Cluster analysis to identify the profiles of individuals with compromised bone health versus unfortunate wrist fractures within the Canadian Longitudinal Study of Aging (CLSA) database

We used cluster analysis to determine the profiles of individuals who sustained wrist fractures. We found two groups: (1) young and active and (2) older and less active. This information may be used to identify individuals who require further bone health interventions to optimize healthy aging.

INTRODUCTION

Distal radial fractures (DRF) are the most common of all fractures, with 6% of males and 33% of females having one at some point in their lifetime. We hypothesize that DRF consists of two subpopulations: one with compromised bone health that is early in the osteoporosis (OP) trajectory and another which are active and healthy and suffer a misfortune fracture due to their high activity levels or risk-taking behaviors. The latter is likely to recover with a minimal disability, while the former may signal a negative health trajectory of disability and early mortality.

OBJECTIVE

To determine the profiles of individuals who sustained wrist fractures using cluster analysis within the Comprehensive Cohort of the Canadian Longitudinal Study on Aging (CLSA) database considering factors that reflect bone health and activity levels.

METHODS

We included all the individuals who had a wrist fracture within the CLSA comprehensive cohort of the database (n = 968). The baseline data was used for this analysis. A 2-step cluster analysis was used to identify profiles that were both statistically and clinically meaningful. Variables that were used in the cluster analysis include demographic variables, physical activity status indicators, general health indicators, mobility indicators, bone health indicators, comorbid conditions, and lifestyle factors.

RESULTS

We were able to identify two distinct profiles that were statistically and clinically meaningful confirming our hypothesis. One cluster included a predominantly younger cohort, who are physically active, with less comorbid conditions, better bone health, and better general health, while the opposite was true of the first cohort.

CONCLUSION

We were able to identify two clusters-a healthy profile and a bone health compromised profile. This information may be used to identify the subgroup of people who should be targeted in the future for more intensive preventive health services to optimize healthy aging.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

Rasch analysis of The Shoulder Pain and Disability Index (SPADI) in a postrepair rotator cuff sample

STUDY DESIGN

Clinical measurement study: Level of evidence (N/A) INTRODUCTION: The Shoulder Pain and Disability Index (SPADI) is a self-reported outcome measure of pain and disability related to shoulder pathology. In comparison to Classical Test Theory (CTT), Rasch analysis offers a more rigorous examination of the measurement properties of a scale.

PURPOSE OF THE STUDY

This study utilizes Rasch analysis to evaluate the psychometric properties of the SPADI to propose potential modifications and avenues for future investigation.

METHODS

SPADI scores (n = 212) from participants one-year post rotator cuff repair were collected from an outpatient specialty clinic. Fit to the Rasch model, unidimensionality of the subscales, and areas of bias were evaluated.

RESULTS

Both the pain and disability subscales satisfied the requirements of the Rasch model with very minimal modifications and demonstrated unidimensionality. The person separation index was found to be high (P > .80), indicating reliability and internal consistency. Sex and the affected dominant side influenced how people scored on the SPADI (Differential item functioning (DIF)).

CONCLUSIONS

The findings suggest some patients in our sample have difficulty discriminating between item responses, particularly within the middle of the scale. Rasch analysis supports the clinical measurement properties of consistency and reliability, previously determined by CTT methods.

The Patient-Rated Elbow Evaluation and the American Shoulder and Elbow Surgeons-Elbow form capture aspects of functioning that are important to patients with elbow injuries

STUDY DESIGN

This is a cross-sectional study.

INTRODUCTION

The Patient-Rated Elbow Evaluation (PREE) and the self-report section of the American Shoulder Elbow Surgeons-elbow form (pASES-e) are two important elbow-specific self-report measures used in routine clinical practice.

PURPOSE OF THE STUDY

To use the International Classification of Functioning Disability and Health (ICF) to link aspects of functioning that are reported using the Patient-Specific Functional Scale by a cohort of patients with elbow disorders and compare it to the content of the PREE and the pASES-e.

