for adults with communications disorders. The ICF provides a clarifying framework for systematically gathering and examining the information about the content of outcome measures and then can be used as a common reference to identify and compare the domains of the outcome measures. The high proportion of elements relating to body functions raises some questions about the purpose and aims of the interventions.     

Six-day course of repetitive transcranial magnetic stimulation plus occupational therapy for post-stroke patients with upper limb hemiparesis: A case series study

Purpose.?To clarify the safety and feasibility of a 6-day protocol of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with intensive occupational therapy (OT) for upper limb hemiparesis.

Methods.?In-hospital combination treatment was provided for 5 post-stroke patients with upper limb hemiparesis after more than 12 months of the onset of stroke. Over 6 consecutive days, each patient received 10 sessions of combination treatment with 1?Hz rTMS and intensive OT (one-on-one training and self-training). Motor function in the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Ten-Second Test at admission, discharge, and 4 weeks after treatment.

Results.?All patients completed the 6-day treatment protocol and none showed any adverse effects throughout the treatment. At the end of treatment, improvements in the scores of FMA, WMFT, and Ten-Second Test were found in all patients. No deterioration of improved upper limb function was observed at 4 weeks after the treatment.

Conclusions.?Our proposed protocol of combination treatment seems to be safe and feasible for post-stroke patients with upper limb hemiparesis, although the efficacy of the protocol needs to be confirmed in a large number of patients.     

A cross-sectional study of post-amputation pain in upper and lower limb amputees,experience of a tertiary referral amputee clinic

Purpose.?To determine the pain characteristics and health-related quality of life (HR-QOL) of upper and lower limb amputees.

Method.?Amputees attending the Prince of Wales Prosthetic Clinics in 2006 were administered a questionnaire survey of their pain experiences, Short form McGill pain questionnaire, Short Form 36 (SF 36) and Pain Self-Efficacy Questionnaire (PSEQ).

Results.?Of the 17 who were upper limb amputees (including the two multiple limb amputees), only 1 was pain free and of the 39 who were lower limb amputees 14 were pain free. Upper limb amputees experienced significantly greater proportion, frequency and severity of post-amputation pain than lower limb amputees. The presence of significant pre-operative pain did not correlate with the development of persistent post-amputation pain. In quality of life measures, the amputees experienced a better physical function, role physical and confidence in performance of activities than chronic pain patients attending the pain clinic. Lower limb amputees fared better than upper limb amputees in terms of bodily pain, social function and mental health. However, the amputee groups have a reduced health status in almost all domains compared to the aged matched Australian population norm.

Conclusions.?The study suggests that upper limb amputees are significantly more likely to suffer post-amputation pain which is more frequent, longer lasting and more severe in intensity when compared to lower limb amputees. This is accompanied by reduced HR-QOL especially that related to bodily pain, social function and mental health. The overall health status of amputees are also significantly lower compared to the Australian population norm.     

Mental health and satisfaction with life among upper limb amputees: a Norwegian population-based survey comparing adult acquired major upper limb amputees with a control group

Purpose.?To assess how upper limb amputation affects mental health and life satisfaction.

Method.?Cross-sectional study comparing the mental health and perceived satisfaction with life among adult acquired major upper limb amputees in Norway with a control group drawn from the Norwegian general population. The scales used were the Satisfaction With Life Scale (SWLS) and the Hopkins Symptom Check List 25-item (SCL-25). The groups were compared using multiple linear regression analyses.

Results.?The amputees scored significantly lower on life satisfaction than the control group. A tendency to poorer mental health in the amputee group was observed, but there was no clear evidence of such a difference. The amputation effect on life satisfaction seemed to be mediated mainly by changes in occupational status and by the occurrence of short- or long-term complications related to the amputation.

Conclusions.?Our findings imply that rehabilitation of upper limb amputees should emphasise facilitating return to work as well as the prevention of short- and long-term complications, and that this will be of importance not only for the amputees' physical function, but for the maintenance of acceptable life satisfaction. Further studies on the effect of upper limb amputation on mental health are recommended.     

Identification of international classification of functioning,disability and health relevant categories to describe functioning and disability of patients with myasthenia gravis

Purpose.?To describe functioning and health of patients with myasthenia gravis (MG) and to identify which are the most common problems patients encounter, by using the international classification of functioning, disability and health (ICF).

Method.?Adult patients with MG were recruited at C. Besta Neurological Institute. The ICF checklist was administered in individual sessions. Categories were identified as relevant if they were reported as a problem by more than 30% of patients (within activities and participation, the threshold was counted on capacity qualifier).

Results.?One hundred two patients were enrolled (mean age 47.2; inpatients were 29.4%, females 68.6%) and 54 ICF categories were selected: 14 body functions categories (26% out of total selected categories), 2 body structures (4%), 22 activities and participation categories (41%) and 16 environmental factors (29%). Environmental factors were essentially reported as facilitators.

Conclusions.?Twelve ICF categories, not contained in ICF core-sets for neurological condition, related to mobility, household and labour activities were identified. The ICF categories identified in this study are an useful guideline for clinicians and researchers, for monitoring interventions and follow-up of clinical conditions on a broad set of functional areas, and for developing ICF-based assessment tools for patients with MG.     

Assessing the impact of musculoskeletal health conditions using the International Classification of Functioning,Disability and Health

Purpose.?To propose the joint use of the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) and to illustrate this proposal using musculoskeletal (MSK) conditions.

Method.?In light of the MSK conditions as classified in the ICD, categories from existing ICF core sets for MSK conditions were pooled to specify functioning. Another approach was to consider other categories from measures or instruments already linked in the literature.

Results.?ICF Categories have been pooled from six core sets for MSK conditions, two specific care settings, one MSK clinical trial setting and eight instrument linkage papers.

Conclusions.?The ICD–ICF joint use would be able to capture the impact of a health condition by taking into account the disease and functioning status which would facilitate clinical care. Therefore, there is reasonable ground to demonstrate the operational linkage and complementary role of the ICD and the ICF in the context of the ICD revision.     

Development of a measure of functioning for stroke recovery: The functional recovery measure

Purpose. To develop a parsimonious measure of functioning for persons after stroke.

Method. A sub-set of 206 community-dwelling subjects with a first stroke from a larger cohort was interviewed within 9 months using 39 items from five indices assessing functioning. Information was collected on influencing variables: age, stroke type and severity, and previous health. Two statistical methods, factor analysis and Rasch analysis, confirmed the item structure, hierarchy and dimensionality of the measure. Statistics confirmed fit to the model; internal consistency was also assessed. Items were deleted iteratively based on fit and relationship to the construct.

Results. The subjects were predominately male (63%) aged on average 68 years old. A 12-item unidimensional functioning measure was developed. All items and persons fit the Rasch model with stable item – person reliability indices of 0.98 and 0.91, respectively. Item precision (standard errors) ranged from 0.14 – 0.37 logits. Gaps in measurement occurred at the extremes of the measure and there was a small ceiling effect.

Conclusions. A 12-item measure captured the concept of functioning that could be used as a prototype to quantify recovery post-stroke. These items could form the basis for a measure of functioning.