Statistical significant change versus relevant or important change in (quasi) experimental design: some conceptual and methodological problems in estimating magnitude of intervention-related change in health services research

The Relationship Between Changes in Movement and Activity Limitation or Pain in People With Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To report whether changes in knee joint movement parameters recorded during functional activities relate to change in activity limitation or pain after an exercise intervention in people with knee osteoarthritis (OA).

DESIGN

Etiology systematic review.

LITERATURE SEARCH

Four databases (MEDLINE, Embase, CINAHL, and AMED) were searched up to January 22, 2021.

STUDY SELECTION CRITERIA

Randomized controlled trials or cohort studies of exercise interventions for people with knee OA that assessed change in knee joint movement parameters (moments, kinematics, or muscle activity) and clinical outcomes (activity limitation or pain).

DATA SYNTHESIS

A descriptive synthesis of functional activities, movement parameters, and clinical outcomes.

RESULTS

From 3182 articles, 22 studies met the inclusion criteria, and almost all were of low quality. Gait was the only investigated functional activity. After exercise, gait parameters changed 26% of the time, and clinical outcomes improved 90% of the time. A relationship between group-level changes in gait parameters and clinical outcomes occurred 24.5% of the time. Two studies directly investigated an individual-level relationship, reporting only 1 significant association out of 8 correlations tested.

CONCLUSION

Most studies reported no change in gait-related movement parameters despite improvement in clinical outcomes, challenging the belief that changing movement parameters is always clinically important in people with knee OA. J Orthop Sports Phys Ther 2021;51(10):492-502. doi:10.2519/jospt.2021.10418.

The mapping of cortical activation by near-infrared spectroscopy might be a biomarker related to the severity of fibromyalgia symptoms

The delta value of oxyhemoglobin (Δ-HbO) determined by functional near-infrared spectroscopy at prefrontal cortex (PFC) and motor cortex (MC) based on primary (25 °C) and secondary (5 °C) thermal stimuli presented a larger peak latency at left MC in fibromyalgia than in controls. The difference between HbO concentration 15 s after the thermal stimuli ending and HbO concentration before the thermal stimuli onset (Δ-HbO*) at left PFC increased 47.82% in fibromyalgia and 76.66% in controls. This value had satisfactory discriminatory properties to differentiate cortical activation in fibromyalgia versus controls. A receiver operator characteristics (ROC) analysis showed the Δ-HbO* cutoffs of − 0.175 at left PFC and − 0.205 at right PFC offer sensitivity and specificity of at least 80% in screening fibromyalgia from controls. In fibromyalgia, a ROC analysis showed that these cutoffs could discriminate those with higher disability due to pain and more severe central sensitization symptoms (CSS). The ROC with the best discriminatory profile was the CSS score with the Δ-HbO* at left PFC (area under the curve = 0.82, 95% confidence interval = 0.61–100). These results indicate that cortical activation based on Δ-HbO* at left PFC might be a sensitive marker to identify fibromyalgia subjects with more severe clinical symptoms.

A comparison of six outcome measures across the recovery period after distal radius fixation-Which to use and when?

PURPOSE

Many standardized outcome measures exist to measure recovery after surgical fixation of distal radius fractures, however, choosing the optimal instrument is difficult. We evaluated responsiveness, ceiling/floor effects, and criterion validity over multiple time intervals across a 2-year follow-up period for six commonly used instruments.

METHODS

A total of 259 patients who received open reduction and internal fixation for distal radius fractures between 2012 and 2015 were recruited. Patients were administered the Patient-Rated Wrist Evaluation (PRWE), Shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), Green and O'Brien score (Cooney modification) (CGNO), Gartland and Werley score (Sarmiento modification) (SGNW), flexion-extension arc (FEArc), and grip fraction test (GripFrac) at 1.5, 3, 6, 12, and 24 months postoperatively. Responsiveness was evaluated by calculating standardized response means (SRM) and Cohen's d effect sizes (ES), and by correlating each instrument's change scores against those of QuickDASH and PRWE, which were also used as external comparators to assess criterion validity. Ceiling/floor effects were calculated for all measures at each time point.

RESULTS

SRM (1.5-24 months) were 1.81, 1.77, 1.43, 1.16, 2.23, 2.45 and ES (1.5-24 months) were 1.81, 1.82, 1.95, 1.31, 1.99 and 2.90 for QuickDASH, PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Spearman correlation coefficients against QuickDASH at 24 months were: 0.809, 0.248, 0.563, 0.285, and 0.318 for PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Significant (>15% of patients reaching maximum score) ceiling effects were observed before 6 months for PRWE and SGNW.

CONCLUSIONS

Our evidence supports the use of QuickDASH, PRWE, FEArc and GripFrac up to 6 months postsurgery, and QuickDASH and PRWE after 6 months.

LEVEL OF EVIDENCE

Level II.

Changes in Health Literacy during the first year following a kidney transplantation: Using the Health Literacy Questionnaire

OBJECTIVES

The study aimed to identify changes in health literacy (HL) and associated variables during the first year following a kidney transplantation.

METHODS

A total of 196 transplant recipients were included in a prospective follow-up study. The patients answered the Health Literacy Questionnaire (HLQ) at 5 days, 8 weeks, 6 and 12 months following the kidney transplantation. Mixed linear models were used to analyze changes in HL and backward elimination was used to identify variables associated with HL.

RESULTS

Two main patterns of change were identified: a) HL increased during the first 8 weeks of close follow-up and b) in several domains, the positive increase from 5 days to 8 weeks flattened out from 5 days to 6 and 12 months. Self-efficacy, transplant-related knowledge, and general health were core variables associated with HL.

CONCLUSIONS

Overall, HL increased during the 8 weeks of close follow-up following the kidney transplantation, while 6 months seem to be a more vulnerable phase. Furthermore, low self-efficacy, less knowledge, and low self-perceived health may represent vulnerable characteristics in patients.

PRACTICAL IMPLICATIONS

Future kidney transplant care should take into account patients' access to and appraisal of health information and social support, and draw attention to potentially vulnerable groups.

Validation of the Radiographic Global Impression of Change (RGI-C) score to assess healing of rickets in pediatric X-linked hypophosphatemia (XLH)

BACKGROUND

Rickets is a primary manifestation of pediatric X-linked hypophosphatemia (XLH) - a rare progressive hereditary phosphate-wasting disease. Severity is quantified from radiographs using the Rickets Severity Scale (RSS). The Radiographic Global Impression of Change (RGI-C) is a complementary assessment in which a change score is assigned based on differences in the appearance of rickets on pairs of radiographs compared side by side.

OBJECTIVE

The current study evaluated the reliability, validity, and sensitivity to change of the RGI-C specifically in pediatric XLH.

METHODS

The reliability, validity, and sensitivity to change of the RGI-C were evaluated using data from two studies in pediatric XLH (113 children aged 1-12 years) in which burosumab treatment significantly improved rickets severity. Intra-rater and inter-rater reliability were assessed by three pediatric radiologists.

RESULTS

Intra-rater reliability for RGI-C global score was >90% for agreement within 1 point, with weighted kappa values >0.5, indicating moderate to almost perfect agreement. Inter-rater reliability was also >90% (0.47-0.52 for all reader pairs; moderate agreement). The RGI-C global score showed significant relationships with changes from baseline to week 64 in serum phosphorus (r = -0.397), alkaline phosphatase (-0.611), total RSS (-0.672), standing height (0.268), and patient-reported global functioning (0.306) and comfort/pain functioning (0.409). Based on standardized response means, RGI-C global scores were sensitive to change in RSS, differentiating between those considered improved and greatly improved. Results for validity and sensitivity to change were similar for the RGI-C wrist, knee, and standing long leg scores.

CONCLUSION

The RGI-C is a reliable, valid, and sensitive measure in pediatric XLH, and complementary to the RSS.

Contextual interference in children with brain lesions: a pilot study investigating blocked vs. random practice order of an upper limb robotic exergame

Introduction

Evidence about contextual interference in children with brain lesions when practising motor tasks is lacking. Our main objective was to evaluate the feasibility of a randomised controlled trial (RCT) comparing blocked with random practice order of an upper limb robotic exergame to improve reaching in children with neuromotor disorders with a pilot trial.

Methods

We recruited children with brain lesions and impaired upper limb functions who underwent a 3-week schedule that consisted of baseline assessments, intervention period (participants were randomised to a blocked or random order group), and follow-up assessment. We evaluated ten feasibility criteria, including the practicability of the inclusion/exclusion criteria, recruitment rate, feasibility of randomisation, scheduling procedure, and the participants’ programme adherence.

Results

The inclusion/exclusion criteria were not completely feasible as patients who were not able to perform the exergames were included. Twelve participants were recruited, and six datasets were used for analysis. The scheduling and randomisation procedures were generally feasible, but the procedure was only partially feasible for the participants, as some sessions were aborted due to lack of motivation and fatigue.

Conclusion

An RCT following this study protocol is not feasible. We formulated suggestions for future studies that aim to investigate contextual interference as in this pilot study.

Trial registration

ClinicalTrials.gov Identifier: NCT02443857, registered on May 14, 2015

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00866-4.

Translation and adaptation of the German version of the Veterans Rand-36/12 Item Health Survey

BACKGROUND

The translated and culturally adapted German version of the Veterans Rand 36 Items Health Survey (VR-36), and its short form, the VR-12 counterpart, were validated in a German sample of orthopedic (n = 399) and psychosomatic (n = 292) inpatient rehabilitation patients.

METHODS

The instruments were analyzed regarding their acceptance, distributional properties, validity, responsiveness and ability to discriminate between groups by age, sex and clinically specific groups. Eligible study participants completed the VR-36 (n = 169) and the VR-12 (n = 177). They also completed validated patient-reported outcome measures (PROs) including the Euroqol-5 Dimensions 5 Level (EQ-5D-5L); Depression, Anxiety and Stress Scale (DASS); Hannover Functional Abilities Questionnaire (HFAQ); and CDC Healthy Days. The VR-12 and the VR-36 were compared to the reference instruments MOS Short Form-12 Items Health Survey (SF-12) version 1.0 and MOS Short Form-36 Items Health Survey (SF-36) version 1.0, using percent of completed items, distributional properties, correlation patterns, distribution measures of known groups validity, and effect size measures.

