Allen W. Heinemann

Performance Profiles Of The Functional Independence Measure

The functional independence measure (FIM) is used to determine the degree of disability that patients experience and the progress that they make through programs of medical rehabilitation. Rasch analysis is a statistical technique for constructing interval measures from ordinal data that was applied to derive FIM measures. The major factors that are taken into account to produce FIM measures are the relative difficulty in performance of FIM items and the ability of the persons tested. Our analyses showed the relative difficulties that patients experienced in performing items in the FIM. There were two dominant patterns of difficulty, one for motor FIM items and the other for cognitive FIM items. The patterns were consistent across impairment groups, although not identical. Of the motor items, eating and grooming were easiest whereas stair climbing, tub/shower transfers and locomotion were most difficult. Of the cognitive items, expression and comprehension were easiest and problem solving was the most difficult. The patterns of difficulty in performing FIM items are illustrated by analysis of the following impairment groups: for motor items, orthopedic conditions, stroke with left hemiparesis and spinal cord dysfunction; for cognitive items, orthopedic conditions, brain dysfunction, stroke with right hemiparesis and spinal cord dysfunction. By understanding patterns of difficulty in performing FIM items according to types of impairment and levels of function, clinicians may more precisely design treatment programs, use services and predict outcomes of medical rehabilitation.

Relationships between impairment and physical disability as measured by the functional independence measure.

This study was conducted to scale the Functional Independence Measure (FIM) with Rasch Analysis and to determine the similarity of scaled measures across impairment groups. The results show that the FIM contains two fundamental subsets of items: one measures motor and the second measures cognitive function. Rasch analysis of the Uniform Data System for Medical Rehabilitation patient sample yielded interval measures of motor and cognitive functions. The validity of the FIM was supported by the patterns of item difficulties across impairment groups. Adequate clinical precision of the FIM was demonstrated, though suggestions for improvement emerged. The frequency of misfit between patients and the performance scales varied across impairment groups, but was acceptable. The results of this project will enable clinicians and researchers to plan cost-effective treatment by providing a valid measure of disability.

What does participation mean? An insider perspective from people with disabilities

Purpose. Although participation is an important construct and valued goal, how it is conceptualized, defined and measured varies widely. This qualitative, multi-site study sought to gain an insider perspective from people with disabilities in grounding what participation means, how to characterize it, and the barriers and supports to participation. Method. Sixty-three people self-identifying with diverse disabilities participated in qualitative focus groups across sites. Results. Participants conceptualized participation as a cluster of values that included active and meaningful engagement/being a part of, choice and control, access and opportunity/enfranchisement, personal and societal responsibilities, having an impact and supporting others, and social connection, inclusion and membership. Conclusions. No gold standard for ideal or optimal participation emerged; no one defined set or frequency of activities accounted for ‘full’ participation. Participants described needing to be free to define and pursue participation on their own terms rather than meeting predetermined societal norms. Participation was viewed as both a right and a responsibility, influenced by and ascribed to the person and to the society. Participation does not occur in a vacuum; the environment dynamically influences participation. Implications of this conceptual framing for assessment, research and systems level change to support participation of people with disabilities are discussed.

Incidence of and Risk Factors for Medical Complications During Stroke Rehabilitation

Background and Purpose — The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility. Methods — A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation. Results — Seventy-five percent of patients experienced ≥1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67). Conclusions — Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.

Item banking to improve, shorten and computerize self-reported fatigue: an illustration of steps to create a core item bank from the FACIT-Fatigue Scale.

Fatigue is a common symptom among cancer patients and the general population. Due to its subjective nature, fatigue has been difficult to effectively and efficiently assess. Modern computerized adaptive testing (CAT) can enable precise assessment of fatigue using a small number of items from a fatigue item bank. CAT enables brief assessment by selecting questions from an item bank that provide the maximum amount of information given a persons previous responses. This article illustrates steps to prepare such an item bank, using 13 items from the Functional Assessment of Chronic Illness Therapy Fatigue Subscale (FACIT-F) as the basis. Samples included 1022 cancer patients and 1010 people from the general population. An Item Response Theory (IRT)-based rating scale model, a polytomous extension of the Rasch dichotomous model was utilized. Nine items demonstrating acceptable psychometric properties were selected and positioned on the fatigue continuum. The fatigue levels measured by these nine items along with their response categories covered 66.8% of the general population and 82.6% of the cancer patients. Although the operational CAT algorithms to handle polytomously scored items are still in progress, we illustrated how CAT may work by using nine core items to measure level of fatigue. Using this illustration, a fatigue measure comparable to its full-length 13-item scale administration was obtained using four items. The resulting item bank can serve as a core to which will be added a psychometrically sound and operational item bank covering the entire fatigue continuum.