METHODS

One hundred patients with a variety of elbow disorders (mean age and SD 53.88 (14.51); M: F 48: 52) were recruited from the Roth-McFarlane Hand and Upper Limb Centre. They self-reported important aspects of functioning using the Patient-Specific Functional Scale. These concerns were linked to the ICF using formal linking procedures. These ICF categories were compared to the categories related to the PREE and the pASES-e. Linking was carried out by two independent raters, and agreement was calculated using percentage agreement.

RESULTS

A total of 423 self-reported functional activities were linked to 25 second-level ICF categories from the activity and participation domain. Commonly reported activities were D640 doing housework (52%); D540 dressing (47%); and D475 driving (35%). PREE had better coverage of the patient concerns (71%) than pASES-e (50%). D475-driving (35%) and D440-fine hand use (24%) were the 2 major categories that were not captured by the questionnaires. Agreement between the raters was 90.5%.

DISCUSSION

This study established that the PREE and the pASES-e were able to capture aspects of functioning important to patients and that align with the ICF, with this happening to a greater extent on the PREE than the pASES-e. Because all patients reported concerns from the activity and participation section ('d' categories) of the ICF, this validated that these PROMs measure this conceptual domain.

CONCLUSION

The PREE provided more comprehensive coverage of patients' functional concerns than the pASES-e.

Psychometric properties and cross-cultural adaptation of the Patient-Rated Tennis Elbow Evaluation (PRTEE); a systematic review and meta-analysis

PURPOSE

To synthesize and appraise the evidence on the translation, cross-cultural adaptation, and psychometric properties of the Patient-Rated Tennis Elbow Evaluation (PRTEE).

METHOD

Five electronic databases were searched from 1999 to 2021. Two independent reviewers assessed the risk of bias and quality of the included studies using the COSMIN recommended guidelines. The overall quality of the evidence on each psychometric property was provided using the GRADE approach.

RESULTS

Twenty-one studies met the criteria for inclusion in this review. The PRTEE was translated and cross-culturally adapted to 13 languages and cultures. High quality of evidence supports sufficient pooled results for test-retest reliability (0.96(CI: 0.94-0.97)), construct validity (against Disabilities of the Arm, Shoulder, and Hand (DASH): 0.81(CI: 0.76-0.85), against Visual Analogue Scale (VAS): 0.70 (0.62-0.74)), and responsiveness of the PRTEE. The overall rating of the structural validity and internal consistency (0.96(CI: 0.94-0.97)) was indeterminate, and the quality of evidence was low and moderate, respectively. Regarding measurement error, the overall rating of the summarized results (Standard error of measurement (SEM): 3.1 (1.8 to 4.4) and Minimal Detectable Change (MDC₉₅): 8.9 (5.3-12.5)) was sufficient, and the quality of evidence was moderate.

CONCLUSION

Moderate to high quality evidence supports adequate psychometric properties of the PRTEE in terms of internal consistency, test-retest reliability, measurement error, hypothesis testing for construct validity, and responsiveness.Implications for RehabilitationThe PRTEE can measure the construct of pain and disability at a single time-point and detect changes over time precisely.The PRTEE can be used in clinical setting for patients with acute, subacute, and chronic Lateral Elbow Tendinopathy (LET), athletes who suffer from elbow pain and tennis players.

Evaluation of the Structural Validity of the Work Instability Scale Using the Rasch Model

Objective

To use Rasch analysis to examine the measurement properties of the 23-item version of the Work Instability Scale (WIS-23) in a sample of worker compensation claimants with upper extremity disorders.

Design

Secondary data analysis on the data retrieved from a cross-sectional study.

Setting

Tertiary care hospital.

Participants

Patients (N=392) attending a specialty clinic for workers with upper limb injuries at a tertiary hospital were prospectively enrolled.

Interventions

Not applicable.

Main Outcome Measures

WIS-23.