RESULTS

Item non-response varied between 1.8%/1.1% (SFVR-36/RESF-36) and 6.5%/8.6% (GHVR-36/GHSF-36). PCS was normally distributed (Kolmogorov-Smirnov tests: p > 0.05) with means, standard deviations and ranges very similar between SF-36 (37.5 ± 11.7 [13.8-66.1]) and VR-36 (38.5 ± 10.1 [11.7-67.8]), SF-12 (36.9 ± 10.9 [15.5-61.6]) and VR-12 (36.2 ± 11.5 [12.7-59.3]). MCS was not normally distributed with slightly differing means and ranges between the instruments (MCSVR-36: 36.2 ± 14.2 [12.9-66.6], MCSSF-36: 39.0 ± 15.6 [2.0-73.2], MCSVR-12: 37.2 ± 13.8 [8.4-70.2], MCSSF-12: 39.0 ± 12.3 [17.6-65.4]). Construct validity was established by comparing correlation patterns of the MCSVR and PCSVR with measures of physical and mental health. For both PCSVR and MCSVR there were moderate (≥ 0.3) to high (≥ 0.5) correlations with convergent (PCSVR: 0.55-0.76, MCSVR: 0.60-0.78) and small correlations (< 0.1) with divergent (PCSVR: < 0.12, MCSVR: < 0.16) self-report measures. Known-groups validity was demonstrated for both VR-12 and VR-36 (MCS and PCS) via comparisons of distribution parameters with significant higher mean PCS and MCS scores in both VR instruments found in younger patients with fewer sick days in the last year and a shorter duration of rehabilitation.

CONCLUSIONS

The psychometric analysis confirmed that the German VR is a valid and reliable instrument for use in orthopedic and psychosomatic rehabilitation. Yet further research is needed to evaluate its usefulness in other populations.

A Novel Fluorescence Optical Imaging Scoring System for Hand Synovitis in Rheumatoid Arthritis - validity and agreement with ultrasound

OBJECTIVES

To develop and validate a new semiquantitative Fluorescence Optical Imaging (FOI) scoring system - the FOI Enhancement-Generated rheumatoid arthritis (RA) Score (FOIE-GRAS) for synovitis assessment in the hand.

METHODS

The development of FOIE-GRAS was based on consensus of 4 experts in musculoskeletal imaging. Forty-six RA patients, eligible for treatment intensification and with ≥1 clinically swollen joint in the hands and 11 healthy controls were included. FOI, ultrasound and clinical assessment of both hands were obtained at baseline and for RA patients after 3- and 6-months' follow-up. Twenty RA patients had an FOI rescan after 4 hours. Synovitis was scored using FOIE-GRAS and the OMERACT ultrasound synovitis scoring system. All FOI images were scored by 2 readers. Inter-scan, inter-and intra-reader reliability were determined. Furthermore, FOIE-GRAS agreement with ultrasound and responsiveness was assessed.

RESULTS

FOIE-GRAS synovitis was defined as early enhancement and scores based on the degree of coverage of the specific joint region after 3 seconds (0-3). Inter-scan, intra- and inter-reader intraclass correlations coefficients (ICC) were good-excellent for all baseline scores (0.76-0.98) and moderate-to-good for change (0.65-76).The FOIE-GRAS had moderate agreement with ultrasound (ICC 0.30-0.54) for total score, a good standardized response mean (>0.80), and moderate correlation with clinical joint assessment and DAS28-CRP. The median (IQR) reading time per FOI examination was 133 (109;161) seconds. Scores were significantly lower in controls 1(0;4) than RA patients 11(6;19).

CONCLUSION

The FOIE-GRAS offers a feasible and reliable assessment of synovitis in RA, with a moderate correlation with ultrasound and DAS28CRP, and good responsiveness.

Psychometric Properties of the Proxy-Reported Life-Space Assessment in Institutionalized Settings (LSA-IS-Proxy) for Older Persons with and without Cognitive Impairment

(1) Background: Life-space mobility assessments for institutionalized settings are scarce and there is a lack of comprehensive validation and focus on persons with cognitive impairment (CI). This study aims to evaluate the psychometric properties of the Life-Space Assessment for Institutionalized Settings by proxy informants (LSA-IS-proxy) for institutionalized, older persons, with and without CI. (2) Methods: Concurrent validity against the self-reported version of the LSA-IS, construct validity with established construct variables, test-retest reliability, sensitivity to change during early multidisciplinary geriatric rehabilitation treatment, and feasibility (completion rate, floor/ceiling effects) of the LSA-IS-proxy, were assessed in 94 hospitalized geriatric patients (83.3 ± 6.1 years), with and without CI. (3) Results: The LSA-IS-proxy total score showed good-to-excellent agreement with the self-reported LSA-IS (Intraclass Correlations Coefficient, ICC_3,1 = 0.77), predominantly expected small-to-high correlations with construct variables (r = 0.21–0.59), good test–retest reliability (ICC_3,1 = 0.74), significant sensitivity to change over the treatment period (18.5 ± 7.9 days; p < 0.001, standardized response mean = 0.44), and excellent completion rates (100%) with no floor/ceiling effects. These results were predominantly confirmed for the sub-scores of the LSA-IS-proxy and were comparable between the sub-groups with different cognitive status. (4) Conclusions: The LSA-IS-proxy has proven to be feasible, valid, reliable, and sensitive to change in hospitalized, geriatric patients with and without CI.

Measurement properties of Patient-Reported Outcome Measures in patients with a tibial shaft fracture; validation study alongside the multicenter TRAVEL study

The aim of this study was to evaluate the measurement properties of the Short Musculoskeletal Function Assessment (SMFA) and Lower Extremity Functional Scale (LEFS) in patients who sustained a tibial shaft fracture, by comparing them with the scores of a general health-related quality of life instrument scale (i.e., EuroQoL-5D). Data of 136 patients participating in a multicenter randomized controlled trial comparing incisions for intramedullary nail entry in adults with a tibial shaft fracture were used. Patients completed the SMFA, LEFS, EQ-5D and an anchor question at 2 and 6 weeks, and at 3, 6 and 12 months. Reliability (internal consistency), construct validity, responsiveness (longitudinal validity), floor and ceiling effects, minimal important change (MIC), and smallest detectable change (SDC) were determined. The SMFA and LEFS (sub)scales showed adequate internal consistency (0.84<α<0.94). Construct and longitudinal validity were also adequate (correctly predicted hypotheses between 83%-100%). Floor effects were not present. Ceiling effects were present at 12 months for the SMFA lower extremity dysfunction and bother subscales (22% and 19%, respectively) and the LEFS (19%). MICs could not be determined with the available data. The SDC was 13.84 points for the SMFA and 38.74 points for the LEFS. This study confirms that the SMFA and LEFS are reliable, valid, and responsive instruments for monitoring functional limitation in patients after sustaining a tibia shaft fracture during at least the first six months post-injury. An anchor-based MIC for the SMFA remains to be determined.

Evaluating quality of life in frailty: applicability and clinimetric properties of the SarQoL® questionnaire

BACKGROUND

The SarQoL® questionnaire was specifically designed to measure quality of life (QoL) in sarcopenia. Frailty and sarcopenia have areas of overlap, notably weak muscle strength and slow gait speed, which may mean that the SarQoL could provide a measure of QoL in frailty. This study aimed to evaluate the clinimetric properties of the SarQoL questionnaire in physical frailty using the Fried criteria.

METHODS

Analyses were carried out on data from the Sarcopenia and Physical impairment with advancing Age study. Frailty was assessed with the Fried criteria and QoL with the SarQoL, the Short-Form 36-Item, and the EuroQoL 5-Dimension (EQ-5D) questionnaires. We evaluated discriminative power (with the Kruskal-Wallis analysis of variance test), internal consistency (with Cronbach's alpha), construct validity (through hypotheses testing), test-retest reliability (with the intraclass correlation coefficient), measurement error (calculating standard error of measurement and smallest detectable change), and responsiveness (through hypotheses testing and standardized response mean).

RESULTS

In total, 382 participants were included for the validation and 117 for the responsiveness evaluation. They had a median age of 73 (69-79) years, took 5 (3-8) drugs, and had 4 (3-5) co-morbidities. There were more women (n = 223; 58.4%) than men and, in total, 172 (45%) robust, 167 (44%) pre-frail, and 43 (11%) frail participants. Discriminative power was confirmed when significantly lower (P < 0.001) overall SarQoL scores, and thus also worse QoL, were observed between robust [77.1 (64.35-85.90)], pre-frail [62.54 (53.33-69.57)], and frail [49.99 (40.45-56.06)] participants. Six of the SarQoL domains performed likewise, with significantly lower scores according to frailty status with Domain 7 (fears) being the exception. Internal consistency was good (α = 0.866). Convergent (using Short-Form 36-Item and EQ-5D) and divergent construct validity (using EQ-5D) was confirmed. Test-retest reliability was excellent [intraclass correlation coefficient = 0.918 (0.834-0.961)], with a standard error of measurement of 3.88 and a smallest detectable change of 10.76 points. We found moderate responsiveness when five of the nine hypotheses were confirmed, coupled with a large effect size for the overall SarQoL score (corrected standardized response mean of -1.44).

CONCLUSIONS

The SarQoL questionnaire has adequate clinimetric properties for use with frail patients in clinical practice and trials and could provide data that are more appropriate and detailed than the generic questionnaires currently used.

Construct Validity, Test-Retest Reliability, Sensitivity to Change, and Feasibility of the Patient-Specific Functional Scale in Acutely Hospitalized Older Patients With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

The Patient-Specific Functional Scale (PSFS) as an individualized patient-reported outcome measure may allow to assess limitations and changes in self-determined functional activities most important to an older patient in the acute care setting. However, its clinimetric properties have not yet been evaluated in these patients. The study aimed to investigate the construct validity, test-retest reliability, sensitivity to change, and feasibility of the PSFS in acutely hospitalized older patients with and without cognitive impairment (CI).

