Complete August 2012 Issue

Transcription

August 2012 Volume 92 Number 8
Research Reports
992
Influence of Fear-Avoidance Beliefs on
Functional Status Outcomes
1006
Therapist-Based Versus Robotic Bilateral
Arm Training
1017
Rasch Validation of the Short Form of the
Wolf Motor Function Test
1027
Repeated Measurements of Arm Joint Passive
Range of Motion After Stroke
1036
Italian Version of the Patient-Rated Tennis
Elbow Evaluation (PRTEE) Questionnaire
1046
Development and Psychometric Properties
of the Activity-based Balance Level Evaluation
Case Reports
1055
Cervical Disk Pathology in Multiple Sclerosis
1065
Integrated Motor Imagery at Home to
Improve Walking After Stroke
LEAP: Linking Evidence And Practice
987
Neuromuscular Training for Chronic Ankle
Instability
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References: 1. Nadler SF, Steiner DJ, Erasala GN, et al. Continuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Spine.
2002;27(10):1012-1017. 2. Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Abeln SB, Weingand KW. Continuous low-level heatwrap therapy for treating acute nonspecific low back
pain. Arch Phys Med Rehabil. 2003;84(3):329-334. 3. Nadler SF, Steiner DJ, Petty SR, Erasala GN, Hengehold DA, Weingand KW. Overnight use of continuous low-level heatwrap
therapy for relief of low back pain. Arch Phys Med Rehabil. 2003;84(3):335-342. 4. Data on file. Pfizer Consumer Healthcare.
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Physical Therapy
Journal of the American Physical Therapy Association
■ Volume 92
■ Number 8
■ August 2012
<LEAP> Linking Evidence And Practice
987
Neuromuscular Training for Chronic Ankle Instability /
Chung-Wei Christine Lin, Eamonn Delahunt, Enda King
Research Reports
992
Influence of Fear-Avoidance Beliefs on Functional Status
Outcomes for People With Musculoskeletal Conditions of
the Shoulder / Bhagwant S. Sindhu, Leigh A. Lehman, Sergey Tarima,
Mark D. Bishop, Dennis L. Hart, Matthew R. Klein, Mikesh Shivakoti,
Ying-Chih Wang
Winslow Homer (American, 1836–1910).
A Basket of Clams, 1873. Copyright © The
Metropolitan Museum of Art, New York,
NY. Photo Credit: Art Resource, NY
Homer spent the summer of 1873 in
Gloucester, Massachusetts, where he
painted a number of works that observed
children in their daily activities. Here, 2
boys carry a heavy bucket of clams; the
smaller boy looks awkwardly—and perhaps
warily—at the contents, rotating his neck
with lateral flexion to the right. The older
boy appears to be looking at the beached
ship, or perhaps looking away from a dead
fish in the foreground. Art historians note
that, in the period immediately following
the Civil War, many American artists seemed
to focus on children as symbols of both a
simpler past and a brighter future.
1006
Effect of Therapist-Based Versus Robot-Assisted Bilateral
Arm Training on Motor Control, Functional Performance,
and Quality of Life After Chronic Stroke: A Clinical Trial /
Ching-yi Wu, Chieh-ling Yang, Li-ling Chuang, Keh-chung Lin,
Hsieh-ching Chen, Ming-de Chen, Wan-chien Huang
1017
Rasch Validation of the Streamlined Wolf Motor Function
Test in People With Chronic Stroke and Subacute Stroke /
Hui-fang Chen, Ching-yi Wu, Keh-chung Lin, Hsieh-ching Chen,
Carl P-C. Chen, Chih-kuang Chen
1027
Repeated Measurements of Arm Joint Passive Range of
Motion After Stroke: Interobserver Reliability and Sources
of Variation / Lex D. de Jong, Pieter U. Dijkstra, Roy E. Stewart,
Klaas Postema
1036
Cross-Cultural Adaptation and Measurement Properties
of the Italian Version of the Patient-Rated Tennis Elbow
Evaluation (PRTEE) Questionnaire / Angelo Cacchio,
Stefano Necozione, Joy C. MacDermid, Jan Dirk Rompe, Nicola Maffulli,
Ferdinando di Orio, Valter Santilli, Marco Paoloni
Craikcast
Listen to PTJ’s new monthly podcast series!
Editor in Chief Rebecca Craik gives her unique
insights on the August issue. Available at ptjournal.apta.org/
content/92/8/suppl/DC1 and through iTunes.
982 ■ Physical Therapy Volume 92 Number 8
August 2012
1046
The ABLE Scale: The Development and Psychometric
Properties of an Outcome Measure for the Spinal Cord
Injury Population / Elizabeth M. Ardolino, Karen J. Hutchinson,
Departments
986
The Bottom Line
1081
Scholarships, Fellowships,
and Grants
Genevieve Pinto Zipp, MaryAnn Clark, Susan J. Harkema
News from the Foundation for
Physical Therapy
Case Reports
1055
Cervical Disk Pathology in Patients With Multiple
Sclerosis: Two Case Reports / Ann E. Mullen,
1083
Product Highlights
1084
Ad Index
Mary Ann Wilmarth, Sue Lowe
1065
Patient-Centered Integrated Motor Imagery Delivered
in the Home With Telerehabilitation to Improve
Walking After Stroke / Judith E. Deutsch, Inbal Maidan,
Ruth Dickstein
Health Policy in Perspective
1078
Rothstein Roundtable Podcast “Medical Homes, PACA,
IFDS—Where Do Physical Therapists Fit in a Reforming
Health Care Environment?”
Corrections
1079
Kersten RF, Stevens M, van Raay JJAM, et al. Habitual
physical activity after total knee replacement: analysis in 830 patients and comparison with a sex- and
age-matched normative population. Phys Ther. doi:
10.2522/ptj.20110273.
1079
Niemeijer AS, Reinders-Messelink HA, Disseldorp LM,
et al. Feasibility, reliability, and agreement of the
WeeFIM instrument in Dutch children with burns.
Phys Ther. 2012;92:958–966.
Visit ptjournal.apta.org
Listen to audio podcasts.
View videoclips.
Listen to discussion
podcasts.
August 2012
TOC_8.12.indd 983
Volume 92 Number 8 Physical Therapy ■ 983
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Physical Therapy
Journal of the American Physical Therapy Association
Editor in Chief
Deputy Editor in Chief
Daniel L. Riddle, PT, PhD, FAPTA
Richmond, VA
Rebecca L. Craik, PT, PhD, FAPTA
Philadelphia, PA
[email protected]
Editor in Chief Emeritus
Jules M. Rothstein, PT, PhD, FAPTA
(1947–2005)
Editorial Board
Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia; W. Todd Cade, PT, PhD, St Louis, MO;
James R. Carey, PT, PhD, Minneapolis, MN; John Childs, PT, PhD, Schertz, TX; Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT, Concord, NH;
Janice J. Eng, PT/OT, PhD, Vancouver, BC, Canada; Steven Z. George, PT, PhD, Gainesville, FL;
Kathleen Gill-Body, PT, DPT, NCS, Boston, MA; Jan Willem Gorter, PhD, MD, FRCPC, Hamilton, Ont, Canada;
Rana Shane Hinman, PT, PhD, Melbourne, Victoria, Australia; Diane U. Jette, PT, DSc, FAPTA, Burlington, VT;
Sarah H. Kagan, PhD, FAAN, RN, Philadelphia, PA; Michel D. Landry, BScPT, PhD, Durham, NC;
Teresa Liu-Ambrose, PT, PhD, Vancouver, BC, Canada; Christopher Maher, PT, PhD, Sydney, NSW, Australia;
Chris J. Main, PhD, FBPsS, Keele, United Kingdom; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA;
Sarah Westcott McCoy, PT, PhD, Seattle, WA; Patricia J. Ohtake, PT, PhD, Buffalo, NY; Carolynn Patten, PT, PhD, Gainesville, FL;
Linda Resnik, PT, PhD, OCS, Providence, RI; Kathleen Sluka, PT, PhD, Iowa City, IA; Nicholas Stergiou, PhD, Omaha, NE;
Chair, Rothstein Roundtable: Anthony Delitto, PT, PhD, FAPTA, Pittsburgh, PA
Statistical Consultants
Steven E. Hanna, PhD, Hamilton, Ont, Canada; John E. Hewett, PhD, Columbia, MO; Melissa Krauss, MPH, St Louis, MO;
Hang Lee, PhD, Boston, MA; Xiangrong Kong, PhD, Baltimore, MD; Michael E. Robinson, PhD, Gainesville, FL;
Paul Stratford, PT, MSc, Hamilton, Ont, Canada; David Thompson, PT, PhD, Oklahoma City, OK; Samuel Wu, PhD, Gainesville, FL
Committee on Health Policy and Ethics
Linda Resnik, PT, PhD, OCS (Chair), Providence, RI; Janet Freburger, PT, PhD, Chapel Hill, NC; Alan M. Jette, PT, PhD, FAPTA, Boston, MA;
Michael Johnson, PT, PhD, OCS, Philadelphia, PA; Justin Moore, PT, DPT, Alexandria, VA; Ruth B. Purtilo, PT, PhD, FAPTA, Boston, MA
<LEAP> Linking Evidence And Practice Advisory Group
Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia (Co-Chair);
Diane U. Jette, PT, DSc, FAPTA, Burlington, VT (Co-Chair); W. Todd Cade, PT, PhD, St Louis, MO;
Christopher Maher, PT, PhD, Sydney, NSW, Australia; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA;
David Scalzitti, PT, PhD, OCS, Alexandria, VA
Senior Reviewers
J. Haxby Abbott, PT, PhD, FNZCP; Karen Abraham-Justice, PT, PhD; Louis Amundsen, PT; Paul Beattie, PT, PhD, OCS, FAPTA;
Anjana Bhat, PT, PhD; Joel Bialosky, PT, PhD; Jill Boissonnault, PT, PhD; Jennifer Brach, PT, PhD; Timothy Brindle, PT, PhD, ATC;
Daniel Cipriani, PT, PhD; Chad Cook, PT, PhD, MBA, OCS, FAAOMPT; Janet Copeland, Dip PT, BA, MHealSc; Leonardo Costa, PT, PhD;
Vanina Dal Bello-Haas, PT, PhD; Diane Damiano, PT, PhD; Todd Davenport, PT, DPT, OCS; Richard Debigare, PT, PhD; Joost Dekker, PhD;
Nandini Deshpande, PhD; Susan Deusinger, PT, PhD, FAPTA; Nancy Devine, PT, DPT; Elizabeth Domholdt, PT, EdD, FAPTA;
Sheryl Finucane, PT, PhD; Janet Freburger, PT, PhD; Julie Fritz, PT, PhD, ATC; Marc Goldstein, EdD; Bruce Greenfield, PT, PhD, OCS;
Christina Gummesson, PT, PhD; Janet Gwyer, PT, PhD, FAPTA; Mijna Hadders-Algra, MD, PhD; Timothy Hanke, PT, PhD;
Lisa (Elizabeth) Hannold, PhD; Regina Harbourne, PT, PhD, PCS; Lisa Harvey, PT, PhD; Chris Hass, PhD; Karen Hayes, PT, PhD, FAPTA;
Thomas Hornby, PT, PhD; Gail Jensen, PT, PhD, FAPTA; Dianne Jewell, PT, DPT, PhD, CCS; Suzanne Kuys; Pamela Levangie, PT, DSc, DPT, FAPTA;
Sandra Levi, PT, PhD; Patricia Manns, PT, PhD; Ray Marks, EdD; Sunita Mathur, PT; Karen McCulloch, PT, PhD, NCS; Christine McDonough, PT, PhD;
Irene McEwen, PT, PhD, FAPTA; Chris McGibbon, PhD; Jan Mehrholz, PT, DrPH, MPH; Susanne Morton, PT, PhD; Michael Mueller, PT, PhD, FAPTA;
Gina Musolino, PT, MSEd, EdD; Kerstin Palombaro, PT, PhD; Claire Peel, PT, PhD, FAPTA; Andrew Ray, PT, PhD; Kathryn Roach, PT, PhD;
Kathleen Rockefeller, PT, ScD, MPH; Dorian Rose, PT, PhD; Michael Ross, PT, DHS, OCS; Robert Sandstrom, PT, PhD;
Ruth Sapsford, AUA, DipPhty; Sheila Schindler-Ivens, PT, PhD; Timothy Sell, PT, PhD; Patricia Sinnott, PT, PhD, MPH;
Jill Stewart, PT, PhD, NCS; Laura Swisher, PT, PhD, MDiv; Julie Tilson, PT, DPT, NCS; Carole Tucker, PT, PhD, PCS; Kirsti Uusi-Rasi, PhD;
Ying-Chih Wang, PhD; Gilbert Willett, PT, PhD, OCS, CSCS; Rick Wilson, PT, PhD
Editorial Office
Managing Editor / Director of Evidence-Based Resources: Jan P. Reynolds, [email protected]; PTJ Online Editor / Assistant Managing Editor: Steven Glaros;
Associate Editor: Stephen Brooks, ELS; Production Manager: Liz Haberkorn; Manuscripts Coordinator: Karen Darley;
Permissions / Reprint Coordinator: Michele Tillson; Advertising Manager: Julie Hilgenberg; Art Director: Barbara Cross; Publisher: Lois Douthitt
APTA Executive Staff
Vice President for Communications: Felicity Feather Clancy; Chief Financial Officer: Rob Batarla; Chief Executive Officer: John D. Barnes
Advertising Sales
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Board of Directors
President: Paul A. Rockar Jr, PT, DPT, MS; Vice President: Sharon L. Dunn, PT, PhD, OCS; Secretary: Laurita M. Hack, PT, DPT, MBA, PhD, FAPTA;
Treasurer: Elmer Platz, PT; Speaker of the House: Shawne E. Soper, PT, DPT, MBA; Vice Speaker of the House: William F. McGehee, PT, MHS;
Directors: Jennifer E. Green-Wilson, PT, MBA, EdD; Jeanine M. Gunn, PT, DPT; Roger A. Herr, PT, MPA, COS-C; Dianne V. Jewell, PT, DPT, PhD, CCS, FAACVPR;
Stephen M. Levine, PT, DPT, MSHA; Kathleen K. Mairella, PT, DPT, MA; Dave Pariser, PT, PhD; Mary C. Sinnott, PT, DPT, MEd; Nicole L. Stout, PT, MPT, CLT-LANA
Masthead_8.12.indd 984
August 2012
7/13/12 4:13 PM
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7/13/12 4:13 PM
The Bottom Line
The Bottom Line summarizes the key points of articles that report research with a direct impact
on patient care.
Influence of Fear-Avoidance
Beliefs on Functional Status
Outcomes
Fear-avoidance beliefs related to pain
are prevalent among people with musculoskeletal conditions, and these beliefs
have been associated with greater disability and functional limitations. However, it is not known how pain-related
fear-avoidance beliefs affect the outcome
of rehabilitation in people with shoulder
impairments. Elevated fear-avoidance
beliefs were associated with poorer improvement in functional status from in-
take to discharge among people in the
following 2 shoulder disease categories:
(1) muscle, tendon, and soft-tissue disorders, and (2) osteopathies, chondropathies, and acquired musculoskeletal
deformities. Message for patients: The
data from this study suggest that if you
have a condition in 1 of the 2 disease
categories above, your physical therapist
may be able to improve your treatment
outcomes by assessing for the presence
of fear-avoidance beliefs and helping you
manage those beliefs.
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August 2012
⬍LEAP⬎
LINKING EVIDENCE AND PRACTICE
Neuromuscular Training for Chronic Ankle Instability
Chung-Wei Christine Lin, Eamonn Delahunt, Enda King
<LEAP> highlights the findings and
application of Cochrane reviews and
other evidence pertinent to the practice of physical therapy. The
Cochrane Library is a respected
source of reliable evidence related to
health care. Cochrane systematic
reviews explore the evidence for and
against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition,
exercise—and the evidence for and
against the use of diagnostic tests for
specific conditions. Cochrane reviews
are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of
research studies published in the scientific literature.1 Each article in this
PTJ series summarizes a Cochrane
review or other scientific evidence on
a single topic and presents clinical
scenarios based on real patients or
programs to illustrate how the results
of the review can be used to directly
inform clinical decisions. This article
focuses on a patient with chronic
ankle instability who has re-sprained
his ankle and is now unable to participate in sports. Could a neuromuscular training program improve his
functional outcomes?
Find the <LEAP> case archive at
http://ptjournal.apta.org/cgi/
collection/leap.
August 2012
Ankle sprain, in particular injury to
the lateral ligament complex of the
ankle joint, is one of the most frequently encountered lower-limb injuries in sporting populations.2 In the
acute phase, ankle sprains are associated with pain, swelling, ecchymosis,
and loss of function, with up to one
quarter of all injured people being
unable to attend work for more than 7
days postsprain.3 In addition to
restricted joint range of motion and
increased joint laxity, common clinical
and research findings are disruption in
neuromuscular control as manifested
by decreased postural stability, altered
muscle activation patterns, and aberrant joint physiological and accessory
movement.
In the weeks following an ankle
sprain, activities of daily living can
be compromised, and, even though
acute symptoms resolve, persistent
symptoms are reported to occur in
30% to 40% of people,4 with higher
incidences being reported in athletes
involved in high-velocity, dynamic
sports.5 These symptoms, which
include a feeling of joint instability
and repeated episodes of the ankle
joint giving way, are part of the clinically described entity chronic ankle
instability.6 “Chronic ankle instability” is an encompassing term used to
describe the presence of mechanical
instability and functional instability
following ankle sprain.6 The symptoms still persist in up to 25% of
people at 3 years after the initial
sprain.7
There are few evidence-based clinical guidelines for ankle sprain management in primary care. Clinical
practice varies widely and often can
be limited to basic advice followed
by immediate discharge in the
absence of ankle joint fracture.8
Recently, Hertel9 developed a widely
accepted paradigm of chronic ankle
instability, whereby various functional insufficiencies and mechanical
insufficiencies are described. Clinicians can use strategies to treat the
various functional insufficiencies
described in the paradigm of Hertel.9
The generic term “neuromuscular
training” is used to describe a combination of functionally based exercises, including postural stability,
proprioceptive, and strength training, as part of a rehabilitation
regimen.
A recent Cochrane review investigated the effectiveness of any conservative or surgical treatments for
chronic ankle instability in adults.10
Of the 10 included studies, 4 evaluated neuromuscular training. The
remaining studies examined surgical
interventions (4 studies) or mobilization versus immobilization after surgery (2 studies). Only the results concerning neuromuscular training are
presented here (Appendix).
Studies compared 4 weeks of supervised
neuromuscular
training
(including wobble board and other
balance exercises) with no training
(3 studies) and bidirectional to unidirectional pedaling on a recumbent
stationary bicycle (1 study). The
study sample sizes were small, and
most studies had methodological
flaws (eg, no concealed allocation).
The studies did not provide
follow-up data other than data collected at the end of the treatment
period. The pooled results from 2
studies showed statistically significant but small functional gains when
neuromuscular training was compared with no training. A third study
comparing neuromuscular training
with no training also showed similar
Volume 92
Number 8
Physical Therapy f
987
<LEAP> Case #9 Neuromuscular Training for Chronic Ankle Instability
results. There was no difference
between bidirectional or unidirectional pedaling. The Cochrane
review did not report adverse events
as an outcome, but reviewing the
included studies showed that 1 of
the 4 studies reported on adverse
events. Hale et al11 compared a
4-week neuromuscular training program with no training and reported
that no participant withdrew from
the study due to adverse events.
Take-Home Message
Because of the low number of studies, the small sample sizes, and the
risk of bias, there is only limited evidence regarding the efficacy of neuromuscular training for ankle instability. However, the results showed a
small, short-term treatment benefit
supporting supervised neuromuscular training conducted over 20 to 30
minutes a few times a week for 4
weeks.
<LEAP> Case #9
Neuromuscular Training for
Chronic Ankle Instability
Can neuromuscular training help
this patient?
Mr. R is a 28-year-old amateur soccer
player who works as an accountant.
He had an acute right ankle sprain,
sustained while running during training, on a background of chronic
ankle instability. He played with a
club in his local competitive league
and had 2 pitch training sessions and
1 game every week during the season, which lasted approximately 32
weeks. He has had recurrent episodes of ankle instability over the
past 4 years, with 2 to 3 re-sprains
per year. All of the episodes have
occurred while participating in or
training for his sport.
Mr. R reported his current symptoms
over the lateral aspect of his right
ankle, with 5/10 pain on the visual
analog scale. His ankle was stiffer
getting out of bed in the morning,
and it took a few minutes before he
988
f
Physical Therapy
Volume 92
could walk freely. His pain was
aggravated by running or any sudden
twisting or turning, and he was currently unable to participate in training or competition. There was moderate effusion of the ankle joint and
bruising along the lateral aspect of
the dorsum of the foot, with marked
laxity on the anterior drawer test and
pain and moderate laxity on the talar
tilt test. There was tenderness along
the lateral ankle, particularly over
the anterior talofibular ligament
(ATFL) and calcaneofibular ligament
(CFL). He had mild weakness
through his peroneal and gastrocnemius muscles, reduced passive dorsiflexion of the talocrural joint, and
hypomobililty on an anteroposterior
glide of the talus. His knee to the
wall score was 11 cm on the left side
and 6 cm on the right side, with
reported stiffness and lateral ankle
pain.12 His timed single-leg stance
postural stability test with eyes
closed was reduced on the right side
(4 seconds; left side, 16 seconds). He
scored 58 on the Foot and Ankle
Score Scale component of the Foot
and Ankle Outcomes Questionnaire.
The Foot and Ankle Score Scale is a
20-item questionnaire on stiffness,
swelling, pain, activity limitation,
balance, and giving way, where 0
represents a poor outcome and 100
represents the best possible outcome.13 The scale has good content
and construct validity and reliability
for a variety of ankle and foot conditions.14 Mr. R’s score placed him
well below the 25th percentile of the
normative data, suggesting marked
disability.15 Magnetic resonance
imaging of Mr. R’s right ankle
showed complete rupture of his
ATFL and a grade 2 tear of his CFL.
There was no evidence of any fracture, but there was mild periosteal
bruising of the talus.
Number 8
How did the physical therapist
apply the results of the Cochrane
Systematic Review to the
patient?
Mr. R reported having an acute ankle
sprain with a background of chronic
ankle instability affecting his sporting and daily activities. The clinical
question, using the PICO (Patient,
Intervention, Comparison, Outcome) format, is: Would Mr. R benefit from a neuromuscular training
program to improve his functional
outcomes? The Cochrane review
supports the use of neuromuscular
training to improve function in
chronic ankle instability. The review
reported on studies that recruited
participants who had characteristics
similar to those of Mr. R; thus, the
results could be generalized to him.
Mr. R was otherwise healthy and did
not have comorbidities that would
prohibit his participation in a supervised exercise program.
Based on Mr. R’s presentation and
the evidence from the systematic
review, the physical therapist recommended a neuromuscular training
program to the patient. Mr. R had
reported carrying out some neuromuscular training after his previous
ankle sprains. His adherence to prescribed programs was poor, but he
was willing to start a new neuromuscular training program. Mr. R
received treatment once a week for
the first 4 weeks and then had his
final review appointment on week 6.
His treatment consisted initially of
reduction of pain and swelling
through ice, compression, and nonsteroidal anti-inflammatory drugs, as
well as passive accessory and passive
physiological joint mobilizations to
restore full talocrural mobility. He
was given a home neuromuscular
training program to improve his balance, ankle mobility, and ankle
strength (Tab.). He was expected to
carry out this program 5 days a
week. As there was ongoing structural laxity, Mr. R had his ankle taped
August 2012
Table.
Mr. R’s Neuromuscular Training Program as Prescribed by His Physical Therapista
Time
Week 1
a
b
Exercise
Progressed by:
Frequency
Postural stability:
● Single-leg standing
● Uneven surfaces
● Closed eyes
● Perturbations
5 min, twice per day
Peroneal muscle strengthening:
● Thera-Band (Hygenic Corporation, Akron,
Ohio) exercises
● Calf raises
● Strength of Thera-Band
● Double leg to single leg as soon as symptoms
allowed (day 5). Then weight added (via a
dumbbell) starting at 5 kg and increased by
2.5 kg per week until full return to play.
3 sets of 10 repetitions, once
per day
Week 3b
Landing off a step in multiple directions
Target hopping in multiple directions
3 sets of 1 min
Week 4
Straight-line running
Alternate days for 30 min
Weeks 5 and 6
Running with increased speed and multiple
direction changes
Alternate days for 30 min
The exercises that were included in the programs investigated by studies from the Cochrane review are shown in italics.
After regaining full pain-free range of movement.
during all training sessions and
matches as he returned to soccer to
provide additional structural support
while continuing to improve his postural stability and strength.
How well do the outcomes of the
intervention provided to the
patient match those suggested
by the systematic review?
After 6 weeks, Mr. R had returned to
full training. He had full talocrural
mobility and full strength in his peroneal and calf muscles. There was
ongoing but pain-free laxity on anterior drawer and talar tilt testing. His
single-leg stance postural stability
test with eyes closed improved to 10
seconds on his affected side. He
scored 97 on the Foot and Ankle
Score Scale, indicating he had almost
returned to full function (normative
mean⫽93.15, SD⫽12.33).15 Mr. R
understood the importance on continuing to improve his static postural
stability and the need to achieve
symmetry and maintain these
improvements during the season to
avoid further re-sprain.
Can you apply the results of the
systematic review to your
patients?
The findings of the Cochrane review
provide some evidence that neuroAugust 2012
muscular training can lead to small,
short-term improvements in function compared with no training. For
Mr. R, the training effect allowed
him to improve function and return
to sporting activities. Although the
studies in the Cochrane review
recruited patients with an average
age in the 20s, as in Mr. R’s case,
there is no reason why the same benefits would not be expected in the
general adult or adolescent population seen by physical therapists for
chronic ankle instability. Studies in
the Cochrane review do not provide
evidence on the long-term benefits
of neuromuscular training, and, to
our knowledge, no relevant randomized controlled trials have been published since the last search date of
this Cochrane review (February
2010). However, evidence from
exercise trials in other musculoskeletal conditions suggests that benefits
of a training program decline over
time and booster sessions are useful
to maintain long-term benefits.16
There are measures related to the
functional and mechanical insufficiencies that are thought to contribute to chronic ankle instability, such
as deficits in strength, proprioception, and neuromuscular or postural
control9 (for a clinical case using
some of these measures, see the case
report by O’Driscoll et al17). These
measures were not included as outcomes in the Cochrane review; however, other evidence is available to
supplement the review’s findings. A
recent systematic review with best
evidence synthesis concurs with the
findings of the Cochrane review and
concludes that neuromuscular training can improve discrete functional
insufficiencies (eg, static and
dynamic postural stability) associated with chronic ankle instability.18
The results indicate that in the future
significant emphasis should be
placed on the mode specificity of
neuromuscular training. This would
seem a pertinent point given the
multifactorial nature of chronic
ankle instability. Another recent systematic review shows that neuromuscular training can reduce lowerlimb injuries in an athletic
population.19 Furthermore, a neuromuscular training program could be
implemented in people after acute
ankle sprain without the diagnosis of
chronic ankle instability. Hupperets
and colleagues20,21 showed that after
an ankle sprain, a home proprioceptive exercise program is effective
and cost-effective at preventing
re-sprain at 1 year.
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989
What can be advised based on
the results of this systematic
review?
The results of the Cochrane review
provide stronger evidence than individual studies that neuromuscular
training can improve short-term
functional outcomes in people with
chronic ankle instability. The programs used in the reviewed studies
are 20 to 30 minutes in duration a
few times a week for 4 to 6 weeks
and mostly consist of progressive
postural stability, proprioceptive,
and strengthening exercises. The
long-term benefits of neuromuscular
training in chronic ankle instability
are not known, but studies have
shown that neuromuscular training
can reduce the risk of other lowerlimb injuries, including ankle
re-sprain.19,21
The Cochrane review also provides
insights for future research in neuromuscular training for ankle instability. What is required is large, adequately powered trials with a broad
age group and information on costeffectiveness. There also is a need to
establish treatment effects beyond
the immediate treatment period and
identify the specific training components that constitute the most effective form of neuromuscular training.
C-W.C. Lin, PT, PhD, Musculoskeletal Division, The George Institute for Global Health
and Sydney Medical School, The University
of Sydney, PO Box M201, Missenden Road,
New South Wales 2050, Australia. Address
all correspondence to Dr Lin at: clin@
george.org.au.
E. Delahunt, PT, PhD, School of Public
Health, Physiotherapy and Population Science and Institute for Sport and Health, University College Dublin, Dublin, Ireland.
E. King, PT, MScManipTher, Physiotherapy
Department, Sports Surgery Clinic, Dublin,
Ireland.
Dr Lin is funded by the National Health and
Medical Research Council, Australia.
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Volume 92
[Lin C-WC, Delahunt E, King E. Neuromuscular training for chronic ankle instability.
Phys Ther. 2012;92:987–991.]
© 2012 American Physical Therapy Association
Published Ahead of Print: May 24, 2012
Accepted: April 11, 2012
Submitted: October 13, 2011
DOI: 10.2522/ptj.20110345
References
1 The Cochrane Library. Available at: http://
www.thecochranelibrary.com/view/0/
index.html. Accessed March 14, 2012.
2 Fong DT, Hong Y, Chan LK, et al. A systematic review on ankle injury and ankle
sprain in sports. Sports Med. 2007;37:73–
94.
3 de Bie RA, de Vet HC, van den Wildenberg
FA, et al. The prognosis of ankle sprains.
Int J Sports Med. 1994;18:285–289.
4 Gerber JP, Williams GN, Scoville CR, et al.
Persistent disability associated with ankle
sprains: a prospective examination of an
athletic population. Foot Ankle Int. 1998;
19:653– 660.
5 Yeung MS, Chan KM, So CH, Yuan WY. An
epidemiological survey on ankle sprain.
Br J Sports Med. 1994;28:112–116.
6 Delahunt E, Coughlan GF, Caulfield B,
et al. Inclusion criteria when investigating
insufficiencies in chronic ankle instability.
Med Sci Sports Exerc. 2010;42:2106 –
2121.
7 van Rijn RM, van Os AG, Bernsen RM, et al.
What is the clinical course of acute ankle
sprains? A systematic literature review.
Am J Med. 2008;121:324 –331.
8 Fong DT, Man CY, Yung PS, et al. Sportrelated ankle injuries attending an accident and emergency department. Injury.
2008;39:1222–1227.
9 Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral
ankle instability. J Athl Train. 2002;37:
364 –375.
10 de Vries JS, Krips R, Sierevelt IN, et al.
Interventions for treating chronic ankle
instability. Cochrane Database Syst Rev.
2011;(8):CD004124.
11 Hale SA, Hertel J, Olmsted-Kramer LC. The
effect of a 4-week comprehensive rehabilitation program on postural control and
lower extremity function in individuals
with chronic ankle instability. J Orthop
Sports Phys Ther. 2007;37:303–311.
12 Bennell K, Talbot R, Wajswelner H, et al.
Intra-rater and inter-rater reliability of a
weight-bearing lunge measure of ankle
dorsiflexion. Aust J Physiother. 1998;44:
175–180.
13 Foot and Ankle Outcomes Questionnaire.
Available at: http://www.aaos.org/research/
outcomes/Foot_Ankle.pdf.
Accessed
December 21, 2011.
Number 8
14 Johanson NA, Liang MH, Daltroy L, et al.
American Academy of Orthopaedic Surgeons lower limb outcomes assessment
instruments: reliability, validity, and sensitivity to change. J Bone Joint Surg Am.
2004;86:902–909.
15 American Academy of Orthopaedic Surgeons website. Available at: http://www.
aaos.org/research/outcomes/outcomes
meanstable.pdf. Accessed December 21,
2011.
16 Pisters MF, Veenhof C, van Meeteren NL,
et al. Long-term effectiveness of exercise
therapy in patients with osteoarthritis of
the hip or knee: a systematic review.
Arthritis Rheum. 2007;57:1245–1253.
17 O’Driscoll J, Kerin F, Delahunt E. Effect of
a 6-week dynamic neuromuscular training
programme on ankle joint function: a case
report. Sports Med Arthrosc Rehabil Ther
Technol. 2011;3:13.
18 O’Driscoll J, Delahunt E. Neuromuscular
training to enhance sensorimotor and
functional deficits in subjects with chronic
ankle instability: a systematic review and
best evidence synthesis. Sports Med
Arthrosc Rehabil Ther Technol. 2011;3:
19.
19 Hübscher M, Zech A, Pfeifer K, et al. Neuromuscular training for sports injury prevention: a systematic review. Med Sci
Sports Exerc. 2010;42:413– 421.
20 Hupperets MD, Verhagen EA, Heymans
MW, et al. Potential savings of a program
to prevent ankle sprain recurrence: economic evaluation of a randomized controlled trial. Am J Sports Med. 2010;38:
2194 –2200.
21 Hupperets MD, Verhagen EA, van
Mechelen W. Effect of unsupervised home
based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009;339:b2684.
22 Martin RL, Burdett RG, Irrgang JJ. Development of the Foot and Ankle Disability
Index (FADI) [abstract]. J Orthop Sports
Phys Ther. 1999;29:A32–A33.
23 Martin RL, Irrgang JJ. A survey of selfreported outcome instruments for the foot
and ankle. J Orthop Sports Phys Ther.
2007;37:72– 84.
24 Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons
with functionally unstable ankles.
J Orthop Sports Phys Ther. 1999;29:478 –
486.
25 Karlsson J, Peterson L. Evaluation of the
ankle joint function: the use of a scoring
scale. Foot. 1991;1:15–19.
26 Higgins JPT, Altman DG, Sterne JAC; on
behalf of the Cochrane Statistical Methods
Group and the Cochrane Bias Methods
Group. Assessing risk of bias in included
studies. In: Higgins JPT, Green S, eds.
Cochrane Handbook for Systematic
Reviews of Interventions, Version 5.1.0.
2011. Available at: http://www.cochranehandbook.org. Accessed October 12,
2011.
August 2012
Appendix.
Neuromuscular Training for Chronic Ankle Instability: Cochrane Review Results10
Characteristics of included trials:
Literature search was conducted in February 2010. Four randomized controlled trials investigating neuromuscular training were included. The study
populations were small (n⫽19–31) and young (mean age⫽20.9–29.7 years), providing data on 98 male and female participants. Participant inclusion
criteria varied slightly across studies, but all participants were required to have a history of ankle sprain with a self-report of ankle instability, ankle
weakness, or recurrent sprains.
Details of the interventions:
Three of the 4 included studies compared neuromuscular training with no training. Neuromuscular training included wobble board, hopping, and
single-leg standing exercises and consisted of 8 to 12 supervised sessions of 20 to 30 minutes lasting 4 weeks. One study also included range of
motion, strengthening, and functional exercises, as well as a home exercise component.
One of the 4 included studies compared bidirectional with unidirectional pedaling on a recumbent stationary bicycle. The bidirectional pedal was able
to tilt 20° in the frontal plane and thus was used to challenge ankle joint stability, ankle joint movement, proprioception, and evertor torque. The
sessions were 3 times a week, 45 minutes a day, and lasted for 6 weeks.
Outcome assessment:
All studies evaluated outcomes at the end of the treatment period without a longer-term follow-up. The primary outcomes of the review were
functional outcome and patient-reported stability. Results on function were reported by the included studies using the following self-report
questionnaires:
● Foot and Ankle Disability Index (FADI)22—consisting of 22 items measuring the activity limitation of daily activities (eg, walking) and 4 items on
pain.
● Foot and Ankle Disability Index Sport Scale (FADI-Sport)22—consisting of 8 items measuring the activity limitation of daily activities (eg, running).
● Both the FADI and FADI-Sport are scored from 0 (lowest score) to 100 (highest score). Although some measurement properties have been
investigated,23 the minimal clinically important difference is not known.
● Ankle Joint Functional Assessment Tool24—consisting of 12 items on impairments (eg, pain) and activity limitation (eg, ability to walk), with
unknown measurement properties.
● Modified Karlsson Functional Score25—consisting of 7 items on impairments (eg, pain) and activity limitation (eg, work, activities), with limited
information on its measurement properties.23
The included studies also reported physiological outcomes (eg, surface electromyography on sudden ankle inversion), but these outcomes were not
outcomes of the review and thus were not presented.
Risk of bias:
The risk of bias tool of the Cochrane Collaboration was used.26
● Selection bias (random sequence generation and allocation concealment): only 1 study had a low risk of bias in random sequence generation. None
of the studies provided enough information on allocation concealment. Overall, the studies had an unclear risk of selection bias.
● Blinding: blinding is difficult in exercise trials using patient-reported outcomes. None of the studies used blinding.
● Attrition bias (incomplete outcome data): All studies had an unclear risk, as there was either no reporting of loss to follow-up or the methods used
to account for loss to follow-up.
● Reporting bias: Three studies reported all of the outcomes specified in the “Method” section and scored a low risk of bias. One study was unclear,
as the reporting was incomplete for most outcomes.
Results:
Overall, there was a small benefit toward neuromuscular training compared with no training.
Neuromuscular training versus no training (3 studies)
● There was a statistically significant between-group difference showing a treatment effect in favor of neuromuscular training. The pooled results from
2 studies showed a mean between-group difference of 8.83/100 (95% confidence interval⫽4.46–13.20) on the FADI and 11.59/100 (95%
confidence interval⫽6.48–16.69) on the FADI-Sport. No information is available on the minimal clinically important difference for either scale.
However, the between-group differences are around 10 points on a 100-point scale and, therefore, could be considered small in magnitude.
● A third study also showed a small and statistically significant treatment effect favoring neuromuscular training (mean between-group difference of 3
on the 48-point Ankle Joint Functional Assessment Tool, 95% confidence interval⫽0.3–5.70).
Bidirectional versus unidirectional pedaling (1 study)
● No statistically significant difference was found. As measured on the Modified Karlsson Functional Score, where the highest score is 85, the scores at
the end of the program were 76.9 in the bidirectional group and 66.3 in the unidirectional group. No measure of dispersion was given.
August 2012
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Research Report
B.S. Sindhu, PhD, OTR, Department of Occupational Science and
Technology, University of Wisconsin–Milwaukee, 2400 E Hartford
Ave, Milwaukee, WI 53211 (USA).
Address all correspondence to Dr
Sindhu at: [email protected].
L.A. Lehman, PhD, OT, Department of Psychology, University of
South Carolina Upstate, Spartanburg, South Carolina.
S. Tarima, PhD, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin.
Influence of Fear-Avoidance Beliefs on
Functional Status Outcomes for
People With Musculoskeletal
Conditions of the Shoulder
Bhagwant S. Sindhu, Leigh A. Lehman, Sergey Tarima, Mark D. Bishop,
Dennis L. Hart,† Matthew R. Klein, Mikesh Shivakoti, Ying-Chih Wang
Background. The influence of elevated fear-avoidance beliefs on change in functional status is unclear.
Objective. The purpose of this study was to determine the influence of fear-
M.D. Bishop, PT, PhD, Department of Physical Therapy, University of Florida, Gainesville, Florida.
avoidance on recovery of functional status during rehabilitation for people with
shoulder impairments.
D.L. Hart, PT, PhD, Focus On Therapeutic Outcomes, Inc, Knoxville,
Tennessee.
Design. A retrospective longitudinal cohort study was conducted.
M.R. Klein, BS, Department of
Occupational Science and Technology, University of Wisconsin–
Milwaukee.
tions of the shoulder receiving rehabilitation. At intake and discharge, upperextremity function was measured using the shoulder Computerized Adaptive Test.
Pain intensity was measured using an 11-point numerical rating scale. Completion
rate at discharge was 57% for function and 47% for pain intensity. A single-item screen
was used to classify patients into groups with low versus elevated fear-avoidance
beliefs at intake. A general linear model (GLM) was used to describe how change in
function is affected by fear avoidance in 8 disease categories. This study also
accounted for within-clinic correlation and controlled for other important predictors
of functional change in functional status, including various demographic and healthrelated variables. The parameters of the GLM and their standard errors were estimated
with the weighted generalized estimating equations method.
M. Shivakoti, MS, Division of Biostatistics, Medical College of
Wisconsin.
Y-C. Wang, PhD, OTR/L, Department of Occupational Science
and Technology, University of
Wisconsin–Milwaukee, and Focus
On Therapeutic Outcomes, Inc,
Knoxville, Tennessee.
†
Dr Hart died April 11, 2012.
[Sindhu BS, Lehman LA, Tarima S,
et al. Influence of fear-avoidance
beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder.
Phys
Ther.
2012;92:
992–1005.]
Methods. Data were collected from 3,362 people with musculoskeletal condi-
Results. Functional change was predicted by the interaction between fear and
disease categories. On further examination of 8 disease categories using GLM
adjusted for other confounders, improvement in function was greater for the low fear
group than for the elevated fear group among people with muscle, tendon, and soft
tissue disorders (⌬⫽1.37, P⬍.01) and those with osteopathies, chondropathies, and
acquired musculoskeletal deformities (⌬⫽5.52, P⬍.02). These differences were
below the minimal detectable change.
© 2012 American Physical Therapy
Association
Limitations. Information was not available on whether therapists used information on level of fear to implement treatment plans.
Published Ahead of Print:
May 24, 2012
Accepted: May 21, 2012
Submitted: September 17, 2011
Conclusions. The influence of fear-avoidance beliefs on change in functional
status varies among specific shoulder impairments.
Post a Rapid Response to
this article at:
ptjournal.apta.org
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August 2012
Influence of Fear-Avoidance Beliefs on Functional Status Outcomes
E
very year, 4 million people
receive medical care for musculoskeletal conditions of the
shoulder,1,2 resulting in direct health
care costs of an estimated 7 billion
dollars.3 Pain is the most common
symptom associated with these conditions.1,2 Many times, shoulder pain
is associated with repetitive motions
at work or during participation in
athletics.4 –7 Among people with
musculoskeletal conditions, fearavoidance beliefs related to pain are
prevalent and have been associated
with greater disability and functional
limitations.8,9 Among individuals with
fewer fear-avoidance beliefs, fear usually dissipates as the condition
resolves. However, elevated fearavoidance beliefs can be maladaptive,
leading to chronic pain, disability, and
reduced function.10 –15 Chronic pain
and disability result from elevated fear,
as described by the fear-avoidance
model (FAM).10,14,16,17 According to
this model, some individuals consider
a painful stimulus as negative, and
avoid or postpone the presentation of
an event that is considered painful.18
Also, these individuals are hypervigilant toward painful stimuli, paying less
attention to other tasks. Over a long
period of time, hypervigilance and
avoidance of physical activity lead to
deconditioning of the musculoskeletal
and cardiovascular systems, which, in
turn, results in the development of
chronic pain and disability.10
Conflicting evidence exists regarding the influence of fear-avoidance
beliefs on treatment outcomes.
Study findings range from poor to
improved
treatment
outcomes
among people with elevated fear. In
support of the FAM, an increasing
number of studies are reporting that
elevated
fear-avoidance
beliefs
adversely affect outcomes of treatment. For example, studies indicate
that outcomes of lumbar surgery are
poorer when patients report ele-
The Bottom Line
What do we already know about this topic?
Fear-avoidance beliefs related to pain are prevalent among people with
musculoskeletal conditions, and these beliefs have been associated with
greater disability and functional limitations. However, it is not known
how pain-related fear-avoidance beliefs affect the outcome of rehabilitation in people with shoulder impairments.
What new information does this study offer?
Elevated fear-avoidance beliefs were associated with poorer improvement
in functional status from intake to discharge among people in the following 2 shoulder disease categories: (1) muscle, tendon, and soft-tissue
disorders, and (2) osteopathies, chondropathies, and acquired musculoskeletal deformities.
vated levels of fear before surgery,19
as well as after surgery.20 Rehabilitation outcomes also are worse when
fear is elevated at intake in people
with low back pain.21,22 In contrast
to these findings and clinical intuition, some studies have shown no
effect of elevated fear on treatment
outcomes. For example, Pincus et
al24 conducted a systematic review
examining the effect of fearavoidance beliefs on treatment outcomes among people with low back
pain. Based on findings from 9 studies, these researchers concluded that
little evidence exists to link fearavoidance beliefs with poor treatment outcomes.23 Furthermore,
other studies have shown greater
improvement among people with
elevated fear. For instance, elevated
fear due to shoulder pain at intake
was associated with a larger reduction in pain at 3-month and 12-month
follow-ups, as well as a greater reduction in functional disability at a
3-month follow-up, in a general practice setting.24 Likewise, elevated fear
was associated with better physical
therapy outcomes among people
with upper-extremity musculoskeletal conditions25 and people with low
back pain.26 In these studies, the
associations between fear and treatment outcomes were mediated by
the relationship among pain, disability, and fear. In other words, people
with elevated fear reported more
pain and disability despite having a
greater change in function.
Additional research into the phenomenon of elevated fear associated
with reduced pain and greater funcAvailable With
This Article at
ptjournal.apta.org
If you’re a patient, what might these findings mean
for you?
The data from this study suggests that if you have a condition in 1 of the
2 disease categories above, your physical therapist may be able to
improve your treatment outcomes by assessing for the presence of fearavoidance beliefs and helping you manage those beliefs.
August 2012
• Discussion Podcast with Julie
Fritz and authors Bhagwant
Sindhu and Mark Bishop.
Moderated by Chris Main.
Volume 92
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993
tional gains requires a more detailed
analysis of the association between
fear and function. Conflicting findings regarding effects of fearavoidance beliefs on treatment outcomes might be because studies
have accounted for different confounding variables in their analysis.
For instance, den Boer et al19 found
that preoperative levels of fear
resulted in poorer outcomes of surgery after controlling for preoperative disability and pain intensity, age,
sex, educational level, duration of
complaints, neurological deficits,
and intake of analgesics. In contrast,
George and Stryker25 found a greater
improvement in function among people with elevated fear after accounting
for differences in anatomical region
and controlling for effect of differences in clinics. Consequently, there is
a need to systematically examine how
the effect of fear changes from before
to after accounting for various confounding variables.
The purposes of the current study
were: (1) to determine the effect of
fear-related cognitions on functional
recovery with and without accounting for various confounding variables
and (2) to determine the influence of
fear-related cognitions on recovery
of functional status during rehabilitation across different diagnostic categories of shoulder impairments. This
study builds on previous work in that
it accounts for differences between 8
disease categories—(1) arthropathies;
(2) muscle, tendon, and soft tissue disorders; (3) osteopathies, chondropathies, and acquired musculoskeletal
deformities; (4) fractures; (5) sprains
and strains, (6) postsurgical, (7)
“other,” and (8) condition not reported—and other factors associated with
change in function. We hypothesized
that patients’ fear-avoidance beliefs at
intake would be predictive of the
changes in function after accounting
for other factors associated with functional status outcomes.
In addition, there is a need to determine the association between fear
and function in specific disease categories. Previous studies have not
only grouped different shoulder conditions together, but also have
grouped shoulder conditions with
neck and upper arm conditions.25,28
Moreover, it is uncertain how fear
influences different regions of the
body. For example, George and
Stryker25 reported that fear-avoidance
beliefs similarly affect 4 different anatomical regions of the body: cervical
spine, lumbar spine, upper extremity,
and lower extremity. In contrast,
Feleus et al27 reported that fear of
movement occurred more with shoulder impairment than neck or arm
injury. This study’s findings, coupled
with the large incidence of painful
musculoskeletal disorders of the shoulder, indicate that varying responses to
pain and levels of fear of pain in different shoulder conditions might be an
important focus for future research.
Method
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Setting and Participants
We conducted a secondary analysis
of data prospectively collected from
people with musculoskeletal conditions of the shoulder who attended
outpatient rehabilitation clinics
throughout the United States. The
data were collected using the Patient
Inquiry system, a patient evaluation
tool provided to clinics by Focus On
Therapeutic Outcomes (FOTO), Inc
(Knoxville, Tennessee).28 –30 FOTO
is a medical rehabilitation database
management company that partners
with clinics to provide outcome
measures and data management services. The FOTO outcomes database
includes standardized assessments of
function, along with instruments
that collect information on demographic characteristics, patient history, physical functioning, pain, psychosocial constructs such as fear
avoidance, and characteristics of
health care providers and organizations.31–33 For the present study, the
Number 8
FOTO database was reduced to
include 3,362 patients who received
outpatient rehabilitation for shoulder conditions between 2008 and
2010 in 35 different clinics. We
selected the time frame of 2008 to
2010, as we sought to determine the
association between fear avoidance
and recovery of shoulder functional
status in the context of currently
used rehabilitation strategies. Patient
data were not included from clinics
contributing fewer than 20 patients
to the FOTO database. We assumed
that smaller clinics might not have an
established protocol for patients
with specific conditions of the shoulder. Therefore, we excluded smaller
clinics to reduce the heterogeneity
attributed by their data (Appendix).