Neuro-QOL Brief measures of health-related quality of life for clinical research in neurology

Objective: To address the need for brief, reliable, valid, and standardized quality of life (QOL) assessment applicable across neurologic conditions. Methods: Drawing from larger calibrated item banks, we developed short measures (8–9 items each) of 13 different QOL domains across physical, mental, and social health and evaluated their validity and reliability. Three samples were utilized during short form development: general population (Internet-based, n = 2,113); clinical panel (Internet-based, n = 553); and clinical outpatient (clinic-based, n = 581). All short forms are expressed as T scores with a mean of 50 and SD of 10. Results: Internal consistency (Cronbach α) of the 13 short forms ranged from 0.85 to 0.97. Correlations between short form and full-length item bank scores ranged from 0.88 to 0.99 (0.82–0.96 after removing common items from banks). Online respondents were asked whether they had any of 19 different chronic health conditions, and whether or not those reported conditions interfered with ability to function normally. All short forms, across physical, mental, and social health, were able to separate people who reported no health condition from those who reported 1–2 or 3 or more. In addition, scores on all 13 domains were worse for people who acknowledged being limited by the health conditions they reported, compared to those who reported conditions but were not limited by them. Conclusion: These 13 brief measures of self-reported QOL are reliable and show preliminary evidence of concurrent validity inasmuch as they differentiate people based upon number of reported health conditions and whether those reported conditions impede normal function.

Functional outcome following rehabilitation of the cancer patient

OBJECTIVE To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE Functional status as measured by the motor score of the Functional Independence Measure. RESULTS Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.

Outcome measures in spinal cord injury: Recent assessments and recommendations for future directions

Study design:Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations.Objectives:Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies.Methods:a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI.Results:Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention.Conclusion:Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.

Development and measurement properties of the Orthotics and Prosthetics Users’ Survey (OPUS): A comprehensive set of clinical outcome instruments

The need to measure and evaluate orthotics and prosthetics (O&P) practice has received growing recognition in the past several years. Reliable and valid self-report instruments are needed that can help facilities evaluate patient outcomes. The objective of this project was to develop a set of self-report instruments that assess functional status, quality of life, and satisfaction with devices and services that can be used in an orthotics and prosthetics clinic. Selecting items from a variety of existing instruments, the authors developed and revised four instruments that differentiate patients with varying levels of lower limb function, quality of life, and satisfaction with devices and services. Evidence of construct validity is provided by hierarchies of item difficulty that are consistent with clinical experience. For example, with the lower limb function instrument, running one block was much more difficult than walking indoors. The instruments demonstrate adequate internal consistency (0.88 for lower limb function, 0.88 for quality of life, 0.74 for service satisfaction, 0.78 for device satisfaction). The next steps in their research programme are to evaluate sensitivity and construct validity. The Orthotics and Prosthetics Users’ Survey (OPUS) is a promising self-report instrument which may, with further development, allow orthotic and prosthetic practitioners to evaluate the quality and effectiveness of their services as required by accreditation standards such as those of the American Board for Certification in Orthotics and Prosthetics that mandate quality assessment.

Relationships among impairment, disability, handicap, and life satisfaction in persons with traumatic brain injury

Four regional brain injury centers surveyed 758 individuals with loss of consciousness from head trauma who were living in the community. Relationships among demographic characteristics, severity of impairment, severity of disability, extent of handicap, and life satisfaction were assessed with multiple regression. While the demographic and impairment variables were relatively weak predictors of disability, the combination of these variables was a much stronger predictor of handicap. In turn, 13% of the adjusted variance in life satisfaction was accounted for by these variables. These results support the World Health Organization model of impairment, disability, and handicap and suggest that efforts to remediate disability have a direct benefit in reducing handicap and enhancing life satisfaction.