METHODS

The clinimetric properties of the PSFS were investigated by secondary data analysis from a prospective observational cohort study examining physical activity and mobility in acutely hospitalized older patients. In this analysis, 120 older patients-83.0 (6.4) years-with (Mini-Mental State Examination [MMSE] 18-23, n = 52) and without CI (MMSE ≥24, n = 68) receiving early multidisciplinary geriatric rehabilitation in acute care were included. Construct validity was assessed by Spearman correlations (rs) with the Activity-specific Balance Confidence Scale (ABC-6), Short Falls Efficacy Scale-International (Short FES-I), EuroQoL-5 Dimensions (EQ-5D), Short Physical Performance Battery (SPPB), de Morton Mobility Index (DEMMI), and Barthel Index (BI); test-retest reliability within 24 hours by intraclass correlation coefficients (ICCs); sensitivity to change by standardized response means (SRMs) calculated for treatment effects, and feasibility by completion rates/times and floor/ceiling effects.

RESULTS

The PSFS showed fair to moderate correlations with all construct variables in patients with CI (rs = 0.31 to 0.53). In patients without CI, correlations were fair for the ABC-6, FES-I, EQ-5D, and BI (rs = |0.27 to 0.36|), but low for the SPPB and DEMMI (rs = -0.04 to 0.14). Test-retest reliability (both: ICC = 0.76) and sensitivity to change (CI: SRM = 1.10, non-CI: SRM = 0.89) were excellent in both subgroups. Excellent feasibility was documented by high completion rates (>94%), brief completion times (<8 min), and no floor/ceiling effects in both subgroups.

CONCLUSIONS

The PSFS has adequate clinimetric properties for assessing patient-specific functional limitations and changes in acutely hospitalized older patients with and without CI. It might be an appropriate complement to traditional functional scales to enhance patient-centeredness in clinical geriatric assessment.

Responsiveness of PROMIS and Patient Health Questionnaire (PHQ) Depression Scales in three clinical trials

BACKGROUND

The PROMIS depression scales are reliable and valid measures that have extensive normative data in general population samples. However, less is known about how responsive they are to detect change in clinical settings and how their responsiveness compares to legacy measures. The purpose of this study was to assess and compare the responsiveness of the PROMIS and Patient Health Questionnaire (PHQ) depression scales in three separate samples.

METHODS

We used data from three clinical trials (two in patients with chronic pain and one in stroke survivors) totaling 651 participants. At both baseline and follow-up, participants completed four PROMIS depression fixed-length scales as well as legacy measures: Patient Health Questionnaire 9-item and 2-item scales (PHQ-9 and PHQ-2) and the SF-36 Mental Health scale. We measured global ratings of depression change, both prospectively and retrospectively, as anchors to classify patients as improved, unchanged, or worsened. Responsiveness was assessed with standardized response means, statistical tests comparing change groups, and area-under-curve analysis.

RESULTS

The PROMIS depression and legacy scales had generally comparable responsiveness. Moreover, the four PROMIS depression scales of varying lengths were similarly responsive. In general, measures performed better in detecting depression improvement than depression worsening. For all measures, responsiveness varied based on the study sample and on whether depression improved or worsened.

CONCLUSIONS

Both PROMIS and PHQ depression scales are brief public domain measures that are responsive (i.e., sensitive to change) and thus appropriate as outcome measures in research as well as for monitoring treatment in clinical practice. Trial registration ClinicalTrials.gov ID: NCT01236521, NCT01583985, NCT01507688.

Use of Physician Global Assessment in systemic lupus erythematosus: a systematic review of its psychometric properties

OBJECTIVE

The Physician Global Assessment (PGA) is a visual analogue score that reflects the clinician's judgement of overall SLE disease activity. The aim of this systematic literature review is to describe and analyse the psychometric properties of the PGA.

METHODS

This systematic literature review was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All articles published through 1 July 2019 in PubMed were screened, with no limitation on year of publication, language or patients' age. Psychometric properties data were analysed according to the OMERACT Filter methodology version 2.1.

RESULTS

The literature search identified 91 studies. Face validity was reported in all the articles retrieved in which the PGA was used alone or as part of composite indices (Systemic Responder Index, Safety of Estrogen in Lupus Erythematosus National Assessment Flare Index, Lupus Low Disease Activity State, Definitions of Remission in Systemic Lupus Erythematosus criteria). Content validity was reported in 89 studies. Construct validity was demonstrated by a good correlation (r ≥ 0.50) between the PGA with the SLEDAI (12 studies), SLAM (4 studies), LAI, BILAG and ECLAM (2 studies each). Criterion validity was assessed exploring the PGA correlation with quality of life measurements, biomarker levels and treatment changes in 28 studies, while no study has evaluated correlation with damage. A good responsiveness for PGA was shown in eight studies. A high variability in scales was found, causing a wide range of reliability (intraclass correlation coefficient 0.67-0.98).

CONCLUSION

PGA is a valid, responsive and feasible instrument, though its reliability was impacted by the scale adopted, suggesting the major need for standardization of its scoring.

Next of kin participation in the care of older persons in nursing homes: A pre-post non-randomised educational evaluation, using within-group and individual person-level comparisons

Background

Next of kin participation in care is a cornerstone of palliative care and is thus important in nursing homes, and outcomes following interventions need to be evaluated using robust methods.

Objective

To use within-group and within-individual analytical approaches to evaluate the participation of next of kin in care following an intervention and to compare the outcome between the intervention and control groups.

Methods

A pre–post intervention/control group study design was used. The educational intervention, directed towards staff members, focused on palliative care. The Next of Kin Participation in Care scale comprises the Communication and Trust subscale and the Collaboration in Care subscale, with nine items each. In total, 203 persons (intervention group: n = 95; control group: n = 108) were included. Three different analytical approaches were used: 1) traditional within-group comparison of raw ordinal scores and linearly transformed interval scores; 2) modern within-individual (person-level) interval score comparisons; 3) comparisons between the intervention group and control group based on individual person-level outcomes.

Results

Within-group comparisons of change revealed no change in any of the groups, whether based on raw or transformed scores. Despite this, significant improvements at the individual level were found in 32.9% of the intervention group and 11.6% of the control group for the total scale (p = 0.0024), in 25% of the intervention group and 10.5% of the control group for the Communication and Trust subscale (p = 0.0018), and in 31.2% of the intervention group and 10.5% of the control group for the Collaboration in Care subscale (p = 0.0016). However, a significant worsening at the individual level in Collaboration in Care was found in 35.1% of the intervention group but only among 8.4% of the control group (p < 0.0005).

Conclusion

The intervention seems to have a positive impact on next of kin participation in care in nursing homes, especially for communication and trust. However, some next of kin reported decreased participation in care after the intervention. Modern individual person-level approaches for the analysis of intervention outcomes revealed individual significant changes beyond traditional group-level comparisons that would otherwise be hidden. The findings are relevant for future outcome studies and may also necessitate a re-evaluation of previous studies that have not used individual person-level comparisons.

Trial registration

This study is part of the intervention project registered under Clinical Trials Registration NCT02708498.

Validation of the Life-Space Assessment (LSA-CI) in multi-morbid, older persons without cognitive impairment

PURPOSE

The "Life-Space Assessment in Persons with Cognitive Impairment" (LSA-CI) to assess mobility within the environment including frequency and independence in 1 week has been developed for and successfully validated in older persons with mild to moderate cognitive impairment. However, its psychometric properties in persons without cognitive impairment are unknown. This study aims to validate the LSA-CI in older persons without cognitive impairment.

METHODS

Comprehensive validation with construct validity, test-retest reliability and sensitivity to change of the LSA-CI including the main composite score and three sub-scores in community-dwelling older persons recruited during geriatric rehabilitation.

RESULTS

Excellent feasibility with 100% completion rate and an average assessment duration of 4 min in 65 older, multimorbid persons (mean age: 81.4 ± 5.9 years; 72.3% female; average number of diagnoses: 11.1 ± 4.4). The LSA-CI composite score stood out with moderate to high construct validity (Spearman correlation coefficients |0.26|-|0.60|), excellent test-retest reliability (intraclass correlation coefficient 0.890) and moderate sensitivity to change (adjusted standardized response mean 0.70). Analysis of sub-scores confirmed most of the composite score results.

CONCLUSIONS

The LSA-CI represents a valid, reliable, responsive, and highly feasible assessment method in multi-morbid, older persons without cognitive impairment, supporting the use of the LSA-CI in clinical practice and research.

Cross-cultural adaptation of the Fresno Test for Turkish language

Objective

National and international medical organizations and boards have recognized the importance of Evidence Based Medicine (EBM) and emphasized that EBM training should be included in medical education programs. Although some Turkish medical schools have developed and implemented EBM training programs, no validated Turkish language assessment tool has been available to compare the effectiveness of these training programs to national or international standards. The aim of this study is to cross-culturally adapt the Fresno Test, which is a validated English language tool utilized worldwide in the assessment of EBM training.

Methods

This study is a cross-sectional validation study, which was performed in two stages: Cross-cultural adaptation of the Fresno Test into Turkish; and evaluation of the psychometric properties, validity, reliability and responsiveness, of the Turkish version of the Fresno Test.

Results

The content validity of the test was evaluated by experienced physicians in the field of Evidence-Based Medicine, and the content validity index was 1.00. The Cronbach α coefficient was 0.78 on the post-test results. The intraclass correlation (ICC) coefficient and the kappa analysis were calculated to evaluate inter-rater reliability. The ICC coefficients ranged from 0.66 to 0.97 for pre- and post-test results. The Kappa coefficients were 1.00 for all pre-test and post-test questions except one post-test question which was 0.89.

The change score of the Fresno Test was used to evaluate responsiveness. The students' score of the Turkish Fresno Test was 49.9 ±18.2 pre-training and 118.9 ±26.3 post-training with a change of 69 points (95% CI, 63.9–74.2). The Cohen’s effect size was 3.04 (95% CI, 2.6–3.5) indicating a very large change in scores.