People seeking rehabilitation for
shoulder impairments provided demographic information (eg, age, sex,
exercise history) before their initial
clinical evaluation. During clinical
evaluation at admission (intake) and at
the end of rehabilitation (discharge),
patients’ upper-extremity functional
status and pain intensity were
assessed. Additionally, fear-avoidance
beliefs were evaluated at intake. Clinical staff entered necessary medical
information at intake, such as diagnosis codes based on the International
Classification of Diseases, Ninth Revision (ICD-9).34 The ICD-9 codes have
been found to have variable interrater
reliability (55%–98% agreement) and
poor to moderate validity, with 40% to
74% agreement between coders and
the gold standard.35–37 Moreover,
ICD-9 codes lack sufficient specificity
values (0.30 – 0.81), even though they
have high sensitivity values (0.81).36
Assessments
The shoulder Computerized Adaptive Test (CAT) was used to measure
upper-extremity function at 2 time
points: intake and discharge. The
shoulder CAT estimates reliable,
valid, sensitive, and responsive measures of functional status for individAugust 2012
uals
with
shoulder
impairments.28,38 – 40
Specifically,
the
shoulder CAT is a self-report assessment of a person’s ability to perform
daily tasks using the affected arm.41
It consists of a 37-item bank administered using a computer algorithm.28,39 The computer algorithm
selects items at the functional level
of a person; thus, patients complete
only those items that provide the
greatest amount of information
about their functional status.42 Each
item is rated on a 5-point scale ranging from 1 (“I can’t do this”) to 5
(“no difficulty”). The final functional
status score represents a point estimate of functional status of a person
on a linear 0 to 100 scale, with
higher scores indicating higher functioning.
Clinically
meaningful
change for shoulder CAT is 23 or
more points for an intake score of 0
to 43, 10 or more points for an intake
score of 44 to 52, 5 or more points
for and intake score of 53 to 60, and
2 or more points for an intake score
of 61 to 100.40
A numerical rating scale (NRS) was
used for reporting shoulder pain
intensity at intake and discharge.
The NRS is a commonly used measure of pain intensity.43 The NRS has
well-established psychometric properties; it is valid43– 46 and sensitive to
changes in pain intensity.47– 49 The
NRS used by FOTO consists of an
11-point scale, with its anchors
being 0 (no pain) and 10 (worst possible pain). A reduction of 1 point on
the NRS is considered as a minimal
clinically important improvement
(MCII) in pain intensity.50 Clinic staff
asked patients to rate their current
pain intensity by indicating a number
from a list of integers displayed horizontally in ascending order.
A single-item screening method was
used to classify patients into groups
with low versus elevated fearavoidance beliefs at intake. This
screening item was selected from
August 2012
the Fear-Avoidance Beliefs Questionnaire physical activities scale (FABQPA), which consists of 16 items
describing the association between
pain and physical activities.51 A single item—“I should not do physical
activities that (might) make my pain
worse”—was identified using item
response theory (IRT) methods and
receiver operating characteristic analyses. This item was found to be effective in distinguishing between elevated fear and low fear. That is, this
item has a sensitivity value of 0.82, a
specificity value of 0.98, and an area
under the receiver operating characteristic curve of 0.94.51 The item was
scored on a 5-point scale ranging from
0 to 4, where 0 means “completely
disagree,” 2 means “unsure,” and 4
means “completely agree.” Responses
of 2 to 4 were classified as elevated
fear, and responses of 0 and 1 were
classified as low fear.51
Data Analysis
We divided our sample into 2 groups
based on level of fear-avoidance
beliefs at intake (ie, low versus elevated fear) using the IRT-based single
item. In addition, the patients were
divided into 3 groups based on duration of condition (acute⫽less than
22 days, subacute⫽22–90 days, and
chronic⫽greater than 90 days),52
into 3 groups based on age (18 – 44
years, 45– 64 years, and 65 years and
older),53 and into 8 disease categories based on their ICD-9 codes
(Tab. 1). Change in functional status
was calculated by subtracting the
shoulder CAT score at intake from
the shoulder CAT score at discharge
(shoulder CAT at discharge ⫺ shoulder CAT at intake). Thus, a positive
functional status change score indicated an improvement in function
from intake to discharge. Differences
in mean functional status change
scores between the 2 fear-avoidance
belief groups were calculated by subtracting the change score for the elevated fear group from the change
score for the low fear group. A neg-
ative difference in means indicated
greater functional improvement in
the elevated fear group, and a positive difference in means indicated
greater functional improvement in
the low fear group. Likewise, change
scores for pain intensity were calculated by subtracting pain intensity at
intake from pain intensity at discharge, with a positive change score
indicating an increase in pain (pain
intensity at discharge ⫺ pain intensity at intake).
All individuals included in our sample (N⫽3,362) reported their functional status and pain scores at
intake. At discharge, however, only
1,946 people reported functional status, 1,538 reported pain intensity,
and 1,519 reported both functional
status and pain intensity. A logistic
regression analysis was used to determine whether a relationship existed
between the incompletion rate (ie,
not having a functional status or pain
intensity score at discharge) and
demographic characteristics measured at intake. This logistic regression allowed us to estimate dropout
probabilities
and
calculate
weights54,55 to account for any
imbalances in demographic characteristics between those who had
only intake data and those who had
both intake and discharge data. This
procedure was designed to reduce
the effect of missing data by providing weighted demographics of the
population at discharge that had similar demographic characteristics as
the unweighted intake data.
Using inverse probability weights
generated from the logistic regression model, we estimated the parameters of a general linear model (GLM)
and their standard errors with the
weighted generalized estimating
equations.56 This model determined
how change in function is affected
by fear-avoidance beliefs, as well as
by interactions of fear with other
demographic variables (age groups,
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Table 1.
Demographic and Health-Related Characteristics of Patients With Shoulder Impairments Who Had Low Versus Elevated FearAvoidance Beliefsa
Elevated FearAvoidance Beliefs
(nⴝ766)
Characteristicsb
Age (y)
Low FearAvoidance Beliefs
(nⴝ2,596)
X or n
SD or %
X or n
SD or %
54.2
16.4
54
15.6
All
(Nⴝ3,362)
X or n
54.1
SD or %
15.8
Sex
Male
342
44.6
1,192
45.9
1,534
45.6
Female
424
55.4
1,404
54.1
1,828
54.4
Middle Atlantic
192
25.1
501
19.3
693
20.6
Mountain
126
16.4
507
19.5
633
18.8
North Central
Region of clinic
355
46.3
1,282
49.4
1,637
48.7
Pacific
10
1.3
26
1.0
36
1.1
South Atlantic
22
2.9
77
3.0
99
2.9
South Central
61
8.0
203
7.8
264
7.9
Acute (0–21 days)
180
23.5
467
18.0
647
19.2
Subacute (22–90 days)
239
31.2
836
32.2
1,075
32.0
Chronic (ⱖ91 days)
347
45.3
1,293
49.8
1,640
48.8
63
8.2
273
10.5
336
10.0
412
53.8
1,485
57.2
1,897
56.4
3
0.4
30
1.2
33
1.0
12
1.6
37
1.4
49
1.5
Duration of condition
Disease categories
Arthropathies (ICD-9 codes 714.41–719.81)
Muscle, tendon, and soft tissue disorders (ICD-9
codes 726–729.5)
Osteopathies, chondropathies and acquired
musculoskeletal deformities (ICD-9 code 731.1)
Fractures (ICD-9 codes 810.03–812.2)
Sprains and strains (ICD-9 codes 840.0–840.972)
66
8.6
175
6.7
241
7.2
117
15.3
268
10.3
385
11.5
Other musculoskeletal conditions (ICD-9 codes
353, 714.41–719.81, 831–831.11, 923, 953.4)c
79
10.3
263
10.1
342
10.2
Not reported
14
1.8
65
2.5
79
2.3
Postsurgical (CPT codes 23000–23929)
Functional status score on shoulder Computerized
Adaptive Test
Intake (0–100)
46.4
15.3
51.7
13.9
50.5
14.4
Discharge (0–100)
66.9
15.5
69.1
14.5
68.6
14.8
Change (discharge ⫺ intake)
20.9
19.0
17.6
16.8
18.3
17.4
Intake (0–10)
5.8
2.4
5.3
2.4
5.4
2.4
Discharge (0–10)
3.2
2.5
2.8
2.2
2.9
2.3
⫺2.4
2.9
⫺2.5
2.7
⫺2.5
2.7
Pain intensity score on numerical rating scale
Change (discharge ⫺ intake)
a
ICD-9⫽International Classification of Diseases, Ninth Edition; CPT⫽Current Procedural Terminology.
Significance for differences between low versus elevated fear groups for various characteristics has not been calculated, as such significance will not be
adjusted for random effects (clinics) and missing data and any reference to it will be misleading.
c
The category of “Other musculoskeletal conditions” was created by combining dislocations (n⫽22, ICD-9 code 831), contusions (n⫽7, ICD-9 code 923),
peripheral nerve disorders (n⫽6, ICD-9 codes 353 and 953.4), and not otherwise classified musculoskeletal conditions (n⫽41) due to their very small sample
size.
b
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sex) and health-related variables (disease category, duration of condition,
function at intake, pain intensity at
intake, change in pain intensity).
Possible within-clinic correlation
was accounted for by including in
the model an exchangeable working
correlation matrix. All interactions
were tested for significance. Fear significantly interacted only with disease categories. A separate GLM was
used to calculate estimates unadjusted for other confounders (but
adjusted for within-clinic correlation) to determine the effect of fear
on change in function as expressed
in each disease category by including
only fear and disease category as
independent variables. These unadjusted estimates represented mean
differences in functional status
change score between low and elevated fear groups (low fear group ⫺
elevated fear group) after controlling
for subject effects and missing data
at discharge. Furthermore, contrast
statements were used to test the significance and to assess the effect of
fear on change in function separately
for each disease category.
Finally, we fitted a GLM adjusted for
other significant predictors of
change in function. In this GLM, the
effect of fear on change in function
for each disease category was
included in the set of predictors as
the variable of primary research
interest. The adjusted estimates represented mean differences in functional status change score between
low and elevated fear groups (low
fear group ⫺ elevated fear group),
while accounting for within-clinic
correlation and for the effect of possible confounders. The confounders
(ie, other significant predictors of
change in function) that we controlled for included both pain intensity at intake and change in pain
intensity from intake to discharge.
These 2 pain intensity scores were
included because both provide different information about change in
August 2012
Figure 1.
Bar graph representing functional status change score (shoulder Computerized Adaptive Test [CAT] functional status score at discharge – shoulder CAT functional status
score at intake) for people with low versus elevated fear-avoidance beliefs, without
accounting for differences in subject effects, missing data, disease categories, clinics,
and other confounding variables (asterisk indicates significance at alpha level of ⱕ.05).
functional status. Change in function
was likely to be predicted by pain
intensity at intake (eg, higher pain at
intake resulting in smaller change in
function). However, pain at intake
does not indicate how pain intensity
changes with treatment. A greater
change in pain intensity was likely to
be associated with a greater change
in function.
In addition to the confounders, we
controlled for subject effects and
missing data at discharge. We identified significant predictors with the
forward stepwise variable selection
procedure. The level of fear, disease
categories, and their interactions
were always kept in the model. All
main effects and 2-way interactions
were tested for significance. The significance of continuous variables
was explored through their linear
and quadratic effects. For categorical
variables, categories with small cell
counts (less than 10) were combined
with adjacent categories or by creat-
ing other meaningful groupings.
Ordinal variables (duration of condition and age group) were treated as
continuous, and their linear effect
was analyzed. The data analysis for
this article was generated using the
SAS software, version 9.2 of the SAS
System for Unix (SAS Institute Inc,
Cary, North Carolina). We declared
findings significant when their P values were less than .05.
Role of the Funding Source
This work was supported, in part, by
the Office of Undergraduate
Research, University of Wisconsin–
Milwaukee, and the Clinical and
Translational Science Institute of
Southeast Wisconsin, Medical College of Wisconsin.
Results
For our sample of 3,362 participants,
the mean age was 54.1 years
(SD⫽15.8, range⫽18 –92). Women
made up more than half of the sample (n⫽1,828, 54%). Almost half of
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997
Table 2.
Results of Wald Statistics for Type 3 General Linear Model (GLM) Model With
Functional Status Change Score as the Dependent Variablea
Sourceb
df
␹2,c
P
Intake shoulder CAT score
1
190.92
⬍.001
Square of intake shoulder CAT score
1
41.87
⬍.001
Intake pain intensity score
1
94.91
⬍.001
Pain observed
1
59.67
⬍.001
Pain change observed
1
263.77
⬍.001
Age group
2
13.74
.001
Duration of condition
2
14.31
⬍.001
15
152.85
⬍.001
1
10.72
.001
Disease category ⫻ fear
Intake shoulder CAT score ⫻ pain observed
Pain observed ⫻ age group
2
18.02
⬍.001
Pain change observed ⫻ age group
2
15.81
⬍.001
a
Only significant terms are reported.
CAT⫽Computerized Adaptive Test, pain observed⫽pain intensity change score was missing (ie, 0) vs
pain intensity change score was reported (ie, 1), pain change observed⫽(pain intensity change
score) ⫻ (pain observed), age group⫽18 – 44 years vs 45– 64 years vs 65 years and older, duration of
condition⫽acute (0 –21 days) vs subacute (22–90 days) vs chronic (ⱖ91 days), fear⫽low vs elevated
fear-avoidance beliefs.
c
Inference of GLM regression parameters was performed using the Wald test statistic where the
estimated parameter was compared with a chi-square distribution. The null hypothesis was no
significant effect on change in function for a continuous variable and no significant difference in
change in function between groups for a categorical variable.
b
the participants were classified as
having chronic symptoms (⬎90 days
from date of onset) (n⫽1,640, 49%),
a third were classified as having subacute symptoms (22–90 days from
date of onset) (n⫽1,075, 32%), and
one fifth were classified as having
acute symptoms (⬍22 days from
date of onset) (n⫽647, 19%). Of the
participants with medical or surgical
codes (n⫽3,283, 98%), the most
common diagnoses were associated
with soft tissue disorders (ICD-9
codes 725–729, 56%). More than a
tenth (12%) of the participants had
postsurgical conditions such as
repair of rotator cuff (Current Procedural Terminology [CPT] codes
23000 –23929) (Tab. 1). Overall,
almost three fourths (72%) of the
participants reported no past surgical history, with 22% reporting 1
past surgery and 5% reporting 2 or
more surgeries. A third (36%) of the
participants reported exercising at
least 3 times a week, followed by
39% who reported seldom or never
exercising, and 26% reported exercising 1 to 2 times a week. Almost a
third (31%) of the participants had 2
or 3 comorbidities, a quarter (25%)
reported having none, another quarter (25%) reported having 1 comorbidity, and a fifth (19%) reported having
4
or
more
functional
comorbidities.
Elevated fear-avoidance beliefs at
intake were observed among more
than a fifth of participants (n⫽766,
23%). The age and sex distributions
were similar for the low fear group
and the elevated fear group (Tab. 1).
Both groups had 27% in the age
range of 18 to 44 years, 45% in the
age range of 45 of 64 years, and 28%
in the age range of 65 years and
older. However, differences existed
between the low and elevated fear
groups in terms of some healthrelated characteristics and not for
Table 3.
Results of General Linear Model Unadjusted for and Adjusted for Other Confounders to Determine Differences in Functional
Status Change Scores Between Low Fear Group and Elevated Fear Group for 8 Disease Categories
Unadjusted Difference in
Functional Status Change Score
Disease Category
Estimate (⌬)
Standard Error
P
Arthropathies
⫺2.48
2.37
.29
Muscle, tendon, and soft tissue disorders
⫺0.15
1.04
.88
4.42
2.84
.12
⫺18.33
4.95
⬍.01a
⫺5.29
4.26
.21
Osteopathies, chondropathies, and acquired
musculoskeletal deformities
Fractures
Sprains and strains
Postsurgical
Other musculoskeletal conditions
Not reported
a
Adjusted Difference in
Functional Status Change Score
Estimate (⌬)
Standard Error
P
0.37
2.41
.87
1.37
0.57
.01a
5.52
2.51
.02a
1.93
3.04
.52
⫺3.73
2.81
.18
⫺2.15
1.82
.23
0.80
1.52
.59
⫺14.70
4.57
⬍.01a
⫺6.66
5.29
.21
⫺2.69
2.04
.18
⫺1.48
1.60
.36
Significant at alpha level of .05.
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others. Both groups had similar distributions of diseases. For example,
muscle, tendon, and soft tissue disorders formed the most common category of disorders in both groups,
with 54% in the elevated fear group
and 57% in the low fear group. Other
musculoskeletal conditions formed
the second largest category of diseases in both fear groups (10%). Pain
intensity at intake was higher by 0.5
point for the elevated fear group
(5.8) compared with the low fear
group (5.3). In addition, pain intensity at discharge was half a point
higher for the elevated fear group
(3.2) compared with the low fear
group (2.8). For both fear groups,
the average reduction in pain intensity was greater than the 1 point
MCII for the NRS (Tab. 1). Functional
status at intake was 6 points higher
for the low fear group (52 points)
compared with the elevated fear
group (46 points). Likewise, functional status at discharge was 2
points higher for the low fear group
(69 points) compared with the elevated fear group (67 points; Tab. 1).
In contrast, the improvement in
function from intake to discharge
was greater by 4 points for the elevated fear group (21 points) compared with the low fear group (17.6
points; Tab. 1, Fig. 1).
In the logistic regression analysis
that we used to estimate dropout
probabilities and calculate weights,
5 variables were significant: age
group (P⬍.0001), pain intensity at
intake (P⬍.0001), function at intake
(P⫽.0473),
disease
category
(P⫽.0053), and region where the
clinic was located (P ⬍.0001). Thus,
these 5 variables were directly used
for calculation of the GLM weights.
The GLM identified that the effect of
fear-avoidance beliefs on improvement in function varied among disease categories (␹2⫽153, P⬍.001;
Tab. 2). On further examination of
unadjusted estimates (ie, mean differences between the low fear
August 2012
group and the elevated fear group)
while accounting for patient differences and missing data but unadjusted for possible confounders, the
GLM revealed that improvement in
function was greater for the elevated
fear group than for the low fear
group among people with fractures
(⌬⫽⫺18.3, Pⱕ.0002) and people
with other musculoskeletal conditions (⌬⫽⫺14.7, Pⱕ.0013). However, improvement in function was
not different between the elevated
and low fear groups among people
with arthropathies; muscle, tendon,
and soft tissue disorders; osteopathies, chondropathies, and acquired
musculoskeletal deformities; sprains
and strains; and postsurgical conditions, as well as among people
whose condition was not reported
(Tab. 3, Fig. 2).
In addition to the interaction
between fear-avoidance beliefs and
disease category, change in function
was predicted by functional status at
intake (linear and quadratic effects),
pain intensity at intake, change in
pain intensity, pain intensity
reported versus not reported, age
group, and duration of condition, as
well as the clinic itself (Tab. 2). The
effect of these significant predictors
on change in function was controlled by calculating adjusted estimates for mean differences between
low and elevated fear groups for the
8 disease categories (Tab. 3, Fig. 3).
After adjustment (ie, extended examination of the 8 disease categories
using adjusted GLM analysis), we
found that improvement in function
was greater for the low fear group
than for elevated fear group among
people with muscle, tendon, and
soft tissue disorders (⌬⫽1.37,
Pⱕ.01) and among people with osteopathies,
chondropathies,
and
acquired musculoskeletal deformities (⌬⫽5.52, Pⱕ.02) (Tab. 3, Fig. 3).
In contrast, improvement in function was not different between the
elevated and low fear groups among
people with arthropathies (⌬⫽0.37,
P⫽.87), fractures (⌬⫽1.93, P⫽.52),
sprains and strains (⌬⫽⫺3.73,
P⫽.18), postsurgical conditions
(⌬⫽0.80, P⫽.59), other musculoskeletal conditions (⌬⫽⫺6.66, P⫽.20),
and
condition
not
reported
(⌬⫽⫺1.48, P⫽.35) (Tab. 3, Fig. 3).
The data presented in Table 3 were
used to make simple post hoc power
calculations and to determine minimal detectable change (MDC) at 80%
power. Using asymptomatic normality of regression coefficients and
observed standard errors, we estimated values of regression coefficients we can detect at 80% power.
For muscle, tendon, and soft tissue
disorders, the observed difference
was 1.37, whereas the minimal
detectable difference at 80% power
(ie, MDC) is 1.56. If the difference is
actually 1.37, the hypothesis of no
difference is rejected in 67% of cases
(ie, an asymptotic power or 67%).
For osteopathies, chondropathies, and
acquired musculoskeletal deformities,
the observed difference was 5.52,
whereas the detectible difference at
80% power (ie, MDC) is 7.03. The
power is 59% if the difference is 5.52.
Discussion
The findings of the present study
revealed a small but significant effect
of elevated fear-avoidance beliefs.
This effect was associated with
poorer recovery in upper-extremity
function with rehabilitation in only 2
out of 8 disease categories—(1) muscle, tendon, and soft tissue disorders
and (2) osteopathies, chondropathies, and acquired musculoskeletal
deformities—and the asymptotic
post hoc power associated with
these changes was 67% and 59%,
respectively. For the 2 disease categories, the functional change difference between elevated and low fear
groups was less than the MDC at 80%
power. This effect of fear-avoidance
beliefs existed after accounting for
several variables that influence
change in function, including patient
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999
Figure 2.
Average values with 95% confidence intervals for unadjusted estimates of mean differences between low versus elevated fear groups
(low fear – elevated fear) on functional status change score (shoulder Computerized Adaptive Test [CAT] functional status score at
discharge – shoulder CAT functional status score at intake) among 8 shoulder disease categories (asterisk indicates significance at
alpha level of ⱕ.05). The category “Other musculoskeletal conditions” was created by combining dislocations (n⫽22), contusions
(n⫽7), peripheral nerve disorders (n⫽6), and not otherwise classified musculoskeletal conditions (n⫽41) due to their very small
sample size. Dashed line at zero indicates no difference between low and elevated fear groups on change in function. Average and
95% confidence interval of unadjusted estimates lying below zero indicate that change in function was greater for the elevated fear
group than for the low fear group. Similarly, average and 95% confidence interval of unadjusted estimates lying above zero indicate
change in function was greater for the low fear group than for the elevated fear group.
differences, missing data, clinic location, upper-extremity function at
intake, change in pain intensity from
intake to discharge, duration of condition, age of the patient, and disease
category of the patient. Findings of
the present study are similar to conclusions drawn from previous studies
investigating
individuals’
responses to chronic low back
pain.25,26 George and colleagues25,26
found diminished rehabilitation outcomes for low back pain among individuals with elevated fear. Among
people with acute low back pain,
greater fear-avoidance beliefs about
work at baseline were significantly
associated with greater levels of disability at the 6-month follow-up.21
These differences in improvement in
function provide evidence for the
FAM.10,14,16,17 According to the FAM,
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elevated fear results in escape and
avoidance of tasks that are anticipated
to be painful. Avoidance combined
with being hypervigilant toward painful stimuli results in deconditioning of
muscles over time. This deconditioning leads to greater disability10 and
poorer treatment outcomes.19 –22
We found differences in the influence of fear-avoidance beliefs on
change in function between GLM
regression analyses unadjusted for
confounders and those adjusted or
confounders. With the unadjusted
analysis, we found that change in
function was greater in the elevated
fear group than in the low fear group
(Fig. 1). This difference can be
explained on the basis of higher
functional status scores for the low
fear group (X⫽51, SD⫽13) com-
Number 8
pared with the elevated fear group
(X⫽46, SD⫽15) at intake (t⫽8.61,
P⬍.001; Tab. 1). Higher functional
status scores at intake suggest that
the low fear group is likely to change
less with rehabilitation. However, in
terms of being able to generalize to
real-world situations where functional improvement is affected by
multiple factors, our findings suggest
the unadjusted analysis is inadequate. This inadequacy results from
the fact that it does not account for
factors besides fear that influence
change in functional status.
In addition, the unadjusted analysis
revealed an interaction between fear
and disease categories for predicting
change in function. On further
examination of this interaction, without adjusting for other important
August 2012
Figure 3.
Average values with 95% confidence intervals for adjusted estimates of mean differences between low and elevated fear groups (low
fear – elevated fear) on functional status change score (shoulder Computerized Adaptive Test [CAT] functional status score at
discharge – shoulder CAT functional status score at intake) among 8 shoulder disease categories (asterisk indicates significance at
alpha level of ⱕ.05). The category “Other musculoskeletal conditions” was created by combining dislocations (n⫽22), contusions
(n⫽7), peripheral nerve disorders (n⫽6), and not otherwise classified musculoskeletal conditions (n⫽41) due to their very small
sample size. Dashed line at zero indicates no difference between low and elevated fear groups on change in function. Average and
95% confidence interval of adjusted estimates lying below zero indicate that change in function was greater for the elevated fear
group than for the low fear group. Similarly, average and 95% confidence interval of adjusted estimates lying above zero indicate
change in function was greater for the low fear group than for the elevated fear group.
covariates, fear was found to be a
predictor for change in function
among individuals with fractures and
those with other diseases (Fig. 2).
People with fractures and other diseases were found to show greater
improvement in function when they
had elevated fear at baseline. This
finding is similar to that of George
and Stryker,25 whose repeatedmeasures analysis of variance test
revealed that people receiving physical therapy for musculoskeletal conditions in 4 different regions showed
greater improvement in function
when experiencing elevated fear at
intake. However, the influence of
fear on function for people with fractures and people in other disease categories changed to not significant
after adjusting for other covariates.
This change in influence of fear may
August 2012
be due to the effect of pain intensity
on function. For example, we might
imagine that a bone fracture commonly results in high levels of pain
intensity. As the fracture heals, pain
usually reduces and function
improves, irrespective of whether
fear is low or elevated. Indeed, our
multivariate analysis revealed that for
people with fractures, change in
function was predicted by change in
pain intensity but not by fearavoidance beliefs (Tab. 2, Fig. 3).
Our findings also suggest that there
is a need to reexamine findings of
some of the earlier studies. For
example, greater improvement in
function among people with elevated fear, as reported by George
and Stryker,25 could be different if
they would have accounted for other
demographic and health-related
characteristics in their analysis.
After adjusting for significant covariates, we found that out of 8 different
disease categories, the influence of
elevated fear on functional recovery
existed only in 2 categories: (1) muscle, tendon, and soft tissue disorders
and (2) osteopathies, chondropathies, and acquired musculoskeletal
deformities. Additionally, we found
that elevated fear-avoidance beliefs
did not result in lower functional status outcomes among individuals in 6
of the 8 disease categories. These
categories were: (1) arthropathies,
(2) fractures, (3) sprains and strains,
(4) postsurgical conditions, (5) other
shoulder conditions, and (6) conditions not reported. To our knowledge, this is the first study to report
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1001
diagnosis-related differences in fearavoidance beliefs among people
with musculoskeletal conditions of
the shoulder. George et al15 found
similar diagnosis-related differences
between individuals with cervical
spine pain and those with lumbar
spine pain. Although we found statistically significant differences, it is
not clear whether the difference in
functional recovery was clinically
meaningful between the low fear
group and the elevated fear group
for muscle tendon and soft tissue disorders, as well as for osteopathies,
chondropathies, and acquired musculoskeletal deformities. For the 2
groups with significant differences,
the asymptotic post hoc power of
these changes in regression parameters was 67% and 59%, respectively.
Also, the observed difference between
low and elevated fear groups was less
than the post hoc calculation of MDC
at 80% power. However, these post
hoc power calculations only describe
power properties of our analyses; they
do not change the statistical inference,
which is based solely on P values less
than .05. In addition, some regression
coefficients had higher standard errors
than others, which could prevent us
from showing significance due to
lower power. Future clinical trials
need to be conducted to determine
the clinical significance of this difference between low and elevated fear
groups.
One possible explanation for a
weaker relationship between fear
and change in function in the 6 disease categories is that patients may
perceive the potential for pain with
physical activity to be greater when
pain results from muscle, tendon,
and soft tissue disorders, as well as
from osteopathies, chondropathies,
and acquired musculoskeletal deformities. Some conditions included in
these categories are rotator cuff
tears, muscle impingement, chondral defects, and other bone problems. Health care professionals may
1002
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Volume 92
convey a different message to
patients in these 2 categories compared with patients with diagnoses
in other categories where fear is not
a predictor of change in function.
For example, among people with
sprains and strains, a rehabilitation
professional may be confident of
recovery in a short duration of time
and may convey a reassuring message to the patient. Subsequently,
patients may view their condition as
temporary, which may lessen the
amount of fear they feel. This
reduced fear of pain related to activity may result in a more confrontational response to the pain, and thus
the potential for greater functional
recovery.15 In contrast, with a rotator cuff tear, a therapist may convey
that rehabilitation may not be successful, and the patient may eventually need surgery if the symptoms do
not improve. Such a message of
more delayed recovery may support
the maintenance of fear-avoidance
beliefs, which, in turn, may hinder
functional recovery. We could have
been more certain of this explanation if we would have measured attitudes of health care professionals
toward different medical conditions.
An alternative explanation for differences in disease categories may be
that interventions implemented by
therapists may be more concentrated on reducing the effects of fear
among the 6 disease categories that
did not show differences between
low and elevated fear groups. However, this differential effect is less
likely because clinicians generally
are not aware of patient fearavoidance beliefs.57,58 Furthermore,
we cannot be certain about the
effect of intervention because we do
not know what intervention was
implemented. Therefore, we have
no information on the effectiveness
of any interventions on reducing
fear-avoidance beliefs.
Number 8
Our findings are similar to those
found among other musculoskeletal
conditions where the association
between fear-avoidance and functional status is significant, yet
small.15,59,60 Overall, fear-avoidance
is not one of the most important predictors of functional outcomes.
However, fear-avoidance was found
to be an important predictor for
some people but not for others, as
indicated by differences among diagnostic groups of shoulder conditions. Consequently, use of diagnostic categories may allow us to
identify subgroups of individuals
who benefit the most from targeted
treatment for fear avoidance.
The present study has 2 important
clinical implications. First, it is
important to assess fear-avoidance
beliefs related to pain among people
with shoulder conditions. Second,
people with shoulder conditions
may benefit from targeted treatment
for fear avoidance, especially when
diagnosed with a muscle, tendon, or
a soft tissue disorder, or osteopathy,
chondropathy, or an acquired musculoskeletal deformity.
Limitations
This study had several limitations.
First, this study was a retrospective
review of cohort data sets where the
potential for patient selection bias
was strong. In this case, we created
disease categories based on data
from patients whose health care providers had voluntarily elected to
enter ICD-9 diagnostic codes into the
system. Moreover, we were unable
to confirm the diagnosis recorded by
the clinician or the methods by
which a clinician selected an individual diagnostic label. Previous studies
have shown ICD-9 codes to have
variable interrater reliability, poor to
moderate validity,35–37 and insufficient specificity values.36 Consequently, the findings of our study
could be biased because of the accuracy of the assigned ICD-9 codes.
August 2012
Second, we do not know the rehabilitation protocol followed in treatment of the patients with shoulder
conditions making up our sample.
Specifically, we do not know
whether therapists used patient
information on elevated fear to
implement interventions to reduce
fear. Our study findings could be
greatly influenced if some therapists
implemented interventions to reduce
fear and others did not implement
such interventions. Finally, our findings may be influenced by other factors that were not controlled for in this
analysis. Accounting for these variables in the statistical analysis could
potentially change the findings of our
multivariate analysis. For example, it
might be important to include characteristics of treating health care professionals, including their training (specialist versus generalist) and their
attitudes toward prognosis of the condition that they treated. Future studies
collecting information from therapists
on treatment provided to patients
would be beneficial. Additionally,
information on other possible predictor variables might be collected and
included in the model. Finally, information on how patients were classified and details of their disease course
could help clarify the extent of variability within groups and perhaps
eliminate some of this variability.
sionals should assess for and manage
fear-avoidance beliefs to improve treatment outcomes. There is a need to
investigate effectiveness of rehabilitative treatments when individuals with
shoulder impairments experience elevated fear-avoidance beliefs.
Dr Sindhu, Dr Lehman, and Dr Tarima provided concept/idea/research design. Dr
Sindhu, Dr Lehman, Dr Bishop, and Mr Klein
provided writing. Dr Hart provided data collection and participants. Dr Sindhu, Dr Lehman, Dr Tarima, Dr Bishop, Mr Klein, Mr
Shivakoti, and Dr Wang provided data analysis. Dr Tarima, Dr Hart, and Mr Shivakoti
provided consultation (including review of
manuscript before submission). The authors
thank Focus On Therapeutic Outcomes, Inc
(Knoxville, Tennessee) for providing data for
this research project.
At the time of this study, Dr Wang and Dr
Hart were employees of Focus On Therapeutic Outcomes, Inc (Knoxville, Tennessee).
This study was reviewed and approved by
the institutional review boards for the protection of human subjects at the University
of Wisconsin–Milwaukee and FOTO, Inc.
Part of the manuscript was presented orally
at the American Occupational Therapy Association Annual Conference; April 26 –29,
2012; Indianapolis, Indiana.
This work was supported, in part, by the
Office of Undergraduate Research, University
of Wisconsin–Milwaukee, and the Clinical
and Translational Science Institute of Southeast Wisconsin, Medical College of
Wisconsin.
DOI: 10.2522/ptj.20110309
Conclusions
Elevated fear-avoidance beliefs were
found to be associated with poorer
functional status in only 2 out of 8
disease categories: (1) muscle, tendon, and soft tissue disorders and (2)
osteopathies, chondropathies, and
acquired musculoskeletal deformities. This effect of fear-avoidance
beliefs on improvement in function
is dependent on covariates included
in the analysis. We accounted for differences in clinics, age groups, sex,
function and pain intensity at intake,
duration of condition, and missing
data. Among the 2 disease categories,
our data suggest rehabilitation profesAugust 2012
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August 2012
Appendix.
Flow Diagram Used for Selecting Study Participants
August 2012
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Research Report
C. Wu, ScD, OTR, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University,
Taoyuan, Taiwan.
C. Yang, MS, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University.
L. Chuang, PT, PhD, School of
Occupational Therapy, College of
Medicine, National Taiwan University, Taipei, Taiwan.
K. Lin, ScD, OTR, School of Occupational Therapy, College of Medicine, National Taiwan University,
and Division of Occupational
Therapy, Department of Physical
Medicine and Rehabilitation,
National Taiwan University Hospital, 17, F4, Xu Zhou Road, Taipei,
Taiwan. Address all correspondence to Dr Lin at: kehchunglin@
ntu.edu.tw.
H. Chen, PhD, Department and
Graduate Institute of Industrial
Engineering and Management,
National Taipei University of Technology, Taipei, Taiwan.
M. Chen, PhD, OT, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University.
W. Huang, MS, Division of Occupational Therapy, Department of
Physical Medicine and Rehabilitation, En Chu Kong Hospital, New
Taipei City, Taiwan.
Ms Yang and Dr Chuang contributed equally to the manuscript.
[Wu C, Yang C, Chuang L, et al.
Effect of therapist-based versus
robot-assisted bilateral arm training on motor control, functional
performance, and quality of life
after chronic stroke: a clinical trial.
Phys Ther. 2012;92:1006 –1016.]
Association
April 19, 2012
Effect of Therapist-Based Versus
Robot-Assisted Bilateral Arm Training
on Motor Control, Functional
Performance, and Quality of Life After
Chronic Stroke: A Clinical Trial
Ching-yi Wu, Chieh-ling Yang, Li-ling Chuang, Keh-chung Lin, Hsieh-ching Chen,
Ming-de Chen, Wan-chien Huang
Background. Although bilateral arm training (BAT) has been widely studied, the
comparative effects of therapist-based BAT (TBAT) versus robot-assisted BAT (RBAT)
remains unknown.
Objective. This study compared the efficacy of TBAT, RBAT, and a control
treatment (CT) on motor control, functional performance, and quality of life after
chronic stroke.
Design. A randomized, pretest-posttest, control group design was used.
Methods. Forty-two patients (mean age⫽54.49 years, SD⫽9.69; mean length of
time since stroke onset⫽17.62 months, SD⫽10.50) were randomly assigned to TBAT,
RBAT, and CT groups. Each group received treatment for 90 to 105 minutes per
session, 5 sessions on weekdays, for 4 weeks. Outcome measures included kinematic
analyses, the Fugl-Meyer Assessment (FMA), the Motor Activity Log, and the Stroke
Impact Scale (SIS).
Results. Large and significant effects were found in the kinematic variables, distal
part of upper-limb motor impairment, and certain aspects of quality of life in favor of
TBAT or RBAT. Specifically, the TBAT group demonstrated significantly better temporal efficiency and smoothness, straighter trunk motion, and less trunk compensation compared with the CT and RBAT groups. The RBAT group had increased
shoulder flexion compared with the CT and TBAT groups. On the FMA, the TBAT
group showed higher distal part scores than the CT group. On the SIS, the RBAT
group had better strength subscale, physical function domain, and total scores than
the CT group.
Limitations. This study recruited patients with mild spasticity and without cognitive impairment.
Conclusions. Compared with CT, TBAT and RBAT exhibited differential effects
on outcome measures. Therapist-based BAT may improve temporal efficiency,
smoothness, trunk control, and motor impairment of the distal upper limb. Robotassisted BAT may improve shoulder flexion and quality of life.
this article at:
ptjournal.apta.org
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August 2012
Therapist-Based Versus Robotic Bilateral Arm Training
P
atients with stroke often have
adaptive compensation by using
alternative movement patterns
during task accomplishment,1 such
as forward trunk inclination for
reaching when elbow extension or
shoulder flexion is limited.2 Trunk
compensation for motor impairment
engenders a pattern of disuse that
might restrict motor improvement of
the upper limb (UL).1,3
Bilateral arm training (BAT) is a
promising treatment approach that
improves UL function after stroke.4,5
This treatment approach usually
involves the repetitive practice of
bilateral, symmetrical movement of
whole-arm functional training, which
usually is supervised and mediated
by a therapist (TBAT)4 or a robot
(RBAT).6 Previous TBAT studies
showed positive outcomes for reducing UL impairment,7,8 enhancing
motor function,8 and increasing
movement smoothness and force
generation during reaching.8,9 However, TBAT requires extensive therapist guidance for treatment delivery;
RBAT has emerged as an alternative
approach to save manpower and
costs by decreasing the time
demands on the therapist.
Robot-assisted BAT involves simultaneous, active movements of both
limbs with a robot providing assistance or resistance.6 This treatment
approach has demonstrated beneficial effects on motor impairment6,10,11 and muscle strength,6,10,11
but not on functional independence
or on capacities for basic daily activities.10 –12 Proper wrist and hand use
is particularly relevant for functional
use of the paretic arm in daily life,13
and functional gains depend more
on wrist and hand movement.14
Training of the distal UL leads to
twice as much carryover effect to
the proximal segments than in the
reverse order of training.15 Therefore, training of bilateral forearms
August 2012
and wrists was adopted in this study
for RBAT.
Taken together, BAT mediated by
therapists or by robots has demonstrated benefits for motor or functional improvement. Therapist-based
BAT involves multijoint, againstgravity, and function-oriented tasks,
whereas RBAT involves single-joint,
gravity-eliminated, and motor skill–
oriented tasks. The different nature
of training content in the 2
approaches may result in differential
effects. The purpose of this study
was to compare the efficacy of
TBAT, RBAT, and a control treatment
(CT) on kinematic analysis, functional outcome, and quality of life.
Kinematic analysis provides information not only on movement quality of
the UL (eg, movement directedness,
smoothness, efficiency) but also on
the extent of trunk compensation to
reaching tasks.15
Method
Participants
We recruited 42 participants who
met the following inclusion criteria:
(1) onset of a unilateral stroke at
least 6 months previously; (2) mildto-moderate motor impairment (total
score of 26 – 66 on the Fugl-Meyer
Assessment [FMA] for the UL)11,16;
(3) no severe spasticity in the paretic
arm (Modified Ashworth Scale score
of ⱕ2 in any joint)17; (4) no serious
cognitive deficits (Mini-Mental State
Examination score of ⱖ22)18; (5) no
other neurologic, neuromuscular, or
orthopedic disease; and (6) no participation within the previous 3
months in any experimental rehabilitation or drug studies. All participants provided informed consent
before data collection.
Design
A randomized, pretest-posttest, control group design was used in this
study. Eligible participants were individually randomized to TBAT, RBAT,
and CT groups (Fig. 1). A prestratifi-
cation strategy was applied according to side of the lesion and severity
of the motor impairment (total score
on the FMA for UL: 26 – 40 versus
40 – 66)11 to ensure an equal distribution of the participants in each
group. The allocation to group was
concealed from the investigators,
and the participants were blinded to
the study hypotheses.
Training was administered during
outpatient occupational therapy sessions, in which each participant
received TBAT or RBAT, depending
on group allocation, along with 15 to
20 minutes of UL functional training
to achieve individual treatment
goals. All other routine interdisciplinary stroke rehabilitation that did
not focus on UL training was continued as usual. Clinical outcome measures were administered at baseline
and immediately after a 4-week intervention by certified, trained occupational therapists blinded to the participant group.
Interventions
All participants received a 90- to 105minute therapy session, 5 times per
week, for 4 weeks. The intervention
was provided at the participating
hospitals under the supervision of
certified occupational therapists
trained to deliver standardized treatment and monitor the safety of
patients undergoing the intervention.
TBAT group. The TBAT group
was asked to practice identical tasks
with each arm simultaneously. Participants moved the unaffected arm
voluntarily while also attempting to
move the affected arm voluntarily.
For those who had difficulty moving
the affected arm simultaneously with
the unaffected arm, therapists provided physical assistance to the
affected arm. Participants practiced
a variety of bilateral functional tasks
under one-on-one supervision of the
therapists. Among the tasks were lift
2 cups, stack 2 checkers, reach for-
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1007
ward or upward to move blocks,
grasp and release 2 towels, and
manipulate 2 coins simultaneously
by each hand. The TBAT group also
practiced 15 to 20 minutes of functional training and 5 minutes of tone
normalization at the end of therapy,
if necessary. Participants received
verbal feedback, including knowledge of results (KR), referring to task
success of failure, and knowledge
of performance (KP), referring to
the nature of movement pattern.19
Examples of KR include “the movement was correct” and “you missed
your target,” and examples of KP
include “move your trunk less” and
“pick up the block faster.”
RBAT group. The Bi-Manu-Track
(Reha-Stim Co, Berlin, Germany;
Fig. 2) robot-assisted arm trainer was
used.6,20 Participants sat at a heightadjustable table with elbows at 90
degrees. They grasped the 3-cmdiameter handles with each hand or
both hands, and their forearms were
placed in the midposition into the
arm troughs. A computer game (eg,
picking up and placing apples) that
tracked participants’ movements
facilitated participation.
The Bi-Manu-Track offers 2 movement patterns: forearm pronationsupination and wrist flexionextension. There are 3 operational
modes: passive-passive mode (mode
1), with both arms being passively
moved by the machine; activepassive mode (mode 2), with the
nonparetic arm driving the paretic
arm to move symmetrically; and
active-active mode (mode 3), with
both arms performing actively by
overcoming resistance. Participants
spent about 30 minutes in modes 1
and 2 and about 10 minutes in mode
3 for each type of movement. They
received 75 to 80 minutes of RBAT,
followed by 15 to 20 minutes of
unilateral and bilateral functional
training and 5 minutes of tone normalization at the end of therapy, if
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Physical Therapy
Volume 92
Assessed for eligibility
(N=250)
Enrollment
Excluded (n=208)
Did not meet inclusion criteria
(n=172)
Refused to participate (n=36)
Randomized (n=42)
TBAT Group
(n=14)
RBAT Group
(n=14)
Analyzed (n=14)
Analyzed (n=14)
CT Group
(n=14)
Analyzed (n=14)
Figure 1.
Flow diagram showing the randomization procedure. RBAT⫽robot-assisted bilateral
arm training, TBAT⫽therapist-based bilateral arm training, CT⫽control treatment.
Figure 2.
The Bi-Manu-Track. (A) Pronation and supination movement of the forearm. (B) Flexion
and extension movement of the wrist.
necessary. The safety features of
Bi-Manu-Track include mechanical
braking of the movement when the
torque exceeds 4 N䡠m, preventing
injuries caused by excessive passive
movement on the affected arm, and
an emergency brake within reach of
the user that enables the user to stop
the arm trainer whenever he or she
feels uncomfortable.21
CT group. The therapeutic activities in the CT group involved weight
bearing, stretching, strengthening of
the paretic arms, coordination, unilateral and bilateral fine motor tasks,
balance, and compensatory practice
on functional tasks.
Number 8
Outcome Measures
Kinematic analysis. Experimental
tasks included 1 unilateral task of
pressing a desk bell and 1 bimanual
task of pulling open a drawer to
retrieve an eyeglass case. Participants sat on a height-adjustable,
straight-back chair with the seat
height set to 100% of the lower leg
length. In the initial position, the
tested arm was pronated and the
hand rested on the edge of the table
in a neutral position with 90 degrees
of flexion at the elbow joint. The
target object (desk bell or drawer)
was placed in the midline of the
body. The reaching distance was
standardized to the participant’s
August 2012
functional arm length, defined as
the distance from the medial border
of the axilla to the distal wrist
crease.22 If the maximum distance
the participant could reach was less
than the functional arm length, the
reaching distance to the target was
adjusted to the maximum reachable
distance. No or minimal trunk movement occurs when an individual
who is healthy reaches for a target
within arm’s length.2 For the unilateral task, the tester’s instruction to
the participants was: “When I say
‘go,’ please use the index finger of
the affected hand to reach and press
the task bell as fast as possible.” For
the bimanual task, the instruction
given to participants was: “When I
say ‘go,’ please pull a drawer with
the affected hand and retrieve an
eyeglass case inside the drawer with
the unaffected hand at a comfortable
self-speed.” Only the pulling phase
was analyzed. After a practice trial, 3
data-producing trials were performed.
A 7-camera motion analysis system
(VICON MX, Oxford Metrics Inc,
Oxford, United Kingdom), recording
at 120 Hz, was used with a personal
computer to capture the movement
of 17 markers that were placed on
the participants’ sternum, spinal process (C7 and T4), bilateral thumbnails, index fingernails, ulnar styloid
processes, radial styloid processes,
lateral epicondyles, middle part of
the humeri, acromial processes, and
clavicular heads. The system was calibrated to have averaged residual
errors not exceeding 0.5 mm for
each camera before data acquisition.
For the unilateral task, 1 channel of
analog signals was collected to signal
the end of the movement when the
bell was pressed. Movement onset
was defined as a rise of tangential
wrist velocity above 5% of its peak
value for both testing tasks. Movement offset for the unilateral task
was defined as the time when the
participant pressed the bell. During
the bimanual task, end of movement
August 2012
was defined as a fall of tangential
wrist velocity below 5% of its peak
value. Movements were digitally lowpass filtered at 5 Hz using a secondorder Butterworth filter with forward and backward pass.
Data reduction for kinematic variables. An analysis program coded
by LabVIEW (National Instruments
Inc, Austin, Texas) language was
used to process the kinematic data.
Kinematic variables were chosen to
describe the arm-trunk movement
quality and trunk compensation.
Movement quality involved reaching
performance characterized by normalized movement time (NMT) and
normalized movement units (NMUs),
and trunk movement was characterized by normalized trunk displacement (NTD). Movement time (MT)
is the interval between movement
onset and offset, which refers to the
time for execution of the reaching
movement and represents temporal
efficiency.22,23 One movement unit
(MU) consists of 1 acceleration
phase and 1 deceleration phase,
which characterizes movement
smoothness. Fewer MUs indicate
smoother movement.23 The MT and
MU were divided by the reaching
distance to normalize for variations
in reaching distance across participants and denoted as NMT and NMU,
respectively. Furthermore, NTD was
expressed as trunk total displacement of the sternum marker divided
by trunk distance,24,25 which is illustrated in Figure 3.
Trunk compensation changes were
denoted by the trunk contribution
slope, which is defined as the ratio of
the sagittal translation of the index
minus that of the sternum marker to
the sagittal translation of the sternum marker, indicating the amount
of trunk displacement on reaching.
The lower the slope value, the more
compensation (or displacement) the
trunk exerted.2 Trunk movement
in adults who are healthy usually
Figure 3.
Normalized trunk displacement denoted
by trunk total displacement/trunk distance is illustrated: the solid line means
trunk total displacement; the dashed line
means trunk-moving distance.
occurs at earlier phases of reaching.
