Functional status and health status

Reliability and validity of the Greek adaptation of the Modified Barthel Index in neurorehabilitation patients

BACKGROUND

The Modified Barthel Index (MBI) (Shah version) is a widely used functional assessment measure with greater sensitivity and improved reliability compared to the original Barthel Index.

AIM

The aim of this study was to adapt the MBI for use in Greece and measure its reliability and validity on a Greek neuro-rehabilitation population.

DESIGN

Observational study.

SETTING

KAT Hospital Rehabilitation Clinic and National Rehabilitation Centre in Athens, Greece.

POPULATION

A total of 100 rehabilitation inpatients and outpatients consisting of 50 stroke and 50 spinal cord injury (SCI) patients were evaluated.

METHODS

The MBI underwent the proper translation and cultural adaptation procedure as required by the World Health Organization and was administered to 100 rehabilitation patients. For criterion validity evaluation all patients were also assessed with the Katz Index of Independence in Activities of Daily Living (Katz Index) and the 36-Item Short Form Survey (SF-36) physical functioning subscale, both questionnaires having been validated for use in Greece.

RESULTS

The unidimensionality solution was rejected and a two- factor solution was adopted based on exploratory and confirmatory factor analysis (Factor 1 - Transfers and Activities of Daily Living, Factor 2 - Mobility). Very high correlation was presented between the Katz Index score and the Greek MBI Factor 1 (r=0.888, P<0.001) and total score (r=0.873 P<0.001) respectively and high with MBI Factor 2 (r=0.561, P<0.001). High correlation was observed between the SF-36 physical functioning subscale score with MBI Factor 1 (r=0.522, P<0.001), MBI Factor 2 (r=0.590, P<0.001) and MBI Total score (r=0.580, P<0.001). The internal consistency of the MBI Factor 1, Factor 2 and Total score was 0.920, 0.860 and 0.923 respectively. Test-retest reliability was remarkably consistent (total score 0.994, P<0.001).

CONCLUSIONS

The Greek version of the Modified Barthel Index has been found to exhibit satisfactory levels of reliability and validity.

CLINICAL REHABILITATION IMPACT

The Greek MBI adaptation is an adequate and useful instrument for use on Greek neuro-rehabilitation patients.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain

BACKGROUND

Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population.

METHODS

This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist.

DISCUSSION

This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Fully Implantable Peripheral Nerve Stimulation for Hemiplegic Shoulder Pain: A Multi-Site Case Series With Two-Year Follow-Up

OBJECTIVE

To explore the feasibility and safety of a single-lead, fully implantable peripheral nerve stimulation system for the treatment of chronic shoulder pain in stroke survivors.

PARTICIPANTS

Participants with moderate to severe shoulder pain not responsive to conservative therapies for six months.

METHODS

During the trial phase, which included a blinded sham introductory period, a percutaneous single-lead peripheral nerve stimulation system was implanted to stimulate the axillary nerve of the affected shoulder. After a three-week successful trial, participants received an implantable pulse generator with an electrode placed to stimulate the axillary nerve of the affected shoulder. Outcomes included pain, pain interference, pain-free external rotation range of motion, quality of life, and safety. Participants were followed for 24 months.

RESULTS

Twenty-eight participants underwent trial stimulation and five participants received an implantable pulse generator. The participants who received the implantable generator experienced an improvement in pain severity (p = 0.0002). All five participants experienced a 50% or greater pain reduction at 6 and 12 months, and four experienced at least a 50% reduction at 24 months. There was an improvement in pain interference (p < 0.0001). There was an improvement in pain-free external ROM (p = 0.003). There were no serious adverse events related to the device or to the procedure.

CONCLUSIONS

This case series demonstrates the safety and efficacy of a fully implantable axillary PNS system for chronic HSP. Participants experienced reduction in pain, reduction in pain interference, and improved pain-free external rotation ROM. There were no serious adverse events associated with the system or the procedure.

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research

Objective: The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of relevant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made.

Method: Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH.

Results: Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived health as the subjective part of the person level and domain- specific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal model is intended to serve as a framework in which different outcomes can be positioned in relation to each other.