Conclusions

The Turkish adapted Fresno Test used to evaluate students’ success and program effectiveness is a valid and reliable measurement tool. It will be of great benefit for the comparison of the effectiveness of Turkish education programs nationally and cross-culturally.

Effectiveness of Hands-Off Therapy in the Management of Primary Headache: A Systematic Review and Meta-Analysis

A number of hands-off therapies have been widely reported and are used in the management of headache. This systematic review and meta-analysis aimed to assess evidence supporting these therapies on selected headache outcomes. A systematic literature search for randomized clinical trials reporting on the effects of hands-off therapies for headache was performed in two electronic databases; PubMed and Web of Science (PROSPERO: CRD42018093559). Risk of bias was assessed using the Cochrane risk of bias tool. Meta-analysis was performed using Review Manager v5.4. Thirty-five studies, including 3,403 patients with migraine, tension-type or chronic headaches were included in the review. Methodological quality of the studies ranged from poor to good. Result-synthesis revealed moderate evidence for aerobic exercises, relaxation training and pain education for reducing pain intensity and disability. Other hands-off interventions were either weak or limited in evidence. Meta-analysis of 22 studies indicated that the effect of hands-off therapies significantly differed from one another for pain intensity, disability and quality of life (p < 0.05). Relaxation training, aerobic and active/stretching exercises had significant effect on pain intensity and disability (p < 0.05). To conclude, few hands-off therapies were effective on selected headache outcomes. Evidence to support other hands-off therapies is limited by paucity of studies.

Assessing responsiveness of the EQ-5D-3L, the Oxford Hip Score, and the Oxford Knee Score in the NHS patient-reported outcome measures

BACKGROUND

The degree to which a validated instrument is able to detect clinically significant change over time is an important issue for the better management of hip or knee replacement surgery. This study examines the internal responsiveness of the EQ-5D-3L, the Oxford Hip Score (OHS), and the Oxford Knee Score (OKS) by various methods. Data from NHS patient-reported outcome measures (PROMs) linked to the Hospital Episodes Statistics (HES) dataset (2009-2015) was analysed for patients who underwent primary hip surgery (N = 181,424) and primary knee surgery (N = 191,379).

METHODS

Paired data-specific univariate responsiveness was investigated using the standardized response mean (SRM), the standardized effect size (SES), and the responsiveness index (RI). Multivariate responsiveness was furthermore examined using the defined capacity of benefit score (i.e. paired data-specific MCID), adjusting baseline covariates such as age, gender, and comorbidities in the Box-Cox regression models. The observed and predicted percentages of patient improvement were examined both as a whole and by the patients' self-assessed transition level.

RESULTS

The results showed that both the OHS and the OKS demonstrated great univariate and multivariate responsiveness. The percentages of the observed (predicted) total improvement were high: 51 (54)% in the OHS and 73 (58)% in OKS. The OHS and the OKS showed distinctive differences in improvement by the 3-level transition, i.e. a little better vs. about the same vs. a little worse. The univariate responsiveness of the EQ-5D-3L showed moderate effects in total by Cohen's thresholds. The percentages of improvement in the EQ-5D-3L were moderate: 44 (48)% in the hip and 42 (44)% for the knee replacement population.

CONCLUSIONS

Distinctive percentage differences in patients' perception of improvement were observed when the paired data-specific capacity of benefit score was applied to examine responsiveness. This is useful in clinical practice as rationale for access to surgery at the individual-patient level. This study shows the importance of analytic methods and instruments for investigation of the health status in hip and/or knee replacement surgery. The study finding also supports the idea of using a generic measure along with the disease-specific instruments in terms of cross-validation.

The effect of non-nutritive sucking combined with oral motor stimulation and oral support on feeding performance in premature infants: A single-blind randomized-clinical trial

PURPOSE

Feeding problems are common in premature infants (PIs) and may lead to negative consequences such as malnutrition, dehydration, excessive weight loss, as well as developmental and psychological deficits. Moreover, they are associated with increased length of hospital stay/cost. There is not enough evidence on how feeding problems should be treated in PIs. The goal of this study was to investigate the effects of non-nutritive sucking combined with oral motor stimulation and oral support on feeding performance in PIs.

METHODS

A single-blind randomized clinical trial was performed on 44 PIs with feeding problems. Patients were randomly categorized into two groups: (1) combined intervention (CI) and (2) non-nutritive sucking (NNS). The CI group received NNS, oral motor stimulation and oral support simultaneously. Infants in both groups received 14 treatment sessions for 14 consecutive days. The Preterm Oral Feeding Readiness Assessment Scale (POFRAS) was used as the primary outcome measure. Weight, volume of milk intake, time to achieve full oral feeding, and length of hospital stay were secondary outcome measures. All measures were assessed before treatment, after the 7th session, after the 14th session, and after 7 days after the end of treatment.

RESULTS

Both groups improved in all outcome measures across time (P < 0.001). The improvements in the POFRAS, volume of milk intake, and time to achieve full oral feeding were significantly greater in the CI group than the NNS group (P < 0.001). The improvements attained in weight and length of hospital stay were not significantly different between the CI and NNS groups (P > 0.05). Large effect sizes were found for POFRAS score in both CI (d = 3.98) and NNS (d = 2.19) groups.

CONCLUSION

The current study showed that the combined intervention including NNS, oral motor stimulation, and oral support significantly improved the feeding performance in PIs.

The Instructional Sensitivity of the Test of Gross Motor Development-3 to Detect Changes in Performance for Young Children With and Without Down Syndrome

The Test of Gross Motor Development is among the most commonly used measures of gross motor competency in children. An important attribute of any developmental assessment is its sensitivity to detect change. The purpose of this study was to examine the instructional sensitivity of the Test of Gross Motor Development-third edition (TGMD-3) performance criteria to changes in performance for 48 children (age 4-7 years) with and without Down syndrome following 10 weeks of physical education. Paired t tests identified significant improvements for all children on locomotor (p < .01) and ball skills (p < .01). These significant differences were associated with moderate to large effect sizes. SEM was low relative to the maximum raw score for each subtest, indicating high confidence in the scores. These findings provide evidence that the TGMD-3 is sensitive to change in performance for children with and without Down syndrome.

Acute and Short-Term Effects of Dry Needling in Patients with Chronic Nonspecific Low Back Pain and Hamstring Tightness: A Pilot Study

BACKGROUND

Chronic nonspecific low back pain (LBP) is one of the common health issues. Hamstring tightness contributes to the development of LBP. This study aimed to investigate the acute and short-term effects of deep dry needling (DN) in patients with chronic nonspecific LBP and hamstring muscle tightness.

METHODS

A single-group pretest-posttest clinical study design was followed. The outcome measures were the visual analog scale (VAS), passive knee extension (PKE) test, finger-floor distance (FFD) test, and functional rating index (FRI). Patients underwent one session of deep DN of three points on both hamstring muscles, each point for one minute. Patients were assessed before (T0), immediately after (T1), and one week after DN (T2). The FRI was assessed at T0 and T2.

RESULTS

Ten women with a mean age of 21.1 years (SD = 1.6) participated in the study. Significant large effect sizes in VAS pain reduction (d = 1.25) and PKE hamstring tightness were obtained (hamstring: right, d = 0.82; left, d = 0.88) at T2. Medium effect sizes were obtained for FFD (d = 0.45) and FRI (d = 0.72) at T2.

CONCLUSION

A single session of deep DN improved pain and function and increased hamstring flexibility. This pilot study supports the use of DN in patients with LBP and hamstring tightness; however, future research with a rigorous study design of randomized controlled trial is required to confirm the findings. This trial is registered with IRCT20180511039612N1.

Validation of the interview-based life-space assessment in institutionalized settings (LSA-IS) for older persons with and without cognitive impairment

BACKGROUND

Self-reported life-space assessment methods so far focus on community-dwelling persons, with a lack of validated assessment methods for institutionalized settings. This study evaluated construct validity, test-retest reliability, sensitivity to change, and feasibility of a new Life-Space Assessment for Institutionalized Settings (LSA-IS) in geriatric patients.

METHODS

Psychometric properties of the LSA-IS in 119 hospitalized geriatric patients (83.0 ± 6.2 years) with and without cognitive impairment (CI) [Mini-Mental State Examination: 22.4 ± 4.9 scores] were evaluated within a comprehensive validation design. For the total group and subgroups according to cognitive status, construct validity was assessed by calculating Spearman's rank correlation coefficients (rho) with established construct variables, test-retest reliability by intra-class correlation coefficients (ICCs), sensitivity to change by standardized response means (SRMs) calculated for effects of early ward-based rehabilitation during hospital stay.

RESULTS

The LSA-IS (total score) demonstrated good test-retest reliability (ICC = .704), and large sensitivity to change (SRM = .806), while construct validity was small to high indicated by significant correlations of the LSA-IS to construct variables (rho = .208-716), depending on relative construct association. On average results of LSA-IS sub-scores confirmed results of the total score. Subgroups according to cognitive status did not differ for most analyzed variables. A completion rate of 100% and a completion time of 3.2 ± 1.2 min documented excellent feasibility.

CONCLUSIONS

The interview-based LSA-IS has proven to be valid, reliable, sensitive, and feasible in hospitalized, multi-morbid, geriatric patients with and without CI documenting good psychometric properties for institutionalized settings.

TRIAL REGISTRATION

DRKS00016028.

Construct Validity and Responsiveness of the University of Wisconsin Running Injury and Recovery Index

OBJECTIVES

The University of Wisconsin Running Injury and Recovery Index (UWRI) is the first running-specific patient-reported outcome measure (PROM). The UWRI evaluates the key elements runners use to self-assess running ability during recovery. This study evaluated the construct-related validity and responsiveness of the UWRI as an evaluative PROM of running ability following running-related injury (RRI).

DESIGN

Prospective longitudinal study.