Accordingly, we divided the reaching movement equally into 3 phases,
calculated the slope separately for
each phase, and used the slope values at the start and middle phases as
the dependent variables.2 The angular changes of the shoulder and
elbow joint refer to the differences
in shoulder and elbow angle from
movement onset and movement
offset and were divided by the reaching distance to normalize for variations in reaching distance across
participants.24,26
Clinical assessment. The UL subscale of the FMA, which assesses
motor impairment, consists of 33
items measuring the movement and
reflexes of the shoulder/elbow/forearm, wrist, and hand and coordination/speed on a 3-point ordinal scale
(0⫽cannot perform, 1⫽can perform
partially, 2⫽can perform fully).27
The proximal and distal scores of
the FMA were calculated to examine
the treatment effects on separate
UL elements of movement. A higher
FMA score indicates less motor
impairment.
The Motor Activity Log (MAL) evaluates daily functions by using a semistructured patient interview that
assesses the amount of use (AOU)
and quality of movement (QOM) of
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1009
Table 1.
Characteristics of Study Participants (n⫽42)a
RBAT Group
(nⴝ14)
Variable
TBAT Group
(nⴝ14)
CT Group
(nⴝ14)
Sex, n
Male
Female
Age, y, X (SD)
10
12
10
4
2
4
55.13 (12.72)
57.04 (8.78)
51.30 (6.23)
Side of brain lesion, n
Right
7
5
4
Left
7
9
10
Statisticb
P
1.05
.59
1.29
.29
1.41
.49
Results
Months after stroke onset, X (SD)
18.00 (8.65)
17.29 (13.29)
17.57 (9.80)
0.02
.99
MMSE score, X (SD)
27.71 (2.33)
28.57 (1.70)
28.08 (1.50)
0.73
.49
a
RBAT⫽robot-assisted bilateral arm training, TBAT⫽therapist-based bilateral arm training, CT⫽control
treatment, MMSE⫽Mini-Mental State Examination.
b
Statistic associated with the chi-square test or the Fisher exact test for categoric variables and with
the analysis of variance for continuous variables.
the affected UL in 30 daily activities.28 The MAL uses a 6-point ordinal
scale, with higher scores indicating
better performance.
The Stroke Impact Scale (SIS), version 3, is a 59-item self-report scale
designed to assess quality of life. It is
grouped into 8 functional subscales:
strength, memory, emotion, communication, activities of daily living
(ADLs)/instrumental ADLs (IADLs),
mobility, hand function, and participation. The strength, hand function,
ADLs/IADLs, and mobility subscales
can be combined into a composite
physical function domain.29 Items
are rated on a 5-point Likert scale,
with lower scores indicating greater
difficulty in task completion during
the previous week. Aggregate scores,
ranging from 0 to 100, are generated
for each subscale.
Data Analysis
Baseline differences between groups
were evaluated with the chi-square
test or the Fisher exact test for categoric data and analysis of variance
(ANOVA) for continuous data. Given
that our research aimed to compare
whether the posttest results were
different among the 3 groups, analysis of covariance (ANCOVA) is a
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more suitable statistical method than
repeated-measures ANOVA to compare the intervention main effect
(ie, posttest score) by holding the
pretest score constant in the former
method.30 For the ANCOVA, pretest
performance was the covariate,
group was the independent variable,
and posttest performance was the
dependent variable. To index the
magnitude of group differences in
performance, ␩2⫽SSb/SStotal was calculated for each outcome variable,
where SS is the sum of squares and b
represents between-groups. The
value of ␩2 is independent of sample
size and represents the variability in
the dependent variable (posttest performance) that can be explained by
group.31 A large effect is represented
by an ␩2 of at least .14, a moderate
effect by an ␩2 of .06, and a small
effect by an ␩2 of .01.32 Least significant difference was used to determine the post hoc significance of
pair-wise comparisons of adjusted
group mean via ANCOVA. Level of
statistical significance (␣) was set at
.05 for all comparisons and was not
adjusted because of the preliminary
nature and size of the study.
Number 8
This project was supported, in part,
by the National Health Research
Institutes (NHRI-EX100-9920PI and
NHRI-EX100-10010PI), the National
Science Council (NSC 97-2314-B-002008-MY3 and NSC 99-2314-B-182014-MY3), and the Healthy Aging
Research Center at Chang Gung University (EMRPD1A0891).
The mean age of the participants was
54.49 years (SD⫽9.69), and they
were at an average of 17.62 months
(SD⫽10.50) after stroke onset. The
demographic and clinical characteristics of participants in the 3 groups
(Tab. 1) did not differ significantly.
Tables 2 and 3 present the descriptive statistics and inferential statistics
for the kinematic variables and clinical measures. Two participants in
the RBAT group and 1 participant in
the CT group did not complete the
bimanual task. No adverse events
of pain were reported among the
participants.
Kinematic Measures
For kinematic variables in the unilateral task, the ANCOVA results
revealed significant differences
among the 3 groups in NMT
(F2,38⫽3.79,
P⫽.032,
␩2⫽.17),
NMUs (F2,38⫽3.95, P⫽.028, ␩2⫽.17),
trunk NTD (F2,38⫽3.82, P⫽.031,
␩2⫽.17), trunk contribution slope
for the middle part (F2,38⫽5.51,
P⫽.008, ␩2⫽.23), and angular
change of shoulder joints (F2,38⫽
4.77, P⫽.014, ␩2⫽.20). Post hoc
analyses revealed that the TBAT
group, but not the RBAT group, demonstrated a significant decrease on
NMT (P⫽.011), NMUs (P⫽.009), and
trunk NTD (P⫽.009) compared with
the CT group. Compared with the
CT and RBAT groups, the TBAT
group produced greater improvements in the trunk contribution
slope for the middle part (TBAT
group versus RBAT group, P⫽.008;
TBAT group versus CT group,
August 2012
Table 2.
Descriptive and Inferential Statistics for Analysis of Reaching Kinematicsa
Pretreatment (XⴞSD)
Variable
Unilateral task
Posttreatment (XⴞSD)
ANCOVA
RBAT Group
TBAT Group
CT Group
RBAT Group
TBAT Group
CT Group
(n⫽14)
(n⫽14)
(n⫽14)
(n⫽14)
(n⫽14)
(n⫽14)
F
␩2
P
NMT (s/mm)
0.008 (0.0045)
0.008 (0.0058) 0.0065 (0.0049) 0.0078 (0.0049) 0.0054 (0.0025) 0.0081 (0.0042) 3.79 .03b
.17
NMUs (unit/mm)
0.043 (0.026)
0.056 (0.064)
3.95 .03b
.17
b
.17
Trunk NTD (mm/mm)
0.033 (0.030)
0.046 (0.031)
0.033 (0.029)
0.049 (0.033)
1.22 (0.18)
1.31 (0.49)
1.58 (1.31)
1.23 (0.21)
1.13 (0.10)
1.52 (0.76)
3.82 .03
3.21 (4.08)
3.37 (3.35)
2.70 (3.96)
4.94 (5.45)
3.25 (4.47)
5.02 (5.62)
0.59
Trunk contribution
(mm/mm)
Slope: start
Slope: mid
.56
b
.03
2.13 (2.15)
0.96 (1.35)
2.84 (3.75)
1.37 (2.07)
2.93 (3.31)
1.55 (2.30)
5.51 .01
nShoulder flexion
0.16 (0.058)
0.13 (0.034)
0.14 (0.045)
0.19 (0.073)
0.14 (0.025)
0.14 (0.039)
4.77 .01b
.20
nElbow extension
0.10 (0.038)
0.061 (0.033)
0.094 (0.039)
0.098 (0.037)
0.078 (0.034)
0.098 (0.053)
0.15
.87
.004
(n⫽12)
(n⫽14)
(n⫽13)
(n⫽12)
0.0033 (0.0032) 1.70
.20
.09
.23
Angular change
(°/mm)
Bimanual task
NMT (s/mm)
NMUs (unit/mm)
(n⫽14)
0.0052 (0.0017) 0.007 (0.0032) 0.0059 (0.0044) 0.0048 (0.0014)
0.005 (0.003)
(n⫽13)
0.022 (0.009)
0.033 (0.029)
0.037 (0.016)
0.023 (0.012)
0.026 (0.022)
0.048 (0.037)
3.09
.06
.15
1.21 (0.16)
1.51 (0.77)
2.06 (2.35)
1.24 (0.20)
2.35 (3.36)
1.24 (0.35)
1.85
.17
.10
Slope: start
⫺0.08 (6.28)
9.15 (13.61)
4.33 (9.34)
1.80 (6.83)
6.90 (9.89)
1.41 (9.75)
0.63
.54
.04
Slope: mid
4.94 (5.11)
4.12 (4.38)
4.70 (6.84)
6.27 (9.61)
8.13 (8.52)
2.12 (4.07)
3.44 .04b
.16
nShoulder flexion
0.16 (0.029)
0.12 (0.035)
0.15 (0.063)
0.17 (0.028)
0.12 (0.045)
0.11 (0.064)
4.92 .01b
.22
nElbow extension
0.062 (0.039)
0.025 (0.050)
0.048 (0.042)
0.074 (0.039)
0.062 (0.056)
0.049 (0.056)
1.23
.07
Trunk NTD (mm/mm)
Trunk contribution
(mm/mm)
Angular change
(°/mm)
.31
a
ANCOVA⫽analysis of covariance, RBAT⫽robot-assisted bilateral arm training, TBAT⫽therapist-based bilateral arm training, CT⫽control treatment,
NMT⫽normalized movement time, NMU⫽normalized movement unit, trunk NTD⫽normalized trunk displacement, nShoulder flexion⫽normalized shoulder
flexion, nElbow extension⫽normalized elbow extension.
b
P⬍.05, ␩2⫽SSb/SStotal.
P⫽.005). The RBAT group engendered a larger improvement in the
angular changes of shoulder flexion
than the TBAT and CT groups (RBAT
group versus TBAT group, P⫽.031;
RBAT group CT group, P⫽.005).
trunk contribution slope for the middle part (P⫽.013) than the CT group.
In addition, higher gains in the angular changes of the shoulder flexion
were produced in the RBAT group
than in the CT group (P⫽.004).
For kinematic variables in the bimanual task, the ANCOVA results
showed differences among the 3
groups in trunk contribution slope
for the middle part (F2,35⫽3.44,
P⫽.043, ␩2⫽.16) and angular
changes of the shoulder joint
(F2,35⫽4.92, P⫽.013, ␩2⫽.22). Post
hoc analyses revealed that the TBAT
group, but not the RBAT group, demonstrated larger enhancement on
Clinical Measures
No group effect on the overall FMA
score, proximal part score of the
FMA, and AOU and QOM of the MAL
was documented; however, performance on the distal part of the FMA
was significantly different among
the 3 groups (F2,38⫽3.84, P⫽.03,
␩2⫽.168). Post hoc analyses revealed
that the score for the distal part of
the FMA was higher in the TBAT
August 2012
group than in the CT group
(P⫽.012). Differences also were
found in the SIS total score
(F2,38⫽4.58,
P⫽.017,
␩2⫽.19),
strength
subscale
(F2,38⫽5.02,
P⫽.012, ␩2⫽.21), and physical function domain (F2,38⫽4.54, P⫽.017,
␩2⫽.19). Post hoc analyses indicated
that the RBAT group showed larger
improvement
in
total
score
(P⫽.005),
strength
subscale
(P⫽.003), and physical function
domain (P⫽.005) of the SIS than the
CT group.
Discussion
To our knowledge, this comparative
efficacy study is the first to evaluate
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1011
Table 3.
Descriptive and Inferential Statistics for Clinical Measuresa
Pretreatment (XⴞSD)
Posttreatment (XⴞSD)
ANCOVA
RBAT Group
(nⴝ14)
TBAT Group
(nⴝ14)
CT Group
(nⴝ14)
RBAT Group
(nⴝ14)
TBAT Group
(nⴝ14)
CT Group
(nⴝ14)
F2,38
P
␩2
Total
43.29 (10.09)
43.43 (10.63)
45.43 (11.42)
47.14 (10.97)
48.71 (10.39)
48.57 (12.32)
1.85
.17
.09
Proximal
31.43 (4.54)
29.57 (5.30)
30.93 (3.93)
33.07 (4.46)
32.14 (4.62)
33.14 (4.31)
0.32
.73
.02
Distal
11.86 (7.05)
13.86 (6.50)
13.40 (7.44)
14.07 (7.66)
16.57 (7.30)
15.43 (9.10)
3.84
.03b
.17
AOU
0.53 (0.47)
0.68 (0.51)
0.87 (1.00)
0.82 (0.65)
1.03 (0.91)
1.25 (1.25)
0.01
.99
.001
QOM
0.66 (0.51)
0.78 (0.61)
0.97 (1.05)
1.03 (0.79)
1.18 (0.83)
1.59 (1.51)
0.40
.68
.02
Total
68.62 (7.62)
64.27 (5.26)
65.23 (11.19)
73.97 (8.68)
67.61 (5.72)
64.75 (12.94)
4.58
.02b
.19
Strength
41.52 (9.99)
40.63 (12.91)
37.05 (12.37)
51.34 (14.75)
44.20 (10.53)
36.16 (14.54)
5.02
.01b
.21
Memory
91.11 (13.70)
89.28 (7.78)
85.46 (15.18)
93.07 (9.04)
89.27 (9.72)
86.73 (14.72)
0.49
.61
.03
Emotion
59.50 (15.17)
60.72 (12.45)
51.19 (10.49)
60.32 (9.66)
62.31 (12.51)
55.76 (13.38)
0.07
.93
.004
Communication
94.48 (13.01)
90.55 (11.68)
85.97 (18.51)
96.23 (8.67)
94.63 (7.40)
87.23 (14.67)
1.76
.19
.09
ADL/IADL
82.38 (10.50)
74.79 (10.83)
77.77 (12.23)
85.64 (11.81)
73.29 (13.66)
73.50 (17.97)
1.90
.16
.09
Variable
FMA
MAL
SIS
Mobility
91.55 (7.93)
83.32 (7.55)
80.16 (17.02)
94.25 (3.98)
86.17 (7.83)
76.40 (23.75)
2.27
.11
.11
Hand function
40.20 (28.78)
34.86 (18.51)
47.86 (25.70)
53.84 (22.50)
48.36 (28.74)
50.57 (27.84)
1.05
.36
.05
Participation
48.23 (20.03)
40.00 (25.50)
56.37 (24.07)
57.09 (28.70)
42.67 (18.60)
51.66 (21.41)
1.08
.35
.05
Physical function
63.91 (11.17)
58.39 (7.07)
60.71 (12.73)
71.27 (9.43)
63.00 (10.07)
59.16 (17.08)
4.54
.02b
.19
a
ANCOVA⫽analysis of covariance, RBAT⫽robot-assisted bilateral arm training, TBAT⫽therapist-based bilateral arm training, CT⫽control treatment,
FMA⫽Fugl-Meyer Assessment, MAL⫽Motor Activity Log, AOU⫽amount of use, QOM⫽quality of movement, SIS⫽Stroke Impact Scale, ADL/IADL⫽activities
of daily living/instrumental activities of daily living.
b
P⬍.05, ␩2⫽SSb/SStotal.
movement quality, trunk compensation, daily functions, and quality
of life of TBAT, RBAT, and CT.
Therapist-based BAT and RBAT demonstrated differential benefits on specific outcome measures compared
with CT. The TBAT group showed
better temporal efficiency (NMT),
smoothness (NMUs), and straighter
trunk motion (NTD) during the unilateral task than the CT group. The
TBAT group also showed less trunk
compensation (trunk contribution)
than the CT group during the unilateral and bimanual tasks and the
RBAT group in the unilateral task. In
contrast, the RBAT group demonstrated specific benefits for increasing shoulder flexion (angular
changes of shoulder joint) compared
with the CT group during the unilateral and bimanual tasks and the
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TBAT group in the unilateral task.
The TBAT group also achieved better
performance in the distal part score
of the FMA than the CT group,
whereas the RBAT group had higher
strength subscale, physical function
domain, and total scores of the SIS
than the CT group.
In general, BAT based on therapist or
robot demonstrated superior performance compared with the control
intervention. Bilateral arm training
seems to contradict the principles
of unilateral training, such as
constraint-induced therapy, where
the movement of the unaffected
limb is limited and intensive practice
of the affected limb is required.
However, BAT and unilateral training, including constraint-induced
therapy, share a similar mechanism
Number 8
of rebalanced interhemispheric inhibition and disinhibition. The mechanisms for BAT involve the generation
of a “template” by the contralesional
hemisphere and the activations in
both hemispheres, leading to balanced inhibitory effects between
hemispheres.33 The mechanism for
unilateral training (eg, constraintinduced therapy) relates to the facilitation of ipsilesional hemisphere
activation, resulting in a disinhibitory effect of the contralesional cortex to the ipsilesional side and, thus,
rebalanced activation between the 2
hemispheres.34
Benefits of TBAT Over Other
Interventions
Generally consistent with a previous
study,8 the TBAT group performed
the reaching task more efficiently
August 2012
(less NMT) and smoothly (less
NMUs) with the affected arm and
with straighter trunk motion (less
trunk NTD) in the unilateral task
than the CT group. The possible
explanation for the superiority of
TBAT may have been the KR and KP
provided by therapists and the active
problem-solving process when functional tasks were practiced. By being
provided with KR and KP, participants were able to perceive information about movement outcome and
process and make the next attempt
more successful by trying to reduce
movement errors.35,36 The feedback
thus might have helped facilitate
motor learning and lead to better
movement quality for patients in the
TBAT group. In contrast, the RBAT
group practiced only forearm
pronation-supination
and
wrist
flexion-extension in passive or active
modes provided by the Bi-ManuTrack, which enforced movements
in designed and suitable trajectories.
Participants in the RBAT group
lacked patient-therapist interaction
and experience in error-based learning in functional tasks, which did not
lead to superior effects on arm and
trunk performance.
The TBAT group recruited less trunk
involvement (greater value of trunk
contribution slope for the middle
part) than the RBAT and CT groups
during unilateral reaching and the
CT group during the bilateral reaching task. When both arms perform a
similar spatiotemporal pattern simultaneously, the “template” generated
by the undamaged hemisphere may
provide normal motor plans (ie,
reaching with minimal trunk displacement)2 to assist in restoring the
movement pattern of the hemiplegic
UL.33 Moreover, the motor system
organizes the trunk and proximal
part musculature of the UL on a bilateral basis.37 The functional tasks in
the TBAT group involved ULs without constraining the trunk and then
provided more opportunities to
August 2012
practice arm-trunk coordination
while performing the tasks. In contrast, the tasks in RBAT involved minimal trunk movement via the static
position of both arms strapped to
the Bi-Manu-Track, which offered
less arm-trunk coordination than
TBAT. Consequently, TBAT may better facilitate trunk-limb organization
in a desirable or normal way and lead
to fewer trunk compensatory movements than RBAT.
The TBAT group improved arm and
trunk movement quality only in
the unilateral task, which might be
explained by the nature of the tasks.
Participants were asked to perform
the unilateral task as fast as possible
but to execute the bimanual task
with comfortable self-speed, which
may not have been sensitive enough
to induce differences among the 3
groups. Moreover, the bimanual task
used in this study (eg, pull a drawer
with the affected hand and retrieve
an eyeglass case with unaffected
hand) involved bilateral, sequential
reaching that was different from the
bilateral, simultaneous movements
practiced in TBAT.
Partially consistent with a previous
study,7 the TBAT group produced
greater improvements in the distal
part score of the FMA, but not in the
overall and proximal part of the
FMA. Simultaneously moving both
arms may have rebalanced interhemispheric activation and inhibition,38 thus reducing the distal part
of motor impairment of the affected
UL.4,39,40 Furthermore, consistent
with previous research,41,42 this
study demonstrated no significant
differences among the groups in
daily functions as measured by the
MAL. This result might be because
the bilateral symmetrical activities of
the TBAT program did not emphasize forced use of the affected UL.
Most bimanual tasks in daily life
require bilateral sequential movement, but not bilateral simultaneous
movement.4 Therefore, practice of
bilateral symmetric activities might
not be able to incorporate gain in the
distal part of motor function into
daily use of the affected UL.
Benefits of RBAT Over Other
Interventions
The RBAT group had larger improvements in angular changes of shoulder flexion compared with the TBAT
and CT groups in unilateral reaching
and with the CT group in bimanual
reaching. The Bi-Manu-Track robot
provides robot-assisted, distal movement training, characterized by a
constant velocity and a high number
of repetitions in passive or active
mode, which reestablishes the normative movement pattern by increasing the quality and quantity of sensorimotor information.43 Thus, the
range of motion was improved. The
distal movement training provided
by the Bi-Manu-Track in the present
study
demonstrated
treatment
effects on the proximal part of the
UL such as shoulder joints. The distal
approach may lead to a stronger activation in the sensorimotor cortex,
given the larger cortical representation, than the proximal training and
thus result in benefits to the proximal joints.6 Another explanation for
the possible advantages may be that
the proximal parts also were working intensely during distal training.15
Interestingly, the 3 groups differed
significantly in shoulder flexion but
not in elbow extension range of
motion. Voluntary elbow extension
is less amenable to change than
shoulder flexion.44 It is difficult to
generate elbow extension in the
affected limb when reaching outward45 because of the strong synergistic joint torque coupling of shoulder abductor and elbow flexion.46 – 48
Direct comparisons between bilateral protocols of the present study
and unilateral protocols of the previous studies49,50 might be arguable.
A previous study50 suggested that
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Physical Therapy f
1013
intensive unilateral arm training
mediated by a therapist or a robot
improved motor impairment of the
proximal UL, but not motor function
and quality of life. In contrast,
another study49 showed that intensive, robot-assisted, unilateral therapy significantly improved quality of
life, but not motor function, immediately after intervention compared
with conventional intervention. Differences in the intensity of training
and the type of robot may explain
the differential effect in these 2 studies. Our study extended the study
findings of Lo et al49 and showed that
the group who underwent robotassisted training based on a bilateral
protocol had larger gains in quality
of life, as reflected by the strength
subscale, physical function domain,
and total score of the SIS, than the
CT group. Even though our study
recruited participants with moderateto-mild UL impairment and used
bilateral protocols different from
those of the study by Lo et al49 using
patients with moderate-to-severe
UL impairment and treatment
approaches with unilateral protocols, both studies adopted intensive,
robot-assisted therapy to enhance
quality of life for patients with
chronic stroke.
In contrast, Volpe et al50 did not find
significant changes in SIS scores after
using a different robot (InMotion2
[Interactive Motion Technology Inc,
Cambridge, Massachusetts], the
commercial version of MIT-MANUS)
for less intensive training (1 hour per
session, 3 times a week for 6 weeks).
The RBAT in this study involved
moving the distal bilateral arm
against initial resistance in mode 3
(ie, active-active), which is similar to
a strength training program and,
therefore, may enhance strength output. Accordingly, patients who
receive RBAT may report higher
quality of life in the strength subscale than those who receive CT.
Moreover, distal paretic limb
1014
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Physical Therapy
Volume 92
strength has a strong relationship
with daily activity, and strengthrelated
training
might
have
enhanced the UL performance in
daily living in individuals with
chronic stroke.51,52 Robot-assisted
BAT increases active range of
motion, as evidenced in the present
study, and possibly decreases spasticity of the wrist and forearm.43 It
follows that improved physical conditions
(self-perceived
muscle
strength and quantitative measures
of range of motion) in daily living
might lead to better perception of
the physical function domain and
overall quality of life.43
A limitation of this study was the lack
of a follow-up assessment, which
may limit the understanding of
potential long-term benefits. Future
research should examine the retention of therapeutic gains after TBAT
and RBAT. In addition, appropriate
methods for measuring real-world
activity are a concern.53 The MAL
exclusively measures the functional
performance of the affected UL,
which may not be the most suitable
one for assessing the outcomes after
bilateral training protocols. Future
studies need to assess changes on
outcome measures relevant to
patients’ daily situations, including
bilateral tasks (eg, the ABILHAND
accelerometry55)
questionnaire,54
for monitoring activity of the ULs in
the community. Finally, the significant results should be considered
with caution, as correction for multiple comparisons was not done due
to the preliminary nature and size of
the study.
Conclusions
This is the first study to compare
bilateral arm training mediated by a
therapist versus a robot in improving
motor control, functional performance, and quality of life in patients
with stroke. These findings suggest
that TBAT might uniquely improve
temporal efficiency, smoothness,
Number 8
and trunk compensation of reaching
movement and motor impairment of
the distal part of the UL. Robotassisted BAT may be a more compelling approach to improve shoulder
flexion range of motion and quality
of life related to paretic UL function.
Dr Wu provided concept/idea/research
design. Dr Wu, Ms Yang, Dr Chuang, Dr Lin,
and Dr Chen provided writing. Ms Yang,
Dr Lin, and Ms Huang provided data collection. Ms Yang, Dr Chuang, Dr Chen, and
Ms Huang provided data analysis. Dr Wu,
Dr Chuang, and Dr Lin provided project
management and fund procurement. Ms
Yang provided participants. Dr Wu, Dr Lin,
and Dr Chen provided facilities/equipment.
Dr Wu and Dr Lin provided institutional liaisons. Dr Chuang and Ms Huang provided
clerical support. Dr Wu, Dr Chuang, Dr Lin,
Dr Chen, and Dr Chen provided consultation (including review of manuscript before
submission).
The institutional review boards of the participating sites approved this study.
This project was supported, in part, by the
National Health Research Institutes (NHRIEX100-9920PI and NHRI-EX100-10010PI),
the National Science Council (NSC 97-2314B-002– 008-MY3 and NSC 99-2314-B-182014-MY3), and the Healthy Aging Research
Center at Chang Gung University
(EMRPD1A0891).
This trial has been registered at Clinical
Trials.gov; Identifier: NCT01525979.
DOI: 10.2522/ptj.20110282
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et al. Intensive sensorimotor arm training
mediated by therapist or robot improves
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51 Faria-Fortini I, Michaelsen SM, Cassiano
JG, Teixeira-Salmela LF. Upper extremity
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52 Harris JE, Eng JJ. Paretic upper-limb
strength best explains arm activity in people with stroke. Phys Ther. 2007;87:88 –97.
53 Uswatte G, Hobbs Qadri L. A behavioral
observation system for quantifying arm
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55 Uswatte G, Giuliani C, Winstein C, et al.
Validity of accelerometry for monitoring
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2006;87:1340 –1345.
August 2012
Research Report
Hui-fang Chen, PhD, Assessment
Research Centre, Hong Kong Institute of Education, Hong Kong,
People’s Republic of China. Dr
Chen was affiliated with the
Department of Occupational
Therapy and Graduate Institute of
Behavioral Sciences, College of
Medicine, Chang Gung University, Taoyuan, Taiwan, at the time
of the study.
Rasch Validation of the Streamlined
Wolf Motor Function Test in People
With Chronic Stroke and
Subacute Stroke
Hui-fang Chen, Ching-yi Wu, Keh-chung Lin, Hsieh-ching Chen, Carl P-C. Chen,
Chih-kuang Chen
Background. The construct validity and reliability of the short form of the Wolf
Motor Function Test (S-WMFT) in people with subacute stroke and chronic stroke
(S-WMFT subacute stroke and chronic stroke versions) have not been investigated.
Objective. The purpose of this study was to investigate the dimensionality, item
difficulty hierarchy, differential item functioning (DIF), and reliability of the S-WMFT
subacute stroke and chronic stroke versions in people with mild to moderate
upper-extremity (UE) dysfunction.
Design. This was a secondary study in which data collected from randomized
controlled trials were used.
Methods. Data were collected at baseline from 97 people with chronic stroke
(⬎12 months after stroke) and 75 people with subacute stroke (3–9 months after
stroke) at 3 medical centers in Taiwan. Test structure, hierarchical properties, DIF,
and reliability were assessed with Rasch analysis.
Results. The test structure for both versions was unidimensional. No DIF relevant
to sex, age, or stroke location (hemispheric laterality) was detected. The tasks of
moving a hand to a box and moving a hand to a table in the S-WMFT for subacute
stroke showed a significantly high correlation. The reliability coefficients for both
versions were approximately .90.
Limitations. The findings were limited to people with stroke and mild to moderate impairment of UE function.
Conclusions. The S-WMFT subacute stroke and chronic stroke versions are useful
tools for assessing UE function in different subgroups of people with stroke and show
evidence of construct validity and reliability. A high correlation between the tasks of
moving a hand to a box and moving a hand to a table in the S-WMFT for subacute
stroke suggests that the removal of 1 of these 2 items is warranted.
C. Wu, ScD, OTR, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine,
Chang Gung University.
K. Lin, ScD, OTR, School of Occupational Therapy, College of Medicine, National Taiwan University,
Taipei, Taiwan, and Division of
Occupational Therapy, Department of Physical Medicine and
Rehabilitation, National Taiwan
University Hospital, F4, 17 Xu
Zhou Rd, Taipei, Taiwan. Address
all correspondence to Dr Lin at:
[email protected].
Hsieh-ching Chen, PhD, Department of Industrial Engineering
and Management, National Taipei
University of Technology, Taipei,
Taiwan.
C.P-C. Chen, MD, PhD, Department of Physical Medicine and
Rehabilitation,
Chang
Gung
Memorial Hospital, Taoyuan,
Taiwan.
C. Chen, MD, Department of
Physical Medicine and Rehabilitation, Chang Gung Memorial
Hospital.
[Chen H, Wu C, Lin K, et al. Rasch
validation of the streamlined Wolf
Motor Function Test in people
with chronic stroke and subacute
stroke. Phys Ther. 2012;92:
1017–1026.]
Association
May 3, 2012
Submitted: May 27, 2011
this article at:
ptjournal.apta.org
August 2012
Volume 92
Number 8
Physical Therapy f
1017
Rasch Validation of the S-WMFT
M
ore than 80% of people who
have had a stroke have
impaired function of the
upper extremity (UE),1 and many do
not regain full functional abilities
of their arms and hands.2 An important issue in addressing these deficits
after stroke and improving UE function after rehabilitation therapy is
to identify reliable and valid outcome measures for examining UE
motor function. The Wolf Motor
Function Test (WMFT), which is
used to measure the recovery of UE
motor function after stroke, is such a
test.3,4
The WMFT was originally designed
to evaluate UE function in people
with chronic stroke5 and was modified to examine the effects of
constraint-induced movement therapy in the Extremity ConstraintInduced
Therapy
Evaluation
(EXCITE) study.6,7 Researchers further extended its use to study the
effects of electrical stimulation–
assisted therapy8 and bilateral arm
training.9
The current WMFT consists of 15
performance tasks and has a performance time scale for evaluating the
time to complete a task and a 6-point
functional ability scale (FAS) for evaluating the quality of UE function during a task. In previous research, classical test theory was extensively
used to study the measurement
properties of the WMFT. The findings indicated that the predictive and
concurrent validity, reliability, and
responsiveness of the performance
time scale and the FAS were adequate to excellent in people after
stroke.10 –14
Rasch analysis has several potential
advantages over classical test theory
in assessing UE function when an
ordinal scale is used. In classical test
theory, a total score is the sum of the
scores for all items on an ordinal
scale. Because the true distances
1018
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Physical Therapy
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between the items and between the
rating categories of the items are
unknown,15 the simple summation
of scores can lead to imprecise conclusions about differences between
people as well as about change.16 To
address this limitation, Rasch analysis has been increasingly used in
rehabilitation research to create
sound measures.
Rasch analysis transforms ordinal
scores into interval data, which may
yield more accurate estimates of test
item information in parametric analyses. Also, Rasch analysis can
explore the construct validity of a UE
measure to determine whether the
tasks reflect a single construct: the
functional ability of the UE.17,18 The
estimated hierarchy of item difficulty
(from easy to difficult to perform)
advances contemporary expectations of deficit, repair, and recovery
after stroke. The targeting of item
difficulty to UE motor ability specifies tasks that people can and cannot
perform, quantifies motor impairment by locating an individual’s ability to function along a continuum of
UE motor function, and informs
progress in the recovery of functional status.
Rasch analysis also enables the examination of differential item functioning (DIF). Differential item functioning is an indicator of biased items
that have resulted in people from
different subgroups within a population, but with similar UE motor function, having different responses to
certain types of UE tasks. When DIF
is present, task performance is
affected by multiple factors that are
not the focus of study, and the instrument may not be accurate for assessing UE motor function. Therefore,
DIF analyses potentially can improve
knowledge of whether observed differences in scores across groups represent a measurement problem, a
true difference in UE function, or
Number 8
both, and can provide evidence to
support the validity of the WMFT.19
Woodbury et al20 conducted a Rasch
analysis to validate the theoretic
basis of the WMFT FAS. Their findings suggested that all items in the
WMFT measure a single latent trait,
UE motor function, and that the item
difficulty hierarchy is consistent with
the original item difficulty expectations. However, researchers have
not documented any findings in DIF
analyses to indicate, after controlling
for people’s UE functional abilities,
whether the relationships between
item responses and UE motor
function measured by the WMFT differ across groups with regard to
demographic and stroke-related
characteristics.
To improve the efficiency of administration, Bogard et al21 evaluated the
relative contributions of the 15
WMFT timed performance tasks to
the overall change in the WMFT total
score in EXCITE study participants
and proposed 2 short forms of the
WMFT (S-WMFT), one for people
with subacute stroke (3–9 months
after stroke)17,18,22 and one for people with chronic stroke (12 months
or longer after stroke). The 2 versions share 4 common tasks (moving
a hand to a box, lifting a can, lifting
a pencil, and folding a towel), and
each version has 2 distinct tasks
(extending elbow 28 cm on tabletop
[0.4536-kg (1-lb) weight] and turning a key in a lock for the chronic
stroke version and moving a hand to
a table and reaching and retrieving
for the subacute stroke version).
Bogard et al21 developed the
S-WMFT to reflect differences in the
progress of motor abilities in people
at different stages of recovery after
stroke.23 People show relatively fast
recovery for performing simple arm
movements early after stroke (eg,
reaching) but slow recovery for performing complex movement tasks.24
August 2012
At 1 year after stroke, people gain
small improvements in movement
skills and are aware of how these
small changes may be related to
functional gains in daily activities.25
These findings imply that various test
items may be required to evaluate
motor function in people at different
stages of recovery.
In 1 investigation,26 the validity of
the S-WMFT subacute stroke version
was studied, but no research to date
has documented the measurement
properties of the S-WMFT chronic
stroke version. The performance
time scale study of the S-WMFT subacute stroke version revealed comparable responsiveness and concurrent
validity but slightly higher predictive
validity relative to those of the
WMFT. These findings indicated the
clinical utility of the S-WMFT subacute stroke version in outcome evaluation and promise for further validation. However, no investigations
of the test hierarchy, DIF, or test
structure of the S-WMFT subacute
stroke or chronic stroke version
have been performed.
Although previous studies investigated the measurement properties of
the WMFT, the measurement properties of the S-WMFT may not be
similar to those of the original scale.
The removal of test items may jeopardize 1 or more important aspects
of the performance of the original
test and, as a result, the psychometric properties of a short form may be
different from those of the original.27
Because the measurement properties of the WMFT may not be generalized to the S-WMFT, further study
of the hierarchical properties of the
S-WMFT in people with subacute or
chronic stroke is warranted.
The goal of the present study was to
extend the previous findings for the
S-WMFT and fill the knowledge gap
about the measurement properties
of the S-WMFT. Because the 2 verAugust 2012
sions of the S-WMFT are targeted to
people with stroke at different stages
of recovery (subacute and chronic),
we examined the psychometric
properties of the 2 versions for their
targeted populations, including the
item difficulty hierarchy, test structure, targeting, and reliability of the
S-WMFT FAS. In addition, we investigated DIF to understand whether
the test structure is the same for people with different clinical and demographic characteristics. The Rasch
rating model was used for the study.
Method
Participants
Ninety-seven people with stroke at
the chronic stage were recruited to
study the psychometric properties of
the S-WMFT chronic stroke version,
whereas data from 75 people with
subacute stroke were used to investigate the measurement properties of
the S-WMFT subacute stroke version.
The sample size required to achieve
stable item calibrations with dichotomous data ranges from 64 to 144
for an accuracy of ⫾0.5 logit at the
95% confidence interval; polytomous observations require a smaller
sample size.28 Thus, the sample sizes
in the present study (97 for people
with chronic stroke and 75 for people with subacute stroke) were sufficient to achieve stable item calibrations. The inclusion criteria were
first-ever stroke with onset between
3 and 9 months prior (subacute
stroke group) or 12 months prior
or longer (chronic stroke group),
ability to understand the study and
respond to questions (score of
ⱖ22 on the Mini-Mental State
Examination),29 demonstration of
Brunnstrom stage III or higher for
the proximal part of the affected
arm,30 and no excessive spasticity at
any joint of the arm (score of ⱕ2 on
the Modified Ashworth Scale).31
Excluded
were
people
with
physician-determined major medical
problems, such as poor physical
condition.
Participants were enrolled in an
ongoing randomized controlled trial
investigating the effects of motor
rehabilitation after stroke. All participants provided written informed
consent.
Outcome Measure
The S-WMFT chronic stroke and subacute stroke versions have 6 items.
They share 4 common tasks, and
each has 2 distinct tasks. Table 1
shows the contents of the 2 versions
of the S-WMFT. For the present
study, we used only FAS item ratings
and not item performance time. The
FAS is a 6-point scale ranging from 0
(no use) to 5 (normal). Detailed
descriptions of the FAS ratings are
given in Table 2.
Procedure
Three certified and trained occupational therapists administered the
WMFT to participants before and
after the rehabilitation programs.
The administration took an average
of 20 minutes. Every participant was
instructed to execute all of the test
tasks with the affected arm and, if
necessary, with help from the unaffected arm.
Data Analysis
Because the focus of the present
study was the S-WMFT, we analyzed
only the baseline scores for certain
tasks. For the subacute stroke group,
these tasks were moving a hand to a
table, moving a hand to a box, reaching and retrieving, lifting a can, lifting a pencil, and folding a towel;
for the chronic stroke group, these
tasks were extending elbow 28 cm
on tabletop (0.4536-kg weight),
moving a hand to a box, lifting a
can, lifting a pencil, turning a key in
a lock, and folding a towel. We
examined the appropriateness of rating categories (ie, rating scale diagnostics), test structure, item difficulty hierarchy, DIF, and reliability
using Winsteps software (version
3.70.0.5).32
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Table 1.
Item Statistics for the Chronic Stroke and Subacute Stroke Versions of the Streamlined Wolf Motor Function Testa
Biserial
Correlation
Item
Difficulty
Measure
(Logit)
Item
Difficulty
(SE)
Extending elbow 28 cm on
tabletop (0.4536-kg [1-lb]
weight)
.72
⫺1.56
.19
Test Version
Chronic stroke
Subacute stroke
Item
Infit
Outfit
MNSQ
ZSTD
MNSQ
ZSTD
1.27
1.70
1.49
2.50
Moving hand to box
.74
⫺1.88
.19
0.95
⫺0.30
1.40
1.90
Lifting can
.84
0.98
.17
0.86
⫺1.0
0.90
⫺0.70
Lifting pencil
.87
0.59
.17
0.99
0.00
1.01
⫺0.10
Turning key in lock
.87
1.15
.17
0.89
⫺0.80
0.94
⫺0.40
Folding towel
.88
0.71
.17
0.67
⫺2.60
0.69
⫺2.40
Moving hand to table (front)
.85
⫺1.06
.21
0.65
⫺2.10
0.66
⫺1.80
Moving hand to box (front)
.84
⫺0.73
.20
0.73
⫺1.60
0.72
⫺1.60
Reaching and retrieving
.75
⫺1.24
.21
1.34
1.70
1.24
1.10
Lifting can
.84
0.88
.18
1.04
0.30
1.04
0.30
Lifting pencil
.80
1.14
.18
1.24
1.50
1.24
1.40
Folding towel
.85
1.01
.18
0.80
⫺1.30
0.86
⫺0.80
a
SE⫽standard error of measurement, MNSQ⫽mean square of the item residuals, ZSTD⫽transformation of the mean square of the residuals to the
standardized form.
Rating scale diagnostics were examined to ensure that people with a
lower level of UE motor function
received predominantly lower ratings and that people with a higher
level of UE motor function received
predominantly higher ratings. The
criteria were as follows33: there were
at least 10 responses per rating category; the average participant’s motor
ability in each rating category
increased as the rating value
increased; and the outfit mean
square, a type of goodness-of-fit statistic, of each rating category was
less than 2. If a rating category failed
to meet these criteria, then collapsing the rating category would be
considered.
To assess construct validity, we
investigated dimensionality, DIF, and
item difficulty hierarchy. Rasch principal components analysis of the
Table 2.
Functional Ability Scale
1020
f
Original
Rating
Revised
Rating
0
0
Does not attempt with the affected arm.
1
0
Attempts to use the involved arm, but it does not participate functionally.
In unilateral tasks, the less affected arm may be used to move the
affected arm.
2
1
Attempts to use the involved arm with assistance from the less affected
arm for minor adjustments or change of positions, requiring more than
2 attempts to complete or completing a task slowly. In bilateral tasks,
the affected arm serves only as a helper.
3
2
Only the affected arm is involved in the task, but movements are
influenced to some degree by synergy or performed slowly, with effort,
or both.
4
3
Only the affected arm is involved in the task; movements are close to
normal, but slightly slower. In addition, movements may lack precision,
fine coordination, or fluidity.
5
4
Only the affected arm is involved in the task, but movements appear to
be normal.
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Description
August 2012
residuals was used to test against the
hypothesis of unidimensionality. The
variance in UE motor function
explained by the S-WMFT was analyzed. Unidimensionality was supported when the variance explained
by the first dimension exceeded 50%
and an eigenvalue of the unexplained variance in the first residual
factor was less than 2.32 Item difficulty and person UE function were
simultaneously evaluated with Rasch
analysis. We expected that less difficult tasks would be more likely to be
accomplished by all participants
than more difficult tasks and that participants with a low level of UE function would be more likely to do
poorly on difficult items than participants with a high level of UE
function.
The mean square and standardized z
score fit statistics were used together
to examine whether an item deviated significantly from the expectation of the Rasch model (misfit).
Two types of unexpected ratings
were summarized: responses close
to the difficulty of an item (infit) and
responses far from the difficulty of
an item (outfit). On the basis of recommendations in the Winsteps software, an item with a mean square of
greater than 1.5 and a standardized z
score outside the range of ⫺2.0 to
2.0 was considered to be misfit.32
The item-person map indicating the
relationship between item difficulty
and person UE motor function was
examined. An ideal instrument is
capable of targeting a wide range of
people’s UE motor function; that is,
the mean person UE motor function
should be relatively close to the
mean item difficulty, and the item
difficulty range should cover a substantial range of people’s UE motor
function.34 Differential item functioning analyses were conducted to
examine whether responses to items
were influenced by demographic or
clinical characteristics after controlAugust 2012
Table 3.
Demographic and Clinical Characteristics of the Participantsa
Chronic Stroke
Group
(nⴝ97)
Variable
Subacute
Stroke Group
(nⴝ75)
Sex
Men
64
58
Women
33
17
56.6 (31.3–86.33)
55.6 (29.6–77)
20 (12–89)
7 (3–9)
Right
50
40
Left
47
35
Age, y, median (range)
Mo after stroke, median (range)
Stroke location (hemispheric laterality)
a
Values are numbers of participants unless otherwise indicated.
ling for person UE motor function.
The 3 factors chosen in the present
study were sex, age (ⱖ65 years old
or ⬍65 years old), and hemispheric
laterality. The DIF contrast was the
difference in item difficulty between
2 groups and should have been at
least 0.5 logit to be noticeable.32 A
DIF contrast of 0.5 or higher with a
probability of less than .05 was considered to be significant.32
Finally, correlations between items
and reliability were assessed. A correlation of greater than .90 indicated
that 2 tasks were highly related. Reliability was examined with the index
of person separation, person reliability, and the Cronbach alpha. Person
separation specified the number of
significant strata into which the samples of participants were divided by
UE motor function. A person separation value of greater than 1.5 indicated that the S-WMFT could distinguish people into at least 2 groups
with different levels of motor function.35 The Winsteps person reliability was algebraically distinct but conceptually similar to the traditional
internal consistency that is usually
measured with the Cronbach
alpha.36 For clinical application, a
value of 0.7 represented an acceptable level of reliability, a value of 0.8
represented a good level, and a value
of 0.9 represented an excellent
level.37
This project was supported, in part,
by the National Health Research
Institutes (NHRI-EX99-9920PI and
NHRI-EX100-10010PI), the National
Sciences Council (NSC 97-2314-B002-008-MY3 and NSC 99-2314-B182-014-MY3), and the Healthy Ageing Research Center at Chang Gung
University
(EMRPD1A0891)
in
Taiwan.
Results
The median ages of the participants
in the chronic stroke and subacute
stroke groups were 56.6 and 55.6
years, respectively. In the chronic
stroke group, 64 of 97 participants
were men, and the mean time since
stroke onset was 20 months. In the
subacute stroke group, 58 of 75 participants were men, and the mean
time since stroke onset was 7
months. Table 3 shows the demographic and clinical characteristics
of the participants.
Rating Scale Diagnostics
Except for the rating category “0,”
the FAS met all of the criteria. The
category “0” was given 9 times in the
chronic stroke group and 7 times in
the subacute stroke group. The sub-
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acute stroke group had disordered
average person measures. Participants with subacute stroke and a rating of 0 on the FAS had –1.86 logits
of motor ability across any item, but
participants with a rating of 1 had
⫺1.88 logits. Thus, we collapsed the
original category “0” with the category “1.” Reanalysis showed that the
new 5-point rating scale met all of
the essential criteria and functioned
properly. The recoded data were
used in the subsequent analyses.
(The revised rating categories are
shown in Tab. 2.)
Dimensionality
Rasch principal components analysis
supported the assumption of unidimensionality. We found that 72.4%
and 70.8% of the variance could be
explained by the Rasch dimension in
the S-WMFT chronic stroke and subacute stroke versions, respectively.
The eigenvalues of the first contrast
residuals were less than 2 in both
versions. Rasch indexes suggested
adequate fit of all tasks (Tab. 1). We
concluded that the S-WMFT chronic
stroke and subacute stroke versions
were unidimensional.
DIF
No significant DIF by sex, age, and
hemiplegia laterality was detected in
either version (P⬎.05). The item difficulty of each task for the women
was not significantly different from
that for the men. Every item had the
same difficulty for the older (ⱖ65
years old) and younger (⬍65 years
old) groups of participants. The difficulty of individual items for participants with right-side lesions was
equivalent to that for participants
with left-side lesions.
Figure 1.
Item difficulty hierarchy of the streamlined Wolf Motor Function Test for participants
with chronic stroke. The numbers at the left are logits. Plots of items along the center
line are based on average difficulty. The most able people and the most difficult items
are at the top, and vice versa. M⫽mean, S⫽standard deviation, T⫽2 standard deviations, X⫽participant’s upper-extremity motor function.
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Item Difficulty Hierarchy
For the S-WMFT chronic stroke version, the item difficulty hierarchy
from low to high was moving a hand
to a box, extending elbow 28 cm on
tabletop (0.4536-kg weight), lifting a
pencil, folding a towel, lifting a can,
August 2012
and turning a key in a lock (Fig. 1).
The average UE function was ⫺0.31
logit (SD⫽2.57). For the S-WMFT
subacute stroke version, lifting a
pencil was the most difficult task,
folding a towel and lifting a can were
next, and reaching and retrieving
was the easiest task (Fig. 2). The
average UE function was 0.86 logit
(SD⫽2.36). These findings suggest
that the S-WMFT subacute stroke version did not target UE motor function as well as the S-WMFT chronic
stroke version did.
Item Correlations and
Test Reliability
In the 2 versions of the S-WMFT, all
but 1 pair of items had correlations
between .37 and .74, and the correlation between the tasks of moving a
hand to a table and moving a hand to
a box in the S-WMFT subacute stroke
version was .93. This correlation
indicated that these items may measure similar contents of UE motor
function. The investigation of residual correlations between pairs of
items revealed that all but 1 pair of
items had correlations of less than
.30. The tasks of moving a hand to a
table and moving a hand to a box in
the S-WMFT subacute stroke version
were highly locally dependent, with
a residual correlation of .70. These 2
items shared more than 50% of their
random variance, suggesting that
only 1 was needed32 for the S-WMFT
subacute stroke version.
The person separation values in the
S-WMFT chronic stroke and subacute stroke versions were 3.19 and
2.78, the person reliability values
were .91 and .89, and the Cronbach
alpha values were .91 and .91,
respectively. People with chronic
stroke could be divided into 4.59
strata/groups, and people with subacute stroke could be divided into
4.04 strata/groups.35
August 2012
Figure 2.
Item difficulty hierarchy of the streamlined Wolf Motor Function Test for participants
with subacute stroke. The numbers at the left are logits. Plots of items along the center
line are based on average difficulty. The most able people and the most difficult items
are at the top, and vice versa. M⫽mean, S⫽standard deviation, T⫽2 standard deviations, X⫽participant’s upper-extremity motor function.
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Discussion
The present study is the first to
examine the test structure, DIF, item
difficulty hierarchy, item characteristics, and reliability of the S-WMFT
FAS for people with chronic stroke
and people with subacute stroke.
