Franco Franchignoni

Trunk Control Test as an Early Predictor of Stroke Rehabilitation Outcome

BACKGROUND AND PURPOSE The aim of this study was to investigate the construct and predictive validity of the Trunk Control Test (TCT) in postacute stroke patients by comparing TCT scores at admission and discharge with the Functional Independence Measure (FIM) scores. METHODS Forty-nine patients participated in the study. The TCT examines four movements: rolling from a supine position to the weak side (T1) and to the strong side (T2), sitting up from a lying-down position (T3), and sitting balance (T4). The FIM is an 18-item scale (13 motor [motFIM] and 5 cognitive [cognFIM]) used to determine the level of dependence of patients in daily life. RESULTS Thirty-six patients (73%) increased their TCT overall score at discharge. The TCT item-total correlations were high, both at admission and discharge (P < .0001). The individual TCT items were intercorrelated. Furthermore, the homogeneity of the TCT was confirmed by a high Cronbachs index. High correlations were found between admission and discharge scores in the different tests (TCT, FIM, and motFIM; P < .0001) and between TCT at admission and FIM (P < .0001) and motFIM (P < .0001) at admission. TCT at admission alone explained 71% of the variance in motFIM at discharge. CONCLUSIONS The TCT showed a good sensitivity to change in assessing recovery of stroke patients. The high item-total correlation and Cronbachs alpha value of the TCT suggest that there is one homogeneous construct underlying the item list. The TCT construct validity was confirmed by the correlation between this test and the FIM scores. TCT at admission predicted motFIM at discharge even better than motFIM at admission alone. Possibly, the TCT captures basic motor skills that foreshadow the recovery of more complex behavioral skills described by the FIM.

Reliability of four simple, quantitative tests of balance and mobility in healthy elderly females

Four common tests of balance and mobility were administered to 45 healthy women, aged 55–71 years: Sharpened Romberg (also defined as tandem stance), eyes open and closed; One-Legged Stance Test, eyes open and closed; Functional Reach; and Sit-To-Stand test. Two independent observers scored the tests, which were performed on two successive days. Inter-rater (IRR) and test-retest reliability (TRR) were good. Across the six different tests, Intraclass Correlation Coefficients ranged from 0.95 to 0.99 for scoring consistency between raters, and from 0.73 to 0.93 within raters. This is in line with previous findings based on similar subjects and similar, though not identical, testing procedures. Intercorrelations between the scores were moderate: r coefficients ranged 0.40–0.66. The results suggest that this simple test battery provides reliable scores, and that the different tests relate to a homogeneous construct, while not being redundant. It thus seems worthwhile to further investigate whether they represent and measure a unidimensional domain, rather than conceptually different dimensions, in view of achieving a unique measure of balance performance.

Comparison of Reliability, Validity, and Responsiveness of the Mini-BESTest and Berg Balance Scale in Patients With Balance Disorders

Background Recently, a new tool for assessing dynamic balance impairments has been presented: the 14-item Mini-BESTest. Objective The aim of this study was to compare the psychometric performance of the Mini-BESTest and the Berg Balance Scale (BBS). Design A prospective, single-group, observational design was used in the study. Methods Ninety-three participants (mean age=66.2 years, SD=13.2; 53 women, 40 men) with balance deficits were recruited. Interrater (3 raters) and test-retest (1–3 days) reliability were calculated using intraclass correlation coefficients (ICCs). Responsiveness and minimal important change were assessed (after 10 sessions of physical therapy) using both distribution-based and anchor-based methods (external criterion: the 15-point Global Rating of Change [GRC] scale). Results At baseline, neither floor effects nor ceiling effects were found in either the Mini-BESTest or the BBS. After treatment, the maximum score was found in 12 participants (12.9%) with BBS and in 2 participants (2.1%) with Mini-BESTest. Test-retest reliability for total scores was significantly higher for the Mini-BESTest (ICC=.96) than for the BBS (ICC=.92), whereas interrater reliability was similar (ICC=.98 versus .97, respectively). The standard error of measurement (SEM) was 1.26 and the minimum detectable change at the 95% confidence level (MDC95) was 3.5 points for Mini-BESTest, whereas the SEM was 2.18 and the MDC95 was 6.2 points for the BBS. In receiver operating characteristic curves, the area under the curve was 0.92 for the Mini-BESTest and 0.91 for the BBS. The best minimal important change (MIC) was 4 points for the Mini-BESTest and 7 points for the BBS. After treatment, 38 participants evaluated with the Mini-BESTest and only 23 participants evaluated with the BBS (out of the 40 participants who had a GRC score of ≥3.5) showed a score change equal to or greater than the MIC values. Limitations The consecutive sampling method drawn from a single rehabilitation facility and the intrinsic weakness of the GRC for calculating MIC values were limitations of the study. Conclusions The 2 scales behave similarly, but the Mini-BESTest appears to have a lower ceiling effect, slightly higher reliability levels, and greater accuracy in classifying individual patients who show significant improvement in balance function.

Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) and Its Shortened Version (QuickDASH)

STUDY DESIGN Prospective, single-group observational design. OBJECTIVES To determine the minimal clinically important difference (MCID) for the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure and its shortened version (QuickDASH) in patients with upper-limb musculoskeletal disorders, using a triangulation of distribution- and anchor-based approaches. BACKGROUND Meaningful threshold change values of outcome tools are crucial for the clinical decision-making process. METHODS The DASH and QuickDASH were administered to 255 patients (mean ± SD age, 49 ± 15 years; 156 women) before and after a physical therapy program. The external anchor administered after the program was a 7-point global rating of change scale. RESULTS The test-retest reliability of the DASH and QuickDASH was high (intraclass correlation coefficient model 2,1 = 0.93 and 0.91, respectively; n = 30). The minimum detectable change at the 90% confidence level was 10.81 points for the DASH and 12.85 points for the QuickDASH. After triangulation of these results with those of the mean-change approach and receiver-operating-characteristic-curve analysis, the following MCID values were selected: 10.83 points for the DASH (sensitivity, 82%; specificity, 74%) and 15.91 points for the QuickDASH (sensitivity, 79%; specificity, 75%). After treatment, the MCID threshold was reached/surpassed by 61% of subjects using the DASH and 57% using the QuickDASH. CONCLUSION The MCID values from this study for the DASH (10.83 points) and the QuickDASH (15.91 points) could represent the lower boundary for a range of MCID values (reasonably useful for different populations and contextual characteristics). The upper boundary may be represented by the 15 points for the DASH and 20 points for the QuickDASH proposed by the DASH website.

How to assess postsurgical scars: A review of outcome measures

Purpose. Complications of surgical incision include pathological scars with functional, cosmetic or psychological consequences. Postsurgical scar assessment is fundamental for a complete functional evaluation and as an outcome measure. Scar assessment scales are here reviewed and discussed from a clinical and psychometric point of view, with a clear definition of different scar parameters. Method. An extensive review of the English-language literature was conducted using the Medline database. Results. Four scales that satisfy psychometrical criteria were identified: Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), Manchester Scar Scale (MSS) and Stony Brook Scar Evaluation Scale (SBSES). Conclusions. To date, VSS is the most widely used rating scale for scars but POSAS appears the most comprehensive, taking into account the important aspect of patients perspective. The MSS has been never used for research, while SBSES has only been very recently proposed.

VALIDATION OF THE ORTHOTICS AND PROSTHETICS USER SURVEY UPPER EXTREMITY FUNCTIONAL STATUS MODULE IN PEOPLE WITH UNILATERAL UPPER LIMB AMPUTATION

OBJECTIVE To evaluate the measurement properties of the Upper Extremity Functional Status module of the Orthotics and Prosthetics User Survey (OPUS). DESIGN Methodological research on an outcome measure administered by clinical interview. PATIENTS A convenience sample of 61 adults who had unilateral upper limb amputations and completed rehabilitation at the Institute for Rehabilitation in Ljubljana, Slovenia, at least one year prior to interview. Thirty-four patients had undergone amputation of the dominant hand. Four patients did not use a prosthesis. METHODS Rating scale analysis (Rasch model) was used to evaluate functioning of the rating scale categories, the validity of the measure by examining fit of items to the latent trait, and the hierarchy of item difficulties compared with expectations of the construct. RESULTS Rasch analysis allowed us to improve the Upper Extremity Functional Status by rescoring to reduce the response categories from 5 to 4, and identifying 19 of 23 items that are useful to measure upper extremity function. The results allow us to have high confidence in the consistency of both person-ability and item-difficulty estimates. CONCLUSION This revised Upper Extremity Functional Status is a promising instrument to measure the degree of manual functioning after a unilateral upper limb amputation.

Evidence of multidimensionality in the ALSFRS-R Scale: a critical appraisal on its measurement properties using Rasch analysis

Objective To examine dimensionality, reliability and validity of the Amyotrophic Lateral Sclerosis Functional Rating Scale-revised (ALSFRS-R) using traditional classical test theory methods and Rasch analysis in order to provide a rationale for possible improvement of its metric quality. Methods Methodological research on ALSFRS-R collected in a consecutive sample of 485 patients with amyotrophic lateral sclerosis (ALS) attending three tertiary ALS centres. Results The ALSFRS-R items showed good internal consistency but dimensionality analysis argues against the use of ALSFRS-R as a single score because the scale lacks unidimensionality. Parallel analysis and exploratory factor analysis revealed three factors representing the following domains: (1) bulbar function; (2) fine and gross motor function; and (3) respiratory function. Rasch analysis showed that all items in each domain fitted the respective constructs to measure, except for item No 9 ‘climbing stairs’ and item No 12 ‘respiratory insufficiency’. Rating categories did not comply with the criteria for category functioning. Collapsing the scales 5 level ratings into 3 levels improved its metric quality. Conclusions The ALSFRS-R fails to satisfy rigorous measurement standards and should be, at least in part, revised. At present, ALSFRS-R should be considered as a profile of mean scores from three different domains (bulbar, motor and respiratory functions) more than a global total score. Further studies on ALSFRS-R using modern psychometric methods are warranted to confirm our findings and refine the metric quality of this scale, through a step by step process.