METHODS

Runners seeking care from a physical therapist for an RRI (n = 396) completed PROMs at baseline and 12 weeks later. Change in UWRI score was validated against the global rating of change (GROC), Veterans RAND 12-Item Health Survey (VR-12) change, and change in body region- specific PROMs. Responsiveness was evaluated using anchor-based and distribution-based techniques.

RESULTS

Change in UWRI score (mean ± SD, 7.7 ± 8.9 points) was correlated with the GROC (r = 0.67), as well as with changes in the VR-12 Physical Component Summary (PCS) (r = 0.54) and Mental Component Summary (MCS) (r = 0.31). Change in UWRI score was correlated with changes in the Foot and Ankle Ability Measure sports subscale (r = 0.75), the 12-item International Hip Outcome Tool (r = 0.75), and the Anterior Knee Pain Scale (r = 0.48), but not with the Oswestry Disability Index Version 2.0 (r = 0.05). Change in UWRI score was significantly different in runners reporting significant improvement (12.2 ± 5.9 points), slight improvement (7.1 ± 6.6 points), no change (0.0 ± 9.1 points), and worsening (-14.6 ± 7.4 points) on the GROC anchor-based responsiveness assessment. The UWRI minimal important change and minimal clinically important difference were 5 and 8 points, respectively.

CONCLUSION

The UWRI is a valid clinical tool for evaluating running ability following RRI; it demonstrated longitudinal validity (GROC), convergent validity (PCS and body region- specific PROMs), divergent validity (MCS), and responsiveness to changes in patient-perceived running ability. J Orthop Sports Phys Ther 2020;50(12):702-710. Epub 28 Oct 2020. doi:10.2519/jospt.2020.9698.

Global versus individual muscle segmentation to assess quantitative MRI-based fat fraction changes in neuromuscular diseases

OBJECTIVES

Magnetic resonance imaging (MRI) constitutes a powerful outcome measure in neuromuscular disorders, yet there is a broad diversity of approaches in data acquisition and analysis. Since each neuromuscular disease presents a specific pattern of muscle involvement, the recommended analysis is assumed to be the muscle-by-muscle approach. We, therefore, performed a comparative analysis of different segmentation approaches, including global muscle segmentation, to determine the best strategy for evaluating disease progression.

METHODS

In 102 patients (21 immune-mediated necrotizing myopathy/IMNM, 21 inclusion body myositis/IBM, 10 GNE myopathy/GNEM, 19 Duchenne muscular dystrophy/DMD, 12 dysferlinopathy/DYSF, 7 limb-girdle muscular dystrophy/LGMD2I, 7 Pompe disease, 5 spinal muscular atrophy/SMA), two MRI scans were obtained at a 1-year interval in thighs and lower legs. Regions of interest (ROIs) were drawn in individual muscles, muscle groups, and the global muscle segment. Standardized response means (SRMs) were determined to assess sensitivity to change in fat fraction (ΔFat%) in individual muscles, muscle groups, weighted combinations of muscles and muscle groups, and in the global muscle segment.

RESULTS

Global muscle segmentation gave high SRMs for ΔFat% in thigh and lower leg for IMNM, DYSF, LGMD2I, DMD, SMA, and Pompe disease, and only in lower leg for GNEM and thigh for IBM.

CONCLUSIONS

Global muscle segment Fat% showed to be sensitive to change in most investigated neuromuscular disorders. As compared to individual muscle drawing, it is a faster and an easier approach to assess disease progression. The use of individual muscle ROIs, however, is still of interest for exploring selective muscle involvement.

KEY POINTS

• MRI-based evaluation of fatty replacement in muscles is used as an outcome measure in the assessment of 1-year disease progression in 8 different neuromuscular diseases. • Different segmentation approaches, including global muscle segmentation, were evaluated for determining 1-year fat fraction changes in lower limb skeletal muscles. • Global muscle segment fat fraction has shown to be sensitive to change in lower leg and thigh in most of the investigated neuromuscular diseases.

Responsiveness and Minimal Clinically Important Difference of the Motor Function Measure in Collagen VI-Related Dystrophies and Laminin Alpha2-Related Muscular Dystrophy

OBJECTIVES

To investigate the responsiveness of the motor function measure (MFM) and determine the minimal clinically important difference (MCID) in individuals with 2 common types of congenital muscular dystrophy (CMD).

DESIGN

Observational, prospective, single center, cohort study.

SETTING

National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH).

PARTICIPANTS

Individuals (N=44) with collagen VI-related dystrophies (COL6-RD, n=23) and 21 individuals laminin alpha2-related muscular dystrophy (LAMA2-RD, n=21) enrolled in a 4-year longitudinal natural history study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Responsiveness of the MFM-32 and the Rasch-scaled MFM-25 and the MCID of the MFM-32 determined from a patient-reported anchor with 2 different methods, within-patient and between-patient.

RESULTS

The original MFM-32 and Rasch-scaled MFM-25 performed similarly overall in both the COL6-RD and LAMA2-RD populations, with all subscores (D1, standing and transfers; D2, axial and proximal; D3, distal) showing a significant decrease over time, except MFM D1 and D3 for LAMA2-RD. The MFM D1 subscore was the most sensitive to change for ambulant individuals, whereas the MFM D2 subscore was the most sensitive to change for nonambulant individuals. The MCID for the MFM-32 total score was calculated as 2.5 and 3.9 percentage points according to 2 different methods.

CONCLUSIONS

The MFM showed strong responsiveness in individuals with LAMA2-RD and COL6-RD. Because a floor effect was identified more prominently with the Rasch-Scaled MFM-25, the use of the original MFM-32 as a quantitative variable with the assumption of scale linearity appears to be a good compromise. When designing clinical trials in congenital muscular dystrophies, the use of MCID for MFM should be considered to determine if a given intervention effects show not only a statistically significant change but also a clinically meaningful change.

Effects of the agility boot camp with cognitive challenge (ABC-C) exercise program for Parkinson’s disease

Few exercise interventions practice both gait and balance tasks with cognitive tasks to improve functional mobility in people with PD. We aimed to investigate whether the Agility Boot Camp with Cognitive Challenge (ABC-C), that simultaneously targets both mobility and cognitive function, improves dynamic balance and dual-task gait in individuals with Parkinson’s disease (PD). We used a cross-over, single-blind, randomized controlled trial to determine efficacy of the exercise intervention. Eighty-six people with idiopathic PD were randomized into either an exercise (ABC-C)-first or an active, placebo, education-first intervention and then crossed over to the other intervention. Both interventions were carried out in small groups led by a certified exercise trainer (90-min sessions, 3 times a week, for 6 weeks). Outcome measures were assessed Off levodopa at baseline and after the first and second interventions. A linear mixed-effects model tested the treatment effects on the Mini-BESTest for balance, dual-task cost on gait speed, SCOPA-COG, the UPDRS Parts II and III and the PDQ-39. Although no significant treatment effects were observed for the Mini-BESTest, SCOPA-COG or MDS-UPDRS Part III, the ABC-C intervention significantly improved the following outcomes: anticipatory postural adjustment sub-score of the Mini-BESTest (p = 0.004), dual-task cost on gait speed (p = 0.001), MDS-UPDRS Part II score (p = 0.01), PIGD sub-score of MDS-UPDRS Part III (p = 0.02), and the activities of daily living domain of the PDQ-39 (p = 0.003). Participants with more severe motor impairment or more severe cognitive dysfunction improved their total Mini-BESTest scores after exercise. The ABC-C exercise intervention can improve specific balance deficits, cognitive-gait interference, and perceived functional independence and quality of life, especially in participants with more severe PD, but a longer period of intervention may be required to improve global cognitive and motor function.

The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling

BACKGROUND

There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS.

OBJECTIVES/RESEARCH QUESTIONS

Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery?

METHODS

A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process.

RESULTS

From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient's preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of < £20,000 per quality-adjusted life-year for patients with any preoperative score below the absolute thresholds (40 for the OHS and 41 for the OKS). Arthroplasty was most cost-effective for patients with lower preoperative scores.

LIMITATIONS

The ACHE tool supports but does not replace the shared decision-making process required before an individual decides whether or not to undergo surgery.

CONCLUSION

The OHS and OKS can be used in the ACHE tool to assess an individual patient's suitability for hip/knee replacement surgery. The system enables evidence-based and informed threshold setting in accordance with local resources and policies. At a population level, both hip and knee arthroplasty are highly cost-effective right up to the absolute threshold for intervention. Our stakeholder user group felt that the ACHE tool was a useful evidence-based clinical tool to aid referrals and that it should be trialled in NHS clinical practice to establish its feasibility.

FUTURE WORK

Future work could include (1) a real-world study of the ACHE tool to determine its acceptability to patients and general practitioners and (2) a study of the role of the ACHE tool in supporting referral decisions.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Responsiveness of the Revised Low Vision Independence Measure (LVIM-R)

IMPORTANCE

The Low Vision Independence Measure (LVIM) was designed to measure the effectiveness of occupational therapy to improve visual ability in low vision rehabilitation.

OBJECTIVE

To validate the Revised LVIM (LVIM-R) as an outcome measure by determining its sensitivity to visual ability changes after occupational therapy.

DESIGN

In this observational study, LVIM-R scores were collected before and after customary low vision intervention.

SETTING

Home health agency or outpatient facility.

PARTICIPANTS

Forty-four participants with a mean age of 80.2 yr (standard deviation = 11.2) and an average length of visual impairment of 6.2 yr. Twenty-three participants (52.3%) were treated in an outpatient setting, and 21 (47.7%) were treated in the home. The majority of participants were non-Hispanic White (92.8%) and had macular degeneration (54.5%).

INTERVENTION

Customary low vision intervention by occupational therapists.

OUTCOMES AND MEASURES

LVIM-R scores were collected before and after intervention, and participants' pre- and posttest scores were anchored into Rasch-calibrated item parameters.

RESULTS

Paired t tests demonstrated significant increases in person measures with large effect sizes for both constructs of the LVIM-R, the visual field or scotoma (t[43] = 6.46, p < .0001; Cohen's d = 0.92) and visual acuity (t[43] = 9.08, p < .0001; Cohen's d = 1.14) constructs.