The 2 versions of the S-WMFT were
unidimensional, as is the original
WMFT. The results of DIF analyses
and the expected item difficulty hierarchy further supported the construct validity. Both versions had
high reliability and were capable of
differentiating our samples into 4 distinct groups on the basis of UE motor
ability. Evidence from the present
study indicated differences between
the 2 versions in the difficulty of the
4 common items. When the mean
person ability was compared with
the mean item difficulty, the average
item difficulty in the S-WMFT subacute stroke version was lower than
that in the S-WMFT chronic stroke
version. The S-WMFT subacute
stroke version may have a redundant
item.
The results of the present study supported the unidimensionality of both
S-WMFT versions, implying that all of
the items in the S-WMFT consistently
measure UE motor function in people with stroke. In accordance with
the findings of Woodbury et al,20
Rasch principal components analysis
of residuals supported unidimensionality. We further validated the construct validity by investigating DIF in
the S-WMFT chronic stroke and subacute stroke versions. No DIF relevant to sex, age, or hemiplegia laterality was detected; that is, the rating
scores for individual tasks in the
S-WMFT were determined by a participant’s UE motor ability, not by
other factors, such as sex, age, or
hemiplegia laterality. These findings
indicate that both S-WMFT versions
may exclusively measure motor
ability.
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The Rasch analysis– derived item difficulty hierarchy depicted how the
items in the S-WMFT chronic stroke
and subacute stroke versions related
to one another, and the findings
were consistent with the motor control literature. Researchers have
reported that increasing the amount
of precision required for the action
and the number of performance
steps amplifies task difficulty. We
found that the easiest items in both
versions of the S-WMFT (eg, moving
a hand to a box in the S-WMFT
chronic stroke version and reaching
and retrieving in the S-WMFT subacute stroke version) required the
control of primarily 1 joint and
involved 1-step actions, whereas the
most difficult items required the control and coordination of multiple
joints and involved multistep
actions. The Rasch analysis–derived
S-WMFT item difficulty hierarchy
provided evidence of the construct
validity of the 2 versions of the
S-WMFT.
Among the 4 tasks common to the 2
S-WMFT versions, the most difficult
task in the chronic stroke version
was lifting a can; folding a towel,
lifting a pencil, and moving a hand to
a box were next. People in the
chronic stage of stroke regain some
fine motor ability (eg, pinching) but
still exhibit spasticity or the late
development of spasticity 1 year
after stroke.38,39 Without sufficient
recovery of volitional control of finger and thumb extension, lifting a
can may be more difficult for people
with chronic stroke than lifting a
pencil or folding a towel. In the subacute stroke version, the item difficulty hierarchy of the 4 common
tasks was lifting a pencil, folding a
towel, lifting a can, and moving a
hand to a box. Previous studies suggested that people need to regain
voluntary control of wrist and finger
extension at the early stage after
stroke to exhibit improved dexterity.40,41 As a result, tasks related to
Number 8
dexterity, such as lifting a pencil and
folding a towel, are considered to be
more difficult than tasks related to
voluntary control of wrist and finger
extension, such as lifting a can.
The order of difficulty for lifting a
pencil and lifting a can was reversed
in the 2 S-WMFT versions. However,
it was impossible to directly compare the results obtained with the 2
versions because the item difficulty
was estimated for 2 different samples
with different scales. The item difficulty estimates were sample dependent, and further transformations
were required for comparisons.
Future studies can make additional
efforts to identify items with similar
difficulty estimates across samples
by use of DIF analysis, to anchor the
“common items” in a separate calibration for each version and, finally,
to compare the hierarchies for the
groups.
The closeness of the average UE
motor function and the average item
difficulty suggested that both versions of the S-WMFT performed well
in targeting UE motor ability in people with stroke. The gaps in the item
hierarchies seemed to be large in Figures 1 and 2; adding more difficult
items (eg, stacking checkers) and
easier items (eg, moving a forearm to
a table) might extend construct coverage. However, the gaps did not
diminish the sensitivity of both versions of the S-WMFT to changes in
UE motor ability. Because there were
5 points in the revised rating scale
and 4 steps in the item calibrations,
each point scored for an individual
task could capture different levels of
UE motor function in people with
stroke. Items in both versions of the
S-WMFT covered a substantial range
of UE motor function. Sensitivity for
detecting changes in ability provides
useful information when clinical
practitioners evaluate individual
changes in UE motor function over
time.
August 2012
All items in the S-WMFT chronic
stroke version showed biserial correlations higher than .7, contrary to the
findings of Morris et al,10 who
reported a low item-total correlation
for extending elbow 28 cm on tabletop (0.4536-kg weight) in the
EXCITE study. The difference may
be a result of methodology. In the
present study, we used Rasch analysis to transform the WMFT FAS
scores from ordinal data to interval
data, possibly yielding unbiased estimates to support the adequate fit of
items in the S-WMFT chronic stroke
version. In contrast, Morris et al10
used classical test theory, which
does not have the described
advantage.
An indication of the redundancy of
items was found in the S-WMFT subacute stroke version. The tasks of
moving a hand to a box and moving
a hand to a table showed a significantly high correlation, indicating
that these 2 items provide similar
information about UE function.
When either of the 2 tasks was
removed from data analyses, the unidimensionality held, and the item difficulty hierarchy of the remaining 5
tasks remained the same. The person
reliability and person separation values dropped slightly, from .89 to .88
and from 2.78 to 2.69, respectively.
The removal of 1 of the 2 tasks did
not seem to adversely affect the construct validity or reliability of the
S-WMFT subacute stroke version;
thus, the removal was warranted.
The S-WMFT chronic stroke and subacute stroke versions had the precision to distinguish people with different levels of UE function after
stroke and exhibited high person
separation and person reliability values.15 Although the person separation values of the 2 versions of the
S-WMFT were slightly lower than
that of the WMFT,20 the 2 versions
could be used to divide our samples
into 4 groups according to the level
August 2012
of UE function. These findings are
consistent with those of a previous
study of the S-WMFT in patients with
subacute stroke,26 which found that
the S-WMFT was sensitive and able
to distinguish people.15,42
Study Limitations and
Future Research
Of note, the rating “0” revealed a low
frequency of use in the S-WMFT for
people with subacute stroke (2%)
and people with chronic stroke
(1%), consistent with the results
found for the WMFT.21 In the present study and the study of Woodbury
et al,20 the participants were people
with stroke and mild to moderate
impairment of motor ability. Future
research might include people with
severe deficits in motor ability to
examine the appropriateness of the
rating “0.”
removed might still maintain similar
Rasch analysis– derived validity and
reliability. We conclude that the
S-WMFT chronic stroke and subacute stroke versions are useful outcome measures for evaluating motor
deficits during recovery or during a
treatment course in people who
have mild to moderate impairment
after stroke and are at different
stages of recovery.
Dr Hui-fang Chen, Dr Wu, Dr Lin, and Dr
Hsieh-ching Chen provided concept/idea/
research design. Dr Hui-fang Chen, Dr Wu,
and Dr Lin provided writing. Dr Wu, Dr Lin,
and Dr Hsieh-ching Chen provided data collection. Dr Hui-fang Chen provided data
analysis. Dr Wu and Dr Lin provided project
management, fund procurement, and institutional liaisons. Dr C.P-C. Chen and Dr C.
Chen provided participants and facilities/
equipment. All authors provided consultation (including review of manuscript before
submission).
Other limitations might influence
the generalizability of the results of
the present study. First, future
research with larger sample sizes is
needed to validate our findings. Second, we did not conduct a longitudinal study to track the withinparticipant progress of motor ability
after stroke. Additional research is
needed to validate the findings for
changes in the item difficulty hierarchy to understand the recovery
process.
Dr Hui-fang Chen and Dr Ching-yi Wu contributed equally to this work.
Conclusion
References
Institutional review board approval for this
study was obtained from the study sites.
This project was supported, in part, by
the National Health Research Institutes
(NHRI-EX99-9920PI
and
NHRI-EX10010010PI), the National Sciences Council
(NSC 97-2314-B-002-008-MY3 and NSC
99-2314-B-182-014-MY3), and the Healthy
Ageing Research Center at Chang Gung University (EMRPD1A0891) in Taiwan.
DOI: 10.2522/ptj.20110175
The S-WMFT chronic stroke and subacute stroke versions are unidimensional measurement scales that are
efficiently administered and appropriately targeted for the assessment
of UE motor function in people who
have had a stroke. The S-WMFT subacute stroke version did not target
the UE motor function of people
with subacute stroke as well as the
S-WMFT chronic stroke version did
for people with chronic stroke. The
S-WMFT subacute stroke version
with 1 of 2 tasks (moving a hand to a
box or moving a hand to a table)
Volume 92
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137–152.
8 Kowalczewski J, Gritsenko V, Ashworth
N, et al. Upper-extremity functional electric stimulation-assisted exercises on a
workstation in the subacute phase of
stroke recovery. Arch Phys Med Rehabil.
2007;88:833– 839.
9 Hayner K, Gibson G, Giles GM. Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upperextremity
dysfunction
after
cerebrovascular accident. Am J Occup
Ther. 2010;64:528 –539.
10 Morris DM, Uswatte G, Crago JE, et al. The
reliability of the Wolf Motor Function Test
for assessing upper extremity function
after stroke. Arch Phys Med Rehabil.
2001;82:750 –755.
11 Fritz SL, Blanton S, Uswatte G, et al. Minimal detectable change scores for the Wolf
Motor Function Test. Neurorehabil Neural Repair. 2009;23:662– 667.
12 Hsieh YW, Wu CY, Lin KC, et al. Responsiveness and validity of three outcome
measures of motor function after stroke
rehabilitation. Stroke. 2009;40:1386 –
1391.
13 Lin KC, Hsieh YW, Wu CY, et al. Minimal
detectable change and clinically important
difference of the Wolf Motor Function
Test in stroke patients. Neurorehabil Neural Repair. 2009;23:429 – 434.
14 Whitall J, Waller SM, Sorkin JD, et al. Bilateral and unilateral arm training improve
motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial. Neurorehabil
Neural Repair. 2011;25:118 –129.
15 Higgins J, Finch LE, Kopec J, Mayo NE.
Development and initial psychometric
evaluation of an item bank created to measure upper extremity function in persons
with stroke. J Rehabil Med. 2010;42:170 –
178.
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16 Wright BD, Linacre JM. Observations are
always ordinal; measurements, however,
must be interval. Arch Phys Med Rehabil.
1989;70:857– 860.
17 Tennant A, Conaghan PG. The Rasch measurement model in rheumatology: what is
it and why use it? When should it be
applied, and what should one look for in a
Rasch paper? Arthritis Rheum. 2007;57:
1358 –1362.
18 Duncan PW, Bode RK, Lai SM, Parera S.
Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale. Arch
Phys Med Rehabil. 2003;84:950 –963.
19 Nichols-Larsen DS, Clark PC, Zeringue A,
et al. Factors influencing stroke survivors’
quality of life during subacute recovery.
Stroke. 2005;36:1480 –1484.
20 Woodbury M, Velozo CA, Thompson PA,
et al. Measurement structure of the Wolf
Motor Function Test: implications for
motor control theory. Neurorehabil Neural Repair. 2010;24:791– 801.
21 Bogard K, Wolf S, Zhang Q, et al. Can the
Wolf Motor Function Test be streamlined?
422– 428.
22 Bond TG, Fox CM. Applying the Rasch
Model: Fundamental Measurement in
the Human Sciences. 2nd ed. Mahwah, NJ:
Lawrence Erlbaum Associates; 2007.
23 Kwakkel G, Kollen B, Twisk J. Impact of
time on improvement of outcome after
stroke. Stroke. 2006;37:2348 –2353.
24 Skilbeck CE, Wade DT, Hewer RL. Recovery after stroke. J Neurol Neurosurg Psychiatry. 1983;46:5– 8.
25 Lang CE, Edwards DF, Birkenmeier RL,
Dromerick AW. Estimating minimal clinically important differences of upperextremity measures early after stroke.
1700.
26 Wu CY, Fu T, Lin KC, et al. Assessing the
streamlined Wolf Motor Function Test as
an outcome measure for stroke rehabilitation. Neurorehabil Neural Repair. 2010;
25:194 –199.
27 Friedman DS, Tielsch JM, Vitale S, et al.
VF-14 item specific responses in patients
undergoing first eye cataract surgery: can
the length of the VF-14 be reduced? Br J
Ophthalmol. 2002;86:885– 891.
28 Linacre JM. Sample size and item calibration stability. Rasch Measurement Transactions. 1994;7:328.
29 Folstein MF, Folstein SE, McHugh PR.
“Mini-mental state”: a practical method for
grading the cognitive state of patients for
the clinician. J Psychiatr Res. 1975;12:
189 –198.
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30 Brunnstrom S. Movement Therapy in
Hemiplegia. New York, NY: Harper &
Row; 1970.
31 Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of
muscle spasticity. Phys Ther. 1987;67:
206 –207.
32 Linacre JM. Winsteps® Rasch Measurement Computer Program User’s Guide.
Beaverton, OR: Winsteps.com; 2010.
33 Linacre JM. Optimizing rating scale category effectiveness. J Appl Meas. 2002;3:
85–106.
34 Linder HYN, Linacre JM, Hermansson
LMN. Assessment of capacity of myoelectric control: evaluation of construct and
rating scale. J Rehabil Med. 2009;41:467–
474.
35 Fisher W Jr. Reliability statistics. Rasch
Measurement Transactions. 1992;6:238.
36 Everett V, Smith J. Evidence for the reliability of measures and validity of measure
interpretation: a Rasch measurement perspective. In: Everett V, Smith J, Smith RM,
eds. Introduction to Rasch Measurement.
Maple Grove, MN: JAM Press; 2004:93–
122.
37 Lohr KN. Assessing health status and
quality-of-life instruments: attributes and
review criteria. Qual Life Res. 2002;11:
193–205.
38 Watkins CL, Leathley MJ, Gregson JM,
et al. Prevalence of spasticity post stroke.
Clin Rehabil. 2002;16:515–522.
39 Welmer AK, von Arbin M, Widén Holmqvist L, Sommerfeld DK. Spasticity and
its association with functioning and
health-related quality of life 18 months
after stroke. Cerebrovasc Dis. 2006;21:
247–253.
40 Fritz SL, Light KE, Patterson TS, et al.
Active finger extension predicts outcomes
after constraint-induced movement therapy for individuals with hemiparesis after
stroke. Stroke. 2005;36:1172–1177.
41 Kwakkel G, Kollen B. Predicting improvement in the upper paretic limb after
stroke: a longitudinal prospective study.
Restor Neurol Neurosci. 2007;25:453–
460.
42 Miller KJ, Slade AL, Pallant JF, Galea MP.
Evaluation of the psychometric properties
of the upper limb subscales of the Motor
Assessment Scale using a Rasch analysis
model. J Rehabil Med. 2010;42:315–322.
August 2012
Research Report
Repeated Measurements of
Arm Joint Passive Range of
Motion After Stroke: Interobserver
Reliability and Sources of Variation
Lex D. de Jong, Pieter U. Dijkstra, Roy E. Stewart, Klaas Postema
Background. Goniometric measurements of hemiplegic arm joints must be reliable to draw proper clinical and scientific conclusions. Previous reliability studies
were cross-sectional and based on small samples. Knowledge about the contributions
of sources of variation to these measurement results is lacking.
Objective. The aims of this study were to determine the interobserver reliability
of measurements of passive range of motion (PROM) over time, explore sources of
variation associated with these measurement results, and generate smallest detectable
differences for clinical decision making.
Design. This investigation was a measurement-focused study with a longitudinal
design, nested within a 2-arm randomized controlled trial.
Methods. Two trained physical therapists assessed 7 arm movements at baseline
L.D. de Jong, PT, MSc, School of
Physiotherapy, Hanze University
of Applied Sciences, Eyssoniusplein 18, 9714 CE Groningen, the
Netherlands, and Department of
Rehabilitation Medicine, University Medical Center Groningen,
University of Groningen, Groningen, the Netherlands. Address
all correspondence to Mr de Jong
at: [email protected].
P.U. Dijkstra, PT, PhD, Department of Rehabilitation Medicine
and Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University
of Groningen.
and after 4, 8, and 20 weeks in 48 people with subacute stroke using a standardized
protocol. One physical therapist performed the passive movement, and the other
read the hydrogoniometer. The therapists then switched roles. The relative contributions of several sources of variation to error variance were explored with analysis
of variance.
R.E. Stewart, PhD, Department
of Health Sciences, Community
and Occupational Medicine, University Medical Center Groningen,
University of Groningen.
Results. Interobserver reliability coefficients ranged from .89 to .97. The PROM
K. Postema, MD, PhD, Department of Rehabilitation Medicine,
University Medical Center Groningen, University of Groningen.
measurements were influenced by error variance ranging from 31% to 50%. The
participant ⫻ time interaction made the largest contribution to error variance,
ranging from 59% to 81%. Smallest detectable differences were 6 to 22 degrees and
were largest for shoulder movements.
Limitations. Verification of shoulder pain and hypertonia as sources of error
variance led to a substantial number of unstable variance components, necessitating
a simpler analysis.
Conclusions. The assessment of PROM with a standardized protocol, a hydrogoniometer, and 2 trained physical therapists yielded high interobserver reliability
indexes for all arm movements. Error variance made a large contribution to the
variation in measurement results. The resulting smallest detectable differences can be
used to interpret future hemiplegic arm PROM measurements with more confidence.
[de Jong LD, Dijkstra PU, Stewart
RE, Postema K. Repeated measurements of arm joint passive range
of motion after stroke: interobserver reliability and sources
of variation. Phys Ther. 2012;92:
1027–1035.]
Association
May 10, 2012
this article at:
ptjournal.apta.org
August 2012
Volume 92
Number 8
Physical Therapy f
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Repeated Measurements of Arm Joint Passive Range of Motion After Stroke
O
f the 15 million people who
have a stroke each year
worldwide, between 77%
and 81% of the survivors have a
motor deficit in the extremities.1
The affected arm remains without
function in almost 66% of survivors,2,3 rendering it inactive and
immobilized. In recent years, several
interventions believed to improve
motor recovery or limit the development of secondary impairments in
the paretic or paralyzed arm after
stroke have been evaluated.4,5
To assess the arm function of
patients with stroke during rehabilitation and in clinical research,
physical therapists regularly assess
passive range of motion (PROM)
of joints by means of goniometry.
In particular, the degree of passive shoulder external rotation and
abduction and wrist extension are
commonly used as outcome measures to evaluate the effects of interventions.6 –13 Reliable measurement
of PROM is therefore an important
prerequisite for the interpretation of
study results.
The reliability of arm range-ofmotion measurements is good in
people who are healthy14,15 and
in patients with orthopedic conditions,16,17 but these findings cannot be generalized to patients
with stroke because stroke-specific
impairments may influence reliability. Over time, many patients
develop contractures10,18 and hypertonia,19,20 especially in shoulder
internal rotators and wrist flexors.
Many patients also develop shoulder
pain, a condition strongly associated
with restricted range of motion.21,22
The aforementioned factors may
hinder a therapist’s attempts to
move the hemiplegic arm, hence
increasing the chance of making
measurement errors. Such errors
also may be increased if PROM
measurements are obtained by only
1 therapist because it is difficult to
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handle a paralyzed arm and the goniometer and read the measurement
simultaneously. Goniometric measurements of arm joints reflect both
the true range of motion of a joint
and measurement errors caused by
different sources of variation. Identifying and quantifying these sources
are important for finding strategies
to reduce their influence on outcomes.23 In addition, to ensure accurate clinical interpretation of joint
PROM measurements and changes in
these measurements over time during poststroke rehabilitation or
research, PROM measurements
should be studied in the context of
these sources of variation.
In previous studies of arm PROM reliability in patients with stroke, sample sizes have not exceeded 18 people.24,25 To our knowledge, research
into factors that may influence hemiplegic arm PROM measurements is
also lacking. During a randomized
controlled trial (L. de Jong, P. Dijkstra, J. Gerritsen, et al, unpublished
data, 2012), 2 physical therapists
(hereafter referred to as “observers”)
assessed arm joint PROM in 48
people on 3 occasions over 20
weeks. This design presented us
with the opportunity to explore
interobserver reliability, analyze the
contributions of sources of variation
to the measurement results, and
calculate smallest detectable differences (SDDs). We chose to use 2
observers because we hypothesized
that doing so would result in fewer
measurement errors than using 1
observer only and because a similar
measurement procedure previously
yielded high reliability indexes.25
Method
As part of a randomized clinical trial
investigating an arm intervention for
people with subacute stroke and
poor arm recovery, we used an existing measurement protocol that was
specifically designed for measuring
the PROM of 7 arm movements. All
Number 8
participants gave written informed
consent before participation.
Participants
Participants were recruited from
3 Dutch rehabilitation centers
between August 2008 and September 2010. All admitted participants were initially screened by a
physician to check the following
inclusion criteria: first-ever stroke
or recurrent stroke (except for subarachnoid hemorrhages) between 2
and 8 weeks after the initial stroke,
age of 18 years or older, paralysis
or severe paresis of the involved
upper limb (Brunnstrom stage of
recovery of ⬍4,26 as judged by the
physician), and no planned date of
discharge within 4 weeks. Participants meeting these criteria were
referred to a research physical therapist, who excluded those with any
contraindications for electrical stimulation, preexisting impairments of
the affected arm (eg, frozen shoulder), severe cognitive deficits or language comprehension difficulties or
both (⬍3/4 correct verbal responses
or ⬍3 correct visual analog scale
scores on the AbilityQ27), and moderate to good arm motor control
(scores of ⬎18/66 on the Fugl-Meyer
Assessment arm section28). After eligibility was confirmed, half of the
participants were randomized to an
experimental group, and half were
randomized to a sham intervention
group (L. de Jong, P. Dijkstra, J. Gerritsen, et al, unpublished data, 2012).
Observers
The 2 observers (both senior physical therapists) had 14 and 27 years
of experience, respectively, across
a wide range of diagnoses, including
stroke. Before the trial, the observers
were trained in obtaining the measurements using a detailed measurement protocol (the protocol,
in Dutch, is available from the first
author). They pretested the protocol
on 3 participants with stroke. The
observers had no pretrial experience
August 2012
with a hydrogoniometer and were
not involved in the design of the
study or the treatment of the
participants.
PROM Measurement Procedure
All PROM measurements were
obtained with a masked fluid-filled
hydrogoniometer (MIE Medical
Research Ltd, Leeds, United Kingdom). The measurement procedure
was similar to the one described in
detail in an earlier publication25
but was expanded to include wrist
extension assessments. Each participant was independently assessed
by the 2 observers at baseline and
after 4, 8, and 20 weeks. Each time,
1 observer carried out the passive
movement, and the other observer
read the goniometer. The observers
then switched roles. They were
unaware of each other’s results
because they used separate score
sheets and were instructed not to
discuss or mention the values found.
The measurement sequence was as
follows: shoulder external rotation,
shoulder flexion, and elbow extension with the participant in the
supine position and then shoulder
abduction, forearm supination, and
wrist extension with and without
finger flexion while the participant
sat on an adjustable plinth with the
back supported. The observers carried out all measurements in the
same fixed order.
Data Analysis
The variance components and their
2-way interactions were calculated
for the measurement conditions of
participants (n⫽48), time (4 assessments over time), and observers
(n⫽2) by analysis of variance (type
III sum of squares). Initially, the allocated intervention was also included
in the calculation of variance components. However, for shoulder PROM,
the variance component for intervention could not be estimated, indicating a redundancy. We therefore
decided not to include intervention
August 2012
in the calculations of variance components. In case of missing data
(eg, because of participant dropout
or vacation taken by 1 of the observers), only data from participants who
were assessed by both observers
were used in the analysis.
the 48 participants are shown in
Table 1. In general, they had restrictions in PROM for all 7 arm movements, especially shoulder movements. They had a median score of
5.5 on the arm section of the FuglMeyer Assessment.
Error variance was calculated as the
sum of all variances minus participant variance. The relative contributions of the sources of variation to this error variance were
expressed as percentages. The agreement between the PROM ratings of
the observers was calculated (see
Streiner and Norman23[p159] for formulas) by means of interobserver
reliability coefficients and accompanying 95% confidence intervals
(CIs). Because the reliability coefficients alone did not indicate the
magnitude of disagreement between
the observers, the standard errors of
measurement (SEMs) [SD⫻公(1⫺r)]
and SDDs (1.96⫻公2⫻SEM) also
were calculated. First, for the disagreement between observers within a measurement occasion, we used
the standard deviation of the mean
difference in ratings between the
observers per movement. Second,
for the disagreement among all
observations over time (“overall”),
the standard deviation of all observations per movement was used. All
analyses were performed with SPSS
(version 18, SPSS Inc, Chicago,
Illinois).
Figure 2 shows the separate variance
components for the results obtained
from shoulder external rotation as
an example. The contribution of
error variance (Tab. 2) to total variance ranged from 31% (wrist extension with flexed fingers) to 50%
(supination). The interaction of participant and time made the largest
contribution to error variance, ranging from 59% (forearm supination)
to 81% (elbow extension). Time
made a smaller contribution to error
variance, especially for shoulder
movements (17%–24%) and forearm
supination (19%). Time did not contribute to the variance in the elbow
joint. The interaction between participants and observers contributed
only marginally to error variance
(0%– 4%); the same was true for the
main effect of observers (0%–2%).
Residual (unexplained) variance contributed between 7% and 17% to
error variance, and this contribution
was generally lowest for shoulder
movements. Table 3 shows the
overall interobserver reliability coefficients (and 95% CIs) and SEMs
and SDDs in both single sessions
(“observers”) and overall for the 7
arm movements.
This study was funded by a grant
from Fonds Nuts Ohra (main study,
project SNO-T-0702-72) and Stichting Beatrixoord Noord-Nederland.
Both funding sources had no role in
study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Results
Figure 1 shows the flow of participants through each stage of
the trial. The characteristics of
Discussion
When different observers independently assess a joint range that does
not change over time, interobserver
reliability generally will be good provided that standardized protocols17
are used and the observers are
trained.29 In addition to common
sources of measurement variation,
the development of contractures,
hypertonia, and shoulder pain may
complicate and negatively influence
the reliability of PROM measure-
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Physical Therapy f
1029
Assessed for eligibility (n=260)
Excluded after initial screening* (n=180)
No ischemic/hemorrhagic stroke (n=9)
>8 weeks poststroke (n=28)
Brunnstrom’s stage of recovery ≥4 (n=169)
Pre-existing arm impairments (n=24)
Planned date of of discharge (n=64)
Refused to/could not participate (n=6)
Other (eg, multiple sclerosis, Alzheimer disease,
locked-in syndrome, participant in other trial, recurrent
stroke) (n=8)
Unknown/missing data (n=4)
Excluded after inclusion testing (n=32)
Unable to fill out/read/understand AbilityQ (n=9)
Fugl-Meyer Assessment arm score >18 points (n=14)
Contraindications for electrical stimulation (n=1)
Other reasons (n=8)
Baseline
Analyzed (n=43 of 48)†
Dropout due to
readmission to hospital (n=2),
discharge (n=1)
At 4 weeks
Analyzed (n=39 of 45)†,‡
Dropout due to
death (n=1),
too much shoulder pain (n=1)
At 8 weeks
Analyzed (n=38 of 43)§
Lost to follow-up due to
severe subluxation (n=1),
not willing (n=3)
At 20 weeks
Analyzed (n=38 of 39)ll
Figure 1.
Flow of participants through each stage of the trial from initial screening by physician to follow-up measurement. *If a participant
was excluded for more than 1 reason, then all reasons were reported separately. †Five participants were assessed by 1 observer only.
‡
One participant missed the 4-week assessment because of poor weather conditions. §Four participants were assessed by 1 observer
only, and 1 participant was not assessed at 8 weeks because of temporary admission to a hospital. 㛳One participant was assessed by
1 observer only.
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August 2012
ments in patients after stroke. We
found that PROM assessment with
a standardized protocol, a hydrogoniometer, and 2 trained observers
yielded high interobserver reliability
indexes (.89 –.97) for 7 arm movements. We also found that error variance made a large contribution
(31%–50%) to the variation in measurement results, with the participant ⫻ time interaction being the
largest source of variance. The
SDDs ranged from 6 to 22 degrees
and were largest for shoulder
movements.
Table 1.
Baseline Characteristics of the 48 Participantsa
Characteristic
Values
Age, y, X (SD)
57.8 (11.9)
Days after stroke, X (SD)
44 (14.0)
Sex, no. of men/women
28/20
Paretic side (left/right), no. of participants
21/27
Stroke type (ischemic/hemorrhagic), no. of participants
39/9
Fugl-Meyer Assessment arm section score, median (IQR)
5.5 (4–10.75)
Shoulder PROM, degrees, X (SD)
External rotation
31.7 (19.4)
Flexion
126.7 (30.6)
Abduction
101.7 (44.1)
Elbow/forearm PROM, degrees, X (SD)
Interobserver Reliability
The interobserver reliability of the
2 observers was high for all 7 arm
movements. These results are in
concordance with previous findings.25,30 The reliability coefficient
for shoulder abduction (.97) was
higher than previously reported values (intraclass correlation coefficients⫽.84 –.87),25 and the reliability
coefficient was lowest for forearm
supination (.89). Supination intraclass correlation coefficients were
higher than previously reported values (.94 –.98),25 but the accompanying 95% CIs were wider (.84 –.98).
Because all of our measurements
were obtained with the same measurement protocol,25 the values that
we obtained may have resulted from
the use of a larger sample. Differences in sample size may also
explain the narrower 95% CIs (.89 –
.95) for elbow extension measurements in the present study than in a
recent study (.68 –.97)24 of 13
patients with stroke and elbow
flexor spasticity. Because larger samples generally yield more precise
estimates of reliability coefficients
(indicated by narrower CIs and
smaller SEMs), the results of the present study can be interpreted with
more confidence than the results of
previous studies.
To our knowledge, the reliability of
wrist movements has not been
August 2012
Extension
2.5 (7.3)b
Supination
77.3 (11.6)
Wrist PROM, degrees, X (SD)
a
b
Extension with fingers extended
55.7 (17.0)
Extension with fingers flexed
63.1 (13.0)
IQR⫽interquartile range, PROM⫽passive range of motion.
A value of 2.5 degrees indicates elbow flexor contracture.
reported in patients with stroke. We
found that the assessment of wrist
extension revealed slightly higher
reliability coefficients and slightly
lower SEMs when the fingers were
flexed instead of extended. The
long finger flexors typically show
increased resistance to passive
stretch (hypertonia), possibly partly
because of the rapid development
of wrist flexor contractures.10,31
This condition occurs especially in
patients with limited arm function
and clearly applied to our participants. Therefore, wrist flexor hypertonia or contracture may have had
a slight negative influence on the
reliability of the assessments of wrist
extension with extended fingers.
This hypothesis is supported by the
fact that residual variance (to which
wrist flexor hypertonia or contracture may also have been a contributing factor) accounted for 16% of
the error variance of the PROM measurements; when the fingers were
flexed, the value was 13%. In conclusion, the resulting high reliability
coefficients suggested that our standardized measurement protocol may
be of use for other observers under
comparable circumstances.
Variance Components
While assessing 7 arm movements
on 4 occasions during a 20-week
time period, we found that the participants in our sample were the largest source of variance. This finding
indicates that the participants could
be distinguished on the basis of their
arm PROM; they had a large variety
of arm joint ranges. Error variance
explained between 31% and 50% of
total variance in the PROM values.
Overall, time and the participant ⫻
time interaction were responsible
for more than 78% of the variation in
measurement results, with the participant ⫻ time interaction contributing the most. This interaction
effect indicates that the effects of
time on PROM of the arm were different in different participants, in
accordance with clinical observations. In some participants, PROM
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Physical Therapy f
1031
Figure 2.
Variance components of shoulder external rotation. Total variance (left circle) comprised participant variance (main effect) and error
variance. Several sources contributed to error variance. These sources (right circle) comprised main effects (time and observer),
interaction effects (participant ⫻ time, participant ⫻ observer, and time ⫻ observer), and residual variance, all expressed as
percentages of error variance.
increased over time probably as a
result of natural neurological recovery or rehabilitation, whereas in
other participants, PROM may have
increased over time as a result of
contracture formation. The main
effects of time and observers did not
contribute to the variation in the
results for elbow extension PROM.
For the latter, the participant ⫻ time
interaction (81%) and random variance (17%) made large contributions
to error variance. Clinically, this finding indicates that over time, elbow
extension developed quite differently in the participants.
Observers contributed only marginally to the variation in measurement
results, with a maximum of 4% (forearm supination). This finding indicates that the differences between
the values obtained by the 2 observers were small, resulting in high
interobserver reliability coefficients.
The fact that 1 observer performed
the passive movement and the other
positioned and read the goniometer
may have led to this finding. On the
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basis of these results, we argue that
arm PROM assessments with a
hydrogoniometer in patients after
stroke should be performed by 2
observers. Clinically and economically, assessments by 2 raters may
not always be practical or feasible.25
Therefore, clinical and economic
arguments must be weighed against
scientific arguments (reliability) in
each situation. Further research is
needed to analyze the influence of
the number of observers on measurement results. Residual variance
in the PROM measurements in our
sample may be explained partly by
random variations in PROM over
time within a participant but may
also have been caused by random
variations in the force applied by
the observers or the alignment
of the hydrogoniometer between
measurements.
SDDs
Overall, the SDDs ranged from 3
degrees to 22 degrees and were
largest for shoulder movements. Taking shoulder external rotation as an
Number 8
example, these data mean that a
change of 17 degrees or more over a
period of 20 weeks (overall SDD)
represents a change in PROM with
95% certainty. Physical therapists
and clinicians can use the overall
SDD to evaluate their patients’
changes in arm PROM between
admission and discharge. Similarly,
researchers can use them to interpret changes in participants in clinical trials. The SDDs obtained in single sessions by our 2 observers also
may serve another purpose. Taking
elbow extension as an example, our
results show that a difference of
more than 3 degrees between 2
observers in 1 session indicates a significant difference in their measurements with 95% certainty.
In stroke research, the Modified
Tardieu Scale32 is increasingly being
used to differentiate muscle contracture from spasticity. Because
this scale relies partly on PROM measurements, the SDD can be used as
a threshold value that must be
exceeded to ascertain with 95% conAugust 2012
Table 2.
Estimated Variance Components and Their Contributions (in Percentages) to the Error Variance of Repeated Measurements of
7 Arm Movements (n⫽48)
Shoulder
Wrist
External
Rotation
Abduction
Flexion
Elbow
Extension
Forearm
Supination
Flexion
With
Extended
Fingers
Participant
385.0
1,234.8
641.2
45.3
118.0
197.0
174.4
Error variance
241.3
702.2
377.1
34.4
117.8
115.5
77.9
a
22.3
3.2
6.5
2.6
2.4
1.5
Variance Component
Time
48.5
118.6
91.3
0.0
4.5
0.3
0.7
0.0a
Observer
Participant ⫻ observer
Flexion
With
Flexed
Fingers
4.1
6.8
4.0
0.1
4.1
2.8
0.2
154.8
524.1
244.6
27.7
69.6
88.7
59.4
Time ⫻ observer
0.4
3.8
0.6
0.8
0.4
Residual variance
28.9
48.7
36.5
5.9
18.4
18.1
10.3
626.4
1,937.0
1,018.4
79.7
235.8
312.5
252.3
38.5
36.3
37.0
43.1
50.0
37.0
30.9
20.1
16.9
24.2
0.0
18.9
2.8
8.3
Observer
1.9
0.0
0.2
0.0
2.2
2.1
1.9
Participant ⫻ observer
1.7
1.0
1.1
0.4
3.5
2.4
0.3
Participant ⫻ time
Total variance
% error varianceb
0.0a
0.0a
% contribution to error
variance of:
Time
Participant ⫻ time
64.2
74.6
64.9
80.6
59.1
76.8
76.2
Time ⫻ observer
0.2
0.5
0.0
1.8
0.7
0.3
0.0
Residual variance
12.0
6.9
9.7
17.2
15.6
15.6
13.3
Negative variance components (ranging from ⫺0.027 to ⫺0.517) were set to 0.
Error variance expressed as a percentage of total variance. For example, for shoulder external rotation, the calculation would be as follows: total variance
(626.4) minus participant variance (385.0) equals error variance (241.3); error variance therefore represents 38.6% of total variance.
a
b
Table 3.
Interobserver Reliability Coefficients (and 95% Confidence Intervals), Standard Errors of Measurement (SEMs), and Smallest
Detectable Differences (SDDs)a
Wrist
Shoulder
External
Rotation
Abduction
Flexion
Elbow
Extension
Forearm
Supination
Extension
With
Extended
Fingers
.94 (.91–.96)
.97 (.95–.98)
.96 (.93–.97)
.92 (.89–.95)
.89 (.84–.93)
.93 (.90–.96)
.96 (.93–.97)
2.0
1.9
1.9
1.0
2.2
1.7
1.0
SDD (observers)
5.4
5.2
5.2
2.7
6.2
4.7
2.6
SEM (overall)
5.9
7.6
6.6
2.4
4.9
4.6
3.3
SDD (overall)
16.3
21.2
18.3
6.8
13.8
12.8
9.1
Variable
Overall reliability (95%
confidence interval)
SEM (observers)
Extension
With
Flexed
Fingers
a
“Overall” refers to the overall reliability, SEM, and SDD for the observers over time; “observers” refers to the SDD and SEM for a single measurement
session.
August 2012
Volume 92
Number 8
Physical Therapy f
1033
fidence that the angles between R1
(“catch”) and R2 (“end range”) are
significantly different and that spasticity is indeed present. Similarly,
the overall SDD for elbow extension
(7°) can be used to indicate significant changes in elbow PROM
over longer periods of time. Comparing our SDDs with those reported
in the literature24,25 is hindered
partly by the influence of sample
sizes on SEMs (larger samples produce smaller SEMs) and therefore
SDDs (smaller SEMs produce smaller
SDDs). Because of our larger sample,
our data can be used to interpret
differences or changes in PROM
with more confidence.
Limitations
An important limitation of the present study is that half of our participants were allocated to a combination intervention consisting of
static muscle stretch and electrical
stimulation. Although the results of
this intervention were not significantly different from those of a sham
intervention and the variance component for intervention could not
be estimated, we cannot rule out the
possibility that the development of
the outcomes over time was confounded by the intervention and
therefore that the intervention contributed to residual variance. Initially, we also tried to verify whether
shoulder pain and hypertonia of
shoulder internal rotators, elbow
flexors, and wrist flexors were
sources of error variance. However,
adding these variables to the statistical analysis led to a substantial number of unstable variance components. Therefore, we chose to
analyze a simpler model. The bestfitting model was subsequently
applied to all other arm movements
by setting all negative variances to 0.
Future research is needed to verify
which factors are actually responsible for random variance, for example, by comparing patients with and
without contractures, hypertonia,
1034
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Physical Therapy
Volume 92
and pain. Another limitation is that,
despite pretrial training, we cannot
say for certain whether the competence of our 2 observers had any
influence on the study results.
We selected people with stroke
and poor recovery of arm motor
control. A median score of 5.5 on
the Fugl-Meyer Assessment arm section at about 6 weeks after stroke
means that a patient typically shows
only hyperreflexia or (partial) mass
synergy patterns, which are usually
dominated by shoulder internal rotation and elbow and finger flexion,
at best. Although our results can be
generalized only to similar groups of
patients, such patients represent
about 36% to 52% of those with subacute stroke between 2 weeks and
3 months after stroke.19 Finally, our
results may indicate reliability within
observers because it is generally recognized that intraobserver reliability
is bound to be higher than interobserver reliability.23
Mr de Jong and Dr Postema provided concept/idea/research design and fund procurement. All authors provided writing and data
analysis. Mr de Jong provided data collection
and project management. Dr Dijkstra and Dr
Postema provided institutional liaisons. The
authors thank all of the study participants.
Special thanks go to observers Ank Mollema
and Marian Stegink.
This study was approved by the Medical
Ethics Committee of the University Medical
Center Groningen (project METc 2008.107).
This study was funded by a grant from
Fonds Nuts Ohra (main study, project SNOT-0702-72) and Stichting Beatrixoord
Noord-Nederland.
The main randomized controlled trial is
registered at the Dutch Trial Register
(Unique Identifier: NTR1748) (available at:
http://www.trialregister.nl/trialreg/index.asp).
DOI: 10.2522/ptj.20110280
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3 Wade DT, Langton-Hewer R, Wood VA,
et al. The hemiplegic arm after stroke:
measurement and recovery. J Neurol Neurosurg Psychiatry. 1983;46:521–524.
4 Sirtori V, Corbetta D, Moja L, Gatti R.
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6 Posteraro F, Mazzoleni S, Aliboni S, et al.
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7 de Jong LD, Nieuwboer A, Aufdemkampe
G. Contracture preventive positioning of
the hemiplegic arm in subacute stroke
patients: a pilot randomized controlled
trial. Clin Rehabil. 2006;20:656 – 667.
8 Turton AJ, Britton E. A pilot randomized
controlled trial of a daily muscle stretch
regime to prevent contractures in the
arm after stroke. Clin Rehabil. 2005;19:
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9 Ada L, Goddard E, McCully J, et al. Thirty
minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2005;
86:230 –234.
10 Pandyan AD, Cameron M, Powell J, et al.
Contractures in the post-stroke wrist: a
pilot study of its time course of development and its association with upper limb
recovery. Clin Rehabil. 2003;17:88 –95.
11 Woldag H, Hummelsheim H. Is the reduction of spasticity by botulinum toxin beneficial for the recovery of motor function
of arm and hand in stroke patients? Eur
Neurol. 2003;50:165–171.
12 Linn S, Granat M, Lees K. Prevention
of shoulder subluxation after stroke with
electrical stimulation. Stroke. 1999;30:
963–968.
13 Bhakta BB, Cozens JA, Bamford JM, Chamberlain MA. Use of botulinum toxin in
stroke patients with severe upper limb
spasticity. J Neurol Neurosurg Psychiatry.
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14 Valentine RE, Lewis JS. Intraobserver reliability of 4 physiologic movements of
the shoulder in subjects with and without
symptoms. Arch Phys Med Rehabil. 2006;
87:1242–1249.
15 Petherick M, Rheault W, Kimble S, et al.
Concurrent validity and intertester reliability of universal and fluid-based goniometers for active elbow range of motion.
Phys Ther. 1988;68:966 –969.
1 Barker W, Mullooly J. Stroke in a defined
elderly population, 1967–1985: a less
lethal and disabling but no less common
disease. Stroke. 1997;28:284 –290.
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16 MacDermid JC, Chesworth BM, Patterson
S, Roth JH. Intratester and intertester reliability of goniometric measurement of passive lateral shoulder rotation. J Hand Ther.
1999;12:187–192.
17 Armstrong AD, MacDermid JC, Chinchalkar S, et al. Reliability of range-ofmotion measurement in the elbow and
forearm. J Shoulder Elbow Surg. 1998;7:
573–580.
18 Sackley C, Brittle N, Patel S, et al. The
prevalence of joint contractures, pressure
sores, painful shoulder, other pain, falls,
and depression in the year after a severely
disabling stroke. Stroke. 2008;39:3329 –
3334.
19 de Jong LD, Hoonhorst MH, Stuive I, Dijkstra PU. Arm motor control as predictor
for hypertonia after stroke: a prospective
cohort study. Arch Phys Med Rehabil.
2011;92:1411–1417.
20 van Kuijk AA, Hendricks HT, Pasman JW,
et al. Are clinical characteristics associated
with upper-extremity hypertonia in severe
ischaemic supratentorial stroke? J Rehabil
Med. 2007;39:33–37.
21 Rajaratnam BS, Venketasubramanian N,
Kumar PV, et al. Predictability of simple
clinical tests to identify shoulder pain after
stroke. Arch Phys Med Rehabil. 2007;88:
1016 –1021.
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22 Bohannon RW, Larkin PA, Smith MB,
Horton MG. Shoulder pain in hemiplegia:
statistical relationship with five variables.
Arch Phys Med Rehabil. 1986;67:514 –516.
23 Streiner DL, Norman GR. Generalizability
theory. In: Streiner DL, Norman GR, eds.
Health Measurement Scales: A Practical
Guide to Their Development and Use. 3rd
ed. Oxford, United Kingdom: Oxford University Press; 2003:153–171.
24 Paulis WD, Horemans HL, Brouwer BS,
Stam HJ. Excellent test-retest and interrater reliability for Tardieu Scale measurements with inertial sensors in elbow flexors of stroke patients. Gait Posture. 2011;
33:185–189.
25 de Jong LD, Nieuwboer A, Aufdemkampe
G. The hemiplegic arm: interrater reliability and concurrent validity of passive
range of motion measurements. Disabil
Rehabil. 2007;29:1442–1448.
26 Brunnstrom S. Movement Therapy in Hemiplegia: A Neurophysiological Approach.
Hagerstown, MD: Harper and Row; 1970.
27 Turner-Stokes L, Rusconi S. Screening for
ability to complete a questionnaire: a preliminary evaluation of the AbilityQ and
ShoulderQ for assessing shoulder pain in
stroke patients. Clin Rehabil. 2003;17:
150 –157.
28 Fugl-Meyer AR, Jaasko L, Leyman I, et al.
The post-stroke hemiplegic patient, 1: a
method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:
13–31.
29 Chesworth B, MacDermid J, Roth J, Patterson S. Movement diagram and “end feel”
reliability when measuring passive lateral
rotation of the shoulder in patients with
shoulder pathology. Phys Ther. 1998;78:
593– 601.
30 Andrews AW, Bohannon RW. Decreased
shoulder range of motion on paretic side
after stroke. Phys Ther. 1989;69:768 –772.
31 Malhotra S, Pandyan AD, Rosewilliam S,
et al. Spasticity and contractures at the
wrist after stroke: time course of development and their association with functional
recovery of the upper limb. Clin Rehabil.
2011;25:184 –191.
32 Morris S. Ashworth and Tardieu Scales:
their clinical relevance for measuring spasticity in adult and paediatric and neurological populations. Phys Ther Rev. 2002:
53– 62.
Volume 92
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Physical Therapy f
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Research Report
A. Cacchio, MD, PhD, Department of Health Sciences, Physical
Medicine and Rehabilitation Unit,
School of Medicine, University of
L’Aquila, P.le S. Tommasi 1, 67100
L’Aquila, Italy, and Department of
Physical and Rehabilitation Medicine, School of Medicine, “La
Sapienza” University of Rome,
Rome, Italy. Address all correspondence to Dr Cacchio at: angelo.
[email protected].
S. Necozione, MD, PhD, Department of Internal Medicine and
Public Health, Clinical Epidemiology Unit, School of Medicine, University of L’Aquila.
J.C. MacDermid, PT, PhD, School
of Rehabilitation Science, McMaster University, Hamilton, Ontario,
Canada, and Hand and Upper
Limb Centre, St Joseph’s Health
Centre, London, Ontario, Canada.
Cross-Cultural Adaptation and
Measurement Properties of the Italian
Version of the Patient-Rated Tennis
Elbow Evaluation (PRTEE)
Questionnaire
Angelo Cacchio, Stefano Necozione, Joy C. MacDermid, Jan Dirk Rompe,
Nicola Maffulli, Ferdinando di Orio, Valter Santilli, Marco Paoloni
Background. The Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire
is a tool designed for self-assessment of forearm pain and disability in patients with
lateral elbow tendinopathy (LET). However, an Italian version of this questionnaire
has not been available.
J.D. Rompe, MD, Orthopedic Surgery, OrthoTrauma Evaluation
Center, Mainz, Germany.
Objective. The aims of this study were: (1) to translate and cross-culturally adapt
N. Maffulli, MD, PhD, Center for
Sports and Exercise Medicine,
Barts and The London School of
Medicine and Dentistry, London,
United Kingdom.
Design. This was a longitudinal, observational measurement study.
F. di Orio, MD, Department of
Internal Medicine and Public
Health, Clinical Epidemiology
Unit, School of Medicine, University of L’Aquila.
V. Santilli, MD, Department of Physical Medicine and Rehabilitation,
School of Medicine, “La Sapienza”
University of Rome, Rome, Italy.
M. Paoloni, MD, PhD, Department
of Physical Medicine and Rehabilitation, School of Medicine, “La Sapienza” University of Rome.
[Cacchio A, Necozione S, MacDermid JC, et al. Cross-cultural adaptation and measurement properties of the Italian version of the
Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Phys
Ther. 2012;92:1036 –1045.]
the PRTEE questionnaire into Italian and (2) to evaluate its measurement properties.
Methods. The PRTEE questionnaire was cross-culturally adapted to Italian according to established guidelines. Ninety-five individuals (41 women, 54 men) with
unilateral, imaging-confirmed, chronic LET were selected consecutively to assess the
measurement properties of the PRTEE questionnaire. Internal consistency, test-retest
reliability, construct validity, and responsiveness were estimated.