Results

The study sample contained 392 participants between the ages of 19 and 73 years (mean, 47.0±10.5y). There were 148 (37.8%) women, 182 (46.4%) men, and 62 (15.8%) participants for whom sex identification was unavailable. The initial WIS data analysis showed significant misfit from the Rasch model (item-trait interaction: χ²=293.52; P<.0001). Item removal and splitting were performed to improve the model fit, resulting in a 20-item scale that met all assumptions (χ²=160.42; P=.008), including unidimensionality, local independence of items, and the absence of differential item function based on age, sex of respondents, employment type, and affected upper extremity area across all tested factors.

Conclusion

With the application of Rasch analysis, we refined the WIS-23 to produce a 20-item WIS for work-related upper extremity disorders (WIS-WREUD). The 20-item WIS-WREUD demonstrated excellent item and person fit, unidimensionality, acceptable person separation index, and local independency. The WIS-20 may provide better measurement properties, although longitudinal psychometric evaluations are needed.

Clinical measurement properties of malnutrition assessment tools for use with patients in hospitals: a systematic review

Background

The use of malnutrition outcome measures (OM) by registered dietitians (RD) with inpatients in hospitals has increased promoting the achievement of nutritional care goals and supporting decision-making for the allocation of nutritional care resources in hospitals. There are 3 commonly used OMs: Subjective Global Assessment (SGA), Patient Generated-Subjective Global Assessment (PG-SGA) and Mini Nutritional Assessment (MNA). The purpose of this current study was to systematically review the evidence of the clinical measurement properties of malnutrition assessment tools for use with patients admitted in hospitals.

Methods

MEDLINE, Cinahl, EMBASE, and PubMed were searched for articles published between 2000 and 2019. Research articles were selected if they established reliability, validity, and responsiveness to change properties of the SGA, PG-SGA and MNA tools, were written in English, and used any of these OMs as an outcome measure. Abstracts were not considered. The risk of bias within studies was assessed using the Quality Appraisal for Clinical Measurement Study (QA-CMS).

Results

Five hundred five studies were identified, of which 34 articles were included in the final review: SGA (n = 8), PG-SGA (n = 13), and MNA (n = 13). Of the 34 studies, 8 had a quality score greater than 75%; 23 had a quality score of 40–75% and 3 studies had a quality score of less than 40%. PG-SGA was found to have excellentdiagnostic accuracy (ROC: 0.92–0.975; Sensitivity: 88.6–98%; Specificity: 82–100%), sufficient internal consistency (Cronbach’s alpha: 0.722–0.73), and strong test-retest reliability (r = 0.866). There was insufficient evidence to suggest adequate diagnostic accuracy and good inter-rater reliability for SGA. Only one study examined the minimum detectable change of MNA (MDC = 2.1).

Conclusions

The evidence of validity for the existing malnutrition assessment tools supports the use of these tools, but more studies with sound methodological quality are needed to assess the responsiveness of these OMs to detect the change in nutritional status.

Establishing the psychometric properties of 2 self-reported outcome measures of elbow pain and function: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

The Patient-Rated Elbow Evaluation (PREE) and the self-report section of the American Shoulder and Elbow Surgeons-elbow form (pASES-e) are 2 patient-reported outcome measures (PROMs) commonly used to assess pain and disability arising from elbow disorders.

PURPOSE OF THE STUDY

To systematically review and summarize the quality and content of the evidence that is available on the psychometric properties of the PREE and pASES-e.

METHODS

We systematically searched the online databases PubMed, EMBASE, ProQuest, Scopus, Cumulative Index to Nursing and Allied Health Literature, UptoDate, ProQuest Dissertations & Theses, and Google Scholar. Ninety-one articles were retrieved, and after screening, 9 were included in the final analysis. Data extraction and quality appraisal was performed by 2 independent raters. Descriptive synthesis of the reviewed studies was completed.