Eye tracking communication devices in amyotrophic lateral sclerosis: Impact on disability and quality of life

Abstract People with amyotrophic lateral sclerosis (PwALS) show progressive loss of voluntary muscle strength. In advanced disease, motor and phonatory impairments seriously hinder the patients interpersonal communication. High-tech devices such as eye tracking communication devices (ETCDs) are used to aid communication in the later stages of ALS. We sought to evaluate the effect of ETCDs on patient disability, quality of life (QoL), and user satisfaction, in a group of 35 regular ETCD users in late-stage ALS with tetraplegia and anarthria. The following scales were administered: 1) the Individually Prioritized Problem Assessment (IPPA) scale, in three conditions: without device, with ETCD and, when applicable, with an Eye Transfer (ETRAN) board; 2) the Psychosocial Impact of Assistive Devices Scale (PIADS); and 3) the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0). With ETRAN, IPPA showed an increase in communicative abilities with respect to the condition without device, but ETCD produced a further significant increase. PIADS evidenced a large increase of QoL, and QUEST 2.0 showed high user satisfaction with ETCD use. In conclusion, ETCDs should be considered in late-stage ALS with tetraplegia and anarthria, since in these patients they can reduce communication disability and improve QoL.

Measuring mobility in people with lower limb amputation: Rasch analysis of the mobility section of the prosthesis evaluation questionnaire.

OBJECTIVE To assess the psychometric properties of the Mobility Section of the Prosthesis Evaluation Questionnaire (PEQ-MS). DESIGN A postal survey, including self-report assessment of prosthetic capability and performance with the PEQ-MS and the Locomotor Capabilities Index, and of other variables associated with prosthetic wear and use. The PEQ-MS data underwent Rasch analysis for rating scale diagnostics and a reliability and validity study. PATIENTS A total of 123 subjects (mean age 54 years) who had undergone lower limb amputation in the previous 5 years and who had completed rehabilitation and a prosthetic training programme. RESULTS According to Rasch analysis and expert review, some response categories of the PEQ-MS (13 items, 11-level numeric rating scale) were collapsed and one item was deleted. The remaining 12 items fitted to the Rasch model and created a revised scale with a 5-level response format, the PEQ-MS12/5. The PEQ-MS12/5 demonstrated good reliability (person-separation reliability = 0.95, item-separation reliability = 0.98) and internal construct validity. Moreover, the correlation with the Locomotor Capabilities Index (rs = 0.78) and with prosthetic wear and use (rs range 0.41-0.59) supported the convergent validity of the PEQ-MS12/5. CONCLUSION The new PEQ-MS12/5 presents good psychometric characteristics for measuring mobility in people with lower limb amputations. These preliminary results provide an already applicable instrument and a solid basis for further validation studies.

Body image in people with lower-limb amputation: A Rasch analysis of the amputee body image scale

Gallagher P, Horgan O, Franchignoni F, Giordano A, MacLachlan M: Body image in people with lower-limb amputation: a Rasch analysis of the amputee body image scale. Am J Phys Med Rehabil 2007;86:205–215. Objective: The aim of this study was to examine the psychometric properties of the Amputee Body Image Scale (ABIS) through Rasch analysis, investigating the quality of its rating categories and its reliability and validity. Design: The ABIS (20 items; ratings of 1–5) and Trinity Amputation Prosthesis Experience Scales (TAPES) were administered by post and completed by 145 people with a lower-limb amputation and currently wearing a prosthesis. Results: According to Rasch analysis and expert review, some response categories were collapsed and six items were deleted. The remaining 14 items created a revised ABIS (ABIS-R) rated with a three-level rating scale. ABIS-R fitted the unidimensional construct that the scale was intended to measure and demonstrated good reliability (Cronbach’s alpha and person separation reliability = 0.87), targeting, and internal construct validity. Moreover, the correlations with the nine TAPES subscales (in particular, r = −0.54 with the general adjustment, r = −0.43 with the social activity restriction, and r = −0.40 with social adjustment) supported the convergent validity of ABIS-R. Conclusions: The 14-item ABIS-R demonstrates good psychometric characteristics for measuring body image disturbances in people with lower-limb amputation. These preliminary results suggest the general adequacy of the new instrument and provide a good foundation on which further validation and psychometric studies of the ABIS-R can be conducted.