Results. The Italian version of the PRTEE displayed a high degree of internal
consistency, with a Cronbach alpha of .95. The test-retest reliability was high for both
short-term and medium-term, with intraclass correlation coefficients (2,1) of .95 and
.93, respectively. The PRTEE exhibited a strong correlation (r⫽.77–.91, P⬍.0001)
with the Disabilities of the Arm, Shoulder and Hand (DASH) at the baseline and a
moderate correlation (r⫽.58 –.74, P⬍.0001) at discharge. The responsiveness was
higher for the PRTEE than for the DASH.
Limitations. A methodological limitation of the study is that due to the small
sample size, a factor analysis was not performed to assess convergent validity.
Conclusions. The Italian version of the PRTEE questionnaire is internally consistent, demonstrates expected correlations with other measures, and is more responsive than the DASH in Italian patients with chronic LET.
Association
May 10, 2012
Submitted: November 14, 2011
this article at:
ptjournal.apta.org
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Number 8
August 2012
Italian Version of the PRTEE Questionnaire
C
hronic lateral elbow tendinopathy (LET) caused by a
failed healing response of the
tendon of the extensor carpi radialis
brevis muscle1 is a common cause of
arm pain in sporting and working
populations. The importance of
monitoring the effectiveness of treatment is widely recognized, as is the
need for evidence-based health care.
Several instruments have been developed to determine the outcome of
elbow conditions.2–9 However, the
success or failure of treatment for
LET is open to interpretation, given
the lack of consensus on how to
measure treatment outcome in a
standardized fashion.3,4
Before being used in different
regions of the world, outcome measures need to be translated, culturally adapted, and retested to ensure
the validity of the revised instruments.10 –12 The cross-cultural adaptation guidelines described by Guillemin et al10 are widely accepted and
used for the translation and adaptation of outcome measures. The term
“cross-cultural adaptation” is used to
describe a process that takes into
account both language (translation)
and cultural adaptation issues in the
preparation of an outcome measure
for use in another setting.10
An Italian version of a pain and functional status questionnaire for people with chronic LET has not been
available. The aims of this study,
therefore, were: (1) to perform a
cross-cultural adaptation of the original English version of Patient-Rated
Tennis Elbow Evaluation (PRTEE)
questionnaire into Italian and (2) to
evaluate the measurement properties of the Italian version of the
PRTEE in patients with imagingconfirmed chronic LET.
Materials and Method
The data were collected between
March 2005 and September 2008 at
our outpatient rehabilitation center
August 2012
at the Department of Physical Medicine and Rehabilitation, School of
Medicine, “La Sapienza” University
of Rome. Informed consent was
obtained from all patients prior to
participation in the study.
The Cross-Cultural Adaptation
Process
Guidelines developed by Guillemin
and colleagues10,11 and Beaton et al12
were used for the cross-cultural
adaptation and validation of the Italian version of the PRTEE. The English version of the PRTEE6 was independently translated into Italian by 2
non–medical professional translators
and one physician whose native language was Italian. The 3 different
Italian translations were analyzed by
a health care committee (2 physiatrists, 2 epidemiologists, 1 orthopedist, 1 physical therapist), who first
ensured that the translations took
Italian cultural characteristics into
consideration, and then selected a
consensus version (version 1) of
these translations. Discrepancies
were resolved by consensus to
achieve conceptual equivalence.
This consensus version was translated back into English by 2 other
non–medical professional translators
whose native language was English.
Neither of these translators was
aware of the concepts being investigated or had a medical background.
At the end of this phase, a new consensus version (version 2) was
obtained and, when compared with
the original version of the PRTEE,6
was found to be semantically and
grammatically equivalent.
At this stage, a meeting was held
with the health care committee to
finalize the Italian version of the
PRTEE. After the committee had confirmed the equivalence of the original PRTEE and the Italian version, we
commenced a pilot test on 10
patients (5 women, 5 men; mean
age⫽40.2 years, range⫽18 –72) with
chronic LET and on 10 sex- and age-
matched individuals who were
healthy. The main aim of this phase
was to determine whether the participants understood the questions.
After they had completed the questionnaire, each participant was
asked whether there were any sentences that were difficult to understand. The participants were asked
what they thought each question
meant. The meaning of the items and
tasks and the selected response were
discussed. This process ensured that
the pre-final version retained adequate equivalence in purpose. All of
the questions were considered to be
easy to understand by all of the participants who filled out the questionnaire. The reliability, validity, and
responsiveness of the final Italian
version of the PRTEE (eAppendix,
available at ptjournal.apta.org) then
were evaluated by means of psychometric tests.
Participants
Ninety-five people (41 women, 54
men) with unilateral (66 right, 29
left), imaging-confirmed, chronic
LET were consecutively enrolled for
the purposes of this study. The participants’ mean age was 38.8 years
(SD⫽15.7, range⫽18 –75). At the
beginning of the study, the mean
elapsed time since onset of LET was
23 months (SD⫽9, range⫽8 – 43).
The inclusion criteria were: clinical
diagnosis of chronic LET (ie, persistent or recurrent local pain and muscle weakness that did not respond to
conservative measures), confirmed
by an imaging evaluation (eg, ultrasound, magnetic resonance imaging), and a pain score of ⱖ3 cm on a
Volume 92
Available With
This Article at
ptjournal.apta.org
• eAppendix: Patient-Rated Tennis
Elbow Evaluation Questionnaire,
Italian Version
Number 8
Physical Therapy f
1037
visual analog scale, induced by 2 or
more of the following tests: (1) palpation of the lateral epicondyle,
(2) resisted wrist extension (Thomsen test), (3) resisted extension of
the middle finger, and (4) a chair
test, in which the participant was
asked to lift a 3.5-kg chair. The exclusion criteria were: age below 18
years; inflammatory or neoplastic disorders; concomitant pathologies in
the shoulder or wrist; cervical radiculopathy or thoracic outlet syndrome; history of fracture or dislocation at the elbow; history of elbow
surgery; treatment with corticosteroid injections in the previous 6
months; and inability to complete a
questionnaire due to cognitive
impairment or language difficulties.
Questionnaires
PRTEE. The PRTEE questionnaire,6
which is an updated version of the
Patient-Rated Forearm Evaluation
Questionnaire (PRFEQ),7,13 is a
15-item questionnaire specifically
designed for patients with LET. The
items investigate pain (5 items) and
the degree of difficulty in performing
various activities (6 specific and 4
usual activity items) due to the
elbow problem over the preceding
week. Each item has 1 response
option (0⫽no difficulty, 10⫽unable
to perform). The scores for the various items are used to calculate an
overall scale score ranging from 0
(best score) to 100 (worst score).
The worst score is 100 points, and
not 150 points, because the specific
and usual activity items are first
summarized and then divided by 2,
which means they account for a
maximum of 50 points, as opposed
to 100 points, in the final score. The
PRTEE questionnaire, which provides a very quick (it takes 5 minutes to complete), easy, and standardized quantitative description of
pain and functional disability in
patients with LET, was recently validated as a reliable means of assessing
LET.14
1038
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Physical Therapy
Volume 92
Disabilities of the Arm, Shoulder
and Hand (DASH). The DASH
questionnaire is an upper-extremity–
specific outcome measure,8 which
has been shown to be reliable and
valid in people with elbow disorders.15 The core of the DASH (part B)
is a 30-item disability/symptom scale
concerning an individual’s upper
extremity during the preceding
week. The items investigate the
degree of difficulty in performing different physical activities because of
arm, shoulder, or hand problems
(items 1–21); the severity of each of
the symptoms of pain, activityrelated pain, tingling, weakness, and
stiffness (items 24 –28); and the
effect the symptoms have on social
activities, work, and sleep (items 22,
23, and 29) and their psychological
impact (item 30). Each item has 5
response options, ranging from “no
difficulty or no symptom” to “unable
to perform activity or very severe
symptom,” and is scored on a 5-point
scale. The scores for all the items are
used to calculate a scale score ranging from 0 (no disability) to 100
(severest disability). For the purposes of this study, we used the
cross-culturally adapted and validated Italian version of the DASH.16
Global rating of change. At the
discharge assessment, 6 weeks after
initial assessment, the physician and
the participant independently completed a 7-point global rating of
change form. “How is the patient
today compared with his/her first
visit?” and “How are you today compared with your first visit?” were
the questions answered by the
physiatrist and the patient, respectively. The participant and physiatrist were unaware of each other’s
responses. The 7 response options
were: (1) “very much worse,” (2)
“much worse,” (3) “little worse,” (4)
“no change,” (5) “little improved,”
(6) “much improved,” and (7) “very
much improved.” The physician’s
and the participant’s global rating of
Number 8
change scores were averaged to give
an overall change score, which was
used in this study as the criterion
standard of change. This measure of
change was used as our external criterion, in the absence of a “gold standard,” for the evaluation of responsiveness.17,18 For this purpose, we
chose global rating of change scores
of 3 or lower to classify a worsened
participant, a score of 4 to classify a
stable participant, and scores of 5 or
higher to classify an improved
participant.
Procedure
At baseline, participants were asked
to complete the PRTEE and the
DASH questionnaires together in a
comfortable room. All participants
then underwent the same shockwave treatment. Because this was
not an intervention study, the shockwave treatment is summarized briefly: the shock-wave treatment was
provided by a radial shock-wave generator. Radial shock-wave therapy
was administered in 4 sessions, at
the rate of 1 session per week. At
each session, 2,500 shocks with a
pressure of 4 bars (equal to an
energy flux density of approximately
0.18 mJ/mm2) and a frequency of 8
shocks per second were applied.
Upon discharge at the end of the
shock-wave treatment, 6 weeks after
the first administration of the PRTEE
and DASH questionnaires, participants were asked to complete these
questionnaires again.
Data Analysis
Parametric tests were used after
using a Kolmogorov-Smirnov test to
ensure that the data were normally
distributed. The level of statistical
significance was set at P⬍.05. All
analyses were conducted using MedCalc, version 11.1.1.0 for Windows
(MedCalc Software, Mariakerke, Belgium), GraphPad InStat, version 3.05
for Windows (GraphPad Software
Inc, San Diego, California), and
August 2012
STATA software, version 8.2 (Stata
Corp, College Station, Texas).
Psychometric Properties
Reliability. “Reliability” is a generic
term used to indicate both the homogeneity (internal consistency) of a
scale and the reproducibility (testretest reliability) of scores.17
Internal consistency of the PRTEE
was assessed using Cronbach alpha
with 95% confidence intervals (95%
CIs), using the data from the baseline
questionnaire, and was considered
acceptable when Cronbach alpha
exceeded .70.19
To assess the test-retest reliability of
the PRTEE, the intraclass correlation
coefficient (ICC) and 95% CIs were
calculated on the basis of a 2-way
random-effects analysis of variance.17,20,21 Additionally, standard
error of measurement (SEM⫽
SD[公 1 ⫺ ICC]) was calculated. The
ICC value was interpreted as follows:
⬍.40⫽poor reliability, .40 –.74⫽
moderate to good reliability, and
ⱖ.75⫽excellent reliability.20
To assess the short-term (first testretest) reproducibility of the PRTEE,
the participants were asked to complete this questionnaire again 3 days
after the first administration at baseline. To minimize the risk of shortterm clinical changes, participants
did not receive any treatment during
this 3-day interval. An interval of 3
days was chosen for 3 reasons: (1) it
minimized the time elapsed between
enrollment and the start of the rehabilitation program, (2) participants
were unlikely to remember what
they had answered 3 days before,
and (3) in the absence of any intervention, it was assumed that the participants’ clinical situation would
remain stable over 3 days.
To assess the reproducibility of the
PRTEE in an interval that more
closely resembles that used for evalAugust 2012
uating individuals in a clinical study,
the participants who were classified
as stable (global rating of change
score of 4) were asked to complete
the PRTEE at the end of the shockwave treatment, 6 weeks after the
first administration (second retest).
Based on global rating of change
scores, this second retest was performed by only 38 participants.
Construct
validity. Construct
validity was tested by determining
the relationship between the PRTEE
questionnaire scores and the scores
of the DASH questionnaire at both
the baseline and discharge assessments. Pearson correlation coefficients (r values) with 95% CIs were
calculated to examine the construct
validity. The r values were interpreted as follows: .00 to .19⫽very
weak correlation, .20 to .39⫽weak
correlation, .40 to .69⫽moderate
correlation, .70 to .89⫽strong correlation, and .90 to 1.00⫽very strong
correlation.22 Because the correlation results in the German version of
the PRTEE14 are given only as a coefficient of determination (r2), we also
calculated this coefficient to make a
direct comparison of our results with
those of the German version.
Responsiveness. Floor and ceiling
effects are considered important for
the analysis of responsiveness
because they indicate limits to the
range of detectable change. Floor
and ceiling effects were determined
by calculating the number of participants who had the best or worst
scores possible at both the baseline
and discharge assessments in all of
the questionnaires. This number
indicates the proportion of patients
whose condition could not significantly improve or deteriorate
because they were already at one
end of the range. Floor or ceiling
effects are considered to be present
if more than 15% of respondents
achieve the lowest or highest possible score, respectively.23
Although there is no consensus on
the most suitable statistical analysis
to assess responsiveness, we decided
to use 3 distribution-based methods
to assess the responsiveness of the
PRTEE and DASH questionnaires—
the effect size (ES),24 the standardized response mean (SRM),25 and
the Guyatt responsiveness ratio
(GRR)26—together with an anchorbased method (ie, the receiver
operating
characteristic
[ROC]
curve).17,18 Changes in the PRTEE
and DASH measurements following
shock-wave treatment in comparison
with the baseline measurements
were assessed using a paired t test.
The values of the 3 distributionbased methods were based on the
data of the participants (n⫽49) classified as improved according to the
consensus judgment of both participants and physicians.
The ES was calculated as the mean
difference between the baseline and
follow-up scores (ie, mean change
scores) divided by the standard deviation of the baseline scores.24 The
SRM was calculated as the mean
change score divided by the standard
deviation of the change scores.25
The ES and SRM scores were interpreted as follows: 0.2⫽small, 0.5⫽
moderate, and 0.8 or higher⫽
large.25,27
The GRR was calculated as the ratio
of the mean change score of the
PRTEE or DASH of participants clinically identified as improved divided
by the standard deviation of the
mean change score of participants
clinically identified as unchanged
based on the global rating of
change.26 If the GRR is larger than 1,
the mean change score in clinically
improved individuals exceeds the
measurement error, and the instrument may be considered to be
responsive to an extent that is pro-
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Physical Therapy f
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portional to the magnitude of the
responsiveness ratio.26
The sensitivity (true positive rate)
and specificity (true negative rate) of
the PRTEE and DASH questionnaires
were examined using the ROC curve
method. The ROC curve was constructed by plotting the sensitivity
values on the y-axis and 1 minus the
specificity values on the x-axis for
the different change scores values.
The ROC curve was calculated on
the basis of the questionnaire change
score and the global rating of change
score (obtained by averaging the participant’s and physician’s global rating of change scores). When plotting
the ROC curve, the global rating of
change, used as external criterion,
was dichotomized to identify those
participants who experienced a clinically meaningful reduction in symptoms.18,28 We chose global change
scores of 5 or higher to represent
important change and scores of 4
or lower to represent no change.
Generally, the area under the ROC
curve (AUC) is a measure of the ability of a questionnaire to distinguish
between individuals who have and
have not changed, according to an
external criterion (ie, global rating
change score).28 In this study,
because for the ROC curve calculation the participants classified as stable were mixed with those who
worsened, the AUC assessed the ability of the PRTEE and the DASH to
distinguish
participants
who
improved from those who did not
improve, whereas the small sample
of participants who worsened did
not allow construction of an ROC
curve to distinguish participants
who worsened from those who did
not worsen.
An AUC of 1.0 indicates perfect discrimination between these 2 health
states. A questionnaire that does not
discriminate more effectively than
chance will have an AUC of 0.5. As a
general rule, AUC values between
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0.7 and 0.8 are considered to have
acceptable discrimination, those
from 0.8 to 0.9 are considered to
have excellent discrimination, and
those above 0.9 are considered to
have outstanding discrimination.28
The point of the ROC curve on the
upper-most left-hand corner was
identified as the optimal cutoff
change score and was used to estimate the minimal clinically important difference (MCID),29,30 although
the baseline entry score may affect
it.31,32 The MCID represents the
point with equally balanced sensitivity (probability of the measure correctly classifying individuals who
demonstrate change on the global
rating of change) and specificity
(probability of the measure correctly
classifying individuals who have
minimally or not changed on the
global rating of change) in the ROC
curve.33
Results
The Cross-Cultural Adaptation
Process
The PRTEE for Italian patients was
adapted using a systematic, standardized approach.10 –12 No difficulties
were encountered in translating the
questionnaire, and the back translation corresponded very well to the
original version. The only real, albeit
minor, problem we encountered
was in the first and third questions in
the functional disability subscale
(specific activities). The first question in the English version was:
“Turn a doorknob or key.” As “doorknobs” are not widely used in Italy,
this term was translated as “door
handle.” The third question in the
English version was: “Lift a full coffee cup . . . to your mouth.” Because
most Italians drink espresso coffee,
which comes in a small cup, we preferred to translate “Lift a full coffee
cup” as “Lift a full cappuccino cup.”
However, conceptual equivalence
was verified by checking the original
Number 8
PRTEE and the back-translated questionnaires for all equivalences.
The prefinal version performed well
in the pilot test. The participants
stated that the items were clear and
that the majority were relevant to
their chronic LET. The average time
taken by the participants to answer
all the items was approximately 5
minutes.
No items were missing from the
PRTEE and DASH scores at either the
baseline or the discharge assessment. No individual scored the worst
or best possible score (no floor or
ceiling effects) in either the PRTEE
questionnaire or the DASH questionnaire. On the basis of global rating of
change scores, 49 participants
improved, 38 remained stable, and 8
worsened.
Reliability
Internal consistency reached a Cronbach alpha of .95 (95% CI⫽.93–.98)
(N⫽95) for the 15 items. When the
alpha coefficient was calculated for
the overall scale by eliminating each
of the 15 items one at a time, the
range was .89 to .98; no single item
was found to change the internal
consistency substantially.
The test-retest reliability yielded an
ICC (2,1) of .95 (95% CI⫽.90 –.97),
with a SEM of 2.68 (95% CI⫽2.64 –
2.73) in the short term (3 days, 95
participants), and an ICC (2,1) of .93
(95% CI⫽.89 –.96), with a SEM of
3.25 (95% CI⫽3.12–3.47), in the
medium term (6 weeks, 38
participants).
Construct Validity
In the evaluation of the correlation
between the PRTEE and DASH questionnaires, we considered the overall
scores of the 2 questionnaires as well
as the pain subscale scores (questions 1–5) and functional activity
subscale scores (questions 6 –15) for
the PRTEE questionnaire and the
August 2012
Table 1.
Correlations Between the Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire and Disabilities of the Arm, Shoulder and
Hand (DASH) Questionnaire Scores at the Baseline Assessment (N⫽95)a
PRTEE Pain Subscale
Score
PRTEE Overall Score
Measure
DASH overall score
a
PRTEE Functional Ability
Subscale Score
r
P
r
P
r
P
.83 (.75–.89)
⬍.0001
.77 (.73–.82)
⬍.0001
.79 (.75–.85)
⬍.0001
DASH symptoms subscale score
.80 (.73–.85)
⬍.0001
.79 (.74–.85)
⬍.0001
.81 (.76–.88)
⬍.0001
DASH function subscale score
.88 (.83–.92)
⬍.0001
.83 (.76–.87)
⬍.0001
.89 (.82–.94)
⬍.0001
Values are expressed as Pearson correlation coefficient (r) (95% confidence interval).
95% CI⫽.48 –.75, P⬍.001). As
regards the coefficient of determination (r2), our results showed an r2 of
.7 (P⬍.0001) (Fig. 1) for the baseline
data and an r2 of .4 (P⬍.001) for the
pretreatment-posttreatment change
scores.
symptoms subscale scores (questions 24 –29) and function subscale
scores (questions 1–21) for the
DASH questionnaire.
Correlations between the PRTEE
overall and subscale scores and the
DASH overall and subscale scores at
the baseline and discharge assessments are summarized in Tables 1
and 2, respectively. The overall
PRTEE and DASH scores for the
whole group of participants at baseline (N⫽95) were strongly correlated with one another (r⫽.84, 95%
CI⫽.75–.89, P⬍.0001) (Fig.1). The
overall PRTEE and DASH scores for
the group of participants who underwent the shock-wave therapy
(N⫽95) at discharge were moderately, albeit still significantly, correlated with one another (r⫽.50, 95%
CI⫽.30 –.65, P⬍.001) (Fig. 2). The
pretreatment-posttreatment change
scores for the PRTEE and DASH also
were moderately, albeit significantly,
correlated with one another (r⫽.64,
Responsiveness
The t tests showed statistically significant changes from baseline to discharge for the PRTEE (t⫽10.66,
P⬍.0001) and the DASH (t⫽6.49,
P⬍.0001). The mean baseline and
discharge scores, as well as the magnitude of changes expressed by the
ES, SRM, and GRR for the improved
participants (n⫽49), are shown in
Table 3. According to the interpretation of Liang et al,25 both the PRTEE
and the DASH yield large ES and SRM
values (PRTEE: ES⫽2.0, SRM⫽2.3;
DASH: ES⫽1.4, SRM⫽1.5). The GRR
values yielded by both the PRTEE
(2.9) and the DASH (2.3) also were
large, according to the interpretation
of Guyatt et al.26
The ROC curve analysis revealed
AUC values of .89 (95% CI⫽.80 –
.95) for the PRTEE and .79 (95%
CI⫽.68 –.87) for the DASH (Fig. 3).
The SEM values were .03 for the
PRTEE and .05 for the DASH. The
AUC for both the PRTEE (P⬍.0001)
and the DASH (P⬍.0001) far
exceeded 0.5. These findings indicate that the change scores yielded
by the PRTEE and the DASH were
significantly better than chance in
identifying an improved individual
from randomly selected pairs of
improved and unimproved individuals. The difference between the
PRTEE and DASH AUC values was
0.10 (SEM⫽0.04, z score⫽2.1,
P⫽.03). This finding indicates that
the discriminative ability of the
PRTEE is better than that of the
DASH in this sample of outpatients
with chronic LET treated with
shock-wave therapy. The ROC
curve also was used to provide an
estimate of the MCID, taken as the
point on the ROC curve nearest the
Table 2.
Correlations Between the Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire and Disabilities of the Arm, Shoulder and
Hand (DASH) Questionnaire Scores at the Discharge Assessment (N⫽95)a
PRTEE Overall Score
Measure
DASH overall score
a
r
P
.50 (.30–.65)
⬍.0001
PRTEE Functional Ability
Subscale Score
PRTEE Pain Subscale Score
r
.58 (.32–.63)
P
r
P
⬍.0001
.60 (.44–.66)
⬍.0001
DASH symptoms subscale score
.55 (.36–.67)
⬍.0001
.54 (.37–.66)
⬍.0001
.43 (.33–.62)
⬍.0001
DASH function subscale score
.46 (.34–.63)
⬍.0001
.52 (.38–.68)
⬍.0001
.61 (.48–.79)
⬍.0001
Values are expressed as Pearson correlation coefficient (r) (95% confidence interval).
August 2012
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Figure 1.
Relationship between the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and Disabilities of the Arm, Shoulder and
Hand (DASH) questionnaire scores at baseline for all participants. Regression plot, with 95% confidence interval for the mean and
the slope.
upper left-hand corner of the
graph (cutoff score), which most
effectively discriminates between
individuals who have improved
and those whose condition is
unchanged. Assuming equivalent
importance for sensitivity and
specificity, the best cutoff scores
(MCID) for predicting global outcome
(“improved”/“not improved”) were 8
points for the PRTEE and 7.5 points for
the DASH.
The sensitivity and specificity values
associated with the PRTEE cutoff
point of 8 were 0.94 (95% CI⫽0.83–
0.98) and 0.78 (95% CI⫽0.58 – 0.91),
respectively, and the positive and
negative likelihood ratios were 4.2
(95% CI⫽3.4 –5.2) and 0.08 (95%
CI⫽0.02– 0.3), respectively. The sensitivity and specificity values associated with the DASH cutoff point of
7.5 were ⫺.77 (95% CI⫽0.63– 0.88)
and 0.74 (95% CI⫽0.54 – 0.89),
respectively, and the positive and
negative likelihood ratios were 2.9
Figure 2.
Relationship between the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and Disabilities of the Arm, Shoulder and
Hand (DASH) questionnaire scores at discharge for participants who underwent shock-wave therapy. Regression plot, with 95%
confidence interval for the mean and the slope.
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August 2012
Table 3.
Baseline and Discharge Scores of the Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire and Disabilities of the Arm,
Shoulder and Hand (DASH) Questionnaire in the Overall Study Sample (N⫽95) and in Participants Who Improved (n⫽49), Were
Stable (n⫽38), and Worsened (n⫽8) and the Magnitude of the Changes After Shock-Wave Therapy in Participants Who
Improved (n⫽49)a
Questionnaire
PRTEE
Group of
Participants
Total (N⫽95)
DASH
PRTEE
Improved (n⫽49)
Stable (n⫽38)
DASH
PRTEE
DASH
a
3-Day
Retest
Score
27.5 (11.3)
27 (10.6)
29.2 (11.6)
DASH
PRTEE
Baseline
Score
Worsened (n⫽8)
Discharge
Score
9.8 (8.9)
16.8 (12)
Change
Score
t
17.5 (12.2)
11.9
⬍.0001
7.2
⬍.0001
12.4 (10)
P
ES
SRM
GRR
29.8 (11.5)
6.4 (4.4)
23.1 (10.2)
10.6
⬍.0001
2.0
2.3
2.9
31.6 (11.2)
16.1 (11.5)
15.5 (10.2)
6.5
⬍.0001
1.4
1.5
2.3
28.1 (10.3)
24.8 (10.4)
1.3 (2.3)
0.7
.58
28.9 (11.4)
27.8 (10.8)
1.1 (2.8)
0.4
.66
26.1 (10.2)
34.4 (11.7)
⫺8.3 (8.8)
⫺1.5
.22
27.8 (11.2)
33.4 (12.5)
⫺5.6 (7.2)
⫺0.9
.31
Values are expressed as mean (SD). ES⫽effect size, SRM⫽standardized response mean, GRR⫽Guyatt responsiveness ratio, t⫽value of paired t test.
(95% CI⫽2.3–3.9) and 0.3 (95%
CI⫽0.1– 0.6), respectively.
Discussion
This study cross-culturally adapted
the PRTEE questionnaire using a systematic, standardized approach10 –12
and determined the measurement
properties of the Italian version in
individuals with chronic LET. With
the exception of 2 terms in 2 different questions, no difficulties were
encountered in translating the questionnaire, and the back translation
corresponded very well to the original English version.
Figure 3.
Receiver operating characteristic curves illustrating the relationship between sensitivity
and complement of specificity (1 ⫺ specificity) for the Patient-Rated Tennis Elbow
Evaluation (PRTEE) questionnaire and the Disabilities of Arm, Shoulder and Hand
(DASH) questionnaire.
August 2012
The Cronbach alpha for the Italian
version of the PRTEE was .95, which
indicates excellent internal consistency, and exceeded .90, which is
the recommended threshold when a
questionnaire is used in a clinical setting.34 The Cronbach alpha for the
Italian version of the PRTEE was
equivalent to those of the German
(.94)14 and Swedish (.94)35 versions
of the PRTEE.
The Italian version of the PRTEE
showed high reliability for both
short-term (3 days, 95 patients) and
medium-term (6 weeks, 38 patients)
test-retest assessments, with ICCs of
.95 and .93, respectively. These values were higher than that of the original PRTEE (ICC⫽.89)7 and similar to
that of the Swedish version.35 The
test-retest reliability of the German
version was .87.14 However, because
test-retest reliability in the German
version was assessed using the Pearson correlation coefficient, a direct
comparison with our results is not
possible. Our ICC values were similar to those reported by Newcomer
et al36 for the English version of the
PRFEQ, although slightly lower than
those of the Hong Kong Chinese version of the PRFEQ.37
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Pearson correlation coefficients
between the PRTEE and DASH displayed a strong correlation at the
baseline assessment, whereas the
correlation at discharge was moderate. The strongest correlation was
found between the PRTEE functional
ability subscale score and the DASH
function subscale score at baseline
(r⫽.89). The weakest correlation
was found between the PRTEE functional ability subscale score and the
DASH symptoms subscale score at
discharge (r⫽.43).
Our Pearson correlation coefficients
at baseline were close to those of the
Swedish version35 but higher than
those reported by Newcomer et al.36
Conversely, our Pearson correlation
coefficients at discharge were lower
than those of the Swedish version35
and those reported by Newcomer
et al.36 A Pearson correlation coefficient (.56) comparable to ours (.58)
was observed between the DASH
overall score and the pain subscale
score in the English version of the
PRFEQ. With regard to the coefficient of determination (r2), our
results yielded an r2 value that was
slightly lower than that reported by
Rompe et al14 for the baseline data
(.70 versus .75) and lower (.40 versus .66) for the pretreatmentposttreatment change values.
Although the quality of measurement questionnaires usually has
been evaluated by considering their
reliability and validity, it has been
suggested
that
responsiveness
should be another criterion in the
choice of a measurement questionnaire.39 Rompe et al14 were the first
to determine the responsiveness of
the PRTEE, but they used only a
distribution-based method (ie, the
SRM) for this purpose. Newcomer et
al36 also analyzed the responsiveness
of the PRFEQ using distributionbased methods alone (ie, ES and
SRM). To our knowledge, this is the
first study that has used all of the
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recommended statistical methods,
including the ES, SRM, and GRR
(distribution-based methods) and the
ROC curve (anchor-based method),
to determine the responsiveness of
the PRTEE questionnaire.
Our results demonstrated a high
degree of responsiveness for both
the PRTEE and the DASH. However,
both the distribution-based methods
and anchor-based method showed
that the PRTEE was clearly more
responsive than the DASH in our
sample of outpatients with chronic
LET treated with shock-wave
therapy.
We compared our ES and SRM
results with those of the 2 previous
studies that evaluated the responsiveness of the PRTEE and PRFEQ.
We observed that our SRM value
(2.3) was slightly higher than that
reported by Rompe et al (2.0)14 and
higher than that reported after 6
weeks (2.3 versus 1.0) and slightly
higher than that reported after 12
weeks (2.3 versus 1.9) of treatment
by Newcomer et al.36 Our ES value
was higher than that reported by
Newcomer et al36 both after 6 weeks
(2.0 versus 1.0) and after 12 weeks
(2.0 versus 1.6) of treatment.
The MCID, defined as the magnitude
of change that best distinguishes
between
patients
who
have
improved and those whose condition remains unchanged, was calculated using the ROC curve analysis.
The MCID was approximately 8
points for the PRTEE and approximately 7.5 points for the DASH. A
comparison of the data yielded by
the analysis of the ROC curve in
our study with those of other studies is not possible because no other
studies, to our knowledge, have
appraised responsiveness of the
PRTEE through the ROC curve.
A methodological limitation of our
study is that due to a small sample
Number 8
size, we did not perform a factor
analysis to assess convergent validity. Our sample of patients, however,
may be considered representative of
the general population that is normally referred to an outpatient rehabilitation center.
The evidence presented in this article indicates that the PRTEE, a
patient-rated, disease-specific questionnaire, was a valid and reliable
means of measuring change in pain
and function over time in our sample
of outpatients with chronic LET
treated with shock-wave therapy and
that it was significantly more responsive than the DASH, a patient-rated,
generic questionnaire. This observation is in keeping with those
reported in other studies that
showed
patient-rated,
diseasespecific questionnaires were more
responsive to the target condition
than patient-rated, generic questionnaires.40 – 42 As the PRTEE is, unlike
the DASH, a disease-specific questionnaire, we suggest that the PRTEE
can be used as a standard outcome
measure in Italian outpatients who
undergo therapy for chronic LET.
Our data indicate that the Italian
version of the PRTEE questionnaire
is a valid, reliable, and responsive
tool that can be used to quantitatively measure outcome in Italian
patients with chronic LET, in both
clinical and research settings. Further research is warranted to determine the measurement properties
of the Italian version of the PRTEE
in people with acute LET and other
elbow diseases, as well as to compare the measurement properties
of the Italian version of the PRTEE
with other disease- and organspecific questionnaires.
Prof Cacchio, Prof Necozione, Prof Rompe,
Prof di Orio, Prof Santilli, and Prof Paoloni
provided concept/idea/research design. Prof
Cacchio, Prof MacDermid, Prof Maffulli, and
Prof Paoloni provided writing. Prof Cacchio,
August 2012
Prof Necozione, Prof Maffulli, Prof di Orio,
Prof Santilli, and Prof Paoloni provided data
collection. All authors provided data analysis.
Prof Cacchio and Prof Paoloni provided project management. Prof Cacchio, Prof Necozione, Prof MacDermid, Prof Maffulli, Prof di
Orio, Prof Santilli, and Prof Paoloni provided
consultation (including review of manuscript
before submission).
Prof MacDermid is the developer of the
Patient-Rated Tennis Elbow Evaluation
(PRTEE).
This study was approved by the local ethics
committee and complied with the Declaration of Helsinki.
DOI: 10.2522/ptj.20110398
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24 Kazis LE, Anderson JJ, Meenan RF. Effect
sizes for interpreting changes in health status. Med Care. 1989;27(3 suppl):S178 –
S189.
25 Liang MH, Fossel AH, Larson MG. Comparisons of five health status instruments for
orthopedic evaluation. Med Care. 1990;
28:632– 642.
26 Guyatt G, Walter S, Norman G. Measuring
change over time: assessing the usefulness
of evaluative instruments. J Chronic Dis.
1987;40:171–178.
27 Cohen JW. Statistical Power Analysis for
the Behavioral Sciences. 2nd ed. Hillsdale,
NJ: Lawrence Erlbaum Associates; 1988.
28 Hosmer DW, Lemeshow S, eds. Applied
Logistic Regression. 2nd ed. New York,
NY: John Wiley & Sons Inc; 2000.
29 Farrar JT, Portenoy RK, Berlin JA, et al.
Defining the clinically important difference in pain outcome measures. Pain.
2000;88:287–294.
30 Beaton DE, Boers M, Wells GA. Many faces
of the minimal clinically important difference (MCID): a literature review and directions for future research. Curr Opin Rheumatol. 2002;14:109 –114.
31 Riddle DL, Stratford PW, Binkley JM. Sensitivity to change of the Roland-Morris
Back Pain Questionnaire: part 2. Phys
Ther. 1998;78:1197–1207.
32 Crosby RD, Kolotkin RL, Williams GR.
Defining clinically meaningful change in
health-related quality of life. J Clin Epidemiol. 2003;56:395– 407.
33 Stratford PW, Binkley JM, Solomon P, et al.
Assessing change over time in patients
with low back pain. Phys Ther. 1994;74:
528 –533.
34 Bland JM, Altman DG. Cronbach’s alpha.
BMJ. 1997;314:572.
35 Nilsson P, Baigi A, Marklund B, Månsson J.
Cross-cultural adaptation and determination of the reliability and validity of
PRTEE-S (Patientskattad Utvärdering av
Tennisarmbåge), a questionnaire for
patients with lateral epicondylalgia, in a
Swedish population. BMC Musculoskelet
Disord. 2008;9:79.
36 Newcomer KL, Martinez-Silvestrini JA,
Schaefer MP, et al. Sensitivity of the
Patient-Rated Forearm Evaluation questionnaire in lateral epicondylitis. J Hand
Ther. 2005;18:400 – 406.
37 Leung HB, Yen CH, Tse PY. Reliability of
Hong Kong Chinese version of the PatientRated Forearm Evaluation questionnaire
for lateral epicondylitis. Hong Kong Med
J. 2004;10:172–177.
38 Guyatt GH, Kirshner B, Jaeschke R. Measuring health status: what are the necessary measurement properties? J Clin Epidemiol. 1992;45:1341–1345.
39 Kopec JA. Measuring functional outcomes
in persons with back pain: a review of
back-specific questionnaires. Spine (Phila
Pa 1976). 2000;25:3110 –3114.
40 Stucki G, Liang MH, Fossel AH, Katz JN.
Relative responsiveness of conditionspecific and generic health status measures in degenerative lumbar spinal stenosis. J Clin Epidemiol. 1995;48:1369 –1378.
41 Wiebe S, Guyatt G, Weaver B, et al. Comparative responsiveness of generic and
specific quality-of-life instruments. J Clin
Epidemiol. 2003;56:52– 60.
Volume 92
Number 8
Physical Therapy f
1045
eAppendix.
Patient-Rated Tennis Elbow Evaluation Questionnaire, Italian Versiona
QUESTIONARIO DI VALUTAZIONE DA PARTE DEL PAZIENTE DELL’EPICONDILITE O“GOMITO DEL
TENNISTA”
Le seguenti domande ci aiuteranno a capire la difficoltà che Lei ha avuto ad usare il suo braccio nella
scorsa settimana. Lei dovrà dare una singola risposta per ciascuna domanda indicando il punteggio,
su una scala da 0 a 10, che ritiene meglio descriva i Suoi sintomi al braccio relativi alla settimana scorsa.
Se Lei non ha svolto una delle sottostanti attività a causa del dolore o perché le era impossibile, Lei dovrebbe
cerchiare il “10”. Se Lei non è sicuro/a indichi il punteggio che meglio esprime il massimo della Sua
capacità possibile ad usare il braccio. Se Lei non compie mai una delle sottostanti attività non risponda
alla relativa domanda e tracci una linea sulla domanda relativa all’attività che non compie mai.
1. DOLORE nel braccio infortunato
Quantifichi il dolore medio del suo braccio durante la scorsa settimana cerchiando il numero che meglio descrive il Suo dolore su una scala da
0–10. Dove zero (0) indica che Lei non aveva alcun dolore, mentre dieci (10) indica che Lei aveva il peggior dolore immaginabile.
QUANTIFICHI IL SUO DOLORE
Peggior
No Dolore
Dolore
A riposo
0
1
2
3
4
5
6
7
8
9
10
Durante un movimento ripetitivo del braccio
0
1
2
3
4
5
6
7
8
9
10
Trasportando le buste della spesa
0
1
2
3
4
5
6
7
8
9
10
Quando il suo dolore era minimo
0
1
2
3
4
5
6
7
8
9
10
Quando il suo dolore era massimo
0
1
2
3
4
5
6
7
8
9
10
2. DISABILITÀ FUNZIONALE
A. ATTIVITÀ SPECIFICHE
Quantifichi la difficoltà che Lei ha provato nel compiere ciascuno dei compiti indicati in basso, durante la scorsa settimana, cerchiando il
numero che meglio descrive la Sua difficoltà su una scala da 0 a 10. Dove zero (0) indica nessuna difficoltà, mentre dieci (10) indica che il
compito era cosı̀ difficile da non poterlo svolgere.
Peggior
No Dolore
Dolore
Aprire una maniglia o girare una chiave
0
1
2
3
4
5
6
7
8
9
10
Portare una borsa o una busta della spesa
per i manici
0
1
2
3
4
5
6
7
8
9
10
Portare alla bocca una tazza di cappuccino o un
bicchiere di latte
0
1
2
3
4
5
6
7
8
9
10
Aprire un barattolo
0
1
2
3
4
5
6
7
8
9
10
Indossare i pantaloni
0
1
2
3
4
5
6
7
8
9
10
Strizzare uno straccio o un asciugamano bagnato
0
1
2
3
4
5
6
7
8
9
10
B. ATTIVITÀ ABITUALI
Quantifichi la difficoltà che Lei ha provato nel compiere le sue attività abituali in ciascuno delle aree indicate, durante la scorsa settimana,
cerchiando il numero che meglio descrive la Sua difficoltà su una scala da 0 a 10. Per “attività abituali” si intendono quelle attività che Lei
svolgeva prima che iniziasse il dolore al braccio. Un valore pari a zero (0) indica nessuna difficoltà, mentre un valore pari a dieci (10) indica
che il compito era cosı̀ difficile da rendere impossibile ogni forma di attività abituale.
Peggior
No Dolore
Dolore
Cura della persona (vestirsi, lavarsi)
0
1
2
3
4
5
6
7
8
9
10
Lavori domestici (pulizia, manutenzione)
0
1
2
3
4
5
6
7
8
9
10
Attività lavorativa
0
1
2
3
4
5
6
7
8
9
10
Attività ricreative o sportive
0
1
2
3
4
5
6
7
8
9
10
Commenti:
(Continued)
August 2012 (eAppendix, Cacchio et al)
Volume 92
Number 8
Physical Therapy f
1
eAppendix.
Continued
ISTRUZIONI PER IL PUNTEGGIO
Ridurre al massimo le non-risposte controllando il questionario quando i pazienti hanno terminato di completarlo.
Assicurarsi che il paziente non abbia lasciato una domanda in bianco solo perché non era in grado di svolgere quel
compito, ricordandogli che in questo caso avrebbe dovuto cerchiare il “10” e non lasciarla in bianco. Se i pazienti
sono incerti perché hanno compiuto raramente una delle attività durante la scorsa settimana, dovrebbero essere
incoraggiati a dare comunque una valutazione media della loro difficoltà. Questo sarà più accurato che lasciare la
domanda in bianco. Se i pazienti non compiono mai una delle attività, non saranno capaci di valutare la difficoltà e
quindi dovrebbero lasciare in bianco la domanda. Se tutte le domande di una sottoscala sono state lasciate in bianco,
si può attribuire a quella sottoscala il risultato medio ottenuto dalle altre sottoscale.
a
2
Sottoscala Dolore – Somma di 5 domande.
Miglior punteggio ⫽ 0; peggior punteggio ⫽ 50
Attività Specifiche – Somma di 6 domande.
Attività Abituali – Somma di 4 domande.
Sottoscala Funzione – (Attività Specifiche ⫹ Attività Abituali)/2
Punteggio Totale ⫽ Sottoscala Dolore ⫹ Sottoscala Funzione
(Il dolore e la disabilità contribuiscono in egual misura alla determinazione del
punteggio totale)
The Patient-Rated Tennis Elbow Evaluation questionnaire, Italian version, may not be reproduced without written permission from the authors.
f
Physical Therapy
Volume 92
Number 8
August 2012 (eAppendix, Cacchio et al)
Research Report
The ABLE Scale: The Development and
Psychometric Properties of an
Outcome Measure for the Spinal Cord
Injury Population
E.M. Ardolino, PT, PhD, Department of Physical Therapy, University of St. Augustine, Austin Campus, 5401 LaCrosse Ave, Austin,
TX 78739 (USA). Address all correspondence to Dr Ardolino at:
[email protected].
K.J. Hutchinson, PT, DPT, PhD,
Department of Physical Therapy
and Athletic Training, Sargent
College, Boston University, Boston, Massachusetts.
G. Pinto Zipp, PT, EdD, Department of Health Sciences, Seton
Hall University, South Orange,
New Jersey.
M. Clark, EdD, School of Health
Professions and Nursing, Long
Island University, Brookville, New
York.
S.J. Harkema, PhD, Department of
Neurological Surgery, University
of Louisville, Louisville, Kentucky;
Kentucky Spinal Cord Injury
Research Center, Louisville, Kentucky; and Frazier Rehabilitation,
Louisville, Kentucky.
[Ardolino EM, Hutchinson KJ,
Pinto Zipp G, et al. The ABLE scale:
the development and psychometric properties of an outcome measure for the spinal cord injury population. Phys Ther. 2012;92:
1046 –1054.]
Association
May 10, 2012
Accepted: May 3, 2012
Submitted: August 12, 2011
Elizabeth M. Ardolino, Karen J. Hutchinson, Genevieve Pinto Zipp, MaryAnn Clark,
Susan J. Harkema
Background. A paucity of information exists on the psychometric properties of
several balance outcome measures. With the exception of the Modified Functional
Reach Test, none of these balance outcome measures were developed specifically for
the population with spinal cord injury (SCI). A new balance assessment tool for
people with SCI, the Activity-based Balance Level Evaluation (ABLE scale), was
developed and tested.
Objective. The purposes of this study were: (1) to develop a scale capturing the
wide spectrum of functional ability following SCI and (2) to assess the initial psychometric properties of the scale using a Rasch analysis.
Design. A methodological research design was used to test the initial psychometric properties of the ABLE scale.
Methods. The Delphi technique was used to establish the original 28-item ABLE
scale. People with SCI at each of 4 centers (n⫽104) were evaluated using the ABLE
scale. A Rasch analysis was conducted to test for targeting, item difficulty, item bias,
and unidimensionality. An analysis of variance was completed to test for discriminant
validity.
Results. The Rasch analysis revealed a scale with minimal floor and ceiling effects
and a wide range of item difficulty capturing the large scope of functional capacity
after SCI. Multiple redundancies of item difficulty were observed.
Limitations. All raters were experienced physical therapists, which may have
skewed the results. The sample size of 104 participants precluded a principal
component analysis.
Conclusion. Development of an all-inclusive clinical instrument assessing balance
in the SCI population was accomplished using the Delphi technique. Modifications of
the ABLE scale based on the Rasch analysis yielded a 28-item scale with minimal floor
or ceiling effects. Larger studies using the revised scale and factor analyses are
necessary to establish unidimensionality and reduction of the total item number.
this article at:
ptjournal.apta.org
1046
f
Physical Therapy
Volume 92
Number 8
August 2012
Development and Psychometric Properties of the ABLE Scale
A
spinal cord injury (SCI) is a
sudden, catastrophic, lifechanging event. An estimated
12,000 new cases of SCI occur each
year in the United States,1 and more
than 1.2 million individuals are living
with an SCI in the United States.2 An
SCI results in some degree of sensation or motor loss below the level of
the lesion, producing a balance
impairment that affects the injured
individual’s ability to participate in
functional activities and activities of
daily living.3
Balance is difficult to assess, yet it is
essential to the evaluation process.
Few quantitative measures exist to
adequately capture balance assessment in SCI. Studies utilizing forceplates and electromyography (EMG)
capture changes in center of pressure and muscle activation patterns.4 –7 Although these measures
provide precise and quantitative
data, time, equipment costs, and
expertise needed for reliable use and
interpretation of such data preclude
their widespread utilization in the
physical therapy clinic.8 Clinicians
often turn to clinical outcome measures such as the Modified Functional Reach Test (MRFT)9 and the
Berg Balance Scale (BBS)10 as
indexes of balance and postural control post-SCI.11
The MFRT9 was adapted from the
standing Functional Reach Test12 in
an effort to differentiate levels of
injury severity in nonambulatory
individuals following SCI. Reliability
of this outcome measure has been
established in both the motor complete9,13 and incomplete14 SCI populations. The MFRT is easy and quick
to administer, requires minimal
equipment and training to perform
accurately, and can be used in both
ambulatory and nonambulatory people. The test assesses sitting balance
only in the anterior-posterior plane
and thus does not provide a complete assessment of functional sitting
August 2012
abilities. Further research is needed
to establish the interrater reliability,
validity, and minimal detectable
change in the SCI population.
The BBS is a 14-item scale originally
designed to assess fall risk in the
elderly population.10 Although the
psychometric properties of the BBS
have been established for a wide
range of neurologic populations,
only 2 studies have examined its reliability and validity in the SCI population.11,15 Although these studies
correlated the BBS with several walking indexes, both studies demonstrated a ceiling effect with the BBS.
Another drawback to the BBS in this
population is that there is only one
sitting balance item. Therefore, for
people with SCI who are unable to
stand and walk, a floor effect will be
observed.
The Functional Independence Measure (FIM) is an 18-item test used to
assess the amount of assistance a person requires with transfers, walking,
and several activities of daily living.16,17 The FIM is widely used in
inpatient rehabilitation settings to
measure burden of care and
improvement in functional mobility
in the SCI population.16 Although
balance is a component of functional
mobility tasks, the FIM does not specifically test balance. A person can
improve in the functional mobility
items on the FIM by compensating
for paralyzed body parts or using
adaptive equipment. Knowing only
that a person requires a certain
amount of assistance to transfer, or
walk 45.7 m (150 ft) does not provide the clinician with useful information for evaluating balance deficits. Therefore, the FIM is not a
sensitive measure for assessing balance in the SCI population.
There currently are no outcome
measures specifically developed and
validated to assess balance abilities in
the SCI population throughout the
full spectrum of functional recovery.
Clinical outcome measures that are
currently utilized are limited in
scope and present significant ceiling
and floor effects. Therefore, there is
a need for the development of a new
balance outcome measure specific to
the SCI population. The purposes of
this study were: (1) to develop an
all-inclusive clinical instrument, the
Activity-based Balance Level Evaluation (ABLE scale), to assess balance
across the full spectrum of recovery
in the SCI population and (2) to
determine the initial psychometric
properties of the ABLE scale using a
Rasch analysis.