RESULTS

Seven of the 9 studies had a quality score of 75% or higher. Agreement between the raters was good (kappa, 0.81). Both the PROMs did not demonstrate any floor and ceiling effects except for the satisfaction subscale of the pASES-e. Factor analysis revealed multidimensionality in the function subscale for both the PROMs. Construct validity was good with correlations above 0.70. Both were highly reliable with interclass correlation coefficient of >0.90. They were also highly responsive with an effect size and standardized response mean above 1. The minimal clinical important difference was not estimated for either measures.

DISCUSSION

This study concluded that strong clinical measurement properties exist for both the PREE and the pASES-e. We identified gaps in the current evidence for both the ASES-e and the PREE. Future studies need to calculate clinically important estimates like MCID, SEM, and others; and provide clear and specific conclusions.

CONCLUSION

The PREE and pASES-e have been established to be valid, reliable, and sensitive to change in both clinical and research settings based on high-quality evidence.

The Effect of Simulated Total Distal Interphalangeal Joint Stiffness on Grip Strength

Purpose

Production of a functional grip pattern requires the concerted action of numerous structures within the hand. This study quantifies the effect of total distal interphalangeal joint (DIPJ) stiffness to grip strength.

Methods

Fifty (25 men, 25 women, 100 hands) individuals with a mean age of 38 years (range: 17-69 years) were recruited. Exclusion criteria included history of previous upper limb injury, neuropathies, or systemic disease. Custom thermoplastic orthoses were used to splint participants' DIPJ in full extension simulating stiffness. Grip strength before and after splinting was measured using a calibrated Jamar dynamometer. Data were analyzed using paired and independent sample t tests and 2 × 2 repeated-measures analysis of variance with hand dominance and configuration (splinted or unsplinted) as within-subject factors.

Results

Restriction of DIPJ flexion led to a 20% decrease in grip strength (P < .001). There was no significant difference in this decrease between dominant and non-dominant hands. Univariate analysis did not demonstrate any interaction between hand dominance and testing configuration. Post hoc analysis revealed no statistical difference in baseline grip strength between the dominant and non-dominant hands. Furthermore, men had significantly stronger grip strength than women in all configurations (P < .001).

Conclusions

Flexion at the DIPJ contributes significantly to grip strength, and stiffness at this joint greatly limits functional capabilities of the hand. This necessitates the need for targeted rehabilitation in DIPJ injuries to minimize adverse effects on grip strength.

Rasch analysis of the patient-rated wrist evaluation questionnaire

Background

The Patient-Rated Wrist Evaluation (PRWE) was developed as a wrist joint specific measure of pain and disability and evidence of sound validity has been accumulated through classical psychometric methods. Rasch analysis (RA) has been endorsed as a newer method for analyzing the clinical measurement properties of self-report outcome measures. The purpose of this study was to evaluate the PRWE using Rasch modeling.

Methods

We employed the Rasch model to assess overall fit, response scaling, individual item fit, differential item functioning (DIF), local dependency, unidimensionality and person separation index (PSI). A convenience sample of 382 patients with distal radius fracture was recruited from the hand and upper limb clinic at large academic healthcare organization, London, Ontario, Canada, 6-month post-injury scores of the PRWE was used. RA was conducted on the 3 subscales (pain, specific activities, and usual activities) of the PRWE separately.

Results

The pain subscale adequately fit the Rasch model when item 4 “Pain - When it is at its worst” was deleted to eliminate non-uniform DIF by age group, and item 5 “How often do you have pain” was rescored by collapsing into 8 intervals to eliminate disordered thresholds. Uniform DIF for “Use my affected hand to push up from the chair” (by work status) and “Use bathroom tissue with my affected hand” (by injured hand) was addressed by splitting the items for analysis. After background rescoring of 2 items in pain subscale, 2 items in specific activities and 3 items in usual activities, all three subscales of the PRWE were well targeted and had high reliability (PSI = 0.86). These changes provided a unidimensional, interval-level scaled measure.