CONCLUSIONS AND RELEVANCE

The LVIM-R is sensitive to changes in visual ability in clients who have good rehabilitation potential and can be used to examine the effectiveness of occupational therapy for low vision.

WHAT THIS ARTICLE ADDS

The LVIM-R is useful for measuring occupational therapy outcomes in low vision rehabilitation in the home or in outpatient settings.

The 6-min walk test as a new outcome measure in Amyotrophic lateral sclerosis

One of the issues highlighted in amyotrophic lateral sclerosis (ALS) clinical trials is the lack of appropriate outcome measures. The aim of this multicentric study was to evaluate the 6-min walk test (6MWT) as tool to monitor the natural history of a cohort of ALS patients followed up over a 6-month interval. Forty-four ambulant patients were assessed at baseline and after 1, 3 and 6 months. Eight out of forty-four lost the ability to walk before the end of the study. The 6MWT and the objective measures linked to motor function, such as 10 m walking test (10MWT) and Time-up and go (TUG), the ALSFRS-R and the ALSFRS-R items 7–9 showed a good responsiveness to change over the 6-month interval. There was a strong correlation between 6 and 10MWT, TUG, ALSFRS-R, ALSFRS-R items 7–9 and FVC% at baseline. There was no correlation with Edinburgh Cognitive and Behavioural ALS Screen (ECAS) and Modified Borg Scale (MBS). The Δ of 6MWT from T0 to T6 significantly correlated with the Δs of 10MWT and TUG. There was no correlation with the Δs of ALSFRS-R, ALSFRS-R items 7 9, ECAS, MBS and FVC%. The discordance between changes of the 6MWT and ALSFRS-R at 6 month highlights the different content validity among these instruments. The concordance among 6MWT, 10MWT and TUG indicates that the 6MWT is an objective, sensitive and robust tool to measure motor performances in a longitudinal setting. The main limitations of our study were the small sample size and the high percentage of patients (18%) lost at follow-up. Therefore, further studies on larger cohorts, and exploring the relation between 6MWT and need of ventilator support or survival could strengthen our results.

Comparisons of the Sensitivity and Reliability of Multiple Measures of Listening Effort

OBJECTIVES

The objective of this study was to evaluate the sensitivity and reliability of one subjective (rating scale) and three objective (dual-task paradigm, pupillometry, and skin conductance response amplitude) measures of listening effort across multiple signal to noise ratios (SNRs).

DESIGN

Twenty adults with normal hearing attended two sessions and listened to sentences presented in quiet and in stationary noise at three different SNRs: 0, -3, and -5 dB. Listening effort was assessed by examining change in reaction time (dual-task paradigm), change in peak to peak pupil diameter (pupillometry), and change in mean skin conductance response amplitude; self-reported listening effort on a scale from 0 to 100 was also evaluated. Responses were averaged within each SNR and based on three word recognition ability categories (≤50%, 51% to 71%, and >71%) across all SNRs. Measures were considered reliable if there were no significant changes between sessions, and intraclass correlation coefficients were a minimum of 0.40. Effect sizes were calculated to compare the sensitivity of the measures.

RESULTS

Intraclass correlation coefficient values indicated fair-to-moderate reliability for all measures while individual measurement sensitivity was variable. Self-reports were sensitive to listening effort but were less reliable, given that subjective effort was greater during the dual task than either of the physiologic measures. The dual task was sensitive to a narrow range of word recognition abilities but was less reliable as it exhibited a global decrease in reaction time across sessions. Pupillometry was consistently sensitive and reliable to changes in listening effort. Skin conductance response amplitude was not sensitive or reliable while the participants listened to the sentences. Skin conductance response amplitude during the verbal response was sensitive to poor (≤50%) speech recognition abilities; however, it was less reliable as there was a significant change in amplitude across sessions.

CONCLUSIONS

In this study, pupillometry was the most sensitive and reliable objective measure of listening effort. Intersession variability significantly influenced the other objective measures of listening effort, which suggests challenges for cross-study comparability. Therefore, intraclass correlation coefficients combined with other statistical tests more fully describe the reliability of measures of listening effort across multiple difficulties. Minimizing intersession variability will increase measurement sensitivity. Further work toward standardized methods and analysis will strengthen our understanding of the reliability and sensitivity of measures of listening effort and better facilitate cross-modal and cross-study comparisons.

Psychometric properties of visual analog scale assessments for function, pain, and strength compared with disease-specific upper extremity outcome measures in rotator cuff repair

BACKGROUND

Patient-reported outcome measures (PROMs) are being increasingly used in orthopedic surgery; however, there is significant variability and burden associated with their administration. The visual analog scale (VAS) for function, strength, and pain may represent a simple and efficient way to measure outcomes, specifically after rotator cuff repair (RCR) surgery.

PURPOSE

To define the efficiency and longitudinal psychometric properties of VAS instruments assessing function, strength, and pain after RCR.

METHODS

Single-question VAS measures assessing function, strength, and pain as a percentage of normal were administered alongside legacy PROMs in patients undergoing RCR. VAS and PROMs were administered at preoperative, 6- and 12-month time points between June 2017 and April 2018. An electronic registry was used to examine time-to-completion data. PROM performance was assessed using Spearman correlation coefficients. Both absolute and relative floor and ceiling effects were examined. Effect size was measured at 6 and 12 months through the calculation of Cohen's d coefficient. Receiver-operating curves with area under the curve calculations were used to determine the ability of preoperative VAS scores in predicting minimally clinically important difference achievement on American Shoulder and Elbow Surgeons score (ASES).

RESULTS

A total of 190 patients (55.6 ± 10.9 years, 66.9% male) met criteria. The 3 VAS PROMs required less time to complete than ASES (1.36 ± 1.12 vs. 5.17 ± 2.39) and Patient-Reported Outcome Measurement Information System (PROMIS) Upper Extremity v2.0 (UE) Computer Adaptive Test (1.72 ± 1.48). Compared with ASES, VAS function, strength, and pain demonstrated fair correlations preoperatively (r = 0.44-0.46) that improved to good at 6 months (r = 0.61-0.67) and further improved at 1 year (r = 0.62-0.78). The performance of VAS measures with other function PROMs was comparable with performance relative to ASES, with poor to very good correlations preoperatively (r = 0.21-0.62) that improved to good to excellent by 1 year (r = 0.62-0.94). A significant relative ceiling effect was demonstrated by PROMIS UE at 12 months (16.9%). Large effect sizes were demonstrated by the ASES, Single Assessment Numeric Evaluation, Constant, PROMIS UE, and VAS function and strength instruments (Cohen d ≥ 0.8).

CONCLUSION

Single-question VAS assessments for function, strength, and pain are an efficient means for assessing outcome in RCR surgery and may be particularly useful in the postoperative setting. VAS instruments collectively trended toward floor effects preoperatively, suggesting that legacy instruments may more appropriately establish preoperative baselines. However, in the postoperative setting, VAS instruments demonstrate good-to-excellent correlation, minimized time-to-completion, and no appreciable floor or ceiling effects.

Prefrontal Cortex Activity and Gait in Parkinson's Disease With Cholinergic and Dopaminergic Therapy

Degradation of striatal dopamine in Parkinson's disease (PD) may initially be supplemented by increased cognitive control mediated by cholinergic mechanisms. Shift to cognitive control of walking can be quantified by prefrontal cortex activation. Levodopa improves certain aspects of gait and worsens others, and cholinergic augmentation influence on gait and prefrontal cortex activity remains unclear. This study examined dopaminergic and cholinergic influence on gait and prefrontal cortex activity while walking in PD. A single-site, randomized, double-blind crossover trial examined effects of levodopa and donepezil in PD. Twenty PD participants were randomized, and 19 completed the trial. Participants were randomized to either levodopa + donepezil (5 mg) or levodopa + placebo treatments, with 2 weeks with treatment and a 2-week washout. The primary outcome was change in prefrontal cortex activity while walking, and secondary outcomes were change in gait and dual-task performance and attention. Levodopa decreased prefrontal cortex activity compared with off medication (effect size, -0.51), whereas the addition of donepezil reversed this decrease. Gait speed and stride length under single- and dual-task conditions improved with combined donepezil and levodopa compared with off medication (effect size, 1 for gait speed and 0.75 for stride length). Dual-task reaction time was quicker with levodopa compared with off medication (effect size, -0.87), and accuracy improved with combined donepezil and levodopa (effect size, 0.47). Cholinergic therapy, specifically donepezil 5 mg/day for 2 weeks, can alter prefrontal cortex activity when walking and improve secondary cognitive task accuracy and gait in PD. Further studies will investigate whether higher prefrontal cortex activity while walking is associated with gait changes. © 2020 International Parkinson and Movement Disorder Society.

Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study

Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

The responsiveness and predictive validity of the de Morton Mobility Index in geriatric rehabilitation

Introduction: The de Morton Mobility Index (DEMMI) is a unidimensional clinical instrument proven reliable and valid for measuring mobility in the elderly, but its responsiveness has not been evaluated when applying the methodology recommended by COSMIN.Purpose: To evaluate the responsiveness and the predictive validity of the DEMMI.Materials and methods: Elderly people, referred for municipality-based rehabilitation, were consecutively included. Eight hypotheses regarding the relationship between the change scores in the DEMMI and other functional measures of mobility were tested by assessing the participants before and after rehabilitation. Three months after completing the rehabilitation, the participants' functional status was evaluated.Results: 250 elderly people (mean age 85 years, 63% women) were included. The change scores in the DEMMI and the other measures correlated (r = 0.422 to 0.547), but only three out of the eight hypotheses were confirmed. A DEMMI score of less than 48 and less than 67 can predict inability of ambulating close to the participant's residence and using public transport, respectively.Conclusions: We found a moderate responsiveness and a high predictive validity of the DEMMI score. The DEMMI appears to be an appropriate instrument for monitoring change in mobility and predicting functional status among elderly patients undergoing rehabilitation.Implications for rehabilitationThe de Morton Mobility Index (DEMMI) is a clinical instrument for measuring mobility.This study shows that the DEMMI was responsive to change in mobility and predicted disability among a diverse group of elderly individuals referred to rehabilitation after hospital discharge.The DEMMI is applicable as an outcome measure in trials investigating the effect of rehabilitation and for clinical decision-making concerning geriatric rehabilitation.