Method
Scale Development
The initial ABLE scale was written by
the primary authors (E.M.A., K.J.H.,
and G.P.Z.) based upon an extensive
review of the literature in conjunction with clinical experience in
administering the BBS and the MFRT
to clients with SCI. The initial ABLE
scale consisted of 30 items, which
tested balance in the domains of sitting, standing, and walking.
This initial ABLE scale was further
developed and refined through the
use of a Delphi technique that seeks
consensus among a group of experts
using a series of questionnaires.18
There were 2 rounds of the Delphi
In summary, forceplates and EMG
recordings for the measurement of
balance are not available for use in
the typical physical therapy clinic.
Volume 92
Available With
This Article at
ptjournal.apta.org
• eAppendix: The Activity-based
Balance Level Evaluation (ABLE
Scale)
• Demonstration Video of
Selected Items From the Activitybased Balance Level Evaluation
(ABLE Scale)
Number 8
Physical Therapy f
1047
technique plus a round of advanced
critique by a panel of SCI researchers
and educators. Experts in all 3
rounds were physical therapists who
had at least 5 years of physical therapist practice, at least 2 years of evaluating and treating people with SCI,
and at least 2 years of administering
the BBS. Twenty-four experts participated in rounds 1 and 2 and were
recruited anonymously from the 14
Model SCI Systems and from the
7 centers of the NeuroRecovery Network (NRN) and the NeuroPT listserve, an electronic mailing list operated by the Neurology Section of
the American Physical Therapy
Association.
In round 1 of the Delphi study, the
experts were presented with the initial ABLE scale online via Seton Hall
University’s ASSET survey program.
All experts recruited for the study
were given instructions on how to
access the survey via the ASSET platform and were given 2 weeks to
complete the survey. The experts
were presented with each item of
the ABLE scale and were asked several questions regarding the item,
including the importance of including the item, clarity of the wording,
appropriateness of the scoring, and
feasibility of administering the item
in a physical therapy clinic. Experts
also were provided with the opportunity to offer suggestions on
improving each item and the scale as
a whole. Through this process, content validity, which ensures that the
test is free from the influences of
factors that are irrelevant to the purpose of the measurement,19 and item
reliability (internal consistency),
which reflects the extent to which
items measure various aspects of the
same characteristic and nothing
else,19 were established.
The results from the first round were
reviewed by the research team.
Although there is no universally
agreed-upon percentage of agree1048
f
Physical Therapy
Volume 92
ment for consensus, the literature
suggests that 70% to 80% is considered a reasonable guideline, and it is
highly recommended that this level
be set prior to the data analysis.20,21
Using an 80% agreement requirement for an item to be modified or
deleted, the ABLE scale was revised.
Nineteen of the 30 items reached an
80% consensus, 8 items were modified, and 3 items were deleted. The
revised scale, noting the items modified or deleted, was posted online
via ASSET. Experts were contacted
again through either the supervisors
at the Model SCI Systems centers and
the NRN centers or through the
NeuroPT listserve. The second survey presented each item of the scale,
and the experts were asked to
answer the questions following any
item that had been modified.
Once the ABLE scale had gone
through a 2-round Delphi review
process with the clinical expert
panel, a final review was conducted
by an additional panel of 7 SCI
researchers and educators to ensure
that the scale would be appropriate
for use in a clinical research setting.
The latter panel of experts was asked
to offer feedback on the clinical
expert version of the scale developed via the Delphi process by
responding to the relative importance and feasibility questions posed
in the Delphi review process via
ASSET. This final round resulted in
what we considered a final Delphi
review.
As a result of the 3 rounds of the
Delphi technique, 3 items were
removed from the scale, 1 item was
added, and minor editorial changes
were made. This process resulted in
an ABLE scale with 28 items across
the 3 functional domains of sitting,
standing, and walking (Tab. 1).
Number 8
Table 1.
Functional Activity Associated With Each
Item of the Activity-based Balance Level
Evaluation (ABLE Scale)
Item
Task
1
Sitting
2
Seated forward reach
3a
Seated lateral reach (right)
3b
Seated lateral reach (left)
4
Pick up object in sitting position
5
Scooting forward in chair
6
Seated external perturbations
7
Transfers
8
Wheelchair perturbations
9
Sit to stand
10
Standing
11
Stand to sit
12
Stand with eyes closed
13
Standing with feet together
14
External perturbations in standing
15
Standing forward reach
16
Pick up object from standing
17
Look over shoulder in standing
18
Turn 180°
19
Alternate step-ups
20
Tandem stance
21a
Standing on one leg (right)
21b
Standing on one leg (left)
22
Walking over level surface
23
Walking with head turns
24
Walking with change in direction
25
Stepping over object while walking
26
Walking with object in 2 hands
27
Walking up/down stairs
28
Walking up/down incline
Participants
One hundred fifty-seven people
were screened for inclusion, and a
total of 104 individuals with SCI
were included in this study.22 This
was a sample of convenience, and
participants were recruited from the
inpatient and outpatient settings of
Magee Rehabilitation Hospital, Philadelphia, Pennsylvania; Shepherd
Center, Atlanta, Georgia; Kessler
Research Center, West Orange, New
August 2012
Jersey; and Frazier Rehabilitation
Institute, Louisville, Kentucky. Inclusion criteria specified that participants be at least 16 years of age and
have a traumatic or nonprogressive,
complete or incomplete SCI. Exclusion criteria, which disqualified 53
potential participants, included:
inability to follow 2-step commands,
need for a spinal stabilization device,
spinal precautions that limit the ability to bend or rotate the thoracic or
lumbar spine, and inability to tolerate upright supported sitting for at
least 1 minute. We certify that all
applicable institutional and governmental regulations concerning the
ethical use of human volunteers
were followed during the course of
this research.
Procedure
To ensure standardization of the
scoring and administration of the
ABLE scale across the data collection
centers, the primary investigator
(E.M.A.) provided an in-person
instructional session and responded
via telephone call or e-mail to any
concerns the therapists had regarding the administration and scoring of
the ABLE scale.
All participants were asked for their
consent to participate by the primary
investigator or one of the designated
physical therapists at the 4 data collection sites. Participants were
tested on the ABLE scale in a single
session in a quiet, designated area in
each of the data collection sites. The
ABLE scale was administered to each
participant based upon the instructions for each item (eAppendix,
available at ptjournal.apta.org). The
equipment used for testing was standardized across all centers according
to the directions noted at the beginning of the scale. Participants were
not allowed to use their personal
wheelchair for items 7 and 8 and
were asked to sit in a standard manual wheelchair provided by the
clinic. Participants were positioned
August 2012
with their hips, knees, and ankles at
90 degrees in a wheelchair with a
sling back to approximately scapular
height and a solid seat. This positioning was done to prevent the influence of a participant’s customized
seating system on his or her balance.
Participants who could complete
only the sitting balance subscale
were finished within 15 minutes,
whereas those who could complete
all 3 subscales required up to 45 minutes. The data for each individual
were recorded in a standardized
Excel spreadsheet (Microsoft Corporation, Redmond, Washington) and
sent to the primary investigator. Data
collection took place between May
2009 and November 2009. All participants were blinded as to the other
participants in the study.
Data Analysis
After reaching consensus via the Delphi process, a Rasch analysis of scale
scores was completed to further
assess and develop the scale. Rasch
analysis is a statistical model that can
estimate the person “ability” and
item “difficulty” of a measurement
tool by comparing the responses of
individuals with those of the entire
sample.23 This model provides a
method to analyze and improve a
rating scale.24 Rasch analysis uses 2
values: the logit, which is the natural
logarithm of the odds of a person
being successful on a particular item,
and fit statistics.23 Infit and outfit statistics determine how well raw data
meet the requirements of the Rasch
model.23 In the Rasch model, we
would expect people with higher
abilities to achieve higher scores on
difficult items. People with lower
abilities would be expected to score
lower on difficult items. A Rasch
analysis is used to test specific properties of a rating scale, including unidimensionality, item bias, targeting,
and item difficulty. Unidimensionality, as measured by fit statistics, is the
concept that all items on the scale
are measuring the same construct, in
this case, balance. Differential item
functioning (DIF) tests for item bias
by examining the estimates, or ability levels, for different groups of individuals.23 In this study, we tested for
item bias across sex, age, and American Spinal Injury Association (ASIA)
Impairment Scale (AIS) classification.25 Targeting reveals the range of
difficulty of the items that correspond to the range in ability noted in
the study population. It ensures that
there are items that are appropriate
to test every level of person ability.
Testing the item difficulty may reveal
redundant items or items that appear
to have the same level of difficulty.23
Using a Rasch analysis to test item
difficulty allows for the items to be
placed in a hierarchy.23 Furthermore, to determine whether any
changes needed to be made to any
items, each item’s rating scale categories, or scoring levels, were examined using threshold ordering.
Each item on the ABLE scale has distinct definitions for each rating scale
category, so that a score of 1 on one
item is not equal to a score of 1 on a
different item.26 In order to correctly
place the items on the scale according to level of difficulty, the rating
scale categories need to be aligned.
Pivot anchoring is a process of aligning these differently worded rating
scale categories to assist in defining
the difficulty of each item. Pivot
anchoring consists of first assigning a
point in each item’s rating scale in
which the categories represent passing or failing an item. For the ABLE
scale, passing was defined as the
ability to complete the specified task
according to the item’s instruction,
without physical assistance or supervision. For example, passing item 1
was defined as “able to sit with posterior pelvic tilt for 2 minutes, independently,” or a score of 3, whereas
passing item 6 was determined to be
a score of 4. Using these definitions,
pivot points were defined for each
item’s rating scale and are boldfaced
Volume 92
Number 8
Physical Therapy f
1049
Table 2.
Table 3.
Demographic Characteristics of the Participants With Spinal Cord Injury (SCI)
(n⫽104)
Items With Disordered Thresholdsa
Characteristic
Values
Age, y, X⫾SD (median)
Item
38.63⫾14.98 (36)
4
Sex, n (%)
Male
79 (76)
Female
25 (24)
Mean time since injury, mo, X⫾SD
44.8⫾68.1
Type of SCI, n (%)
Motor complete
10
17 (16)
Motor incomplete
87 (84)
Tetraplegia
59 (57)
Paraplegia
45 (43)
Functional level, n (%)
Wheelchair dependent
42 (40)
Able to stand for ⱖ10 s with or without
minimal assistance
30 (29)
Able to ambulate ⱖ6.1 m (20 ft) without
an assistive device
32 (31)
11
13
in the ABLE scale (eAppendix).
These passing points then are
anchored to a common value for all
items on the scale, and the item difficulties are recalibrated across the
scale.26
A one-way analysis of variance
(ANOVA) was performed to test the
hypothesis that the person ability
levels, or estimates, for 3 functional
groups of wheelchair users, standers, and walkers were equal. Multiple comparisons were completed
using the Bonferroni procedure.
Descriptive statistics were used to
analyze the demographic data,
including age, sex, time since injury,
severity of SCI, and functional level.
All demographic data and the
ANOVA results were analyzed with
Statistical Software for the Social Sciences (SPSS), version 14.0 (SPSS Inc,
Chicago, Illinois). The Rasch analysis
was completed using WINSTEPS
software, version 3.68.2 (Winsteps,
Chicago, Illinois).
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Results
Demographics
One hundred four participants were
tested once on the ABLE scale. Table
2 summarizes the demographic characteristics. Participants were stratified into 3 distinct categories based
upon functional ability. Individuals
who were unable to stand or walk
(n⫽42) were classified as “wheelchair users,” those who could stand
for at least 10 seconds with minimal
to no physical assistance (n⫽30)
were classified as “standers,” and
those who could ambulate at least
6.1 m (20 ft) without an assistive
device or physical assistance (n⫽32)
were classified as “walkers.”
Threshold Ordering
An examination of the category
threshold measures, in logits, was
made to identify any disordered
thresholds (ie, response categories
that were utilized in a manner inconsistent with the trait being measured). On the ABLE scale, response
category 3 should have a higher logit
value than response category 2, indi-
Number 8
14
a
Response
Category
Category
Measure
(Logits)
0
⫺6.90
1
⫺5.71
2
⫺2.41
3
⫺4.24*
4
1.65
0
⫺4.94
1
⫺2.21
2
⫺0.56
3
⫺0.86*
4
2.67
0
⫺3.65
1
⫺0.76
2
⫺2.08*
3
0.08
4
2.97
0
⫺3.40
1
⫺0.19
2
0.21
3
⫺0.08*
4
3.06
0
⫺4.48
1
⫺0.15
2
0.82
3
0.20*
4
3.62
Asterisk indicates disordered category.
cating that category 3 is more difficult than category 2. Table 3 displays
the 5 items with disordered thresholds. In items 4, 10, 13, and 14, category 2 had a higher measure than
category 3. In item 11, category 1
had a higher measure than category
2.
Consequently, we reviewed these
disordered thresholds to see what
changes could be made. The
response categories of 2 and 3 for
item 4 were reversed, as this made
sense clinically. This change resulted
in an improved fit of item 4, as the
August 2012
outfit value improved from 0.50 to
0.85. Review of the other items with
disordered thresholds determined
that reversing the response categories did not make sense clinically.
Therefore, we rewrote these
response categories, and we are
retesting these items in a follow-up
study. The revised version of the
ABLE scale is presented in the
eAppendix. (See a video demonstrating selected items from the ABLE
scale, available at ptjournal.apta.
org.)
Unidimensionality
Although recent studies suggest that
unidimensionality should be determined through a combination of
Rasch fit statistics and principal component analysis (PCA) residuals, our
sample size was too small to conduct
a PCA.27,28 The fit statistics reported
here are rudimentary analyses of the
unidimensionality of this scale. Table
4 shows the infit and outfit mean
square values for all of the items of
the ABLE scale. Two items, 7 (transfers) and 8 (seated wheelchair perturbations), were determined to
have infit mean square values of
⬎1.4, suggesting that these items
may be measuring a construct other
than functional balance. Items with
an outfit mean square value of ⬍0.6
are considered to be less efficient in
measuring the construct. Although
these items are not a threat to the
validity of the scale, they may produce deceptively high reliability estimates. Seventeen items had outfit
values of ⬍0.6: 2 (seated forward
reach), 4 (pick up object in sitting), 6
(posterior external perturbations in
sitting), 9 (sit to stand), 11 (stand to
sit), 13 (standing with feet together),
15 (standing forward reach), 18
(turn 180°), 19 (alternate step test),
21b (left single-leg stance), 22 (walking over level surface), 23 (walking
with head turns), 24 (walking with
change in direction), 25 (stepping
over object while walking), 26
(walking with object in 2 hands), 27
August 2012
(walking up/down stairs), and 28
(walking up/down incline). Items
with an outfit value of ⬎1.4 are a
greater threat to validity and represent outliers. Four items had an outfit
value of ⬎1.4: 3a and 3b (seated lateral reach to the right and left), 7
(transfers), and 8 (seated wheelchair
perturbations). Therefore, these
items should be tested further using
a factor analysis with a larger sample
size.
Table 4.
Mean Square Values for Each Item of the
Activity-based Balance Level
Evaluation (ABLE Scale)
Item
Targeting and Item Difficulty
Rasch analysis places item difficulty
and person ability along the linear
continuum of a logit scale. The Figure is a person-item map that displays the item difficulty and person
ability of the ABLE scale for 104 participants with SCI after pivot anchoring was applied. To the left of the
dashed line are the person ability
measures, and to the right of the
dashed line are the item measures
placed longitudinally by degree of
difficulty in “passing” the item (see
“Method” section). Each item is represented by its corresponding number on the ABLE scale (Tab. 1). The
participants with the lowest balance
ability are located at the bottom of
the scale, whereas those with the
highest ability are located at the top
of the scale. Similarly, the easiest
items are located at the bottom of
the scale and the most difficult items
are positioned at the top of the scale.
Targeting compares the range of
item difficulties with the range of
person abilities. An extremely large
range of abilities were identified in
this sample, which reflects the wide
range in abilities observed following
SCI. A slight ceiling effect still
existed, as there were no items to
measure the one subject with abilities greater than 6 logits (Figure).
There also was a slight floor effect, as
there were no items to measure the
one participant with an ability of less
than ⫺7 logits.
Infit
Outfit
1
1.11
1.32
2
0.78
0.30
3a
1.03
2.44
3b
1.01
2.98
4
0.78
0.50
5
1.07
0.79
6
1.33
0.50
7
1.66
1.85
8
3.05
9.90
9
0.53
0.41
10
1.13
0.76
11
0.68
0.36
12
1.14
0.80
13
0.57
0.40
14
1.03
0.60
15
0.59
0.50
16
1.16
1.28
17
0.79
0.76
18
0.59
0.24
19
0.75
0.41
20
0.71
0.74
21a
1.22
0.78
21b
0.74
0.51
22
0.41
0.25
23
0.66
0.30
24
0.49
0.19
25
0.84
0.29
26
0.60
0.24
27
0.76
0.50
28
0.51
0.22
Analysis of item difficulty revealed
that the most difficult item is 21a
(right single-leg stance). The easiest
item is 5 (scooting forward in a
chair), which is located on the ⫺7
logit. Several item redundancies
were noted at the ⫺1, 0, 2, and 3
logits (eg, 7 different items had a
similar level of difficulty located on
logit 0).
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Physical Therapy f
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was to determine what modifications
needed to be made to the scale based
upon the initial properties of unidimensionality, targeting, item difficulty, and item bias identified with
the Rasch analysis. We also tested
the scale’s ability to discriminate
among the 3 groups of participants
stratified across functional ability.
Analysis of the fit statistics suggests
that 2 items (7 and 8) measure a construct other than balance. These 2
items, along with items 3a and 3b,
also had a high outfit value, which
implies that they are outliers. Our
small sample size precluded performing a PCA, and a follow-up study
on a larger sample is warranted to
determine whether these items
should be removed from the scale.
Figure.
Person-item map for the 28 items of the Activity-based Balance Level Evaluation (ABLE
scale) as tested on 104 individuals with spinal cord injury. Each “.” is one participant,
each “#” is 2 participants.
DIF
We used DIF to determine whether
any items were biased according to
sex, age, or AIS classification. The
DIF effect sizes for sex and age were
negligible and did not reach statistical significance for any item. When
DIF was examined by AIS classification, 2 items (7 and 8) showed significant bias for the AIS C group
(P⬍.05).
Discriminant Validity
A one-way ANOVA was conducted
on the person estimates to assess
whether the ABLE scale differentiates among the 3 distinct functional
groups. The average person estimates were found to be different
across
groups
(F2,101⫽258.37,
P⬍.0001). Bonferroni post hoc com1052
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Physical Therapy
Volume 92
parisons performed at the .05 level
of significance showed that the
mean person ability for the “walker”
group (X⫽3.64, SD⫽1.66, n⫽32)
was significantly higher than for the
“stander” group (X⫽⫺0.13, SD⫽1.04,
n⫽30) and for the “wheelchair-user”
group (X⫽⫺4.08, SD⫽1.54, n⫽42).
The mean person ability for the
stander group also was found to be
significantly higher compared with
the wheelchair-user group at the .05
level of significance.
Discussion
The purpose of this study was 2-fold.
First, our goal was to develop an allinclusive clinical instrument to
assess balance in the SCI population,
which was accomplished via the Delphi technique. The second purpose
Number 8
Analysis of the item map (Figure)
shows that the ABLE scale has an
appropriate targeting range, with
minimal floor and ceiling effects. In
an attempt to further minimize the
ceiling effect, an additional walking
item (walking during perturbations)
was added following this analysis. An
appropriate targeting range is important, as there currently is no outcome measure that can capture the
full spectrum of recovery in the SCI
population. Datta et al29 found floor
and ceiling effects with the BBS and
suggested the development of a new
balance scale for this population.
The large spread of item difficulty
will allow a clinician to use a single
outcome measure with a patient
throughout his or her entire recovery. For example, a patient in the
acute phase of recovery who may
just be regaining sitting balance can
be assessed using the sitting balance
subscale. As he or she progresses,
not only can progression of sitting
balance be tested, but standing or
walking items, scored specifically for
people recovering from SCI, also can
be incorporated into testing.
August 2012
The analysis of item difficulty
revealed 4 logits in which there were
multiple redundancies. Some of
these redundancies may have been
caused by disordered thresholds of 5
items, as well as by a decreased ability to discriminate among scoring criteria in several of the items. Upon
completion, scoring criteria were
revised for the items with disordered
thresholds, as well as for the items
with outfit values of ⬍0.6, to
improve separation, clarity, and
accuracy in scoring. Given the large
number of items on the scale, we
were not surprised to see some overlap in item difficulty levels. To
address this overlap, further testing
is needed on a larger sample to conduct a factor analysis, which would
allow for reduction in number of
items.
There were several limitations to this
study. First, all of the participants
were tested by raters who were
experienced in administering balance assessments to the SCI population. It is unclear how these individuals might have been rated by
physical therapists with less experience in balance assessment or the
rehabilitation of people with SCI.
The use of less experienced raters
may have resulted in increased difficulty in distinguishing among the different rating scale categories for
each item. As the purpose of this
study was to determine what
changes need to be made to the
ABLE scale, experienced raters were
specifically chosen so that reliable
assessments of the participants could
be made and would not influence
the outcome of the study.
Analysis of item bias through DIF
revealed only 2 items (7 and 8) with
significant bias in individuals with
AIS C classification. These 2 items
may be unfairly difficult for this
group of individuals. It is unclear
whether the problem lies with the
items themselves, as individuals with
AIS C classification often have a complicated pattern of recovery and may
be inconsistent in performance of
functional tasks. However, as these
items also had high infit and outfit
statistics, they may be removed from
a future version of the scale, after a
PCA is completed.
A second limitation was the sample
size of 104 participants. Although
this sample size has been shown to
be appropriate for conducting a
Rasch analysis of an outcome measure with 20 items, it precluded performing a PCA.22,26,27 Therefore, this
study was only the first step in assessing the validity of this new instrument. In the future, a PCA will be
completed on a larger sample of participants to further develop the unidimensionality of the scale and to
ensure that all of the items on the
ABLE scale measure balance, and not
another related construct.
One major strength of the ABLE scale
is its ability to discriminate among
individuals, not based on injury
severity (eg, AIS classification), but
by functional mobility levels. Several
studies of the MFRT showed that it is
able to discriminate among injury
severities, but does not differentiate
or correlate with functional mobility.9,13,30 The use of the ABLE scale
will provide the clinician with a
more detailed assessment of a client’s balance abilities.
This study identified several weaknesses of the initial ABLE scale, and
several of the redundant and poorly
fitting items were rewritten to
improve their clarity. This modified
version of the ABLE scale is currently
being tested on a larger sample in a
multicenter format in order to conduct a PCA and reduce the total number of items of the scale. Once the
PCA is completed, further research
should be conducted to examine
other psychometric properties.
Intrarater and interrater reliability
August 2012
should be established for the ABLE
scale in the SCI population using
both experienced and novice clinicians. Concurrent validity of the
ABLE scale with other currently utilized outcome measures, including
the BBS and the MFRT, should be
assessed. Finally, fall incidence and
performance on the ABLE scale
should be correlated to determine
whether the ABLE scale has the sensitivity or specificity needed to predict fallers in the SCI population.
Conclusion
Currently, there is no clinical outcome measure that has been
designed specifically to assess balance in the SCI population. This
study was the first step in developing
a scale that can assess balance across
the full spectrum of recovery in this
population. Although the Rasch analysis showed that the ABLE scale has
an appropriate targeting range and
discriminate ability, further study is
needed to ensure that it is a unidimensional and valid scale.
Dr Ardolino, Dr Hutchinson, Dr Pinto Zipp,
and Dr Harkema provided concept/idea/
research design. Dr Ardolino, Dr Hutchinson,
Dr Pinto Zipp, and Dr Clark provided writing
and data analysis. Dr Ardolino and Dr
Harkema provided data collection. Dr Ardolino provided project management. Dr
Harkema provided study participants. Dr
Clark and Dr Harkema provided institutional
liaisons. Dr Hutchinson and Dr Clark provided consultation (including review of manuscript before submission).
The authors thank the staff and patients at
Magee Rehabilitation, the Shepherd Center,
Kessler Rehabilitation, and Frazier Rehabilitation for their time and participation in this
study. They also thank the Balance Committee of the NeuroRecovery Network for their
assistance in initiating the development of
the ABLE scale.
Approval for the study was granted by the
institutional review boards of Magee Rehabilitation Hospital, Shepherd Center, Kessler
Research Center, Frazier Rehabilitation Institute, and Seton Hall University.
DOI: 10.2522/ptj.20110257
Volume 92
Number 8
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11 Wirz M, Müller R, Bastiaenen C. Falls in
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15 Lemay J, Nadeau S. Standing balance
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17 Granger CV, Hamilton BB, Linacre JM,
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20 Biondo PD, Nekolaichuk CL, Stiles C, et al.
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August 2012
eAppendix.
The Activity-based Balance Level Evaluation (ABLE Scale)a
Purpose: to assess changes in balance across the full spectrum of recovery in the spinal cord injury population.
General Instructions:
• The scale consists of 3 subscales: sitting, standing, and walking. The scale may be administered in full, or each subscale may
be administered and scored separately.
• The participant may be given the option to attempt each task twice. Score the higher of the 2 attempts.
• The participant may not use an assistive device or bracing for any item on the test, except for items 6 and 21, which allow
the participant to use an assistive device only.
• The items should be done in the order listed.
• The examiner must adhere to the instructions provided.
• The examiner must use the equipment as described below.
• If a participant attempts an item, but is unable to perform the activity as per the scoring specifications, the examiner may
choose to use the comment box to remark on the participant’s performance for future reference.
Equipment:
• 1 standard-height (18- to 19-in) chair without armrests (size appropriate for participant to be seated with hips,
knees, and ankles at 90°)
• 1 standard-sized manual wheelchair with removable armrests
• 1 meter stick/yardstick
• 1 large plastic cup (12–16 oz)
• 1 6- to 8-in step stool
• 1 2- ⫻ 4-in block of wood at least 15 in long
• 1 inflatable beach ball (12-in diameter)
• 1 stopwatch
• 1 ADA ramp
• At least 8 standard-height (6- to 8-in) steps
• 3 cones or tape to mark walkway
General Definitions:
Safely: The participant performs the task without loss of balance or risk of falling
Loss of balance: The participant shifts weight out of BOS and is unable to recover/return to within BOS.
Physical assistance: The examiner places his/her hands on the participant during an activity in order to provide
support, or in some instances, to lift the participant.
Minimal physical assistance: The examiner places his/her hands on the participant during an activity in
order to steady the participant.
Moderate physical assistance: The examiner places his/her hands on the participant in order to prevent the
participant from falling or to help the participant initiate a lift.
Maximal physical assistance: The examiner places his/her hands on the participant in order to lift the
participant through the majority of the range of motion.
Supervision: The participant completes the task while the examiner purposefully stands within an arm’s reach of
the participant, but does not actually touch the participant during the activity.
(Continued)
August 2012 (eAppendix Ardolino et al)
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eAppendix.
Continued
Independent: The participant safely and successfully completes the task and does not require any physical
assistance, and the examiner can stand more than an arm’s reach away from the participant.
Demographic and Self-Report Items: The purpose of these items is to provide the clinician and researcher with
demographic information, as well as to help the examiner determine which subscales may be needed for testing.
A. What is your date of birth?
B. What is your sex?
C. What was the date of your injury?
D. What is the level of your injury?
E. Is your injury complete or incomplete?
• Complete
• Incomplete
• Unsure
F. Do you have sensation below the level of your injury?
• Yes
• No
G. Do you have voluntary movement below the level of your injury?
• Yes
• No
H. Can you feel when you go to the bathroom?
• Yes
• No
I. What percentage of your day do you use a wheelchair to get around your home and/or community? Please
choose one:
a.
b.
c.
d.
e.
I use a wheelchair all of the time, in both my home and community
I use a wheelchair sometimes at home, always in my community
I use a wheelchair sometimes at home and sometimes in my community
I never use a wheelchair at home and only occasionally in my community (for long distances)
I never use a wheelchair at home or in my community
J. Are you able to stand for at least 10 s, with a little assistance from a caregiver or therapist, without bracing and
without an assistive device?
• Yes
• No
• Unsure
(Continued)
2
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eAppendix.
Continued
K. Can you walk 20 ft, with an assistive device if needed, but without bracing and without help from a caregiver?
• Yes
• No
• Unsure
L. How many times have you fallen in the past month __________ and/or past 12 mo ___________ (or since your
injury if less than 12 mo since injury)? A fall is an event that results in a person coming to rest inadvertently
on the ground or other lower level (World Health Organization). If you have fallen on multiple occasions, please
respond with the most frequent scenario surrounding your fall episodes. Please provide us with the following
information:
a. What were you doing when you fell?
b. What time of day did you fall?
c. Where were you when you fell?
Sitting Balance Subscale:
1. Sitting with back unsupported but feet supported on the floor or on a foot stool
Administration of item: The participant should be seated in a standard-height chair without armrests. The
participant should be positioned on the chair so that his/her back is not touching the back of the chair and his/her
lower extremities have 90° of flexion in the hips, knees, and ankles. If the participant cannot achieve a full neutral
pelvis due to an orthopedic condition (eg, lumbar stenosis, fusion of vertebrae), have the participant sit as upright
as possible and score appropriately.
Instruction to participant: Please sit up as straight as you can, with a slight arch in your low back and with
your arms folded or resting in your lap for 2 min.
Scoring:
4.
3.
2.
1.
0.
Able to sit with a neutral pelvis (neither anteriorly nor posteriorly tilted) independently, 2 min
Able to sit 2 min with posterior pelvic tilt, independently
Able to sit ⱖ30 s with posterior pelvic tilt, with supervision
Only able to sit with posterior pelvic tilt, 10 to 29 s, with supervision
Unable to sit without support ⱖ10 s
Comments:
2. Seated forward reach
Administration of item: The participant should be seated in a standard-height chair without armrests, leaning
against the back of the chair, with his/her sacrum approximately 3 in from the back of the chair, so that his/her
back is on an 80° incline. The participant should have 90° of flexion in the knees and ankles, with both feet resting
on the floor. A meter stick will be held by another examiner at the height of the participant’s shoulder. The
participant will flex one shoulder to 90°; the other upper extremity may rest in the participant’s lap, but cannot
provide support. The ulnar styloid process should be used as a bony landmark for measurement. If the participant
is unable to flex either upper extremity to 90°, then both upper extremities can rest in the participant’s lap but
may not be used for support. In this case, the acromion can be used as the bony landmark for measurement. At
no point should the participant touch or rest against the meter stick.
(Continued)
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eAppendix.
Continued
Instruction to participant: Please raise your preferred arm up to the height of your shoulder. Reach forward
as far as possible, and then return to an upright position without using your hands for support. Do not twist
your trunk as you reach.
Scoring: Upper extremity used (please circle):
4.
3.
2.
1.
0.
Right
Left
Able to reach forward ⬎15 in independently
Able to reach forward 10 to 15 in independently
Able to reach forward 5 to 10 in but needs supervision
Reaches forward ⬍5 in and needs supervision
Loses balance when trying, requires physical assistance
Comments:
3. Seated lateral reach
Administration of item: The participant should begin while seated in the same position as for the seated forward
reach test, in a chair without armrests. Prior to reaching laterally, the participant should sit upright so that his/her
trunk is no longer touching the back of the chair. When reaching to the right, the participant should abduct the
right shoulder to 90°, and the ulnar styloid process should be used as the bony landmark for measurement. The
left upper extremity may rest in the participant’s lap, but cannot be used for support. If the participant is unable
to abduct the shoulder to 90°, then the acromion may be used as the bony landmark. Repeat with the left upper
extremity. Score each upper extremity separately. The participant’s hips may come up on the opposite side of the
reach.
Instruction to participant: Please raise one arm up to the height of your shoulder. Reach out to the right as
far as possible and return to the middle. Wait 5 s, then reach out to the left as far as possible and return to the
middle. Do not twist your trunk while you reach, and keep your feet flat on the floor.
Scoring: Please mark score in the box provided
Right
Left
4.
3.
2.
1.
Able to reach >6 in independently
Able to reach 2 to 6 in with supervision
Able to reach ⬍2 in with supervision
Able to turn head in direction of reach and uses contralateral limb in lap to assist during reach with
supervision
0. Loses balance when trying, requires physical assistance
Comments:
4. Pick up/touch an object from the floor from a seated position
Administration of the item: The participant should begin while seated in the same position as for the seated
forward reach test in a chair without arm rests. A 12- to 16-oz plastic cup should be placed on the floor between
the participant’s feet. Any strategy may be used to pick up the cup, including the use of 2 hands on the cup. If
the participant is unable to pick up the cup because of impaired hand function, he/she may just touch the cup.
(Continued)
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Continued
Instruction to participant: Please pick up the cup placed in front of your feet any way you like. Try to use
your arms for balance as little as possible.
Scoring:
4. Able to pick up/touch cup independently without using arms to maintain balance.
3. Unable to pick up/touch the cup but comes within 1 to 2 in of the cup and keeps balance independently
without using arms
2. Able to pick up/touch the cup independently but uses arms for support
1. Reaches halfway to cup and needs supervision while trying
0. Loses balance when trying, requires physical assistance to keep from falling
Comments:
5. Scooting forward in a chair
Administration of the item: The participant should be seated in a standard-height chair without arm rests with
his/her feet in contact with the floor, sitting back as far as possible in the chair so that his/her back is against the
backrest. In order to move forward, the participant may scoot the buttocks forward either unilaterally or
bilaterally. The participant should not push against the back of the chair to slide the buttocks forward. The
examiner may demonstrate segmentally moving each buttock forward.
Instruction to participant: Please move your bottom forward to the edge of the chair, using your arms if
necessary. Do not push against the back of the chair.
Scoring:
4.
3.
2.
1.
0.
Able to move one buttock forward at a time without assistance, without upper extremities
Able to move both buttocks forward simultaneously, with or without upper extremities
Able to lift buttocks off of chair, but unable to move forward, with or without upper extremities
Requires minimal assistance to lift buttocks and move forward, with or without upper extremities
Requires moderate to maximal assistance to lift buttocks and move forward, with or without upper
extremities
Comments:
6. Wheelchair-to-chair transfers
Administration of item: The participant should be seated in a standard-height chair without armrests. Arrange
a standard-height/standard-width manual wheelchair with a solid seat and no back cushions (use chair size to keep
hip and knee flexion roughly at 90° perpendicular to each other for a stand or squat pivot/lateral transfer). The
participant may use a sliding board if necessary, but cannot score higher than 2. The left armrests and footrests
may be removed prior by the examiner prior to the transfer.
Instruction to participant: Please transfer from the chair you are sitting in, to the wheelchair next to you,
using your hands as little as possible. Then, when you are ready, please transfer back into the other chair. You
may use a sliding board if you need one.
(Continued)
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eAppendix.
Continued
Scoring:
4. Able to independently perform a stand pivot/stand step transfer without use of hands
3. Able to perform a stand pivot/stand step transfer with use of hands as a guide, with no weight bearing
through upper extremities, requires supervision
2. Able to perform a squat pivot/lateral transfer with use of upper-extremity weight bearing without a sliding
board
1. Able to perform a squat pivot/lateral transfer with use of upper-extremity weight bearing with a sliding board
0. Needs physical assist with or without a sliding board
Comments:
7. Support surface displacement while seated in a wheelchair
Administration of the item: The participant should be seated in a standard-height/standard-width manual
wheelchair, as described in item 6. The participant holds a 12-in-diameter inflatable beach ball with both hands
and/or wrists, while his/her feet are supported on wheelchair footrests. The brake on the left wheel should be
locked. Facing the participant, the examiner contacts the top of the propulsion rim on the right side of the
wheelchair with his/her left hand, while guarding the individual with his/her right arm. The chair is then turned
one eighth of a circle (or 45°) forward in 1 s by pulling the hand down toward the floor. After a balance response
is made or once the participant is returned to an upright sitting posture, the examiner returns the propulsion rim
rapidly back (45° in 1 s) to the starting position. The trunk is unsupported during this test, and the participant is
not allowed to bear weight through the hands on the lap during the test.
Instruction to participant: Hold the ball with both hands and raise it as high as you can. Keep your trunk
still while I turn your chair. Try not to lean against the back of the chair.
Scoring:
4. Able to raise ball to 90° shoulder flexion with elbows extended and maintain or recover balance during turns
in both directions
3. Able to raise ball 3 in off lap and maintain or recover balance while turning one direction only
2. Keeps hands on ball in lap but does not bear weight through the upper extremities and trunk remains steady
during turns in both directions
1. Keeps hands on ball in lap and upper-extremity weight bearing is used to recover trunk balance during turns
in both directions
0. Unable to sit unsupported for 30 s, unable to attempt or tolerate perturbations
Comments:
Standing Subscale: All individuals who are unable to stand would score a zero on items 9 through 28.
8. Arising from a chair
Administration of item: The participant should begin while seated in a standard-height chair without armrests,
with back of the knees 6 in from the edge of the chair.
Instruction to participant: Please stand up without using your arms for support.
(Continued)
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Scoring:
4. Arises from chair to full upright standing position without use of arms on first attempt
3. Arises from chair to full upright standing position with use of arms for momentum, requires >1
attempt
2. Arises from chair with use of arms for weight bearing, requires ⬎1 attempt
1. Able to arise from chair with minimal assistance
0. Unable or needs moderate to maximal assist to stand
Comments:
9. Static standing balance
Administration of item: Once in a standing position on a level surface, the participant is instructed to stand with
eyes open, without holding on to any devices or people.
Instruction to participant: Please stand for as long as you can without holding on to anything.
Scoring:
4.
3.
2.
1.
0.
Able to stand ⱖ1 min independently
Able to stand ⱖ30 s on first attempt with supervision
Able to stand ⱖ15 s on first or second attempt with supervision
Able to stand ⱖ10 s on first or second attempt with minimal assistance
Unable to stand, or stands ⬍10 s with minimal or greater assistance
Comments:
10. Stand to sit
Administration of item: The participant should transition from a full standing position to a seated position in
a standard-height chair without armrests.
Instruction to participant: Please sit down, trying not to use your hands for support.
Scoring:
4.
3.
2.
1.
0.
Sits independently, controls descent without use of hands
Sits independently, with use of hands to control descent
Requires supervision and/or uses back of legs against chair to control descent
Requires minimal assistance to sit safely
Needs moderate or maximal assistance to sit
Comments:
(Continued)
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eAppendix.
Continued
11. Static standing balance with eyes closed
Administration of item: The participant should stand on a level surface, with feet hip width apart, without
leaning or holding on to any surface and with eyes closed.
Instruction to participant: Please close your eyes and stand still for 30 s.
Scoring:
4. Able to stand >30 s independently with normal sway (uses ankle strategies only)
3. Able to stand ⱖ30 s safely with minimal excess sway (uses ankle and hip strategies), requires supervision
2. Able to stand ⱖ10 s with moderate excess sway (uses upper extremities to counteract balance), requires
supervision
1. Tolerates eyes closed for ⬍10 s but remains standing with supervision
0. Unable to stand or needs help to keep from falling
Comments:
12. Static standing balance with feet together
Administration of item: The participant should stand on a level surface without leaning or holding on to any
surface and with feet touching so that the medial malleoli of his/her ankles are in contact with each other. If the
participant is unable to place the feet completely together due to a biomechanical constraint (eg, extreme genu
valgum or obesity), he/she may stand with the medial aspect of the knees touching. The participant begins with
eyes open. If the participant can maintain independent standing with feet together and eyes open for 30 s, ask
him/her to stand in this position with eyes closed for 10 s.
Instruction to participant: Please move your feet so they are touching each other and stand without holding
on to anything. Begin with your eyes open. If the participant stands with eyes open for 30 s, then say “Please
close your eyes and remain standing with your feet together for 10 s.”
Scoring:
4.
3.
4.
1.
0.
Moves feet together and stands independently ⱖ10 s with eyes closed
Moves feet together and stands independently >30 s
Requires supervision to move feet together and remain standing for ⱖ30 s
Needs minimal assistance to assume the position but can stand for 10 s, with supervision
Unable to stand or requires moderate or maximal assistance to assume or hold the position
Comments:
13. External perturbations in standing
Administration of item: The examiner gently nudges the participant from the front with one hand on the
sternum 3 times while standing on a level surface with feet a shoulder width apart, ensuring that the participant
is displaced no more than 3 in. The examiner should apply each nudge 5 s apart. If the participant uses an ankle
or hip strategy to independently maintain balance during displacement in this position, have him/her stand with
feet together, as in item 13, and repeat the perturbations.
(Continued)
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Continued
Instruction to participant: Stand with your feet shoulder width apart (or feet together, as indicated). I am
going to challenge your balance 3 times. Try to keep your balance while I nudge you.
Scoring:
4.
3.
2.
1.
Utilizes ankle and hip strategies to maintain balance, with feet together
Utilizes hip and ankle strategies to maintain balance, with feet a shoulder width apart
Steps backward and uses legs against chair to maintain balance, with feet a shoulder width apart
Maintains balance after first push but falls into chair after second or third push, with feet a shoulder width
apart
0. Unable to stand or maintain balance/falls into chair after first push, with feet shoulder width apart
Comments:
14. Standing forward reach
Administration of item: The participant should raise his/her preferred arm to 90°; however, he/she should be
cued to avoid trunk rotation. The ulnar styloid process is used by the primary examiner as the bony landmark
for measurement. If the participant is unable to raise either upper extremity to 90°, the acromion can be used
as the bony landmark for measurement. A ruler should be held by a second examiner at the height of the
participant’s shoulders on his/her preferred side. The participant must keep his/her feet still, with heels
maintaining contact with the ground while returning to an upright/erect posture, and may not use an assistive
device.
Instruction to participant: Raise your preferred arm to the height of your shoulder. Reach forward as far
as you can without falling and without twisting your trunk. Then return to full upright standing. Do not move
your feet.
Scoring:
4.
3.
2.
1.
0.
Able to reach forward ⱖ12 in independently
Able to reach forward ⱖ6 in independently
Able to reach forward >2 in independently
Able to reach forward ⱖ2 in with supervision
Reaches ⬍2 in or unable to attempt or requires physical assistance to prevent loss of balance
Comments:
15. Pick up/touch object from the floor from a standing position
Administration of the item: A 12- to 16-oz plastic cup should be placed 6 in in front of the participant’s feet.
The participant must begin from a standing position and must return to a full standing position. Any strategy may
be utilized to pick up the cup. If the participant is unable to pick up the cup because of impaired hand function,
he/she may just touch the cup.
Instruction to participant: Pick up the cup that is in front of your feet any way you like and stand up with
it. Try not to use your hands for support.
(Continued)
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eAppendix.
Continued
Scoring:
4. Able to pick up/touch the cup independently, without using arms for balance
3. Able to pick up/touch the cup, but uses hands for balance and/or requires supervision
2. Able to bend down to pick up/touch the cup, but requires minimal assistance to return to full standing
position
1. Reaches halfway to cup and needs supervision while trying
0. Unable to try or loses balance when trying
Comments:
16. Standing trunk rotation
Administration of item: The participant should stand without leaning or holding on to any surface. A second
examiner should stand centered 6 in behind the participant’s shoulder, opposite to the side of rotation, to
encourage a better weight shift. The participant is tested in both directions, but scored only once. Note any
cervical or thoracolumbar fusion under the comment section.
Instruction to participant: Turn and look at the other examiner over your left shoulder, while keeping your
feet planted. Repeat by looking over your right shoulder.
Scoring:
4.
3.
2.
1.
0.
Independently rotates shoulders and cervical spine each to 90°, in both directions
Independently rotates shoulders and cervical spine each to 90°, in one direction only
Independently rotates shoulders or cervical spine separately to <90°, in both directions
Requires supervision during rotation
Requires physical assistance during rotation
Comments:
17. Turn 180°
Administration of item: The participant may not hold on to anything and must complete a half-circle turn in
each direction. The time stops once the participant’s feet face exactly opposite to the start position. The
participant is tested in both directions, but scored only once. The participant can start turning in whatever
direction he/she chooses.
Instruction to participant: While standing, turn around in a half circle, pause for 5 s, then turn a half circle
back in the other direction.
Scoring:
4.
3.
2.
1.
0.
Able to turn 180° independently in ⱕ2 s, in each direction
Able to turn 180° independently in ⱕ4 s, in each direction
Able to turn 180° independently in each direction, in >4 s
Needs close supervision or verbal cuing during turning in both directions
Unable to attempt or needs assistance while turning
Comments:
(Continued)
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18. Alternating step test
Administration of item: Place a 6- to 8-in step/stool 4 to 6 in in front of the participant’s feet. The participant
must alternate placing his/her entire foot on the step while maintaining standing. The participant may not hold
on to anything. The examiner counts how many times the participant can place his/her foot on the step in 15 s.
Instruction to participant: Without holding on to anything, alternate tapping each foot on the step/stool as
many times as you can in 15 s, with the goal of getting 15 foot taps. Do not step up on to the stool.
Scoring:
4.
3.
2.
1.
0.
Able to complete 15 foot taps in 15 s independently
Able to complete 8 foot taps in 15 s independently
Able to complete ⱖ4 foot taps in 15 s, but requires supervision
Able to complete ⱖ2 foot taps in 15 s, but requires minimal assistance
Unable to attempt, needs moderate or maximal assistance to keep from falling, or steps with one limb only
Comments:
19. Balance in tandem/stride stance
Administration of item: The examiner should demonstrate the tandem stance position and alternate stance foot
position (step forward with feet shoulder width apart) for the participant. If the participant attempts the tandem
stance and cannot hold the position, he/she may attempt the alternate position. The participant chooses which
limb to place forward and is scored only on this one position. The participant is allowed at most 2 attempts to
achieve the highest scoring foot position possible, starting each attempt from normal stance position.
Instruction to participant: Please stand with the heel of one foot directly in front of the toes of the other foot.
If you cannot keep your balance in this position, you can take a step forward with one foot, keeping your feet
about a hip width apart.
Scoring: Forward limb (please circle):
Right
Left
4. Able to independently achieve and maintain tandem stance >30 s
3. Requires minimal assistance to achieve tandem stance, but can maintain this position for ⱖ15 seconds
with supervision
2. Able to step forward and maintain stride stance, feet shoulder width apart, ⱖ30 s independently
1. Requires minimal assistance to step but can maintain this position ⱖ15 s with supervision
0. Unable to attempt or requires moderate or maximal assistance to complete
Comments:
20. Single-leg stance
Administration of item: The participant must be tested on each leg and will be scored separately for each leg.
The participant may not lean or hold on to any surface during testing.
(Continued)
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eAppendix.
Continued
Instruction to participant: Stand on your right leg as long as you can without holding on to anything.
Please lift your left leg at least 2 in off of the ground. Repeat standing on your left leg, lifting your right leg
at least 2 in off of the ground.
Scoring: Please mark score in the box provided.
Right
Left
4. Able to lift leg at least 2 in independently and hold ⱖ10 s
3. Able to lift leg at least 2 in independently and hold 5 s, no contact of weight-bearing limb with
non–weight-bearing limb
2. Able to lift leg at least 2 in and hold 5 s, with contact of weight-bearing limb with non–weight-bearing limb,
requires supervision
1. Attempts task but is unable to lift ⱖ2 in and/or holds ⬍5 s
0. Unable to try or needs physical assistance to prevent fall
Comments:
Walking Subscale: For items 22 to 26, the examination should take place on the same 20-ft level walkway surface
consisting of tile or low-pile carpeting. The walkway should be cleared of all obstacles. The participant is not allowed
physical assistance or use of bracing during these tasks, but may use an assistive device on item 22 only. The start
and finish of the walkway should be clearly marked with tape or cones.
21. Walking over level surface
Administration of item: The participant should walk 20 ft over a level surface. The participant may NOT
receive physical assistance from the examiner. The participant may use an assistive device as necessary, but
cannot score higher than a 2. No bracing is allowed during testing.
Instruction to participant: Walk at your normal speed from here to the end of the walkway.
Scoring:
4. Able to walk 20 ft without an assistive device, independently; no loss of balance and maintains
constant speed
3. Able to walk 20 ft without an assistive device while maintaining constant speed, with supervision; regains
balance easily using abducted arms
2. Able to walk 20 ft without an assistive device, with supervision, but does not maintain constant speed
1. Able to walk 20 ft with an assistive device and supervision
0. Unable to walk 20 ft with an assistive device without physical assistance
Comments:
22. Walking with horizontal head turns
Administration of item: The participant should ambulate on the same walkway as in the previous item. The
participant is asked to turn his/her head 90° (or to the point of cervical range restriction), maintaining each head
position for 3 steps. The examiner is encouraged to demonstrate this item. The participant may not use an
assistive device or physical assistance from the examiner.