Conclusion

Like a previous analysis of the Patient-Rated Wrist and Hand Evaluation, this study found the PRWE could be fit to the Rasch model with rescoring of multiple items. However, the modifications required to achieve fit were not the same across studies, our fit statistics also suggested one of the pain items should be deleted. This study adds to the pool of evidence supporting the PRWE, but cannot confidently provide a Rasch-based scoring algorithm.

Electronic supplementary material

The online version of this article (10.1186/s40945-018-0046-z) contains supplementary material, which is available to authorized users.

An evaluation of the structural validity of the shoulder pain and disability index (SPADI) using the Rasch model

PURPOSE

The shoulder pain and disability index (SPADI) has been extensively evaluated for its psychometric properties using classical test theory (CTT). The purpose of this study was to evaluate its structural validity using Rasch model analysis.

METHODS

Responses to the SPADI from 1030 patients referred for physiotherapy with shoulder pain and enrolled in a prospective cohort study were available for Rasch model analysis. Overall fit, individual person and item fit, response format, dependence, unidimensionality, targeting, reliability and differential item functioning (DIF) were examined.

RESULTS

The SPADI pain subscale initially demonstrated a misfit due to DIF by age and gender. After iterative analysis it showed good fit to the Rasch model with acceptable targeting and unidimensionality (overall fit Chi-square statistic 57.2, p = 0.1; mean item fit residual 0.19 (1.5) and mean person fit residual 0.44 (1.1); person separation index (PSI) of 0.83. The disability subscale however shows significant misfit due to uniform DIF even after iterative analyses were used to explore different solutions to the sources of misfit (overall fit (Chi-square statistic 57.2, p = 0.1); mean item fit residual 0.54 (1.26) and mean person fit residual 0.38 (1.0); PSI 0.84).

CONCLUSIONS

Rasch Model analysis of the SPADI has identified some strengths and limitations not previously observed using CTT methods. The SPADI should be treated as two separate subscales. The SPADI is a widely used outcome measure in clinical practice and research; however, the scores derived from it must be interpreted with caution. The pain subscale fits the Rasch model expectations well. The disability subscale does not fit the Rasch model and its current format does not meet the criteria for true interval-level measurement required for use as a primary endpoint in clinical trials. Clinicians should therefore exercise caution when interpreting score changes on the disability subscale and attempt to compare their scores to age- and sex-stratified data.

Reliability of three landmarking methods for dual inclinometry measurements of lumbar flexion and extension

Background

To examine the intra and inter-rater reliability of lumbar flexion and extension measurements attained using three landmarking methods for dual inclinometry.

Methods

This was a repeated measures reliability study. Convenience sampling was used to obtain forty volunteer subjects. Two assessors measured a series of lumbar flexion and extension movements using the J-Tech™ dual inclinometer. Three different landmarking methods were used: 1) straight palpation of PSIS and L1, 2) palpation of PSIS and the site of the nearest 5 cm interval point closest to L1 and 3) location of PSIS and 15 cm cephalad. Upon landmarking, adhesive tape was used to mark landmarks and the inclinometer was placed on sites for three trials of flexion and extension. Tape was removed and landmarks were relocated by the same assessor (intra-rater) for an additional three trials; and this process was repeated by a second assessor (inter-rater). Reliability was determined using intra-class correlation coefficients.

Results

Reliability within a set of three repetitions was very high (ICCs > 0.90); intra-rater reliability after relocating landmarks was high (ICCs > 0.80); reliability between therapists was moderate to high (0.60 > ICCs < 0.76). Assessment of flexion and extension movements by straight palpation of bony landmarks as in the Straight palpation of PSIS and L1 method (ICC: Flexion 0.60; Extension 0.74) was found to be marginally less reliable than the other two landmarking measurement strategies (ICC: Flexion 0.66; Extension 0.76).