Conclusion: Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

Content Validity of an Assessment Tool to Identify Home Fall Hazards: The Westmead Home Safety Assessment

Identifying hazards in the homes of elderly people adequately is of central importance to reducing the risk of falls; however, no assessment tool has demonstrated validity in the area of, or focuses specifically on, home fall hazards. Content validity was undertaken to develop further and refine the Westmead Home Safety Assessment (WeHSA).

A list of stimulus attributes was generated from an extensive literature review and contributed to an expert review by providing a descriptive scheme of the tool's domain of interest. A content analysis of the literature and the expert review process established the tool as having a high degree of content validity and an overall content validity index of 0.80. The rigorous process ensured that the items in the tool were complete and relevant to the focus of the assessment and helped to guide manual development. The WeHSA provides a meaningful tool to enhance therapists' ability to observe and judge hazards.

Peripheral nerve stimulation compared with usual care for pain relief of hemiplegic shoulder pain: a randomized controlled trial

OBJECTIVE

This study sought to establish the efficacy of single-lead, 3-wk peripheral nerve stimulation (PNS) therapy for pain reduction in stroke survivors with chronic hemiplegic shoulder pain.

DESIGN

This study is a single-site, pilot, randomized controlled trial of adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-wk treatment of single-lead PNS or usual care. The primary outcome was the worst pain in the last week (Brief Pain Inventory, Short Form, question 3) measured at baseline and weeks 1, 4, 12, and 16. The secondary outcomes included pain interference (Brief Pain Inventory, Short Form, question 9), pain measured by the ShoulderQ Visual Graphic Rating Scales, and health-related quality-of-life (Short-Form 36 version 2).

RESULTS

Twenty-five participants were recruited, 13 to PNS and 12 to usual care. There was a significantly greater reduction in pain for the PNS group compared with the controls, with significant differences at 6 and 12 wks after treatment. Both PNS and usual care were associated with significant improvements in pain interference and physical health-related quality-of-life.

CONCLUSIONS

Short-term PNS is a safe and efficacious treatment of shoulder pain. Pain reduction is greater compared with usual care and is maintained for at least 12 wks after treatment.

Does Behcet's disease associate with neuropathic pain syndrome and impaired well-being?

Previously peripheral neuropathy signs have been reported in inflammatory chronic diseases but the presence of neuropathic pain syndrome (NPS) in Behcet's disease (BD) is unclear. The aim of this study was to investigate the association of BD with NPS and impaired quality of life and sleep quality. A total of 111 patients diagnosed as BD and 52 healthy controls were included. Pain severity was assessed by visual analogue scale (VAS) in rest and during activity. The NPS was diagnosed according to the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) index. The well-being and sleep disturbances of the groups were evaluated with Psychological General Well-Being (PGWB) Scale and Pittsburg Sleep Quality Index (PSQI). Although there were no one with NPS in healthy controls, the proportion of NPS in patients with BD was 19.8 % (p = 0.001). The VAS scores both in activity and at rest were higher in BD (p < 0.001). There was statistically significant decrease in total PGWB score in BD patients compared to healthy controls (p < 0.001). And significant increase in LANSS score was observed in patients with BD compared to healthy controls (p = 0.000). The total LANSS scores showed significant positive correlation with PSQI scores (r = 0.322) and negative correlation with total PGWB scores (r = -0.672) in patients with BD. We observed a positive correlation between LANSS and VAS (rest and activity) scores (r = 0.44, r = 0.42 respectively). The NPS seems to be associated with BD which should be taken into consideration in patients with neuropathic signs. The quality of life (QoL) and quality of sleep of the patients with BD were found to be impaired and this may be due to the presence of NPS.

Functional status and use of healthcare facilities in long-term survivors of transient ischaemic attack or minor ischaemic stroke

BACKGROUND

Stroke may have a major effect on survivors and on the healthcare system.

AIMS

To study the functional status and use of healthcare facilities in long-term survivors of a transient ischaemic attack (TIA) or minor ischaemic stroke (MIS) and evaluate associations with baseline and follow-up characteristics.