(Continued)
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Continued
Instruction to participant: Begin walking at your normal pace. When I tell you “look right,” keep walking
straight, but turn your head to the right. Keep looking to the right until I tell you “look straight,” then keep
walking straight, but return your head to the center. When I tell you “look left,” keep walking straight, but turn
your head to the left. Keep your head to the left until I tell you “look straight,“ then keep walking straight, but
return your head to the center.
Scoring:
4. Able to maintain constant gait speed while turning head in both directions, independently
3. Hesitates slightly while turning head, but does not lose balance or deviate inside a 15-in-wide path
2. Hesitates considerably and/or laterally deviates within a 15-in-wide path with head turns, requires
supervision
1. Laterally deviates outside a 15-in-wide path while turning head, requires supervision
0. Unable to try/requires physical assistance to prevent a fall
Comments:
23. Walking with change in direction
participant may not use an assistive device or physical assistance from the examiner. Place a cone halfway down
the walkway. The examiner may demonstrate a smooth turn around the cone. The participant may turn around
the cone in either direction. Document the direction of turn in the comment box for reference for future testing.
Instruction to participant: Please walk to the cone, turn around it without hesitation, and return to the
starting position.
Scoring:
4.
3.
2.
1.
0.
Able to turn direction without hesitation and without loss of balance, independently
Able to turn direction with minimal hesitation and without loss of balance, independently
Approaches cone, stops, slowly turns around cone, without loss of balance, requires supervision
Approaches cone, stops, loses balance when turning, but does not need physical assistance to prevent fall
Unable to try/requires physical assistance to prevent fall
Comments:
24. Stepping over object while walking
participant may not use an assistive device or physical assistance from the examiner. Place a 2- ⫻ 4-in piece of
wood halfway down the walkway, perpendicular to the walkway. The examiner may demonstrate stepping over
the 2- ⫻ 4-in piece of wood.
Instruction to participant: Begin walking at your normal speed. When you come to the piece of wood, please
step over it, not around it or on it.
(Continued)
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eAppendix.
Continued
Scoring:
4.
3.
2.
1.
0.
Able to maintain constant speed while stepping over 2- ⫻ 4-in piece of wood.
Stops, steps over 2- ⴛ 4-in piece of wood, does not lose balance
Able to clear 2- ⫻ 4-in piece of wood, loses balance but does not need physical assistance to recover
Stops, unable to clear 2- ⫻ 4-in piece of wood, but does not lose balance
Unable to try/requires physical assistance to prevent falling
Comments:
25. Walking while carrying an object with 2 hands
Administration of item: The participant should ambulate the full length of the walkway used for the previous
items. The participant may not use an assistive device or physical assistance from the examiner. The object
should be a 12-in inflatable beach ball, or an object of similar size and weight. The participant must carry the ball
with both hands (clenched fists are acceptable for participants with impaired hand function).
Instruction to participant: Walk down the walkway at your normal pace while holding this ball with both
of your hands.
Scoring:
4.
3.
2.
1.
Maintains consistent speed while holding object, ambulates independently,
Cadence slows slightly while holding object, but ambulates independently
Laterally deviates within a 15-in-wide path while holding object, requires supervision
Laterally deviates outside a 15-in-wide path while holding object or drops object ⬎2 times during one pass,
0. Unable to try/needs physical assistance or an assistive device to a prevent fall
Comments:
26. Walking up/down stairs
Administration of item: At least 8 standard-height (6- to 8-in) steps should be used. The participant may not
use an assistive device to complete the task. If more than 10 steps are used, note the total number of steps that
the participant was able to negotiate.
Instruction to participant: Walk up the stairs with your typical pattern using the rails if you need to for
safety. At the top of the stairs, turn around and walk down.
Scoring:
4. Able to walk up and down steps without rail, with reciprocal pattern, independently
3. Able to walk up and/or down steps with rail with reciprocal pattern, with supervision, or able
to walk up/down stairs without rail, with step-to pattern, independently
2. Able to walk up and down steps with or without rail, with step-to pattern, with supervision
1. Able to walk up and down steps with rail, with step-to pattern, with minimal physical assistance in each
direction
0. Unable to try/requires moderate or maximal physical assistance
Total no. of steps: ________
Comments:
(Continued)
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Continued
27. Walking up/down an incline
Administration of item: An ADA graded ramp (1 ft of length for every 1 in of rise), such as an entrance ramp
into a building, should be used. The participant is not allowed to use an assistive device.
Instruction to participant: Please walk up and down the ramp without holding on.
Scoring:
4.
3.
2.
1.
Able to walk both up and down ramp, independently, at or close to normal walking speed
Able to walk both up and down ramp, independently, but one direction is at a slower speed
Able to walk both up and down ramp slowly, with minimal path deviations, independently
Able to walk both up and down ramp slowly, with large path deviations (outside 15-in-wide path) and
0. Unable to try/requires an assistive device and/or physical assistance to walk up/down ramp
Comments:
28. Reactive balance testing during walking
Administration of the item: The participant should walk the entire 20 ft of the walkway. The examiner
displaces the participant at the level of the pelvis as he/she walks along the 20-ft walkway. On the start of the
third stride, the participant is displaced laterally 3 in in 1 s to the contralateral side.
Instruction to the participant: We are going to challenge your balance while you walk; try to keep walking
straight ahead at your normal pace.
Scoring:
4.
3.
2.
1.
0.
Makes appropriate postural adjustments, safely maintains gait speed without loss of balance
Produces a lateral stepping strategy to maintain balance, but continues walking
Stops with or without stepping strategy before continuing down the walkway
Participant requires minimum/moderate assistance after perturbation to prevent a fall
Unable to safely attempt/unable to ambulate
Comments:
a
Pivot points were defined for each item’s rating scale and are boldfaced. 1 in⫽2.54 cm, 1 ft⫽0.3048 m, 1 oz⫽28 g. BOS⫽base of support,
ADA⫽Americans With Disabilities Act. The Activity-based Balance Level Evaluation (ABLE scale) may not be used or reproduced without written permission of
the authors.
Volume 92
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Case Report
Cervical Disk Pathology in Patients
With Multiple Sclerosis:
Two Case Reports
Ann E. Mullen, Mary Ann Wilmarth, Sue Lowe
Background and Purpose. A patient with multiple sclerosis (MS) may be seen
by a physical therapist for evaluation before the MS diagnosis is definitively made,
after a relapse, or during a progression. The diagnosis of MS should be part of the
differential diagnosis if the symptoms of a patient with neurological issues fit the
pattern of a progressive disease. Multiple sclerosis can affect any part of the central
nervous system. Cervical pathology can be confused with relapsing symptoms of MS.
The purpose of this case report is to demonstrate how easily cervical pathology can
be overlooked in a patient with MS.
Case Description. Two case reports of patients with relapsing MS are presented. Both patients were referred for physical therapy after not responding to
standard treatment with intravenous methylprednisolone. One patient reported multiple falls and complained of increasing cervical pain and spasm, fatigue, bouts of
diplopia, and difficulty ambulating. The other patient complained of headaches,
visual disturbances, and cervical pain with radicular symptoms. Contrast magnetic
resonance imaging (MRI) did not reveal new MS lesions or the extension of old MS
lesions. The cervical herniations in the first patient, not previously documented, were
old. The bulging disks in the second patient, seen in a previous study, were
unchanged. The MRI findings did not support the diagnosis of acute inflammatory MS
or acute cervical pathology.
Outcomes. Both patients responded to physical therapy intervention once the
cervical symptoms were directly addressed. As the cervical pain and spasm
decreased, the relapsing MS symptoms of dysmetria, balance disturbance, and ataxic
gait began to diminish. In both patients, eye function was slow to recover, with
persistent impairment. Both patients returned to their premorbid activity and socialization level.
Discussion. Cervical disk disease should be considered in the differential diagnosis when a patient with MS has a history of trauma and displays abnormal postures,
spastic weakness, and changes in pain complaints. In these 2 cases, treating the
cervical pathology in addition to the MS symptoms provided the most effective
approach for functional improvement.
A.E. Mullen, PT, DPT, College of
Professional Studies, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts. Mailing address: 845
Karen St, Palm Harbor, FL 34684
(USA). Address all correspondence
to Dr Mullen at: annemullen@
verizon.net.
M.A. Wilmarth, PT, DPT, MS,
OCS, MTC, CertMDT, Adjunct
Faculty, College of Professional
Studies, Bouvé College of Health
Sciences, Northeastern University,
and Harvard University Health Services, Cambridge, Massachusetts.
Dr Wilmarth also is owner of
Back2back
Physical
Therapy,
Andover, Massachusetts.
S. Lowe, PT, DPT, GCS, CEEAA,
Transitional DPT Program, College
of Professional Studies, Bouvé College of Health Sciences, Northeastern University.
[Mullen AE, Wilmarth MA, Lowe S.
Cervical disk pathology in patients
with multiple sclerosis: two case
reports. Phys Ther. 2012;92:1055–
1064.]
Association
April 19, 2012
Submitted: January 11, 2011
this article at:
ptjournal.apta.org
August 2012
Volume 92
Number 8
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T
he patient with multiple sclerosis (MS) is frequently
encountered in physical therapist practice. There are 25,000
newly diagnosed cases of MS in the
United States.1 There is strong evidence that MS is an autoimmune disease, although there is controversy
as to whether the invasive elements
that trigger the immune response are
viral or bacterial.2 This inflammatory
response to an invasive agent is
responsible for disrupting the bloodbrain barrier and allowing the
destruction of primarily white matter and, to a lesser degree, gray matter. Susceptibility to MS is considered multifactorial. Other factors
that may disrupt the blood-brain barrier include trauma, environmental
pollutants,3
and
vaccinations.
Genetic disposition4 can influence a
person’s vulnerability to MS. Lifestyle factors such as inactivity,
stress,5 and diet6 can influence susceptibility to MS relapse and the
course of the disease.
Multiple sclerosis is a poorly understood disease process that dismantles the myelin and myelinproducing cells, leaving lesions or
plaques in the central nervous system (CNS). Gray matter destruction
is associated with physical disability,
fatigue, and cognitive impairment.7
Prinster et al8 were able to correlate
regional loss of gray and white matter with indexes of clinical and radiological severity, Expanded Disability
Status Scale scores, and lesion load in
people with relapsing-remitting MS.
The McDonald diagnostic criteria are
now being used to diagnose MS, but
there is still a degree of ambiguity
and confusion as to the definition
of terms.9 The diagnostic criteria
define an exacerbation, time
between attacks, requirement of
magnetic resonance imaging (MRI)
findings, cerebral spinal fluid and
evoked potential abnormalities, cri-
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teria of follow-up MRIs, and progression characteristics.
Although late onset of symptoms and
early presentation of optic neuritis
are favorable predictors of outcome,
multiplicity of symptoms and frequency of relapse suggest a poor outcome. Prediction of relapse using
MRI loading, or factoring the number and location of lesions, is becoming more promising to diagnose
exacerbations.10
Signs and symptoms of MS depend
on the area of CNS involvement and
can result in a plethora of symptoms.
Patients with MS have sensorimotor
and balance impairments, ataxia,
tremor, seizures, cranial motor
impairments, cognitive deficits, and
behavioral disorders. Cervical myelopathic and radicular symptoms are
seen in active MS involvement of the
spinal cord. Magnetic resonance
imaging with gadolinium contrast
has been the conventional method
to confirm new active lesions at the
spinal cord or new spinal pathology,
or as a process of elimination to differentiate them from mechanical
derangement of old cervical
pathology.
The physical therapist may encounter a patient with MS early in the
disease process before a definitive
diagnosis is made or after a relapse or
progression. Although it is important
for the physical therapist to be aware
of MS as a differential diagnosis in
the patient with neurological disease,11 it also is important that there
be a high level of suspicion for
comorbid cervical disease or pathology that may confuse the clinical picture or response to treatment.12
It has been suggested that patients
with MS having spastic weakness or
postural deformities are more susceptible to spinal abnormalities and
infections because of the abnormal
compressive forces on the vertebra.2
Number 8
Both diseases are common, their
coexistence is not unusual,13 and
multilevel disease can coexist in MS
and confuse the diagnosis.14 The
most common symptoms found during a retrospective study of 14 people with definite MS who were
scheduled for cervical decompression surgery were progressive
myelopathy and radiculopathy.15
Important clinical considerations for
cervical disease include the following: the age of the patient, a history
of falls or trauma, repetitive activities, deconditioning, and comorbid
diseases such as osteoporosis and
diabetes that place the patient at
risk.16 Correctly identifying spinal
abnormalities will determine effective strategies, physical therapy
interventions, goals, and optimal outcome for rehabilitation.
Discussing the clinical radiological
paradox, Dousset et al17 noted that
acute MS lesions most often can be
detected on T2-weighted images
based on the water content. Gadolinium crosses an open blood-brain barrier and reveals acute inflammatory
lesions. Gadolinium studies are not
foolproof in that chronic lesions can
show up as acute lesions or new
lesions may be completely missed;
thus, adjunct MRI studies are being
developed.17 Most centers do not
perform these expensive batteries of
tests. Most of the MS trauma-related
research has focused on injury as a
cause of MS and not on investigating
the effect of trauma on definitive
cases of MS.18
Patient History and
Review of Systems
This case report describes 2 patients
who were referred for home health
care with a diagnosis of relapsing
MS. Both patients were referred for
physical therapy by nursing staff
after completing the standard treatment of IV methylprednisolone with
only marginal resolution of their
August 2012
Table 1.
Medications and Dosages for Patients 1 and 2a
Patient 1
Medication
Dosage
Medication
Dosage
Advair Diskus (GlaxoSmithKline, Research Triangle
Park, NC)
250 mcg
Crestor (AstraZeneca LP, Wilmington, DE)
10 mg po qd
INH
bid
D3
6,000 mg po qd
Advil (Pfizer Inc, Kings Mountain, NC)
200 mg po qod
Lyrica (Pfizer Inc)
100 mg po qd
Betaseron (Bayer HealthCare Pharmaceuticals,
Berlin, Germany)
0.3 mg subcutaneously
qod
Nexium (AstraZeneca LP)
40 mg po qd
Carbamazepine
200 mg po bid
Nortriptyline hydrochloride
10 mg po qd
Citalopram
20 mg po qd
Singulair (Merck & Co Inc, West Point, PA)
10 mg po qd
Symbicort (AstraZeneca LP)
160 mcg INH bid
Tizanidine hydrochloride
2 mg po qd
Patient 2
Medication
a
Dosage
Medication
Dosage
Advair Diskus
250 mcg INH bid
Crestor
10 mg po qd
Advil
200 mg po qod
D3
6,000 mg po qd
Betaseron
0.3 mg subcutaneously
qod
Lyrica
100 mg po qd
Carbamazepine
200 mg po bid
Nexium
40 mg po qd
Citalopram
20 mg po qd
Nortriptyline hydrochloride
10 mg po qd
Singulair
10 mg po qd
Symbicort
160 mcg INH bid
Tizanidine hydrochloride
2 mg po qd
INH⫽isoniazid, po⫽orally, qd⫽every day, qod⫽every other day, bid⫽twice a day, D3⫽cholecalciferol.
symptoms. The patients demonstrated exacerbation of previous MS
symptoms, particularly complaints
of severe cervical pain, spasm, weakness of the upper extremities, and
gait instability. No new MS lesions or
extension of old lesions were noted
in either case when gadolinium contrast MRI was done; however, old
cervical pathology was noted at multiple levels.
The patient in the first case
described her cervical pain as “different pain and spasms than I had
before.” The slow resolution of cervical symptoms after IV steroids
prompted the physician to diagnose
the patient with secondary progressive MS. An MRI was done to confirm
suspected new lesions. The MRI did
not support the diagnosis; however,
it did confirm old cervical pathology
that was previously unsuspected.
August 2012
The patient in the second case complained of an exacerbation of previous MS symptoms, as well as new
radicular pain in the left upper
extremity. This patient previously
had an abnormal MRI with known
cervical bulging at 4 levels. The more
recent MRI with contrast, however,
showed no new MS lesions or
change in cervical pathology.
Patient 1
The patient was a 41-year-old woman
who was first diagnosed with fibromyalgia, but 10 years later was confirmed by McDonald criteria to have
MS.9 The patient was referred for
home health care physical therapy
with a diagnosis of relapsing MS. The
patient was referred for physical
therapy after IV steroid infusion,
which slightly resolved her symptoms. The patient’s past history was
significant for seizure disorder,
migraine headaches, visual loss,
depressive disorder, hyperlipidemia,
asthma, gastroparesis, a right ankle
fracture 1 year previously requiring a
bone graft, and multiple falls. Her
past cortical and spinal MRIs had
demonstrated MS plaques but no
bony changes. During the physical
therapist’s evaluation, the patient
complained of headaches, cervical
pain and spasm that were “different,” and diplopia. There was dysmetria, weakness and tremor of both
arms, and increased impairment of
balance and ataxia. The patient also
complained of an increase in
Uhthoff’s phenomenon, or worsening of her MS symptoms with elevation of body temperature after exercise. Patient 1’s medications and
dosages are listed in Table 1.
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Patient 2
who also was referred for home
health care physical therapy for
relapsing MS 1 month after returning
from a vacation trip to Panama. She
also received IV steroid medication,
with some resolution of her symptoms. She was first diagnosed with
MS 5 years ago using the McDonald
criteria. She initially was seen in the
emergency department with symptoms of feeling detached and smelling foul, unusual odors. She was
admitted to a psychiatric unit until
experiencing optic neuritis, which
prompted a thorough neurological
examination and MRI. She was diagnosed with MS and a urinary tract
infection.
The patient’s past history was significant for migraine, vertigo, depressive disorder, and urinary tract infections. An MRI done 5 years ago
showed demyelinating disease in 2
cortical areas and fluid surrounding
the optic nerve. The cervical MRI
showed a possible MS lesion in the
cervical cord at the C5 level and in
the T1–2 interspace. There also was
mild posterior degenerative annular
bulging at 4 cervical levels.
She had recently taken a vacation
and rode a cable suspended over the
rain forest holding on to a pulley
slide. She was taking Provigil (Cephalon Inc, Frazer, Pennsylvania) medication to boost endurance and stated
“I may have pushed too hard.” She
experienced worsening of MS symptoms, including cervical pain, within
24 hours after returning home. She
also had swelling of the right jaw,
which a dentist diagnosed as failure
of a previous bone graft with
infection.
She complained of patchy visual loss,
headaches, severe cervical pain with
radicular symptoms down the C5– 6
distribution, sensory loss, increased
tremor and dysmetria of both of her
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upper extremities, twitching of her
thumb and index fingers bilaterally,
and left arm weakness.
The most recent MRI showed confirmation of the old cervical spine
plaque, with no active cortical
lesions or changes in the bulging
disks. Patient 2’s medications and
dosages are listed in Table 1.
Examination
The patients initially received a physical therapist evaluation that
included assessment of the cardiovascular and pulmonary system,
including vital signs; auscultation of
the lungs; girth measurements; tests
of gait, locomotion, and balance,
including the Timed “Up & Go” Test
(TUG),19 the Tinetti PerformanceOriented
Mobility
Assessment
(POMA),20 and gait analysis; assessment of activities of daily living
(ADL) and range of motion (ROM);
manual muscle testing; reflex testing; the Modified Fatigue Impact
Scale21; and special tests such as the
Spurling test, Lhermitte sign, Babinski test, Hoffman test, distraction
test, compression test,22 cranial
nerve testing, smooth eye pursuit,
finger-to-nose testing, and clonus
testing.
The physical therapist outlined
short-term and long-term goals,
including interventions. A prognosis
to reach the stated goals also was
included. The format of the home
care progress notes included goals
and interventions that were evaluated on each note. Significant findings are listed in Tables 2 and 3, and
measurements are shown in Table 4.
Patient 1
The patient complained of severe
cervical and bilateral arm pain that
was “different than before” and rated
the pain as 10/10, where a rating of
10 represents “worst pain imaginable.” Cervical ROM was limited in
all planes by 50%. Her sensation in
Number 8
the hands was diminished and did
not appear to follow a dermatome.
Her reflexes were ⫹1 throughout
both upper extremities. The lower
extremities revealed clonus in both
ankles, to a greater degree on the
right. Tremor in the upper extremities was greater on the right and was
more noticeable with fatigue.
Strength of her right side was ⫹3/5
compared with strength of 4/5 on
the left side. Dysmetria appeared
greater in her right upper extremity.
Her dynamic sitting balance was 4/5,
and her dynamic standing balance
was ⫹3/5. She required a roller
walker to ambulate. She scored
10/28 on the POMA, indicating that
she was at high risk for falls.23 Her
TUG score was 28. Her gait was
ataxic and staggering. She required
assistance for dressing, bathing, and
all household activities.
Patient 2
The patient complained of cervical
and radicular pain of 10/10 down the
left upper extremity. During examination, radicular symptoms were
immediately relieved after performing the distraction test. This is one of
the positive tests for radiculopathy
and indicated that manual traction
could be effective.20 There was
numbness in her C5– 6 distribution.
Her cervical ROM was limited in all
planes by 40%, except cervical rotation to the left, which was 50%. Muscle strength of her left arm was
grossly ⫹3/5. There were decreased
reflexes of the left upper extremity.
Reflexes in her right upper extremities and both lower extremities were
within normal limits. Her dynamic
sitting balance was 5/5, and her
dynamic standing balance was 4/5.
She refused to use an assistive
device, although her POMA score
was 18/28 and her TUG score was
18.
Clinical Impression
According to the Guide to Physical
Therapist Practice,24 the treatment
August 2012
Table 2.
Differential Diagnosis: Symptoms in Multiple Sclerosis That Are Also Found in Disk Pathologya
Radiculopathy
Symptoms
Myelopathy
Patient 1
Patient 2
Patient 1
Patient 2
Decreased cervical ROM
x
L cervical rotation 40°
x
x
Postural deformity
x
Pain
Headaches
x
x
x
LUE C5–6
Cervical
Cervical
x
x
x
LUE
R side ⬎ L side
Reflex changes
Decreased LUE
Decreased BUE, increased BLE
Sensory changes
Decreased LUE
All 4 extremities
Muscle weakness
Dysmetria
x
x
Dizziness
x
x
x
x
Positive Lhermitte sign
Positive Spurling test
x
Positive distraction test
x
x
Fasciculations
x
x
Babinski sign
R x, L x
Bladder/bowel incontinence
x
Clonus
x
Unsteady gait
x
x
Romberg sign
x
x
a
ROM⫽range of motion, LUE⫽left upper extremity, BUE⫽bilateral upper extremities, BLE⫽bilateral lower extremities, R⫽right, L⫽left. “x” indicates
presence of symptom.
of MS is within the scope of a physical therapist’s practice. Multiple
sclerosis is classified into pattern 5E:
Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central
Nervous System. Cervical disk disease is classified into pattern 4F:
Impaired Joint Mobility, Motor Function, Muscle Performance, Range of
Motion, and Reflex Integrity Associated With Spinal Disorders.24 This
clinical pattern was obvious in
patient 2, but not confirmed in
patient 1 until after the contrast MRI.
Intervention
Cervical pathology was addressed
using cryotherapy for pain and
spasm for patient 1. Soft tissue mobilization, graded manual traction,
ROM exercises, deep flexor stabilization, and proprioceptive neuromuscular facilitation (PNF) exercises
were performed on her cervical
regions. General strengthening exercises for her trunk and lower extremities and balance-based torso weighting techniques were used. Her
ambulation progressed from a roller
walker to a quad cane. A home exercise program was devised for her,
and a cervical home traction unit
was provided.
Both patients were treated for exacerbation of their MS symptoms in
addition to their functional cervical
disk pathology. Treatment time was
1 hour or longer, according to the
patients’ tolerance. Not all of the
modalities could be used at once.
Cryotherapy, ultrasound, and soft tissue mobilization were utilized for
pain and spasm for patient 2. Graded
manual traction, ROM exercises,
deep flexor exercises, and PNF exercises were directed to her cervical
August 2012
regions and upper extremities. A
home program for general conditioning using her pool was added. She
was shown how to use a cervical
home traction device.
The interventions utilized with both
patients are summarized in Table 5.
Cryotherapy was effective for them.
The patient in the first case was
familiar with cooling body jackets
that are designed for patients with
MS. Both patients kept the environmental temperatures in their homes
at 65° to 70°F. Soft tissue mobilization, graded manual traction, a home
cervical traction unit, and balancebased torso-body weighting were
utilized.
The patient in case 2 ambulated
throughout the home while wearing
a diving belt. The patient in case 1
was encouraged to start a walking
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Table 3.
Symptoms of Multiple Sclerosis in Patients 1 and 2a
Symptoms
Patient 1
Patient 2
x
x
Migraine type headache
x
x
Trigeminal neuralgia
x
Stabbing aching pain
x
Secondary pain due to muscle weakness, spasticity,
or rigidity
x
Fatigue ⬎ 6.5 on the Fatigue Severity Scale
program, and pool exercises were
shown to the patient in the second
case. Physical therapy was scheduled twice a week for 6 weeks for
both patients.
Pain
x
Eyes
Diplopia (especially lateral gaze)
x
Partial vision, pain in one eye
x
x
Abnormal smooth eye pursuit
x
x
Uhthoff syndrome, heat sensitivity with visual
symptoms
x
x
Sensorimotor system
Incoordination/ataxia
LEs
Decreased sensation
UE/LEs
LUE
Dysmetria
BUE
BUE
Tingling or burning
BUE
LUE
Hyperactive reflexes below the level of active lesion
BLE
Clonus
BLE
Tremor
BUE
Spasticity
BUE
BLE
Muscle weakness
Lhermitte sign
R side ⬎ L side
LUE
x
x
Babinski sign
BLE
Hoffman sign
No test
RUE
Romberg sign
x
x
Autonomic disturbances
Sexual dysfunction
Urinary incontinence
x
Gastroparesis
x
Bowel constipation
Cortex
Seizures
x
Aphasia
x
Speech hesitancy
x
Emotional disturbances
Dx/bipolar
Depression
x
Dizziness/vertigo
x
x
Dementia
a
LE⫽lower extremity, UE⫽upper extremity, LUE⫽left upper extremity, BUE⫽bilateral upper
extremities, BLE⫽bilateral lower extremities, R⫽right, L⫽left, Dx⫽diagnosis. “x” indicates presence of
symptom.
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Outcomes
Patient 1
Upon treatment completion, the
patient reported her pain at 4/10
daily, but not constantly. Diplopia
occurred only with fatigue. Her cervical ROM was within normal limits
except for left cervical rotation that
was 10 degrees less than on the right
side. Strength of her cervical muscles
increased one grade within range.
Weakness of her right side was one
grade less than that of her left side
and persisted. Her POMA score was
21/28. Her TUG score was 18. She
continued to use the home cervical
traction unit and followed through
with the home exercise program.
Her
level
of
independence
improved, with the Outcome and
Assessment Information Set (OASIS)–
based ADL scores as follows:
M1820⫽2/0,
M1830⫽3/0,
and
M1860⫽2/1.25
She continued to complain of
fatigue; however, her level of social
participation improved so that she
was able to enjoy dinners or family
outings with proper pacing. An
improved gait pattern allowed her to
use a quad cane. There were no
reported falls in the home. She was
able to take public transportation
and use air travel to visit her family.
Patient 2
The patient’s cervical pain completely resolved. Cervical ROM had
improved to within normal limits.
There was resolution in her fasciculations bilaterally. Strength in the left
upper extremity increased by half a
grade in all muscle groups. Her
POMA score was 21/28. Her TUG
score was 15. Her ADL scores as
defined in the OASIS had improved:
August 2012
Table 4.
Clinical Findings in Patients 1 and 2a
Before Treatment
After Treatment
Patient 1
Patient 2
Patient 1
Patient 2
Pain
10/10 cervical and bilateral arm pain
10/10 left C5–6 radicular pain
4/10
Resolved
WNL except left external rotation, which
was 10% less than right external
rotation
WNL
Resolved
None
Strength was improved 1 grade, but the
right side persisted weaker than the
left
LUE increased 1⁄2 grade
ROM
Decreased 50% in all planes
Decreased 40% in all planes except
external rotation 50%
Both upper extremities, greater on right
None
RUE ⫹3, LUE 4
RLE ⫹3, LLE 4
LUE ⫹3
Tremor
Strength
Tinetti Performance-Oriented Mobility Assessment
10/28
18/28
21/28
21/28
20
15
TUG
28
18
a
ROM⫽range of motion, WNL⫽within normal limits, RUE⫽right lower extremity, LUE⫽left upper extremity, RLE⫽right lower extremity, LLE⫽left lower
extremity, TUG⫽Timed “Up & Go” Test.
M1860⫽1/0,
M1130⫽3/0,
and
M1880⫽1/0. Vision in her right eye
was slow to detect light. She was
beginning to see some light. More
visual studies were planned for the
future. She returned to her premorbid activity level and was able to
accompany her son in college
selection.
Discussion
Two patients with MS, who were
taking disease-modifying drugs, were
referred for home health care physical therapy with complaints of
relapsing MS symptoms. A relapse is
a clinical diagnosis characterized by
signs of MS, which are either new or
old and last for a few days or months.
Both patients fit this description clinically; however, when MRIs with
gadolinium contrast were done, no
new lesions or extension of old
lesions were seen in either patient.
Magnetic resonance imaging with
gadolinium contrast has been considered the gold standard for determinAugust 2012
ing new MS activity. A series of specific tests for MS have a sensitivity of
94% and a specificity of 55%.26 Work
has shown that gadolinium crosses
the blood-brain barrier and detects
active lesions in people with MS.27
This activity persists for 4 weeks, on
average, and at most 8 weeks. In
both patients presented here, the
gadolinium MRI was done within a 2to 4-week period of symptoms. The
MRI should have detected new
lesions but did not. New inflammation was not perceptible on the MRI.
Corticosteroids can diminish or
resolve active MS lesions on MRI, but
the MS symptoms did not quickly
resolve as expected with administration of IV steroids.
The gold standard MRI was done
appropriately with gadolinium during the appropriate time period,
after IV steroids that marginally
resolved relapse symptoms.
A study by Merwick and Sweeney28
showed that relapses may not be easily linked to a particular lesion on
MRI, and can be pseudo-relapses. If
there are no MRI changes, these
relapses may be attributed to physiologic changes such as those due to
infection, fever, medications, or electrolytes. The first patient was treated
for an upper-respiratory infection,
and the second patients was treated
for a dental infection, but neither
patient had improvement of her MS
symptoms when treated with antibiotics. These 2 cases do not fit the
definition of pseudo-relapse.
There is another concept that may
explain the discrepancy between
clinical presentation and MRI findings. This concept is called the
“clinical-radiological
paradox,”
which is described as a lack of clinical symptoms when the MRI is
abnormal. These MS lesions are
“silent” because neuroplastic processes may have occurred at the cor-
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Table 5.
Evidence-Based Treatmenta
a
Intervention
Rationale
Study
Cryotherapy, ultrasound, soft tissue
mobilization
Acute onset pain and spasm reduction. Heat therapy
is indicated in acute muscle pain and spasm, to a
minimum due to heat insensitivity. Cryotherapy
reduces inflammation, edema, and muscle spasm
and decreases conduction velocity of nociceptors
to block pain impulses.
Practice for health professionals: pain and multiple
sclerosis. Available at: http://www.msaustralia.org.au/
documents/ms-Practice/pain.pdf.
PNF to the cervical muscles
To improve proprioceptive joint sense of deep
flexors, eye-head control, and relocation of head
on the trunk.
Jull G, Falla D, Treleaven J, et al. Retraining cervical joint
position sense: the effect of two exercise regimes.
J Orthop Res. 2007;25:404–412.
Strengthening exercises
Patients with mild to moderate fatigue levels, if
exercising at proper intensities, can improve
strength without increasing or accelerating the
disease process.
DeBolt LS, McCubbin JA. The effects of home-based
resistance exercise on balance, power, and mobility in
adults with multiple sclerosis. Arch Phys Med Rehabil.
2004;85:290–297.
Dalgas U, Stenager E, Jakobsen J, et al. Resistance training
improves muscle strength and functional capacity in
multiple sclerosis. Neurology. 2009;73:1478–1484.
Balance-based torso-body
weighting
Torso weighting is used to counteract directional
balance loss in a patient with MS.
Gibson-Horn C. Balance-based torso weighting in a patient
with ataxia and MS: a case report. J Neurol Phys Ther.
2008;32:139–146.
Specific cervical deep flexor
exercises
Pain impairs deep flexor cervical muscles that
stabilize the neck.
Jull GA, Falla D, Vincenzino B, Hodges PW. The effect of
therapeutic exercise on activation of the deep muscle in
people with chronic neck pain. Man Ther. 2009;14:696–
701.
Cervical traction
Treatment of cervical radiculopathy using a
multimodal technique. Cervical traction can be
used for cases of herniated disks with mild
compressive myelopathy.
Waltrop M. Diagnosis and treatment of cervical
radiculopathy using a clinical prediction rule and
multimodal intervention approach: a case series.
J Orthop Sports Phys Ther. 2006;36:152–159.
Browder DA, Erhard RE, Piva SR. Intermittent cervical
traction and thoracic manipulation for management of
mild compressive myelopathy attributed to cervical
herniated disc: a case series. J Orthop Sports Phys Ther.
2004;43:701–712.
Aquatic therapy
Patients with MS can participate in aquatic therapy
without increase in fatigue level or heat
intolerance and improve their functional scores.
Petersen C. Exercise in 94°F water for a patient with
multiple sclerosis. Phys Ther. 2001;81:1049–1058.
Pariser G, Madras E, Weiss E. Outcomes of an aquatic
exercise program including aerobic capacity, lactate
threshold, and fatigue in two individuals with multiple
sclerosis. J Neurol Phys Ther. 2006;30:82–90.
Aerobic exercise program
Aerobic training partially affected the health-related
quality of life of patients with MS.
Rampello A, Franceschini M, Piepoli M, et al. Effect of
aerobic training on walking capacity and maximal
exercise tolerance in patients with multiple sclerosis: a
random crossover controlled study. Phys Ther. 2007;87:
545–555.
PNF⫽proprioceptive neuromuscular facilitation, MS⫽multiple sclerosis.
tical and spinal cord levels, resulting
in functional reorganization.29
There also can be clinical neurological deficits without MRI findings.
After an inflammatory process, the
destructive process that occurs to
axons and myelin takes time to
degenerate, phagocytize, and produce symptoms. For that reason,
demyelination must be studied at the
molecular level. Vascular adhesions
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and transmigration of mononuclear
cells are key prerequisites in new
lesion formation in people with MS.
Magnetic resonance molecular imaging and nanotechnology have been
proposed to increase the potential of
MRI analysis.30 Abnormalities can be
missed in normal-appearing cervical
cord tissue. There is a strong correlation between cervical cord area, a
measure of atrophy, and clinical presentation. However, the frequency at
Number 8
which spinal cord MRI should be
performed to track lesion load and
atrophy has not been fully determined. Diffusion tensor imaging is
being investigated as an adjunctive
technique.31
One common denominator in both
patients was trauma with previous
cervical pathology. In the first case,
the patient had one serious fall in the
previous year but had multiple
August 2012
minor falls just preceding the exacerbation of symptoms. The cervical
herniations were not suspected and
were undetected until the last MRI.
In the second case, the cervical
pathology was unchanged. Although
trauma was less clear, patient 2
could have aggravated her preexisting cervical pathology during
the recreational pulley ride over the
forest, resulting in functional exacerbation of symptoms.
tion after soft tissue injury of the
cervical spine, which they concluded was likely due to dysfunction
of the proprioceptive system in the
cervicocranial area.
There are some other possible explanations for the exacerbation of the
other MS symptoms without acute
MRI findings. Multiple sclerosis is
characterized by demyelination.
Conduction velocity and amplitude
of nerve transmission are suboptimal
to begin with in patients with MS.
Trauma may further weaken an
impaired nervous system. The most
reliable correlation between clinical
status of the patient with MS and
spinal cord lesions is cord atrophy.
Although these articles are not
strong evidence, they do seem to
support the importance of cervical
function, vision, and balance. In the
2 cases presented in this case report,
once the cervical dysfunction was
treated, there was decrement of
pain, improvement of head and eye
coordination, and correction of cervical alignment. Treatment to the
cervical region improved coordination of the upper extremities and
steadiness of gait. There may be
other factors that explain the
improvement in gait and coordination, such as amelioration of deconditioning effects, improvement of
cardiopulmonary status, and an
improved sense of independence
and well-being.
A corresponding study offers an
explanation for the appearance of
diplopia, dysmetria, balance disturbance, and ataxia seen in patients
with cervical pain. These symptoms
are seen in people with MS and may
be exacerbated by trauma and pain.
A study by Krisjansson and Treleaven32 looked at the effect of 2
physical therapy techniques—proprioceptive training and craniocervical flexion exercises—in the rehabilitation of patients with cervical pain.
They suggested that pain afferents
disrupt the proprioceptive afferents
into the dorsal horn, resulting in
abnormal position sense. Abnormal
stresses on the vertebral joint may
alter cervical afferent firing.32
In summary, 2 patients with a diagnosis of relapsing MS were referred
for home health care physical therapy. Both cases showed no new MS
lesions on contrast MRIs. This finding could have been a limitation of
the MRI technique; however,
improved sensitivity and specificity
of 94% and 55%, respectively, have
been reported.35 Corticosteroids
could have diminished acute findings on the MRIs; however, many of
the MS symptoms, although diminished, persisted for weeks afterwards. The steroids may have had an
anti-inflammatory effect on some of
the soft tissue structures and connective tissue, which may explain some
of the initial improvement.
In one case report, a patient with
cervical cord injury and myelopathy
had bilateral upper-extremity dysmetria and ataxic gait.33 The symptoms
subsided after surgical intervention.
Hildingsson et al34 studied 38
patients with eye motility dysfunc-
Both patients had chronic cervical
disk pathology shown by MRI, which
could account for a functional exacerbation of symptoms. Both patients
had sustained trauma prior to the
exacerbation of symptoms. Both
patients had evidence of severe cer-
August 2012
vical spasm, scapular malalignment,
and kyphoscoliosis because of the
muscle imbalance. Derangement can
place abnormal stresses on the nerve
roots, as they exit the spine. Cervical
pain and spasm can affect the proprioceptive input to the CNS, in
turn, affecting coordination of the
extremities and trunk.
When the appropriate physical therapy intervention was instituted, the
cervical symptoms decreased and
coordination and proprioception
improved, with reduction in motor
impairment and disability. Cervical
disk disease should be considered in
the differential diagnosis in a patient
with MS if he or she complains of
cervical symptoms.
The symptoms of cervical disk
pathology can easily be confused
with symptoms of relapsing MS.
When the patient in the first case had
suboptimal responses to IV steroids,
the physician ordered a new MRI
with contrast, suspecting secondary
progressive MS requiring methotrexate, a more aggressive pharmacological treatment. When the MRI findings showed no new lesions, the
physical therapy treatment was modified to treat the cervical pathology.
The cervical radicular symptoms in
the second case were more obvious,
and the diagnosis of radiculopathy
was made. Physical therapy treatment was directed to the cervical
region early, based on clinical examination. The MRI results confirmed
old cervical pathology and no new
MS lesions shortly thereafter.
Patients with MS are referred for
physical therapy with a diagnosis of
relapsing MS. It is important that the
clinician do a thorough review of the
patient’s medical history, establish a
time line of progression, review pertinent diagnostic studies that are
available, and perform a comprehensive systems review during the physical therapist evaluation. Patterns of
Volume 92
Number 8
Physical Therapy f
1063
diagnoses are important to recognize, as well as which signs and test
results may be clinically significant.
Clinical improvement in response to
cervical treatment potentially indicates that trauma may have been the
catalyst to exacerbate previous cervical symptoms and weaken neurological areas that were already weakened in these 2 cases. The physical
therapist must screen for spinal
abnormalities when presented with
a middle-aged patient with MS and a
history of trauma showing abnormal
postures or spastic weakness with
complaints of changes in pain.
Dr Mullen and Dr Wilmarth provided concept/idea/project design, project management, and clerical support. All authors provided writing and consultation (including
review of manuscript before submission). Dr
Mullen provided data collection/analysis and
patients. Dr Wilmarth provided institutional
liaisons.
The manuscript was written in partial fulfillment of Dr Mullen’s Doctor of Physical Therapy degree at Bouvé Institute, Northeastern
University.
DOI: 10.2522/ptj.20110004
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2 Burks J, Johnson K. Multiple Sclerosis:
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4 Cassetta I, Granieri E. Prognosis of multiple sclerosis: environmental factors. Neurol Sci. 2000;21(suppl 2):S839 –S842.
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12 Luzzio C, Dangond F; Keegan BM, ed. Multiple sclerosis: clinical presentation. Available at: http://emedicine.medscape.com/
article/1146199-clinical. Published 2011.
Updated February 16, 2012.
13 Ronthal M. On the coincidence of cervical
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14 Korovessis P, Maraziotis M, Stamatakis M,
Balkousis A. Simultaneous three-level disc
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com/Rheum/OA/Ostrthrts.htm. Accessed
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17 Dousset V, Brochet B, Deloire MS, et al.
MR imaging of relapsing multiple sclerosis
patients using ultra-small-particle iron
oxide and compared with gadolinium.
ANJR Am J Neuroradiol. 2006;27:1000 –
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19 Posiadlo D, Richardson S. The timed “Up
and Go”: a test of basic functional mobility
for frail elderly persons. J Am Geriatr Soc.
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Kostyk SK. Reliability and validity of the
Tinetti Mobility Test for individuals with
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21 Fatigue severity scale. Available at: http://
www.mult-sclerosis.org/fatigueseverity
scale.html. Updated June 29, 2011. Accessed April 29, 2012.
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22 Cook C, Hegedus E. Orthopedic Physical
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Approach. Upper Saddle River, NJ: Prentice Hall; 2008.
23 Waldrop MA. Diagnosis and treatment of
cervical radiculopathy using a clinical prediction rule and a multimodal intervention
approach: a case series. J Orthop Sports
Phys Ther. 2006;36:152–159.
24 Guide to Physical Therapist Practice.
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25 OASIS based home health agency patient
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OASIS/09b_hhareports.asp#TopOfPage.
Accessed April 29, 2012.
26 Tas MW, Barkhol F, van Walderveen MA,
et al. The effect of gadolinium on the sensitivity and specificity of MR in the initial
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Neuroradiol. 1995;16:259 –264.
27 Petrella JR Grossman RI, McGowan JC,
et al. Multiple sclerosis lesions: relationship between MR enhancement pattern
and magnetization transfer effect. ANJR:
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28 Merwick A, Sweeney BJ. Functional symptoms in clinically definite MS: pseudorelapse syndrome. Int MS J. 2008:15:47–
51.
29 Pelletier J, Audoin B, Reuter F, Ranjeva J.
Plasticity in MS: from functional imaging
to rehabilitation. Int MS J. 2009;16:26 –31.
30 Wu X. Multiple Sclerosis: MRI Diagnosis,
Potential Treatment and Future Potential for Nanoparticle Applications [doctoral thesis]. Stockholm, Sweden: Karolinska Institute; 2005.
31 Rovira A. MRI as a biomarker: advances in
multiple sclerosis. Presented at: 2010
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32 Kristjansson E, Treleaven J. Sensorimotor
function and dizziness in neck pain: implications for assessment and management.
377.
33 Lin HC, Chen CH, Khor GT, Huang P.
Upper limb-dysmetria caused by cervical
spinal cord injury: a case report. BMC Neurol. 2009:9:50.
34 Hildingsson C, Wenngren BI, Toolanen G.
Eye motility dysfunction after soft-tissue
injury of the cervical spine: a controlled
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35 Silver NC, Good CD, Barker GJ, et al. Sensitivity of contrast enhanced MRI in multiple sclerosis: effects of gadolinium dose,
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August 2012
Case Report
Patient-Centered Integrated Motor
Imagery Delivered in the Home With
Telerehabilitation to Improve Walking
After Stroke
Judith E. Deutsch, Inbal Maidan, Ruth Dickstein
Background and Purpose. This case report describes the clinical reasoning
process used to examine a person after stroke and intervene with a novel integrated
motor imagery treatment designed for the rehabilitation of walking and delivered in
the home through telerehabilitation. The integrated motor imagery treatment consisted of patient-centered goal setting and physical practice combined with motor
and motivational imagery.
Case Description. The patient was a 38-year-old woman who had had a diffuse
left subarachnoid hemorrhagic stroke 10 years earlier. She lived independently in an
assisted living complex and carried a straight cane during long walks or in unfamiliar
environments. Examination revealed a slow gait speed, reduced walking endurance,
and decreased balance confidence. Although she was in the chronic phase, patientcentered integrated motor imagery was predicted to improve her community mobility. Treatment sessions of 45 to 60 minutes were held 3 times per week for 4 weeks.
The practiced tasks included transitioning from sitting to standing, obstacle clearance, and navigation in interior and exterior environments; these tasks were first
executed and then imagined at ratios of 1:5. Task execution allowed the creation of
a scene based on movement observation. Imagery scenarios were customized to
address the patient’s goals and observed movement problems. Motivational elements
of arousal, problem solving, and reward were embedded in the imagery scenarios.
Half of the sessions were provided on site, and the remaining sessions were delivered
remotely. Seven sessions were delivered by the clinician in the home, and 5 sessions
were delivered using telerehabilitation.
Outcomes. Improvements in motor imagery ability, gait parameters, and balance
were observed after training. Most gains were retained at the 3-month follow-up.
Compared with on-site delivery, the telerehabilitation sessions resulted in less therapist travel time and cost, as well as shorter therapy sessions.
J.E. Deutsch, PT, PhD, Department
of Rehabilitation and Movement
Science, University of Medicine
and Dentistry of New Jersey, 65
Bergen St, SSB 723, Newark, NJ
07101 (USA). Address all correspondence to Dr Deutsch at:
[email protected].
I. Maidan, PT, MS, Department of
Rehabilitation and Movement Science, University of Medicine and
Dentistry of New Jersey.
R. Dickstein, PT, DSc, Department
of Physical Therapy, Faculty of
Social Welfare and Health Sciences, University of Haifa, Mount
Carmel, Haifa, Israel.
[Deutsch JE, Maidan I, Dickstein R.
Patient-centered integrated motor
imagery delivered in the home
with telerehabilitation to improve
walking after stroke. Phys Ther.
2012;92:1065–1077.]
Association
April 12, 2012
Submitted: August 31, 2011
Discussion. The delivery of integrated motor imagery practice for walking recovery was feasible both on site and remotely.
this article at:
ptjournal.apta.org
August 2012
Volume 92
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Integrated Motor Imagery at Home to Improve Walking After Stroke
M
otor imagery (MI) practice,
either alone or in combination with physical practice,
has been applied for the movement
rehabilitation of people after
stroke.1,2 Substantial gains attributed
to MI practice in combination with
physical practice were reported for
upper-extremity use,3,4 performance
of activities of daily living,5,6 foot
sequence learning, and transitioning
from sitting to standing.7,8 Studies of
rehabilitation of walking after stroke
with imagery alone9 –11 and with a
combination of imagery and physical
practice12 yielded promising results
as well. A recent review indicated
that locomotor activities either performed physically or imagined can
be used to promote ambulation.13
Generally, it is believed that the overlap of neural substrates between
movement imagination and execution explains some of the positive
effects of MI practice on motor performance. The mechanism and neural basis of MI were reviewed extensively by Lotze et al,14 Munzert et
al,15 and Guillot and Collet.16
Reports of the use of MI in the stroke
rehabilitation literature have focused
on skills without the incorporation
of a motivational component. Motivational imagery has been explained
with an attention-arousal theory.17 It
is postulated that imagery places the
system in an optimal state of arousal,
allowing the learner to focus on taskrelevant cues.17 A second explanation is that imagery builds psychological skills, such as increased
confidence and decreased anxiety,
which are critical for performance
enhancement. Thus, motivational
imagery is used to imagine arousal
and affect.18 It has been associated
with improvements in self-efficacy19
by
increasing
attention
and
arousal.20 Evidence from the sports
literature has suggested that incorporating motivational strategies into
imagery may improve outcomes,
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such as confidence, self-efficacy, and
performance.19,21,22
The delivery of MI in the home
increases compliance and facilitates
a patient-centered intervention. The
rationale for a patient-centered intervention is based on the accumulating
evidence that successful rehabilitation focuses on the patient and the
attainment of goals rather than on
the resolution of problems.23 Patientcentered therapy is important both
for goal setting and for the delivery
of rehabilitation because it promotes
active involvement with therapy.24,25
In addition, MI provided in the home
enables a patient to train in the relevant environment and to encounter
specific difficulties that interfere
with goal attainment.26,27 It is known
that home-based exercises for people in the chronic stage after stroke
result
in
larger
intervention
effects28,29 and substantial reductions in dropouts, which are common in group therapy.30
Although delivery in the home has
benefits, it also has challenges,
including therapist travel time and
lack of access to care for people in
remote areas. One solution to these
challenges is remote delivery. Telerehabilitation has been implemented
in stroke rehabilitation primarily for
upper-extremity recovery31,32 but
also for lower-extremity training.33,34
To date, however, MI has not been
provided in a telerehabilitation
model.