Validity and Responsiveness of Preference-Based Quality-of-Life Measures in Informal Carers: A Comparison of 5 Measures Across 4 Conditions

OBJECTIVES

Carer quality-of-life (QoL) effects are recommended for inclusion in economic evaluations, but little is known about the relative performance of different types of QoL measures with carers. This study evaluated the validity and responsiveness of 3 care-related QoL measures (the Carer Experience Scale [CES], CarerQoL-7D, and ASCOT-Carer), 1 health-related QoL measure (the EQ-5D-5L), and 1 generic QoL measure (the ICECAP-A).

METHODS

Validity and responsiveness were assessed in a UK sample of informal carers of adults with dementia, stroke, mental illness, or rheumatoid arthritis. A questionnaire containing the 5 QoL measures was posted to carers identified through the Family Resources Survey (N = 1004). Hypotheses regarding the anticipated associations between constructs related to the QoL of carers were tested to investigate construct validity and responsiveness.

RESULTS

Each measure exhibited some level of construct validity. In general, larger effect sizes and stronger associations were detected for the ASCOT-Carer and ICECAP-A measures in the pooled sample and across all conditions. The 5 measures did not exhibit clear responsiveness to changes over a 12-month period in care recipient health status or hours of care provided per week.

CONCLUSION

The results of this study provide initial evidence of the validity of care-related, health-related, and generic QoL (capability) measures in informal carers of adults with 4 highly prevalent conditions. Care-related measures were not always more sensitive to constructs associated with QoL of carers compared with generic measures. The performance of the ICECAP-A was comparable with that of the best-performing care-related measure, the ASCOT-Carer.

Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments Correlate Better With Legacy Measures in Knee Cartilage Patients at Postoperative Than at Preoperative Assessment

PURPOSE

To define the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression computer adaptive tests (CATs) in patients undergoing knee cartilage surgical procedures.

METHODS

The PROMIS PF, PI, and Depression CATs were administered preoperatively and at 6 months alongside legacy knee patient-reported outcome measures (PROMs) in patients undergoing knee cartilage surgical procedures. Statistical analysis consisted of the time to completion, psychometric analysis for correlative strengths, absolute and relative floor and ceiling effects, and Cohen effect size.

RESULTS

Our study included 250 patients (57.2% male patients), averaging 1.87, 1.53, and 1.91 minutes for completion of the PF, PI, and Depression CATs, respectively. Preoperatively, the PROMIS PF and PI CATs showed wide ranges of correlation coefficients with respect to function (r = 0.14-0.72 and r = 0.29-0.77, respectively) and health-related quality-of-life PROMs (r = 0.64-0.70). At 6 months, the PROMIS PF CAT (r = 0.82-0.93) and PI CAT (r = 0.77-0.93) both exhibited excellent correlations with respect to legacy function and health-related quality-of-life PROMs except for the Marx Activity Rating Scale (r = 0.36-0.44). None of the PROMIS instruments exhibited any significant floor or ceiling effects.

CONCLUSIONS

The PROMIS PF, PI, and Depression CATs performed better with respect to legacy PROMs in the postoperative period than the preoperative period. In addition, the PROMIS PF and PI measures performed best with respect to the International Knee Documentation Committee questionnaire, and no floor or ceiling effects were identified for the PROMIS instruments. The PROMIS instruments may be more suited to track outcomes postoperatively than to establish preoperative baselines in cartilage surgery patients.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Validation of the Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score Pain and Function Subscales for Use in Total Hip Replacement and Total Knee Replacement Clinical Trials

BACKGROUND

Total hip replacement (THR)/total knee replacement (TKR) studies do not uniformly measure patient centered domains, pain, and function. We aim to validate existing measures of pain and function within subscales of standard instruments to facilitate measurement.

METHODS

We evaluated baseline and 2-year pain and function for THR and TKR using Hip disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), with primary unilateral TKR (4796) and THR (4801). Construct validity was assessed by correlating HOOS/KOOS pain and activities of daily living (ADL), function quality of life (QOL), and satisfaction using Spearman correlation coefficients. Patient relevant thresholds for change in pain and function were anchored to improvement in QOL; minimally clinically important difference (MCID) corresponded to "a little improvement" and a really important difference (RID) to a "moderate improvement." Pain and ADL function scores were compared by quartiles using Kruskal-Wallis.

RESULTS

Two-year HOOS/KOOS pain and ADL function correlated with health-related QOL (KOOS pain and Short Form 12 Physical Component Scale ρ = 0.54; function ρ = 0.63). Comparing QOL by pain and function quartiles, the highest levels of pain relief and function were associated with the most improved QOL. MCID for pain was estimated at ≥20, and the RID ≥29; MCID for function ≥14, and the RID ≥23. The measures were responsive to change with large effect sizes (≥1.8).

CONCLUSION

We confirm that HOOS/KOOS pain and ADL function subscales are valid measures of critical patient centered domains after THR/TKR, and achievable thresholds anchored to improved QOL. Cost-free availability and brevity makes them feasible, to be used in a core measurement set in total joint replacement trials.

Responsiveness of Device-Based and Self-Report Measures of Physical Activity to Detect Behavior Change in Men Taking Part in the Football Fans in Training (FFIT) Program

The capacity of physical activity (PA) measures to detect changes in PA within interventions is crucial. This is the first study to examine the responsiveness of activPAL3™ and the International Physical Activity Questionnaire (IPAQ; Short Form) in detecting PA change during a 12-week group-based, men-only weight management program-Football Fans in Training (FFIT). Participants wore an activPAL3™ and completed the IPAQ pre- and post-program (n = 30). Relationships between change scores were assessed by Spearman's correlations. Mean or median changes in PA were measured using paired samples t-tests and Wilcoxon signed-rank tests. Responsiveness to change was assessed utilizing Standardized Response Mean (SRM). Both device-based and self-report measures demonstrated significant changes pre-post intervention, although these changes were not significantly correlated. The SRM values for changes in activPAL3™ metrics were: 0.54 (MET-mins/day); 0.53 (step counts/day); and 0.44 (MVPA/day), indicating a small to medium responsiveness to change. SRM values for changes in IPAQ scores were: 0.59 (for total PA mins/day); 0.54 (for total MET-mins/day); 0.59 (for walking MET-mins/day); 0.38 (for vigorous MET-mins/day); and 0.38 (for moderate MET-mins/day), revealing a small to medium responsiveness to change. These findings reveal that two commonly used device-based and self-report measures demonstrated responsiveness to changes in PA. While inclusion of both device-based and self-report measures is desirable within interventions it is not always feasible. The results from this study support that self-reported measures can detect PA change within behavioral interventions, although may have a tendency to overestimate changes compared with device-based measures on absolute values, but not standardized response values.

Mindfulness-based resilience training for aggression, stress and health in law enforcement officers: study protocol for a multisite, randomized, single-blind clinical feasibility trial

BACKGROUND

Law enforcement officers (LEOs) are exposed to significant stressors, elevating their risk for aggression and excessive use of force, as well as mental health consequences, including post-traumatic stress disorder, burnout, alcohol misuse, depression, and suicide. Mindfulness training is a promising approach with high-stress populations that has been shown effective for increasing resilience and improving negative mental health outcomes common among LEOs.

METHOD

Implemented at two sites, the proposed study is designed to establish optimal protocols and procedures for a future full-scale, multisite trial assessing effects of mindfulness-based resilience training versus an attention control (stress management education) and a no-intervention control on physiological, behavioral, and psychological outcomes. To prepare for this future clinical trial, the current study is designed to: enhance efficiency of recruitment, engagement, and retention; optimize laboratory, assessment, and data management procedures; optimize intervention training and ensure fidelity to intervention protocols; and assess participant experience and optimize outcome measures across two sites. Herein, we describe the protocol and methodology of this multisite, randomized, single-blind clinical feasibility trial.

DISCUSSION

The long-term objective of this line of research is to develop an intervention that will reduce violence and increase resilience and mental health among LEOs, as well as yield significant benefits for the communities and residents they serve.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03784846. Registered on 24 December 2018.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

Patient-related outcomes in Sjögren syndrome treated with stimulants of salivary secretion: Randomized clinical trial

OBJECTIVES

To investigate the impact of gustatory stimulants of salivary secretion (GSSS) on Sjögren's syndrome patients' self-perception of xerostomia, oral health-related quality of life (OHRQoL) and salivary secretion.

METHODS

A total of 110 Sjögren's syndrome patients were randomly allocated to be treated with either a malic acid lozenge or a citric acid mouthwash and then crossed over. Before and after the interventions, the Xerostomia Inventory 5 (SXI-5-PL) and the Oral Health Impact Profile (OHIP-14-PT) questionnaires (both in the Portuguese language) were administered to patients. Unstimulated, mechanical and gustatory-stimulated salivary flows were determined. Repeated measures and between-subject analyses were performed. Statistical significance was set at 5%.

RESULTS

After the intervention and within each group, both GSSS elicited a reduction in the SXI-5-PL and OHIP-14-PT scores and an increase in salivary output, significant in the malic acid lozenge group. The malic acid treatment resulted in a greater effect size and percentage improvement than citric acid mouthwash. The malic acid lozenge also produced a significant greater salivary output than the citric acid rising solution.

CONCLUSIONS

In Sjögren's syndrome patients, lozenges containing malic acid increased saliva production and xerostomia relief, resulting in improved quality of life.

Cross cultural adaptation and refinement of an English version of a Dutch patient-reported questionnaire for hand sensitivity: The Radboud Evaluation of Sensitivity

STUDY DESIGN

Longitudinal clinical measurement.

INTRODUCTION

Sensory alterations in the hand can present as both decreased sensation or numbness, and hyperesthesia, including mechanical allodynia and cold intolerance. However, few patient-reported outcomes have been developed and validated for evaluation, particularly for increased sensitivity. The Radboud Evaluation of Sensitivity was developed in the Netherlands for patient-reported evaluation of hand sensitivity in complex regional pain syndrome.