METHODS

Follow-up of patients who had participated in the Dutch TIA Trial or the European Atrial Fibrillation Trial was extended to a mean period of 15.6 years. Patients were interviewed through a postal questionnaire (n = 468) and a sample of this group was also interviewed at home (n = 198). Demographic data, information on comorbidity, functional status (Barthel Index, Frenchay Activities Index and modified Rankin Scale) and use of healthcare facilities were recorded.

RESULTS

About one third of the survivors interviewed at home experienced any residual disability and 26% were moderately to severely handicapped. Factors associated with poor functional status were advanced age and the presence of any infarct on a baseline computed tomography scan, the recurrence of a new major stroke or the presence of comorbidity of locomotion. One third of survivors used any kind of professional care, which was predominantly related to the functional status at follow-up.

CONCLUSIONS

Recurrent stroke and the presence of comorbidity of locomotion are important determinants of long-term disability of survivors of a TIA or an MIS, which, in turn, is strongly associated with the long-term use of professional care. The need for measuring comorbidity with regard to functional status is recommended in research on stroke outcome.

Psychometric and Administrative Properties of Measures Used in Assistive Technology Device Outcomes Research

Although there have been numerous calls for increasing the quantity and quality of assistive technology outcomes research, no one has analyzed the nature of data that the field has been accumulating. This article summarizes our evaluation of 82 outcome studies, published between 1980 and 2001, addressing assistive technology devices (ATDs). Our data indicate that the "typical" ATD outcomes study published in the past 20 years is one that (a) used a sample population that was diverse in terms of age, disability population, and type of ATD being used; (b) measured user-reported dependent variables with instruments designed specifically for the study; (c) did not report adequate information on the reliability and validity for the measurement instruments that were used; (d) did not discuss the staff workload associated with learning, administering, and scoring its data collection tools; and (e) did not differentiate its findings in terms of distinguishable participant subgroups. Several suggestions are provided to guide future development of assistive technology outcome measures in the domains of usability, quality of life, and social role performance. In addition, seven recommendations are offered to outcomes researchers, policy makers, journal editors, and reviewers in order to improve the reporting of assistive technology outcomes research.

Validation of the Tunisian version of the Roland-Morris questionnaire

Our aim was to validate a culturally adapted, Tunisian-language version of the Roland-Morris Disability Questionnaire (RMDQ), which is a reliable evaluation instrument for low-back-pain disability. A total of 62 patients with low back pain were assessed by the questionnaire. Reliability for the 1-week test/re-test was assessed by a construction of a Bland Altman plot. Internal construct validity was assessed by Cronbach's alphatest. External construct validity was assessed by association with pain, the Schober test and the General Function Score. Sensitivity to change was determined using a t-test for paired data to compare RMDQ scores at inclusion and at completion of the therapeutic sequence of local corticosteroid injections. We also compared the questionnaire score with the General Function Score, both taken after completion of the therapeutic sequence. The constructed Bland Altman plot showed good reliability. Internal consistency of the RMDQ was found to be very good and the Cronbach's alpha test was 0.94, indicating a good internal construct validity. The questionnaire is correlated with the pain visual analogue scale (r=33; p=0.0001), with the Schober test (r=0.27; p=0.0001) and the General Function Score (r=56; p=0.0001) indicating an adequate external construct validity. The RMDQ administered after the therapeutic sequence is sensitive to change (r=0.83; p=0.000). Comparison of the questionnaire score to the General Function Score, after completion of the therapeutic sequence, was satisfactory (r=0.75; p=0.000). We conclude that the Tunisian version of the Roland-Morris questionnaire has good reliability and internal consistency. Furthermore, it has a good internal- and external construct validity and high sensitivity to change. It is an adequate and useful tool for assessing low-back-pain disability.

A New Conceptual Model for Assistive Technology Outcomes Research and Practice

Predictive conceptual models help us frame research questions, interpret results, and guide clinical practice. Although numerous models have appeared in the assistive technology (AT) literature, none has been shown to predict AT usage. The lack of a valid predictive model indicates the need for development of new approaches to modeling AT outcomes. This article proposes a user-centered conceptual model that predicts AT usage as a function of the perceived relative advantages of AT. Device usage is not modeled as a one-time, all-or-nothing proposition, but as a decision process recurring over time. The influence of parallel interventions working concurrently with, or as an alternative to, AT is a central consideration that ultimately drives AT usage. Usage is shown as a proximal influence on AT impact, and AT impact is shown to be a predictor of future use. Research is cited supporting various elements of the new model.