Conclusion

All three methods of land marking are reliable. We recommend the use of the PSIS to 15 cm cephalad method as used in the modified-modified Schobers test as it is the simplest to perform and aligns with current clinical practice.

The push-off test: development of a simple, reliable test of upper extremity weight-bearing capability

STUDY DESIGN

Longitudinal clinical measurement study.

INTRODUCTION

The push-off test (POT) is a novel and simple measure of upper extremity weight-bearing that can be measured with a grip dynamometer. There are no published studies on the validity and reliability of the POT. The relationship between upper extremity self-report activity/participation and impairment measures remain an unexplored realm.

PURPOSE

The primary purpose of this study is to estimate the intra and inter-rater reliability and construct validity of the POT. The secondary purpose is to estimate the relationship between upper extremity self-report activity/participation questionnaires and impairment measures.

METHODS

A convenience sample of 22 patients with wrist or elbow injuries were tested for POT, wrist/elbow range of motion (ROM), isometric wrist extension strength (WES) and grip strength; and completed two self-report activity/participation questionnaires: Disability of the Arm, Shoulder and the Hand (DASH) and Work Limitations Questionnaire (WLQ-26). POT's inter and intra-rater reliability and construct validity was tested. Pearson's correlations were run between the impairment measures and self-report questionnaires to look into the relationship amongst them.

RESULTS

The POT demonstrated high inter-rater reliability (ICC affected = 0.97; 95% C.I. 0.93-0.99; ICC unaffected = 0.85; 95% C.I. 0.68-0.94) and intra-rater reliability (ICC affected = 0.96; 95% C.I. 0.92-0.97; ICC unaffected = 0.92; 95% C.I. 0.85-0.97). The POT was correlated moderately with the DASH (r = -0.47; p = 0.03). While examining the relationship between upper extremity self-reported activity/participation questionnaires and impairment measures the strongest correlation was between the DASH and the POT (r = -0.47; p = 0.03) and none of the correlations with the other physical impairment measures reached significance. At-work disability demonstrated insignificant correlations with physical impairments.

CONCLUSION

The POT test provides a reliable and easily administered quantitative measure of ability to bear the load through an injured arm. Preliminary evidence supports a moderate relationship between loading bearing measured by the POT and upper extremity function measured by the DASH.

LEVEL OF EVIDENCE

1b.

A survey of practice patterns for rehabilitation post elbow fracture

BACKGROUND AND PURPOSE

Elbow fractures amount to 4.3% of all the fractures. The elbow is prone to stiffness after injury and fractures can often lead to significant functional impairment. Rehabilitation is commonly used to restore range of motion (ROM) and function. Practice patterns in elbow fracture rehabilitation have not been defined. The purpose of this study was to describe current elbow fracture rehabilitation practices; and compare those to the existing evidence base.

METHODS

Hand therapists (n=315) from the USA (92%) and Canada (8%) completed a web-based survey on their practice patterns and beliefs related to the acute (0-6 weeks) and functional (6-12 weeks) phases of elbow fracture rehabilitation.

RESULTS

More than 99% of respondents agreed that fracture severity, co-morbidities, time since fracture, compliance with an exercise program, psychological factors, and occupational demands are important prognostic indicators for optimal function. Strong agreement was found with the use of patient education (95%) and active ROM (86%) in the acute stage while, home exercise programs (99%), active ROM (99%), stretching (97%), strengthening (97%), functional activities (ADLs and routine tasks) (97%), passive ROM (95%), and active assisted ROM (95%) were generally used in the functional stage. The most commonly used impairment measures were goniometry (99%), Jamar dynamometry (97%), and hand held dynamometry (97%). Agreement on the use of patient-reported outcome measures was very minimal (1.3%- 35.6%).

CONCLUSIONS

Exercise, education, and functional activity have high consensus as components of elbo fracture rehabilitation. Future research should focus on defining the optimal dosage and type of exercise/activity, and establish core measures to monitor outcomes of these interventions.