In previous work, we showed that a
home-based
MI
intervention
improved walking for people in the
chronic stage after stroke.10 The purpose of this case report is to describe
the implementation of an integrated
MI intervention including patientcentered goals, motivation aspects of
imagery, and the delivery of therapy
both on site and through telerehabilitation. These innovations were used
for a woman who was in the chronic
Number 8
phase after stroke and who experienced walking restrictions and
apprehension about walking in the
community. The clinical decisionmaking process described by Schenkman et al35 was used to frame the
case.
Patient History and
Review of Systems
who had sustained a diffuse left subarachnoid hemorrhagic stroke 10
years earlier. Before her stroke, she
worked as an art therapist and led an
active lifestyle with no physical or
cognitive limitations. On the day of
the stroke, she experienced nausea
and vomiting. A computed axial
tomography scan revealed a clinical
grade 1 or 2 hemorrhage caused by a
terminal bifurcation aneurysm. The
patient underwent a left-side peritoneal craniotomy, clipping of the
bifurcation aneurysm, and placement of a spinal drain. Although she
tolerated the initial procedure well,
she developed hydrocephalus and
remained for approximately 40 days
in a surgical intensive care unit,
where she received an emergency
ventriculoperitoneal shunt. She completed 4 weeks of inpatient rehabilitation consisting of physical therapy
and speech therapy. At discharge,
she had regained gross function of
the right upper extremity; however,
she continued to demonstrate weakness of the right lower extremity,
difficulty with fine motor movements, and problems with word finding and sentence completion. For
several months, she continued physical therapy, occupational therapy,
and cognitive therapy, including several sessions of vestibular rehabilitation to address complaints of dizziness upon standing. At the
completion of therapy, she was independent in the performance of activities of daily living, ambulation, and
communication and was living with
her parents.
August 2012
Two years before the current episode of care, she was living independently in her own apartment in an
assisted living complex. She
reported carrying a straight cane for
occasional use during long walks or
in unfamiliar environments because
they made her feel anxious and fearful. These concerns limited her community mobility. Before her first evaluation, she signed an informed
consent statement, in accordance
with the guidelines of the institutional ethics review board.
Examination
The examination approach, which
was based on an integrated model
for decision making in neurologic
physical therapist practice,35 had 3
main objectives: assessment of imagery ability, measurement of motor
behavior outcomes, and movement
assessment for selecting and guiding
the intervention. Because there is no
definitive test of imagery ability for
people after stroke, imagery ability
was measured through complementary assessments of imagery modalities (Kinesthetic and Visual Imagery
Questionnaire [KVIQ]),36 temporal
congruence (mental chronometry),37 and spatial working memory38
(we used the Wechsler test component, which is not validated to be
used individually). Motor behavior
outcomes were selected on the basis
of the patient’s mobility goals and
represented motor recovery (FuglMeyer Test),39,40 temporal features
of walking (10-m and 6-minute walk
tests),41,42 balance confidence,43,44
and cognition and self-efficacy
(Timed “Up & Go” Test [TUG],45
TUG with dual tasks,46,47 and
Activities-specific Balance Confidence Scale [ABC]). Movement was
assessed by observing executed
tasks, which were performed (as a
form of ongoing examination) during every intervention session.
Examinations of imagery ability and
motor behavior outcomes were conAugust 2012
ducted in the Rivers Laboratory (University of Medicine and Dentistry of
New Jersey, Newark, New Jersey) at
3 time points: before therapy, after
therapy, and 3 months after the end
of therapy. For the purpose of
increasing internal validity, the
examiner was blinded to the
intervention.48
Implementation of the telerehabilitation technology was tracked during
training, and costs were calculated
after the intervention. At the conclusion of the intervention, both the
patient and the clinician completed
the Post-Study System Usability
Questionnaire. It consists of 19 items
rated on a scale from 1 to 7 (where
1⫽strongly agree and 7⫽strongly
disagree). It contains 3 domains: system usefulness, information quality,
and interface quality. The clinician
completed the entire questionnaire.
The patient completed the questionnaire without the information quality
domain.49 The complete test is available online (http://drjim.0catch.
com/usabqtr.pdf). The examination
tools, relevant psychometric information, and findings of the first
examination are summarized in
Table 1.
Clinical Impression
The initial examination identified
walking limitations that could partially explain the patient’s identified
problems with walking in unfamiliar
environments,
outdoors,
and
crowded places.35 The limitations
included slow speed and loss of balance. These limitations were compounded by vision problems such as
diplopia and dizziness, which led to
apprehension and fear that affected
the patient’s walking ability, reduced
her confidence and motivation for
community mobility, and restricted
her participation in social activities.
The examination results indicated
slow gait speed, reduced walking
endurance, and decreased balance
confidence. These findings were
consistent with a physical therapist
diagnosis of impaired motor function
and sensory integrity associated with
a nonprogressive disorder of the central nervous system acquired in
adulthood (Guide to Physical Therapist Practice Pattern 5D50). The
corresponding diagnosis in the International Statistical Classification of
Diseases, 9th Revision, Clinical
Modification (code 781.2), was
abnormality of gait.
Scores on the tests of imagery ability
(KVIQ, mental chronometry, and
Wechsler) indicated that the patient
had the ability to imagine. Furthermore, because of her premorbid role
as a recreational therapist, she was
familiar with imagery practice as a
practitioner and as an instructor.
Imagery scenarios were constructed
to address the patient’s goals by
remediating
motor
behaviors
observed in the examination. The
imagery scripts were further refined
through movement observation and
assessments of the executed tasks
during the intervention.
Prognosis
Even though the patient was in the
chronic phase after stroke, which
is associated with a lack of change
in walking function at home and in
the community, we predicted that
she would benefit from the therapy.
This prediction was based on the
patient’s measured imagery ability
and premorbid experience with
imagery and on our plan of care. We
planned to combine mental practice
with a small amount of physical practice for relearning motor strategies.
The addition of physical practice to
imagery practice has been shown to
produce a better result than imagery
practice alone.51,52 Furthermore,
because we planned to include motivational aspects of imagery, we
anticipated a good outcome on the
basis of evidence from the sports
field of the impact of MI on affective
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1067
Table 1.
Testsa
Test
Purpose and Description
Measurement
Scores
5–25 for each
modality
Psychometric Cutoff Scores
Initial
Examination
Scores
Kinesthetic and Visual
Imagery Questionnaireb
Visual (V) and kinesthetic
(K) imagery modalities
measured on a 5-point
ordinal scale
Test-retest reliability (ICC⫽.8–.9),
construct validity (V⫽0.89,
K⫽0.87)36
V⫽16, K⫽18
Mental chronometryb
Comparison of imagined
and real walking times at
5- and 10-m intervals
Test-retest reliability (ICC⫽.81–.90)37
5 m⫽0.01 s,
10 m⫽3.02 s
Spatial working memory
(Wechsler and
Hartogs38)b
2-dimensional stimulus
response cards of
Wechsler Memory Scale
0–12 for each
spatial span
Fugl-Meyer Test (lower
extremity [LE])c
Sensorimotor recovery of
patients with hemiplegia
after stroke
Total⫽56, LE⫽0–32,
sensory⫽0–24
Test-retest reliability (ICC⫽.81),40
criterion validity (r⫽.61 with gait
speed)39
LE⫽20,
sensory⫽12
10-m timed walk testc
Measurement of
comfortable walking
speed (average of 3 trials)
Middle 6-m data
collected by
GAITRite Systemd
Test-retest reliability (ICC⫽.95–.99),65
cutoff (speeds of ⬎0.8 m/s
indicate community ambulation)41
0.6 m/s
6-minute walk test
(6MWT)c
Assessment of distance
walked over 6 min for
endurance estimation
(performed at fastest
speed possible)
Distance
Test-retest reliability (ICC⫽.96),66
criterion validity (high correlation
with gait speed and leg
strength),42 minimal detectable
change (36.6 m)45
257 m
Timed “Up & Go” Test
(TUG)c
Assessment of mobility,
balance, and fall risk
(patient rises from a
chair, walks 3 m at a
comfortable pace, turns,
walks back to the chair,
and sits) (average of 3
trials)
Time to complete
task
Test-retest reliability (ICC⫽.96),
criterion validity (r⬎.86 with CGS,
FGS, SCas, SCde, and 6MWT),45
cutoff (times of ⬎13.5 s are
associated with fall risk)47
13.4 s
TUG with dual tasksc
Same as TUG, except that
patient concurrently
counted backward by
fives, starting at 100
(average of 3 trials)
Time to complete
task
criterion validity (r⫽⫺.66 with
BBS),46 cutoff (times of ⱖ15 s are
associated with fall risk)47
14.6 s
Activities-specific Balance
Confidence Scalec
16-item self-report measure
of balance confidence in
performing various
ambulatory activities
without falling
Items are rated from
0 to 100, added,
and divided by
16
construct validity (r⫽.36 with BBS
and r⫽.48 with gait speed),43
cutoff (scores of ⬍67% indicate
risk for falling)44
65%
Post-Study System
Usability Questionnaire
(ease-of-use
questionnaire)e
Evaluation of use of
telerehabilitation system
(1 questionnaire each
was administered to
patient and clinician)
12–84 for patient,
19–133 for
clinician
Instrument was adapted from
existing indexes for this case report
Discharge only
Costse
Assessment of costs related
to remote sessions
Travel and time
costs
Forward⫽10,
backward⫽7
Discharge only
a
ICC⫽intraclass correlation coefficient; CGS⫽comfortable gait speed; FGS⫽fast gait speed; SCas⫽stair climb, ascending; SCde⫽stair climb, descending;
BBS⫽Berg Balance Scale.
b
Imagery or memory measure.
c
Motor test.
d
CIR Systems Inc, Sparta, New Jersey.
e
Technology test.
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August 2012
Table 2.
Interventions
Technology Management,
Therapy Progression, and
Caregiver Instruction
Mode of Delivery During Session:
a
Tasks (Sequences)a
2
3
1
Sit-walk (E, I⫻5, E), obstacle course
(E, I⫻5, E), and walk interior (I)
Local
Local
Local
Familiarization with computer,
camera; clinician on site (local
clinician) responsible for making
sure the patient knew how to
handle the software
2
Sit-walk (E, I⫻5), obstacle course (E,
I⫻5), walk interior (E, I⫻5, E), and
walk exterior (I)
Local
Local
Remote
Practice logging in outside of session
3
Sit-walk (E, I⫻5), obstacle course (E,
I⫻5), walk community interior (I),
and walk community exterior (I)
Local
Remote
Remote
Progression of speed and endurance,
addition of real-world or
ecologically valid obstacles
4
Sit-walk (E, I⫻5, E), obstacle course
(E, I⫻5, E), walk community
interior (I), and walk community
exterior (I)
Local
Remote
Remote
Checking computer competency,
walking goal different from that in
week 3
Week
1
E⫽physically executed, I⫻5⫽imagined 5 times.
deficits.19 The goal of the intervention was to improve the patient’s
community mobility and balance
confidence.
Intervention Dose and Structure
The intervention consisted of 12 sessions of 45 to 60 minutes each 3
times per week for 4 weeks.53 As
indicated in Table 2, each week contained 3 core tasks: sit-walk, obstacle
course, and walking in different environments. These tasks were selected
because they form the basis for
mobility and represent the repertoire of real exercises used in the
rehabilitation of people after stroke,
who are prone to falls.54,55
On the basis of previous research,53
each practice session, guided by the
clinician, was composed of the following 6 elements: (1) execution of
the task; (2) relaxation for 1 to 2
minutes; (3) provision of explicit
information on characteristics of the
task and the environment; (4) imagining walking with different imagery
modalities (kinesthetic and visual),
perspectives (first and third persons), and cognitive and motivational cues; (5) repeat execution of
the task; and (6) debriefing of the
August 2012
patient. The task was executed to
ensure that the patient understood
the imagery task and to help the
trainer create a scene based on the
observation of real movement. The
ratio of executed tasks to imagined
tasks was 1:5.51,52 Execution could
be performed only for a subset of
tasks. The selection of imagery perspectives and modalities and the
addition of cognitive challenges and
affective cues were based on
observed motor behaviors, mental
chronometry, and the patient’s
report of engagement.
The therapy was delivered either on
site (Tab. 2, “local”) or through
telerehabilitation (Tab. 2, “remote”).
Table 2 also shows technology management and therapy progression.
Movement Assessment and
Integrated MI Practice
The plan of care was implemented
by integrating the intervention with
the movement assessment. At each
session, the patient’s movement during the executed tasks was observed.
In accordance with the patientcentered therapy approach, the
patient set goals for the tasks and
environments that were relevant to
her. Specifically, she wanted to walk
quickly in the hallway, walk in the
parking lot, walk in the street leading
out from her housing complex, and
walk in the mall. Tasks in environments where she often was unable
to physically practice, such as the
mall, were only imagined.
Therapy progression was based on
the ongoing movement assessment
conducted in the home according to
the taxonomy of Gentile56 to classify
environments and tasks and the temporal sequence of movement of Hedman et al57 to analyze tasks, as interpreted in the integrated model of
Schenkman et al.35 Movements in
the patient’s apartment, common
spaces, grounds, and neighborhood
were observed. Table 3 shows the
environment and task categories
based on the 4 conditions adapted
from Gentile56 and observations of
the patient’s performance. Thus, the
intervention was based on recurring
examination and evaluation of the
patient’s goals and observed motor
behaviors. Specifically, we observed
that she had difficulties with tasks
when she was moving and the environment was either “stationary”
(walking in the hallway) or “moving”
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Table 3.
Environment and Task Categories Based on the Taxonomy of Gentile56
Environment
(Gentile Taxonomy)
Task
Observations of Movement and Confidence
Stationary individual,
stationary environment
Sitting on all surfaces in the apartment
Independent and confident
Moving individual,
stationary environment
Walking in the apartment
Independent; movements were slow and halting and
became slower when the patient spoke to someone
in the room or when someone crossed her path
Stationary individual,
moving environment
Sitting on all surfaces with people
moving around in the apartment or
outside on the grounds
Independent and confident
Moving individual, moving
environment
Walking from the apartment to the
hallway, to the parking lot, and
along the street with unpredictable
perturbations from people and cars
Close supervision to contact guard; movements became
slower as the patient transitioned from the apartment
to the hallway and then from the hallway to outside;
the patient stopped when she encountered people
walking in her vicinity (not necessarily to speak with
them but just to let them go by); while walking
outside, the patient needed minimal assistance when
a car approached her in the parking lot; she reported
a high level of fatigue and feeling nervous after
walking outside
(walking on the sidewalk with cars
passing by).
Each task was analyzed according to
the temporal sequence of Hedman et
al57 with 5 stages of movement.
Table 4 shows an analysis of 3 tasks
(sitting, walking in the hallway, and
walking in the parking lot) performed by the patient. Her preparation for movement always involved
seeking an external source of support (the wall as a reference point or
a person nearby). She showed a consistent delay or hesitation in preparation for all movements. Her execu-
tion was slow and uncoordinated.
On the basis of her report, these
movement difficulties were a result
of poststroke sequelae and discomfort with movement.
For task practice, the integrated
imagery approach, combining cogni-
Table 4.
Task Analysis of the Patient’s Performance According to the Temporal Sequence of Movement of Hedman et al57
Task
Initial Conditions
Preparation
Initiation
Execution
Termination
Sitting
Posture unremarkable;
patient was able to
interact with the
environment
No delay
Unremarkable
Unremarkable
Unremarkable
Walking in the hallway
when it was empty
Patient oriented herself
toward the walls or
banister
Delay
Head was fixated, gaze
was on the floor,
and movement
direction was lateral
rather than forward
Direction was forward,
step length was
reduced, step
length was longer
on the left, and
speed was slow and
became slower as
the patient
intended to
terminate
movement
Movement continued after
intended stop, with
oscillation of trunk and
repositioning of feet
Walking in the parking
lot with cars pulling
in and out
Patient oriented herself
close to the person
guarding
Delay
Head was fixated, gaze
was on the floor,
base of support was
wide, direction of
movement was
lateral rather than
forward, and
amplitude was
reduced
Direction was forward,
step length was
reduced, step
length was longer
on the left, speed
was slow, and
movements were
halting and
uncoordinated with
perturbations
Movement appeared to be
premature relative to
target destination, with
oscillation of trunk and
repositioning of feet
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tive rehearsal of motor tasks with
motivational components, was used.
This concept was adapted from
sports to create a structure for delivering imagery practice; the components were arousal-attention, problem solving, and a sense of
accomplishment. This approach was
selected to motivate and engage the
patient in a manner consistent with
motor learning principles requiring
problem solving for learning.
Through imagery, feelings of confidence were reinforced for both task
performance and successful accomplishment of the practiced tasks.58,59
Reinforcement was accomplished by
devising imagery scripts tailored to
the patient’s goals and movement
problems.60 The Appendix shows an
imagery script illustrating all of the
components of integrated MI tailored to address the patient’s goal of
walking in the parking lot.
Telerehabilitation
All of the practice sessions were conducted by the same physical therapist. Seven practice sessions were
carried out at the patient’s home,
and 5 practice sessions were
directed remotely. During the
remote sessions, 1 researcher (the
local therapist) was on site ensuring
that the technology was working and
that the patient was safe. The local
therapist was never required for
patient safety but assisted with the
technology
setup.
Another
researcher (the remote therapist)
delivered the therapy remotely from
her home. The remote sessions were
conducted with the patient’s computer. A camera for tracking the
patient’s movements was installed in
her home, and a headset, which
included a microphone and earphones, was used to ensure better
engagement in imagery practice. The
patient had a desktop computer with
an Internet connection, and she was
comfortable using the computer.
The remote therapist used her lapAugust 2012
top, which had a built-in camera.
Communication
between
the
patient’s site and the remote therapist’s site was accomplished through
a videoconference conducted with
Blackboard Collaborate communication software (Blackboard Inc, Washington, DC). There was 2-way audiovisual communication. The remote
therapist could observe the patient
during the delivery of instructions,
imagery, and debriefing but only partially during execution. For this reason, the patient did not execute the
external walking tasks during the
remote sessions. The remote sessions were, on average, 15 minutes
shorter than the on-site sessions.
Outcome
Response to Intervention
The patient was able to imagine the
scripts, as confirmed by comparison
of the executed task times and the
imagined task times. Adjustments
were made in the instructions when
the congruence decreased. The
patient attended all of the planned sessions. In the debriefing that occurred
after each script, she provided information on how she felt about the
imagined walking experience, what
obstacles she encountered, and how
she solved them. Representative comments were “I could see myself in the
rain, walking safely; it felt good” and “I
was nervous, but then I felt my leg and
it was strong.”
walking speed changed from that of
household ambulation to that of limited community ambulation.61 Her
walking distance on the 6-minute
walk test increased from 257 m
before the intervention to 277 m
after the intervention and to 282 m
at the retention test.
Balance, Cognition, and Balance
Confidence
The TUG time decreased from the
initial examination to discharge, and
further decreases were seen at
follow-up for both the TUG and the
TUG with dual tasks (Fig. 2). After
training, the TUG time was below
the cutoff for fall risk.47 The ABC
scores increased from 65 points
before the intervention to 76 points
at discharge and to 69 points at the
retention test. A 10-point change is
considered clinically meaningful.44
Motor Imagery Ability
The KVIQ scores changed from 16
points to 24 points in the visual
domain and from 18 points to 24
points in the kinesthetic domain, and
these gains were retained at followup. Chronometry was not used as an
outcome measure.
Telerehabilitation
The patient’s score on the Post-Study
System Usability Questionnaire for
telerehabilitation technology was 23
of 84. The clinician’s score was 34 of
133 (the scores on the domains were
as follows: 13/56 for system usefulness, 14/49 for quality of information, and 7/28 for quality of interface). Lower numbers indicated that
the system was comfortable and easy
to use. The patient’s score for most
items was 1 or 2; the highest score
was seen for “the system has all the
functions and capabilities I expect it
to have.” The patient’s comment relative to this item was that she preferred having the second therapist
on site. The patient also commented
that therapy delivered through telerehabilitation was fine if it was “in
addition” to physical therapy delivered in person.
Gait Parameters
Gait speeds at discharge increased
57% for self-selected speed and 37%
for fast speed, and these increases
were maintained at the 3-month
follow-up (Fig. 1). The patient’s
There were some technical challenges. Both the patient and the clinician reported noise and audio lag
during audio communication. The
clinician complained that the camera
had a limited field of view. For exam-
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Figure 1.
Gait speed. Gait speeds of less than 0.4 m/s indicate household ambulation, gait speeds of 0.4 to 0.8 m/s indicate limited ambulation
in the community, and gait speeds of greater than 0.8 m/s indicate full ambulation in the community.61
ple, it captured only a small part of
the walking path, and observing
small movements, such as breathing
and facial expression, was difficult.
Costs were defined as travel time,
travel cost, and session time. The
average travel time in each direction
for the therapist was 30 minutes (1
hour for a session), and the travel
cost per session was $15 (30-mile
round trip reimbursed at $0.50 per
mile). Five sessions were conducted
remotely, resulting in savings of 5
hours of travel time and $75 of travel
cost. Remote therapy sessions lasted
45 to 60 minutes, and on-site therapy
sessions lasted 60 to 75 minutes;
thus, remote therapy resulted in a
savings of 75 minutes of therapy
time.
Figure 2.
Times on the Timed “Up & Go” Test (TUG) and the TUG with dual tasks (TUG-DT). Times of 13.5 seconds or greater were associated
with fall risk.47
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Additional costs related to telerehabilitation technology, such as a computer and Internet access, were not
relevant in this case because the
patient had her own computer and
connection to the Internet. The camera and the headset were provided
by a researcher.
Discussion
We described the clinical reasoning
process that led to an integrated
imagery intervention, delivered on
site and remotely, for gait and balance confidence training for a person after stroke. This case report
illustrates how to design a patientcentered intervention after careful
examination and customization of an
intervention based on patient goals
and the results of a movement analysis. In this single case, providing
integrated MI training remotely was
feasible. Furthermore, the patient
showed changes in mobility and balance confidence outcomes that were
specifically selected as outcome
measures relevant to her goals.
The examination yielded the relevant therapy outcomes for mobility
and balance confidence, and the
movement assessment during the
intervention allowed for customization of the therapy. Furthermore, we
involved the patient in setting the
goals for therapy because doing so
has been linked to increased adherence to therapy tasks, greater goal
attainment and satisfaction, facilitation of a person’s sense of control
over rehabilitation, and improved
therapy outcomes.24,62 For this
patient, the construction of integrated MI emphasized the affective
domain because she reported apprehension with walking.
Although one cannot attribute causality in a single case report, we
believe that changes in the mobility
and balance confidence measures
suggested the specificity of imagery
training. The patient showed
August 2012
improvements in walking speed
(10-m walk test) and endurance
(6-minute walk test). Both speed and
endurance were trained only by
imagery and not by physical execution. During imagery training, the
patient was instructed to walk fast,
and imagery scenarios for community mobility that required imagining
walking long distances were used.
The patient also showed improvements in balance and balance confidence. The intervention was specifically designed to address these issues
through imagining problem solving
and emotions connected to a task.
During imagery training, the patient
succeeded (by her report) in overcoming some of her feelings of discomfort. We speculate that problem
solving difficult situations and imagining being satisfied were captured
by the improvements measured on
the TUG with dual tasks and the
ABC. The patient often reported feeling more comfortable executing
movements after she had imagined
them. We speculate that improvements in balance self-efficacy may
have been related to increasing
attention and arousal during the
intervention.20
The motivational component of the
imagery intervention is novel. This
approach emphasized difficulties of
an affective-cognitive nature, such as
fear of falling, poor attention, organizational problems, and difficulty
problem solving.63 These difficulties
could be a source of subsequent
losses of autonomy. The MI scenes
incorporated elements of attention,
problem solving, and sense of
accomplishment in accordance with
the patient’s goals. We speculate that
the MI training enabled repeated
practice of both physically and affectively challenging scenes to overcome fears and address problems
during practice. Thus, the motivational aspect of the imagery was
related to both patient-centered
goals and customization of scripts
with the appropriate cognitive and
affective cues. It is important that we
relied on patient report and did not
specifically measure motivation.
The validity of imagery training is
often questioned on the basis of the
difficulty in determining whether
people are really imagining. During
training, the patient was asked how
she performed the imagery training
and about any difficulties that she
had. In addition, we measured the
congruency between imagined tasks
and executed tasks. We often found
that if the scripts were too openended, then the imagined task times
were shorter than the executed task
times. We learned that it was better
to provide instruction, give the person time to imagine walking to a
specific destination, ask the person
to signal arrival, and then continue
the script. This strategy increased
the congruence between imagined
and executed task times. A second
source of evidence for engagement
in imagery was the improvement in
KVIQ scores. We suggest that
improvements in imagery skill were
attributable to imagery practice. We
found similar imagery improvements
in people after stroke involved in a
Feldenkrais training program in
which they were directed to feel the
movements demonstrated improved
kinesthetic imagery scores after
training.64
To our knowledge, this is the first
attempt to deliver MI therapy via
telerehabilitation. The patient was
able to access the software and communicate with the remote therapist.
The delivery of therapy remotely
required less time (an average of 45
minutes) than the delivery of therapy
on site (an average of 65 minutes), in
part because of less socializing
between the clinician and the
patient and because exterior walking
tasks were not executed in the
absence of the therapist. Also, in an
earlier on-site visit, time was spent
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ensuring that the technology was
operational and understood by the
patient. However, time was spent on
setting up the telecommunication,
and there were occasional interruptions in the communication. Importantly, the patient lived alone and
functioned at a sufficiently high level
to execute the tasks without the
assistance of a caregiver.
Possible challenges in implementing
the intervention remotely with other
people after stroke include a requirement for comfort and competence
with the technology and a requirement for physical assistance with
executed tasks. We anticipate that
training of both patients and caregivers with the technology may be
required. Whether the costs of
implementing the intervention outweigh the benefits in savings of
travel time and cost needs to be
determined.
In summary, this case report
described the clinical reasoning process of designing an examination and
an intervention based on patientcentered goals and movement observations. The intervention was
refined by observing performance
during executed movements and
then was implemented with imagined movement practice. The novelty of this case is that the imagery
practice had a motivational component, which included affective and
cognitive additions to MI scripts that
were designed to promote arousal,
attention, and problem solving and
to provide reward. Because both the
patient-centered approach to therapy design and the motivational
components of imagery were
believed to increase motivation, it is
impossible to separate the possible
contributions of these factors to the
improvements in mobility and balance confidence. However, this case
report provides a guideline for the
application of MI to practice. The
delivery of integrated MI training
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remotely was demonstrated to be
feasible. Further research is needed
to parse the motivational components of integrated imagery and to
characterize the benefits and disadvantages of the remote delivery of
integrated MI training.
Dr Deutsch and Dr Dickstein provided concept/idea/project design. Dr Deutsch and
Ms Maidan provided writing and data collection. Dr Deutsch provided data analysis,
project management, fund procurement,
patient, facilities/equipment, and institutional liaisons. Dr Dickstein provided consultation (including review of the manuscript
before submission).
The authors acknowledge Michal Kafri, PT,
PhD, who served as a masked assessor.
This work was supported by the National
Institute of Child Health and Human
Development.
DOI: 10.2522/ptj.20110277
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The effects of multidimensional homebased exercise on functional performance
in elderly people. J Gerontol A Biol Sci
Med Sci. 2004;59:154 –160.
55 Salbach NM, Mayo NE, RobichaudEkstrand S, et al. The effect of a taskoriented walking intervention on improving balance self-efficacy poststroke: a
randomized, controlled trial [erratum in:
J Am Geriatr Soc. 2005;53:1450]. J Am
Geriatr Soc. 2005;53:576 –582.
56 Gentile AM. Skill acquisition: action,
movement, and neuromotor processes. In:
Carr JH, Shepard RB, eds. Movement Science: Foundations for Physical Therapy.
Rockville, MD: Aspen Publishers; 2000:
93–154.
57 Hedman LD, Rogers MW, Hanke TA. Neurologic professional education: lining the
foundation science of motor control with
physical therapy interventions for movement dysfunction. J Neurologic Phys Ther.
1996;20:9 –13.
58 Green L. The use of imagery in the rehabilitation of injured athletes. In: Sheikh
AA, Korn ER, eds. Imagery in Sport and
Physical Performance. New York, NY:
Baywood Publishing Co; 1994:157–174.
59 Riccio CM, Nelson DL, Bush MA. Adding
purpose to the repetitive exercise of
elderly women through imagery. Am J
Occup Ther. 1990;44:714 –719.
60 Scully D, Kremer J. Imagery, mental
rehearsal and visualization. In: Butler R,
ed. Sports Psychology in Performance.
Oxford, United Kingdom: Butterworth
Heinemann; 1997:158 –162.
61 Perry J, Garrett M, Gronley JK, Mulroy SJ.
Classification of walking handicap in the
stroke population. Stroke. 1995;26:982–
989.
62 Leach E, Cornwell P, Fleming J, Haines T.
Patient centered goal-setting in a subacute
rehabilitation setting. Disabil Rehabil.
2010:159 –172.
63 Talbot LR, Viscogliosi C, Desrosiers J, et al.
Identification of rehabilitation needs after
a stroke: an exploratory study. Health
Qual Life Outcomes. 2004;2:53.
64 Batson G, Deutsch JE. Use of Feldenkrais
to improve balance in individuals poststroke. Complement Health Pract Rev.
2005;10:203–210.
65 Collen FM, Wade DT, Bradshaw CM.
Mobility after stroke: reliability of measures of impairment and disability. Int Disabil Stud. 1990;12:6 –9.
66 Eng JJ, Dawson AS, Chu KS. Submaximal
exercise in persons with stroke: test-retest
reliability and concurrent validity with
maximal oxygen consumption. Arch Phys
Med Rehabil. 2004;85:113–118.
Volume 92
Number 8
Physical Therapy f
1075
Appendix.
Script
Goal: To safely walk from her apartment to the parking lot while it is raining.
You are standing at the hallway next to your apartment door, holding an umbrella in one hand and your handbag
in the other hand.
Visual cue: See yourself starting to walk toward the entrance of the building.
Kinesthetic cue: Feel your right heel as it touches the floor and your weight as it shifts forward toward your right
leg. Feel your right foot push against the floor and advance forward.
Pause (the clinician stopped the script and gave the patient time to imagine)
Visual cue: Notice that you pass the last door before the hallway opening next to the building entrance.
Kinesthetic cue: Continue walking, feeling the weight of the umbrella on one hand and the heaviness of the
handbag on the other hand.
Pause
Visual cue: See that you are approaching the front door of the building.
You open the door by pressing the “open” button. The door is opening, and you see that it is raining outside. You
feel nervous because you are concerned that the sidewalks are slippery.
Problem solving: You take a deep breath, stop, open your umbrella, and plan your route to the car.
Pause
You start walking carefully toward your car. The sidewalk is slippery.
Problem solving: You keep your balance and continue walking.
Kinesthetic cue: Feel your right heel touch the floor carefully but securely and your weight shift forward on your
foot.
You are confident with your steps and feel safe.
Pause
You keep walking on the sidewalk toward your car. Notice that there is someone running toward you trying to get
into the building to avoid getting wet. You are worried that he will bump into you.
Problem solving: You pause and wait for him to pass.
You feel happy that you avoided a collision.
Pause
(Continued)
1076
f
Physical Therapy
Volume 92
Number 8
August 2012
Appendix.
Continued
You continue walking; you pass the first car, and your car is the next one. You are approaching your car. You
are about to step down from the curb to the road to open your car’s door. The water is running as a stream by
the edge of the road.
Problem solving: You step carefully.
Pause
Problem solving: You take out your keys and open the door while managing the bag and the umbrella.
Now you are pleased that you got into the car, and you feel relieved and satisfied to be inside it.
You are so happy to be in the car dry and safe.
Debriefing (statements made by patient): “I was afraid about slipping and managing the umbrella and the
bag. . . .” “It helped to pause and plan my walk. . .this way I did not panic. . .I was paying attention.”
August 2012
Volume 92
Number 8
Physical Therapy f
1077
Health Policy in
Perspective
Rothstein Roundtable Podcast—“Medical
Homes, PACA, IFDS—Where Do Physical
Therapists Fit in a Reforming Health Care
Environment? ”
Panelists: Stacey Cochran-Comstock, Anthony Delitto, Carolyn Oddo. Moderator: Everette James.
A
t PT 2012 in Tampa, Florida, on June 8, 2012, the Rothstein Roundtable featured frontline physical therapists
who are defining the role of the physical therapist—and demonstrating the value of physical therapy
services—in innovative environments consistent with health care reform initiatives, such as medical homes
and integrated financial delivery systems. They discussed challenges and opportunities, barriers to success, and
strategies to overcome those barriers. As former Pennsylvania Secretary of Health, Moderator Everette James oversaw
the regulation of all of the hospitals, nursing homes, and managed care plans in Pennsylvania and brought a broad
scope to the roundtable. Cochran-Comstock, Delitto, and Oddo discussed their innovations in incorporating physical
therapy in the management of acute and outpatient care services in disadvantaged populations and in managing
high-cost conditions such as low back pain.
The podcast is available at: http://ptjournal.apta.org/content/92/8/1078/suppl/DC1
S. Cochran-Comstock, PT, DPT, CSCS, Physical Therapist, Providence Portland Medical Center, Portland, Oregon.
A. Delitto, PT, PhD, FAPTA, PTJ’s Chair of the Rothstein Roundtable, Professor and Associate Dean for Research, School of Health and
Rehabilitation Sciences, and Director of Research Comprehensive Spine Center, University of Pittsburgh; and Vice President for Education and
Research Centers for Rehabilitation Services (formerly CORE Network), Pittsburgh, Pennsylvania.
C. Oddo, PT, FACHE, Vice President for Operations Support/Associate Administrator, Harris County Hospital District, Houston, Texas.
E. James, JD, MBA, Associate Vice Chancellor for Health Policy and Planning, Schools of the Health Sciences, and Professor of Health Policy
and Management, Graduate School of Public Health, University of Pittsburgh.
[DOI: 10.2522/ptj.2012.92.8.1078].
1078
f
Physical Therapy
Volume 92
Number 8
August 2012
Corrections
Kersten RF, Stevens M, van Raay JJAM, et al. Habitual physical activity after total knee
replacement: analysis in 830 patients and comparison with a sex- and age-matched normative
population. Phys Ther. doi: 10.2522/ptj.20110273.
On May 24, 2012, “Habitual Physical Activity After Total Knee Replacement: Analysis in 830 Patients and Comparison With a Sex- and Age-Matched Normative Population” by Kersten RF, Stevens M, van Raay JJAM, et al1
was published online ahead of print in Physical Therapy (PTJ). In the June 2012 issue of Journal of Physiotherapy, “After Total Knee Arthroplasty, Many People Are Not Active Enough to Maintain Their Health and Fitness: An
Observational Study” by Groen J-W, Stevens M, Kersten RFMR, et al2 was published. These two related articles,
both of which reported on the same sample of subjects, were written and published each without recognizing
the other.
The first article aims to report the habitual physical activity behavior of patients with total knee arthroplasty and
provides detailed data on number of minutes of activity per week spent in total, on different intensity categories,
on different activity categories, and on separate activities (walking and cycling). These data were reported for male
and female patients separately and for different age categories. Moreover, these data were compared with a normative group. The second article focuses on the adherence to different health and fitness guidelines and which factors
contribute to these. Although two different research questions are addressed in both articles, it is relevant for the
reader to know that these two papers are related. We regret omitting this information from our articles.
Martin Stevens, PhD
Department of Orthopedics
Univesity Medical Center Groningen
University of Groningen
Inge van den Akker-Scheek, PhD
Martini Hosptial Groningen
University Medical Center Groningen
Unviersity of Groningen
Groningen, The Netherlands
References
1 Kersten RF, Stevens M, van Raay JJAM, et al. Habitual physical activity after total knee replacement: analysis in 830 patients and
comparison with a sex- and age-matched normative population [published online ahead of print May 24, 2012]. Phys Ther. doi:
10.2522/20110273.
2 Groen J-W, Stevens M, Kersten RFMR, et al. After total knee arthroplasty, many people are not active enough to maintain their health
and fitness: an observational study. Journal of Physiotherapy. 2012;58:113–116.
[DOI: 10.2522/ptj.20110273.cx]
Niemeijer AS, Reinders-Messelink HA, Disseldorp LM, et al. Feasibility, reliability, and agreement of the WeeFIM instrument in Dutch children with burns. Phys Ther. 2012;92:958–966.
In the July 2012 article by Niemeijer et al titled “Feasibility, Reliability, and Agreement of the WeeFIM Instrument in Dutch Children With Burns,” the equation for calculation of minimal or least detectable difference
(LDD) was presented incorrectly in the “Method” and “Results” sections as ξʹ ൈ ͳǤͻ͸ ൈ rather than
ξʹ × 1.96 × SEM. The statements, with corrected equation, in those sections should be:
Taking .05 as the significance level, the LDD equaled ξʹ × 1.96 × SEM.
The LDD on the total score between 2 raters was ξʹ × 1.96 × 3.7=10.3 points.
The Journal regrets the errors.
[DOI: 10.2522/ptj.20110419.cx]
August 2012
Erratum 8.12.indd 1079
7/18/12 3:43 PM
Assessing Competence:
A Resource Manual
An Invaluable Tool for Employers and Clinicians
Designed to help both employers and physical therapists, this resource manual
features reviews of nine of the most common methods for measuring competence:
Order No. E-60
Regular Price: $87.00
APTA Member price: $51.95
To order, call APTA’s Member
Services Department at
800/999-APTA (2782), ext 3395,
Mon-Fri, 8:30 am-6:00 pm, EST
or order online at www.apta.org.
• Case report
• Chart review
• Outcome measurements
• Employee performance appraisal
• Portfolio review
• Key-feature problems/examinations
• Self-assessment
• Competence checklists
• Proficiency testing
Assessing Competence provides samples and updated references and resources.
Employers can use the manual to develop methods for assessing their employees’
performance. Clinicians can use it to evaluate the strengths and weaknesses of
their practices. As a self-assessment tool, it can help guide your professional
development now and in the future.
My APTA Brings More Patients to
My Practice With Find a PT.
When health care consumers need physical therapy,
they rely on APTA’s Find a PT. This searchable database
connects patients with clinicians who fit their needs.
To register and reach prospective patients:
•
Specify one or more locations and areas of expertise
•
Describe your educational background and
accomplishments
•
Clarify which types of insurance your practice
accepts, and more!
Visit www.apta.org/findapt to register or update
your profile.
Not a Member Yet?
Visit www.apta.org/join or call 800/999-2782, ext 3395 to join.
Scholarships,
Fellowships, and Grants
News from the Foundation for Physical Therapy
Foundation Alumni
Publications
“A Three-Compartment Muscle Fatigue Model Accurately Predicts
Joint-Specific Maximum Endurance Times for Sustained Isometric
Tasks,” by Frey-Law LA, Looft JM,
and Heitsman J, was published
online in the Journal of Biomechanics on May 9, 2012. Laura A.
Frey-Law, PT, PhD, was awarded a
Mary McMillan Doctoral Scholarship in 2000, a Promotion of Doctoral Studies (PODS) I scholarship
in 2001, and a PODS II scholarship
in 2002.
“Tibiofemoral and Patellofemoral
Mechanics Are Altered at Small
Knee Flexion Angles in People
With Patellofemoral Pain,” by Salsich GB and Perman WH, was
published online in the Journal
of Sports Science and Medicine on
May 9, 2012. Gretchen B. Salsich,
PT, PhD, was awarded a New Investigator Fellowship Training Initiative (NIFTI) in 1999.
“Early Complexity Supports Development of Motor Behaviors in the
First Months of Life,” by Dusing SC,
Thacker LR, Stergiou N, and Galloway JC, was published online in
Developmental Psychobiology on
May 9, 2012. Stacey C. Dusing, PT,
PhD, was awarded a Mary McMillan Doctoral Scholarship in 2002
and a PODS II scholarship in 2005.
“Improvements in Balance in Older Adults Engaged in a Specialized
Home Care Falls Prevention Program,” by Whitney SL, Marchetti GF,
Ellis JL, and Otis L, was published
online in the Journal of Geriatric
Physical Therapy on May 8, 2012.
Susan L. Whitney, PT, DPT, PhD,
NCS, ATC, FAPTA, was awarded a
Doctoral Training Research Grant
in 1989.
August 2012
Foundation 8.12.indd 1081
“Quadriceps Muscle Weakness,
Activation Deficits, and Fatigue
With Parkinson Disease,” by
Stevens-Lapsley J, Kluger BM, and
Schenkman M, was published in
Neurorehabilitation and Neural
Repair (2012;26:533–541). Jennifer
E. Stevens-Lapsley, PT, MPT, PhD,
was awarded a PODS I scholarship
in 2000, a PODS II scholarship at
2001, and a Pittsburgh–Marquette
Challenge Research Grant in 2007.
Margaret L. Schenkman, PT, PhD,
FAPTA, was awarded a Doctoral
Training Research Grant in 1990
and a Orthopaedic Section Research Grant in 2001.
“Rehabilitation and Parkinson’s
Disease,” by Earhart GM, Ellis T,
Nieuwboer A, and Dibble LE, was
published online in the Journal
of Parkinson’s Disease on April 5,
2012. Gammon M. Earhart, PT, PhD,
was awarded a PODS II scholarship in 1999. Leland E. Dibble, PT,
PhD, ATC, was awarded a Geriatric
Section Research Grant in 2004.
Foundation Announces
Winning Schools of
Pittsburgh–Marquette
Challenge
The Foundation announced the
winners of the Pittsburgh–Marquette Challenge at its annual gala
on June 7 in Tampa, Florida. Physical therapist and physical therapist
assistant students from 65 schools
across the country raised $240,201
to support physical therapy research. In 24 years, the Challenge
has raised more than $2,000,000 to
benefit the Foundation.
Congratulations to the winners of
the Pittsburgh–Marquette Challenge:
• 1st Place: University of Pittsburgh ($50,000)
• 2nd Place: Virginia Commonwealth University ($14,288.18)
• 3rd Place: Sacred Heart University ($13,822.60).
The Foundation would also like to
recognize the Marquette University
students for their financial commitment to the Challenge in donating
$20,000.
Award of Excellence (donating
$10,000 or more): The University of Oklahoma Health Sciences
Center.
Award of Merit (donating $6,000
or more): Mayo School of Health
Sciences, New York University,
Quinnipiac University, Rosalind
Franklin University of Medicine &
Science, and University of Alabama
at Birmingham.
Honorable Mention (donating
$3,000 or more): Arcadia University, Boston University, Creighton
University, Emory University, Indiana University, Massachusetts
College of Pharmacy & Health
Science–Worcester, MGH Institute
of Health Professions, Midwestern
University, Northeastern University, Northwestern University, Somerset Community College, UMDNJ
and Rutgers–Camden, University
of Colorado–Denver, University
of Delaware, University of Iowa,
University of Miami, University of
North Carolina–Chapel Hill, University of St Augustine, and Washington University in St Louis.
Special Awards:
• Most Successful Newcomer: Massachusetts College of Pharmacy
& Health Science–Worcester
• Biggest Stretch School: Quinnipiac University
• Most Successful PTA School:
Somerset Community College.
7/13/12 4:21 PM
Scholarships, Fellowships, and Grants
We’d also like to thank the rest of
the participating schools:
The Foundation alumni 2012 Fellows include:
A.T. Still University, Clarkson University, Cleveland State, Concordia
University Wisconsin, Daemen College, Elon University, George Washington University, Governors State
University, Hardin-Simmons University, Jefferson Community & Technical College, Long Island University,
Louisiana State University Health
Science Center in Shreveport, Marymount University, Nazareth College
of Rochester, Ohio University, Ohio
State University, Pennsylvania State
University, Simmons College, St Ambrose University, Temple University,
Texas Woman’s University–Houston, Thomas Jefferson University,
University of Evansville, University
of Findlay, University of Hartford,
University of Nebraska, University
of Nevada Las Vegas, University of
Saint Francis, University of South
Dakota, University of Southern California, University of the Sciences,
University of Wisconsin–Madison,
Walsh University, Western University of Health Science, Wichita State
University, and Youngstown State
University.
• Janet L. Gwyer, PT, PhD, FAPTA
(1980 Doctoral Training Research
Grant [DTRG])
The 2012–2013 Pittsburgh–Marquette
Challenge kicks off at the National
Student Conclave in Arlington, Virginia, on November 2, 2012.
Foundation Alumni Honored
at PT 2012
Congratulations to the Foundation
alumni named as 2012 Catherine
Worthingham Fellows of APTA.
The FAPTA designation is the highest honor among APTA’s membership categories and is given to
physical therapist members of the
association whose contributions
to the physical therapy profession
through leadership, influence, and
achievements have demonstrated
frequent and sustained efforts to
advance the profession.
• Ellen Hillegass, PT, EdD, CCS,
FAACVPR, FAPTA (1995 DTRG)
• Wayne A. Stuberg, PT, PhD, PCS,
FAPTA (1987 DTRG, 2003 Pediatric Research Grant)
• Rita Wong, PT, EdD, FAPTA (1988
DTRG).
Congratulations to the Foundation
alumni who received other awards
at APTA’s annual conference.
• Edelle Field-Fote, PT, PhD (1994
DTRG)—Chattanooga Research
Award
• Kathryn E. Roach, PT, PhD (1987,
1994 DTRG)—Chattanooga Research Award
• Lynn Snyder-Mackler, PT, ScD,
SCS, FAPTA (1988, 1991 DTRG)—
Helen J. Hislop Award for Outstanding Contributions to Professional Literature
• Allison Hyngstrom, PT, PhD
(2003 PODS I, 2004 PODS II)—
Eugene Michels New Investigator
Award
• Robert Palisano, PT, ScD, FAPTA
(1984 DTRG)—Marian Williams
Award for Research in Physical
Therapy.
Congratulations and Kudos
Jonathan Dropkin, PT, ScD (2010
PODS II), successfully defended
his dissertation and received his
post-professional doctoral degree
in May from the University of Massachusetts, Lowell.
Share Your Research News and
Announcements
To have your information posted in
the Foundation’s section of Physical Therapy, please e-mail Rachael
Crockett
at
RachaelCrockett@
Foundation4PT.org.
Stay Connected in 3 Easy Ways
1. www.facebook.com/foundation
4PT.
2. Check
out
our
Foundation4PT.org.
website:
3. Subscribe to our monthly newsletter for updates on our donors,
Foundation alumni, events, and
much more! E-mail Rachael
[email protected] to
sign up today.
[DOI: 10.2522/ptj.2012.92.8.1081]
Keith Avin, PT, PhD (2008 Kendall Doctoral Scholarship, 2009
PODS I, 2010 PODS II) received
his post-professional doctoral degree in May from the University of
Iowa after successfully defending
his dissertation. His training will
continue at the University of Pittsburgh through a T32 post-doctoral
training award.
Foundation 8.12.indd 1082
Andrew Littmann, PT, PhD (2006
Kendall, 2007, 2008 PODS I, 2009
PODS II) successfully defended
his dissertation and graduated
from the University of Iowa in
May. Dr. Littmann will be joining
the faculty at Regis University in
Denver, Colorado.
August 2012
7/13/12 4:21 PM
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(Continued)
Index to General Information
Found at: www.apta.org
Physical Therapy (PTJ)
Accredited Education
Programs ............http://www.capteonline.org/Programs/
Awards ..................... http://www.apta.org/HonorsAwards/
Bylaws ................................. http://www.apta.org/Policies/
Call for Nominations .......... http://www.apta.org/Elections/
Code of Ethics .................................... http://www.apta.org/
CoreDocuments/
Abstracts of Papers Accepted for
Presentation at Annual Conference
(added every May) ............................ ptjournal.apta.org/
site/misc/annualcon.xhtml
Submission Guidelines .......................... ptjournal.apta.org/
site/misc/ifora.xhtml
In Memoriam............................................................March
Mary McMillan Lecture ......................................September
Membership Statistics ..................................................June
Presidential Address ...........................................September
Statement of Ownership .....................................December
August 2012
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Weingand KW. Continuous low-level heatwrap therapy for treating acute
nonspecific low back pain. Arch Phys Med Rehabil. 2003;84(3):329-334.
3. Nadler SF, Steiner DJ, Petty SR, Erasala GN, Hengehold DA,
Weingand KW. Overnight use of continuous low-level heatwrap therapy for
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Interacoustics................................................ Cover 3
Parker Laboratories ....................................... Cover 4
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APTA Products and Services
APTA Marketplace ............................................... 981
Assessing Competence: A Resource Manual .......... 1080
Guidelines for Clinicians ........................................ 986
Membership ..................................................... 1080
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Complete August 2012 Issue

Transcription

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