Concept analysis of functional status

Nursing as a discipline is striving toward evidence-based practice whose foundation is built upon clarity of concepts and theories and appropriate measures. The objectives of the paper are to clarify an overused and vague concept and to provide a precise operational definition of functional status. By following the Walker and Avant concept analysis guidelines, the concept, functional status, can best be defined as the level of activities performed by an individual to realize needs of daily living in many aspects of life including physical, psychological, social, spiritual, intellectual, and roles. Level of performance is expected to correspond to normal expectation in the individual's nature, structure, and conditions.

Clinical Application of a Self-Report, Functional Independence Outcomes Measure in the DVA's Blind Rehabilitation Service

This article reports on a self-report measure of functional independence that is being used to measure outcomes of blind rehabilitation programs in the Department of Veterans Affairs (DVA). Analyses of the data have resulted in the clinical protocol that is currently in use nationally by the DVA Blind Rehabilitation Service.

The effect of peripheral percutaneous transluminal angioplasty on quality of life in patients with intermittent claudication

BACKGROUND AND OBJECTIVE

intermittent claudication is associated with a significant reduction in quality of life. Treatment of claudicants aims to reduce mortality from cardio- and cerebro-vascular events and to improve quality of life. Quality of life assessment should be used to guide and evaluate treatment in this group of patients. Peripheral percutaneous transluminal angioplasty (PTA) is now widely used in the treatment of intermittent claudication. The aim of this review is to examine the effect of PTA on quality of life (QOL) in patients with intermittent claudication.

METHODS

a review was conducted of prospective clinical trials assessing the effect of peripheral PTA on QOL. Publications were retrieved by searching Medline and PreMedline, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of systematic reviews, AMED and CINAHL. The reference lists of the relevant publications were also searched.

RESULTS

seven prospective studies (10 publications) on the effect of PTA on QOL in claudicants were identified. Several different questionnaires were used to measure quality of life (Nottingham Health Profiile, SF-36, EuroQol) none of which were disease specific. All the studies showed some improvement in QOL after PTA at follow-up periods of between 6 weeks and 24 months, except for one which showed some improvement at 6 months but not at 24 months.

CONCLUSIONS

despite the fact that studies on the effect of PTA on QOL in claudicants have used generic QOL questionnaires which are relatively insensitive, the findings suggest that PTA may result in some improvement in QOL in these patients, although level I evidence to support this is lacking. The availability of disease-specific questionnaires should enable a more accurate assessment of PTA on QOL in these patients.

McGill Ingestive Skills Assessment (MISA): development and first field test of an evaluation of functional ingestive skills of elderly persons

There is a lack of reliable and valid clinical assessment tools for individuals with loss of ingestive skills. The McGill Ingestive Skills Assessment (MISA) was developed to facilitate the reliable and valid bedside assessment of elderly persons with feeding difficulties. Items were generated by a literature review and selected with the collaboration of a multidisciplinary team. The first version of the MISA comprised 190 items in 7 scales, covering the domains of medical history, mealtime environment, physical characteristics of the patient, food textures consumed, solid ingestion, liquid ingestion, and behaviors related to self-feeding. The first field test for item selection included 50 individuals, aged 60 years and older, living in the community, supervised housing, and long-term care centers. After field testing, 134 items were eliminated due to poor face validity, redundancy, or poor psychometric performance. The remaining 56 items were provided with 4 response categories and were reorganized into 5 scales. The revised version was field tested to determine its preliminary psychometric properties on 33 individuals, 60 years of age and older, residing in a long-term care center. Six items were eliminated due to redundancy after the second field test. Analyses of the revised version resulted in the elimination of another 6 items that were redundant or that demonstrated poor reliability. Internal consistency of all scales is > or = 0.86 and interrater agreement is > or = 0.92. These analyses suggest that the psychometric properties of the MISA are adequate for diagnosis and treatment planning. This supports its readiness for clinical use following further reliability and validity testing with a larger sample.