PURPOSE OF THE STUDY

The purpose of this study was to translate into English and culturally validate the Radboud Evaluation of Sensitivity for the North American context.

METHODS

Forward and backward translation, followed by a psychometric evaluation of the synthesized version of the translated tool, was undertaken in a heterogeneous group of persons after hand injury, including nerve injuries, hand trauma, and complex regional pain syndrome.

RESULTS

Thirty-six persons completed test-retest reliability testing, yielding an intraclass correlation coefficient of 0.92 (95% CI 0.85 to 0.96) for single measures. Internal consistency was also high at α = 0.96 in a larger sample (n = 56). Although some support for construct validity was generated, several validity hypotheses were not confirmed. Of interest, there appeared to be significant differences in the scores between persons with hypoesthesia as compared with those with hyperesthesia.

CONCLUSIONS

The Radboud Evaluation of Sensitivity, English version appears to be a reliable tool for the self-reported evaluation of sensory alterations in the hand, including both hypoesthesia and hyperesthesia. More research is needed to add to the extent of and confidence in the validity and responsiveness of this assessment.

LEVEL OF EVIDENCE

Level II.

Reliability and responsiveness of the Jebsen-Taylor Test of Hand Function and the Box and Block Test for children with cerebral palsy

AIM

To assess the reliability and to evaluate the responsiveness of both the Jebsen-Taylor Test of Hand Function (JTTHF) and the Box and Block Test (BBT) in children with cerebral palsy (CP).

METHOD

In this retrospective study, the reliability analyses were conducted with paired t-tests considering a short (mean 14d) and a long (mean 120d) time in between two assessment periods. In addition, an intraclass correlation coefficient (ICC) was used to assess the level of congruency. The responsiveness to therapy was conducted with a paired t-test in the whole sample regarding the age, the manual ability level as classified with the Manual Ability Classification System (MACS), and the topography.

RESULTS

Our main results confirmed the tests' reliability in a short time period for the JTTHF in both hands and for the BBT on the less affected hand. These results were consistent with the ICC. The responsiveness was confirmed, except on the less affected hand for the JTTHF, with similar results for age, MACS, and topography approach.

INTERPRETATION

This study supports the use of the JTTHF and the BBT to examine changes after short-term interventions for children with CP. These results should be interpreted with association to normative values or with a control group when used over long assessment periods.

WHAT THIS PAPER ADDS

The Box and Block Test (BBT) is reliable in a brief period of assessment in children with cerebral palsy (CP). The Jebsen-Taylor Test of Hand Function (JTTHF) is reliable in a brief period of assessment in children with CP. The JTTHF and BBT are responsive to changes in a brief period of intensive therapy in children with CP. The reliability and responsiveness of the JTTHF and BBT are weak over long assessment periods.

Approaches to Integrating Biomarkers Into Clinical Trials and Care Pathways as Targets for the Treatment of Inflammatory Bowel Diseases

BACKGROUND & AIMS

There is no consensus on the best way to integrate biomarkers into inflammatory bowel disease (IBD) research and clinical practice. The International Organization for the Study of Inflammatory Bowel Disease aimed to outline biomarker definitions, categories, and operating properties required for their use in registration trials and clinical practice. Using fecal calprotectin as an example, we provide a framework for biomarker development and validation in patients with IBD.

METHODS

We reviewed international society guidelines, regulatory agency guidance documents, and standardized reporting guidelines for biomarkers, in combination with publications on fecal calprotectin levels in patients with IBD. We assessed the validity of fecal calprotectin to serve as a surrogate biomarker of IBD activity and outlined a framework for further validation and development of biomarkers.

RESULTS

No endpoints have been fully validated as surrogates of risk of disease complications; mucosal healing is the most valid endpoint used to determine risk of disease complications. Fecal level of calprotectin has not been validated as a biomarker for IBD activity because of lack of technical and clinical reliability, assessment of performance when used as a replacement for endoscopy, and assessment of responsiveness to changes in disease states. The level of fecal calprotectin can be used only as a prognostic factor for disease recurrence in patients in remission after medical or surgical treatment.

CONCLUSIONS

We reviewed guidelines, regulatory documents, and publications to identify properties required for the development of biomarkers of IBD activity and areas in need of clarification from regulatory agencies and societies. We propose a path forward for research of biomarkers for IBD.

Validation of a Modified Life-Space Assessment in Multimorbid Older Persons With Cognitive Impairment

BACKGROUND AND OBJECTIVES

To investigate the validity, reliability, sensitivity to change, and feasibility of a modified University of Alabama at Birmingham Study of Aging Life-Space Assessment (UAB-LSA) in older persons with cognitive impairment (CI).

RESEARCH DESIGN AND METHODS

The UAB-LSA was modified for use in persons with CI Life-Space Assessment for Persons with Cognitive Impairment (LSA-CI). Measurement properties of the LSA-CI were investigated using data of 118 multimorbid older participants with CI [mean age (SD): 82.3 (6.0) years, mean Mini-Mental State Examination score: 23.3 (2.4) points] from a randomized controlled trial (RCT) to improve motor performance and physical activity. Construct validity was asessed by Spearman's rank (rs) and point-biseral correlations (rpb) with age, gender, motor, and cognitive status, psychosocial factors, and sensor-derived (outdoor) physical activity variables. Test-retest reliability was analyzed using intra-class correlation coefficients (ICCs). Sensitivity to change was determined by standardized response means (SRMs) calculated for the RCT intervention group.

RESULTS

The LSA-CI demonstrated moderate to high construct validity, with significant correlations of the LSA-CI scores with (outdoor) physical activity (rs = .23-.63), motor status (rs = .27-.56), fear of falling-related psychosocial variables (rs = |.24-.44|), and demographic characteristics (rpb = |.27-.32|). Test-retest reliability was good to excellent (ICC = .65-.91). Sensitivity to change was excellent for the LSA-CI composite score (SRM = .80) and small to moderate for the LSA-CI subscores (SRM = .35-.60). A completion rate of 100% and a mean completion time of 4.1 min) documented good feasibility.

DISCUSSION AND IMPLICATIONS

The LSA-CI represents a valid, reliable, sensitive, and feasible interview-based life-space assessment tool in multimorbid older persons with CI.

Large Treatment Effect With Extended Home-Based Transcranial Direct Current Stimulation Over Dorsolateral Prefrontal Cortex in Fibromyalgia: A Proof of Concept Sham-Randomized Clinical Study

This randomized, double-blind controlled trial tested the hypothesis that 60 sessions of home-based anodal (a)-transcranial direct current stimulation (tDCS) over dorsolateral prefrontal cortex (DLPFC) would be better than home-based sham-tDCS to improve the widespread pain and the disability-related to pain. The anodal-tDCS (2 mA for 30 minutes) over the left DLPFC was self-administered with a specially developed device following in-person training. Twenty women, 18 to 65 years old were randomized into 2 groups [active-(a)-tDCS (n = 10) or sham-(s)-tDCS (n = 10)]. Post hoc analysis revealed that after the first 20 sessions of a-tDCS, the cumulative pain scores reduced by 45.65% [7.25 (1.43) vs 3.94 (1.14), active vs sham tDCS, respectively]. After 60 sessions, during the 12-week assessment, pain scores reduced by 62.06% in the actively group [visual analogue scale reduction, 7.25 (1.43) to 2.75 (.85)] compared to 24.92% in the s-tDCS group, [mean (SD) 7.10 (1.81) vs 5.33 (.90)], respectively. It reduced the risk for analgesic use in 55%. Higher serum levels of the brain-derived neurotrophic factor predicted higher decreases on the pain scores across of treatment. PERSPECTIVE: These findings bring 3 important insights: 1) show that an extended period of treatment (60 sessions, to date the largest number of tDCS sessions tested) for fibromyalgia induces large pain decreases (a large effect size of 1.59) and 2) support the feasibility of home-based tDCS as a method of intervention; 3) provide additional data on DLPFC target for the treatment of fibromyalgia. Finally, our findings also highlight that brain-derived neurotrophic factor to index neuroplasticity may be a valuable predictor of the tDCS effect on pain scores decreases across the treatment.

Energy Expenditure Index as a measure of efficiency of walking on outdoor uneven surface in individuals with cerebral palsy

Purpose: This study aims to validate and report responsiveness of Energy Expenditure Index (EEI) during walking on outdoor uneven surface in individuals with cerebral palsy (CP).Methods: Eighty ambulant children with spastic diplegia (Gross Motor Function Classification System II & III) aged between six and 18 years and 58 age matched typically developing children were recruited for ascertaining reliability and validation of EEI during outdoor walking. Responsiveness of EEI was ascertained using anchor-based approach using Functional Mobility Scale in 29 children with CP who were recruited for surgical intervention.Results: EEI had acceptable test-retest reliability and agreement in both typically developing and children with CP. Friedman's analysis of variance of 29 children with CP showed a significant difference in EEI (χ² = 10.15, p = 0.006), Functional Mobility Scale - 50 m (χ² =18.77, p = 0.000) and 500 m (χ² = 40.19, p = 0.000) scores at 6 and 12 months when compared with baseline. The minimal clinical important difference of EEI during walking on uneven outdoor surface with a concomitant change in functional mobility scale (500 m) at 6 and 12 months was 0.29 and 0.37 beats/m, respectively.Conclusions: EEI during walking on outdoor uneven surface is a stable, valid and reliable measure of energy efficiency in individuals with CP and is responsive to orthopedic intervention in CP.IMPLICATIONS FOR REHABILITATIONEnergy Expenditure Index during outdoor walking on uneven surface is a valid, reliable and responsive outcome measure for documenting changes in walking efficiency to post-surgical interventions employed to improve walking in individuals with cerebral palsy.Rehabilitation professionals should document the efficiency during outdoor walking on all the post-operative visits.Energy Expenditure Index during outdoor walking can serve as surveillance tool for deterioration in outdoor walking ability.