Quality of life: an outcomes perspective

This article compares a traditional biomedical model with an outcomes model for evaluating medical and rehabilitation care. The traditional model emphasizes diagnosis and disease-specific outcomes. In contrast, the outcomes model emphasizes life expectancy and health-related quality of life (QOL). Although the models are similar, they lead to different conclusions with regard to some interventions. For some conditions, diagnosis and treatment may reduce the impact of a particular disease without extending life expectancy or improving QOL. Older individuals with multiple comorbidities may not benefit from treatments for a particular disease if competing health problems threaten life or reduce QOL. Overall outcomes and benefits of treatment can be summarized by using measures of life expectancy that adjust for QOL. The quality-adjusted life year (QALY) has been proposed as a comprehensive summary index. QALYs have gained widespread usage in many areas of medicine. The outcomes model has been applied widely in rehabilitation research, but few studies estimate the benefits of treatments using QALYs. These methodologies can also serve as a basis for approaches to sharing medical decisions between patients and providers. Opportunities to apply these new methods are discussed.

Ambulatory measurement of upper limb usage and mobility-related activities during normal daily life with an upper limb-activity monitor: a feasibility study

The aim of this research was to assess the ability of an upper limb-activity monitor (ULAM) to discriminate between upper limb usage and non-usage in healthy and disabled subjects during normal daily life. The ULAM was based on ambulatory accelerometry and consisted of several acceleration sensors connected to a small recorder worn around the waist. While wearing this ULAM, four healthy and four disabled subjects performed an activity protocol representing normal daily life upper limb usage or non-usage. The motility feature (derived from the raw acceleration signals) was used as a measure of the extent of upper limb usage. Agreement scores between ULAM output and videotape recordings (reference method) were calculated. ULAM data that were of special interest for rehabilitation were detected satisfactorily (overall agreement 83.9%). There were no systematic differences in the agreement percentages between healthy and disabled subjects for mobility-related activities (p = 0.345) and the different forms of upper limb usage or non-usage (p= 0.715). The ULAM can be used in future studies in subjects with upper limb disorders to discriminate between upper limb usage and non-usage during performance of mobility-related activities to determine activity limitations.

Validation of the Turkish version of the Roland-Morris Disability Questionnaire for use in low back pain

STUDY DESIGN

A reliability and validity study of a previously translated version of the Roland-Morris Disability Questionnaire (RMDQ).

OBJECTIVES

To validate the Turkish version of the RMDQ for use in low back pain.

SUMMARY OF BACKGROUND DATA

Clinical and epidemiologic research related to low back pain in the Turkish population would be facilitated by the availability of well-established outcome measures.

METHODS

A total of 81 outpatients with low back pain, 64 of whom were followed up on a second occasion, were assessed by the RMDQ. Reliability was assessed using internal consistency and the intraclass correlation coefficient. Internal construct validity was assessed by Rasch analysis; external construct validity was assessed by association with pain and spinal movement. Responsiveness was tested by both the nonparametric and parametric effect sizes.

RESULTS

Internal consistency of the RMDQ is found to be adequate (>0.85) at both times, with high intraclass correlation coefficient also at both time points. Internal construct validity of the scale is good, indicating a single underlying construct. Expected associations with pain confirm external construct validity. There is little evidence of differential item functioning. The scale is at the ordinal level. Responsiveness of the RMDQ is good and greater than observed change in spinal movement.

CONCLUSIONS

The RMDQ is a robust unidimensional ordinal measure, largely free of differential item functioning, which works well in the Turkish population. Nonparametric effect sizes of ordinal scales are found to overestimate or underestimate the true effect size depending on the nature of the scale and the distribution of patients at baseline.

A patient-oriented health status measure in outpatient rehabilitation

OBJECTIVES

The purpose of this study was to assess the utility of a patient-centered health status measurement tool in multiple outpatient rehabilitation clinics and to characterize health status before and after an outpatient physical therapy intervention as part of that assessment.

DESIGN

Six outpatient rehabilitation clinics voluntarily agreed to incorporate a standardized patient-centered health status questionnaire into everyday practice. Patients completed the SF-36 health status questionnaire before initiating treatment and again at discharge. Only nonsurgical patients without comorbidities were enrolled.

RESULTS

Voluntary application of the SF-36 on a small scale was achieved over a period of 3-4 mo. All health concepts improved except general health perceptions.

CONCLUSION

The results suggest that (1) a standard patient-oriented health status questionnaire can be incorporated into outpatient rehabilitation clinics, and useful information can be derived regarding outcomes; (2) careful administrative coordination is necessary to optimize follow-up and decrease burden on both patients and clinicians; (3) although improvements in health status were demonstrated, small sample sizes and the lack of control groups prevents conclusions regarding the effectiveness of physical therapy treatment; and (4) the magnitude of effect sizes suggests that controlled studies could be performed by clinicians partnering with researchers to improve outpatient rehabilitation.

Cognitive ability and functional status

Significant confusion exists in the literature about functional status. Despite its importance, little attention has focused on developing and substantiating frameworks that detail the underpinnings of functional status, which has resulted in lack of agreement about its definition and dimensions. The purpose of this literature review was to examine the development of functional status and to describe the inclusion of its cognitive dimension. Cognition is one key dimension of functional status. One must 'know how' to perform to be successful in an activity. While cognitive capacity is generally considered in relation to functional status, the nature of the cognitive dimension is poorly described and poorly understood. Three databases were selected for review: Citations in Nursing and Allied Health (CINAHL), Psychology Literature (PsychLit), and the Medical data base known as MedLine. Key word searches identified thousands of sources. This analysis includes an extensive sampling of these sources from the 1960s through to 1998. The sources sorted into four primary categories and demonstrate a growing recognition of the cognitive dimension of functional status in the literature. Despite this recognition, the lack of conceptual clarity of both the term functional status and its cognitive dimension limits communication among disciplines and limits comparisons of functional status outcomes across studies. Functional status models are needed that include cognition as a core dimension. Population specific descriptions of the cognitive dimension should be guided by knowledge in the neurosciences.

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research

OBJECTIVE

The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of re evant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made.

METHOD

Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH.

RESULTS

Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived hea th as the subjective part of the person level and domain-specific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal mode is intended to serve as a framework in which different outcomes can be positioned in relation to each other.

CONCLUSION

Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

Techniques for measurement and assessment of mobility in rehabilitation: a theoretical approach

OBJECTIVE

Mobility is an important construct in rehabilitation; many instruments have emerged which measure or assess (aspects of) mobility. In the selection or development of an appropriate technique, knowledge about the fundamentals of rehabilitation medicine is needed, as well as about essential characteristics of techniques and fundamental differences between them. The aim of this paper is to classify, assess and discuss current techniques which are or can be used to measure aspects of mobility.

DESIGN

Eight techniques (physical science techniques, clinimetry, observation, diaries, questionnaires, actigraphy, physiological techniques and activity monitors) are classified, assessed and discussed, based on the level of outcome measures, the aspect of mobility they measure, and methodological and practical criteria.

RESULTS AND CONCLUSIONS

Rehabilitation medicine has a particular need for instruments that enable measurement of outcome measures on the level of activity and role fulfillment. Techniques differ in the type and number of mobility aspects they measure. Furthermore, important differences exist based on methodological and practical criteria. One optimal technique does not exist: the choice of a technique always depends on a complexity of factors, such as clinical problem, research questions, the mobility aspect of interest, required methodological strength, costs and availability.

Predictors of health status and life satisfaction in spinal cord injury

OBJECTIVE

To analyze relationships between injury-related variables, demographic variables, functional health status, and life satisfaction of people with spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

A community in the Netherlands.

SUBJECTS

Three hundred eighteen people with SCI, aged 18 to 65 years. Mean age was 39.4 years and mean time after injury was 3.6 years.

MAIN OUTCOME MEASURES

Health status was measured with the SIP68. Its six scales were aggregated to three dimensions, measuring physical, psychologic, and social functioning. Life satisfaction was measured with the Life Satisfaction Questionnaire. Data were analyzed by path analysis using LISREL V8.

RESULTS

Obtained scores showed that respondents suffered from serious limitations in physical functioning and social functioning, had only a few limitations in psychologic functioning, and were satisfied with their lives in general and with most life domains. Physical functioning was accurately predicted by injury-related variables, but psychologic functioning was not. Next to level and completeness of the injury, the number of secondary complications turned out to be a predictor of functional health. In a path model that had a close fit with the data, injury-related variables were related to health status but not to life satisfaction. Social functioning (-.48), marital status (-.38), psychologic functioning (-.19), and age (-.16) were significant predictors of life satisfaction (total R2=.44).

CONCLUSIONS

This study points out the high prevalence of secondary complications and their importance to the health status of people with SCI. Level of social and psychologic functioning are more important predictors of life satisfaction than the seriousness of the injury.

The health status of women with cerebral palsy

OBJECTIVE

To determine preliminary associations between collected health status variables of women with cerebral palsy (CP) residing in the community.

DESIGN

Cross-sectional study using survey research.

PARTICIPANTS

Sixty-three women residing in the community were administered the Telephone Questionnaire when contacted to arrange their visit to the study site located within the medical clinic of a local developmental services office. During the course of their visit to the study site, all 63 women completed the CP Study Protocol, in addition to the Mail-in Questionnaire upon completion of study participation. The women ranged in age from 20 to 74 years.

MAIN OUTCOME MEASURES

Health status, consisting of four elements: (1) self-reported health status; (2) associated conditions; (3) secondary conditions; and (4) health behaviors (alcohol and tobacco use, physical activity, diet, and health care visit).

RESULTS

Women with CP residing in community living arrangements perceived themselves as healthy. The majority of women did not smoke (98%), had not consumed alcohol in the previous month (95%), and ate a balanced diet (52%). Participants also reported engaging in common physical activities (83%) and stretching and doing range-of-motion exercises in the previous week (43%), and participation in aerobic exercise in the previous week (43%). Sixty-eight percent (41 of 60) of the women walked, and more than 50% of the women did not require assistance with activities of daily living. The ability to walk and the use of a wheelchair were associated with participation in the common physical activities. The women reported associated conditions of mental retardation (34%), learning disabilities (26%), and a seizure history (40%). Additionally, the women in the sample reported the occurrence of several secondary conditions common among individuals with CP, including pain (84%), hip and back deformities (59%), bowel problems (56%), bladder problems (49%), poor dental health (43%), and gastroesophageal reflux (28%). Poor dental health was associated with a history of seizures, and associations were also found between pain and mental retardation, and between gastroesophageal reflux and mental retardation.

CONCLUSIONS

Women with CP residing in the community perceived themselves as healthy, and the observed health status measures (eg, self-reported health, associated conditions, secondary conditions, and selected health behaviors) support this concept. For the most part, independent relationships were found between several of these measures indicating no significant association among the variables. Where associations were found, however, such as between walking and participation in physical activity, further investigation is warranted for a better understanding of their ramifications in the design of health promotion activities for women with CP.

The SIP68: a measure of health-related functional status in rehabilitation medicine

OBJECTIVE

To demonstrate the usefulness of the SIP68, a recently developed short version of the sickness impact profile (SIP), for measuring health-related functional status in rehabilitation medicine.

DESIGN

Survey, oral interviews.

SETTING

Patient's homes.

PATIENTS

315 persons (out of 423 that could be reached) with a spinal cord injury whose mean average age was 39.4 years and who were living in the community at the time of the interview.

MAIN OUTCOME MEASURES

Internal consistency is tested by computing Cronbach's alpha. Construct validity is tested by principal components analysis and computing Cattell's similarity index. Criterion validity is tested by comparing SIP68 results with the level of the spinal cord lesion and with results of specific measures of disability (Barthel Index) and life satisfaction (Life Satisfaction Questionnaire), and with vocational status.

RESULTS

SIP68 scores and subscale scores indicate that our spinal cord injured group falls well within the scope of this instrument. Internal consistency figures are good and the proposed six-dimensional structure is confirmed. Criterion validity figures are also satisfactory. Barthel Index scores show high agreement with the scores of the subscale "somatic autonomy," moderate agreement with the other physically related and socially related subscales, and low agreement with the mentally related subscales of the SIP68. LSQ scores show low agreement with the physically related subscales and moderate agreement with the mentally and socially related subscales. Figures of vocational status show strongest agreement with the socially oriented subscales.

CONCLUSION

The SIP68 is recommended as a useful generic outcome measure for research in rehabilitation medicine.

Performance measurement in prostate cancer care: beyond report cards

OBJECTIVES

Review and analyze various approaches to performance measurement in health care, demonstrating the value of provider-initiated performance measurement in which ongoing monitoring of both processes and outcomes of care coupled with the use of clinical guidelines enhances performance improvement efforts. Describe some of the issues and findings associated with the use of such a methodology in prostate cancer care.

METHODS

Literature review and case study.

RESULTS

There are a number of significant limitations in the use of a "report card" methodology to improve quality and efficiency in health care. The complementary approach of combining "instrument panels" and clinical guidelines within an overall continuous quality improvement framework appears to have resulted in improved clinical outcomes and reduced costs in a six-physician urology group located in a heavily managed-care penetrated market.

CONCLUSIONS

Performance measurement tools are integral to efforts to improve outcomes and efficiency in health care. Providers of care might consider adapting the kind of performance improvement methodology described in this article. Practice benefits including improved clinical and economic outcomes are likely to follow.

Quality of life in patients with intermittent claudication

OBJECTIVE

As intermittent claudication (IC) infrequently progresses to limb loss many clinicians adopt a conservative approach to treatment. Recently percutaneous transluminal angioplasty (PTA) has been applied to patients with IC. If this were to become the first line treatment for IC it would have major implications in terms of hospital facilities as well as cost. A measure is required, therefore, to decide on rationing of limited financial resources. "Quality of life" may be more influential in determining demand on services since objective medical criteria cannot give an insight into the patients feelings of well being.

DESIGN

We applied the Nottingham Health Profile, by post, to a group of claudicants and age/sex matched controls. 70% responded from both groups. Claudicants who had recently received intervention were excluded, as were controls complaining of any leg pains on walking.

RESULTS

The results showed that claudicants have greater perceived problems in the areas of energy, pain, emotional reactions, sleep, and physical mobility compared to controls (p < 0.05; Mann-Whitney Test). This was reflected by a significantly greater positive response rate to problems with activities of daily living (0.05 > p > 0.02; Chi-square Test) in the claudicant group.

CONCLUSION

Because of the cost and resource implications of introducing measures such as PTA to the treatment of vast numbers of patients with IC, we suggest that trials are needed to compare various treatments using quality of life measurements in addition to traditional efficacy/safety parameters.

Determining functional/health status and its relation to disability in stroke survivors

BACKGROUND AND PURPOSE

Determining the functional/health status of stroke survivors poses special difficulties because of cognitive impairments that frequently result from stroke. A possible means of assessing the status of stroke survivors who are cognitively impaired is getting proxy responses from a family member or other caregiver. Proxy agreement was evaluated for two measures of functional/health status, the Frenchay Activities Index (FAI) and the Health Status Questionnaire (HSQ), and a measure of disability, the Functional Independence Measure (FIM).

METHODS

Thirty-eight stroke survivors were administered the measures at follow-up (median time since the stroke, 6 months). Caregivers were instructed to answer as proxies for the stroke survivors in their care. Demographics on age, sex, race, marital status, educational level, side of lesion, and relation of stroke survivor to caregiver were collected.

RESULTS

Proxy agreement was excellent for the FAI (intraclass correlation, .85) and the FIM (.87), but poor for the HSQ scales (average proxy agreement, .32). Patients' scores were low and positively skewed for the FAI but high and negatively skewed for the FIM. Although Spearman rho coefficients between the measures were fairly high for both stroke survivors and proxy respondents, the correlation of scores was substantially weaker when the group of less severely impaired survivors (as established by FIM ratings) was considered separately.

CONCLUSIONS

The FAI and the FIM are useful for assessing the functional/health status of stroke survivors because answers can be obtained by proxy. Future studies should examine the relations between disability and functional/health status, with explicit attention paid to variations in the level of disability in the stroke survivors.