Linda J. Woodhouse

Measuring shoulder function: A systematic review of four questionnaires

OBJECTIVE To conduct a systematic review of the quality and content of the psychometric evidence relating to 4 shoulder disability scales: the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Shoulder Pain and Disability Index (SPADI), the American Shoulder and Elbow Surgeons (ASES) score, and the Simple Shoulder Test (SST). METHODS We conducted a structured search using 3 databases (Medline, CINAHL, EMBase). In total, 71 published primary studies were analyzed. A pair of raters conducted data extraction and critical appraisal using structured tools. A descriptive synthesis was performed. RESULTS Quality ratings of 55% of the studies reviewed reached a level of > or =75%. Most studies suggest that all 4 questionnaires have excellent reliability (intraclass correlation coefficient > or =0.90). The 4 questionnaires are strongly correlated (r >0.70) with each other and with a number of similar indices, and the questionnaires were able to differentiate between different populations and disability levels. The minimal detectable change (MDC) is approximately 9.4 for the ASES, 10.5 for the DASH, and 18 for the SPADI; the minimal clinically important difference (MCID) is approximately 6.4 for the ASES and 10.2 for the DASH, and ranges between 8 and 13 for the SPADI. MDC and MCID have not been defined for the SST. CONCLUSION The psychometric properties of the ASES, DASH, and SPADI have been shown to be acceptable for clinical use. Conversely, some properties of the SST still need be evaluated, particularly the absolute errors of measurement. Overall, validation studies have focused on less clinically relevant properties (construct validity or group reliability) than estimates of MDC and MCID.

Muscle-specific mutations accumulate with aging in critical human mtDNA control sites for replication

The recently discovered aging-dependent large accumulation of point mutations in the human fibroblast mtDNA control region raised the question of their occurrence in postmitotic tissues. In the present work, analysis of biopsied or autopsied human skeletal muscle revealed the absence or only minimal presence of those mutations. By contrast, surprisingly, most of 26 individuals 53 to 92 years old, without a known history of neuromuscular disease, exhibited at mtDNA replication control sites in muscle an accumulation of two new point mutations, i.e., A189G and T408A, which were absent or marginally present in 19 individuals younger than 34 years. These two mutations were not found in fibroblasts from 22 subjects 64 to 101 years of age (T408A), or were present only in three subjects in very low amounts (A189G). Furthermore, in several older individuals exhibiting an accumulation in muscle of one or both of these mutations, they were nearly absent in other tissues, whereas the most frequent fibroblast-specific mutation (T414G) was present in skin, but not in muscle. Among eight additional individuals exhibiting partial denervation of their biopsied muscle, four subjects >80 years old had accumulated the two muscle-specific point mutations, which were, conversely, present at only very low levels in four subjects ≤40 years old. The striking tissue specificity of the muscle mtDNA mutations detected here and their mapping at critical sites for mtDNA replication strongly point to the involvement of a specific mutagenic machinery and to the functional relevance of these mutations.

Performance Measures Provide Assessments of Pain and Function in People With Advanced Osteoarthritis of the Hip or Knee

Background and Purpose. Pain and physical function are core outcome measures for people with osteoarthritis, and self-report questionnaires have been the preferred assessment method. There is evidence suggesting that self-reports of physical function represent what people experience when performing activities rather than their ability to perform activities. The purpose of this study was to examine the factorial validity of performance-specific assessments of pain and function. Subjects. The sample consisted of 177 participants who had osteoarthritis of the hip (n=81) or knee (n=96) and who were awaiting total joint arthroplasty. Methods. Through a cross-sectional design, participants performed 4 performance activities (self-paced walk test, stair test, Timed “Up & Go” Test, and Six-Minute Walk Test). Outcomes were time or distance (function) and pain ratings obtained immediately after each activity. The authors conceptualized 2 correlated factors, with pain items loading uniquely on 1 factor and functional items loading on the second factor, and uncorrelated error terms. Confirmatory factor analysis was applied. Results. Initial analysis yielded results consistent with the conceptualized model in this study with the exception of a nonzero correlation between the stair pain and function error terms. Dropping the stair test provided results consistent with the conceptualized model. Discussion and Conclusion. Given the limitations of self-report alone as a method of obtaining reasonably distinct assessments of pain and function, the extent to which performance-specific assessments could accomplish this goal was examined in this study. It was found that collectively the walk test, Timed “Up & Go” Test, and Six-Minute Walk Test yielded 2 factors consistent with the health concepts of pain and function. The authors believe that the application of these tests may provide clinicians and clinical researchers with more distinct impressions of pain and function that complement information from self-report measures.

A systematic review of the psychometric properties of the Constant-Murley score

HYPOTHESIS The purpose of this study was to conduct a systematic review of the psychometric evidence relating to Constant-Murley score. MATERIALS AND METHODS A search of 3 databases (Medline, CINAHL, and EMBASE) and a manual search yielded 35 relevant publications. Pairs of raters used structured tools to analyze these articles, through critical appraisal and data extraction. A descriptive synthesis of the psychometric evidence was then performed. RESULTS Quality ratings of 23% of the studies reviewed reached a level of 75% or higher. Studies evaluating the content validity of the Constant-Murley score suggest that the description in the original publication is insufficient to accomplish standardization between centers and evaluators. Despite this limitation, the Constant-Murley score correlates strongly (>or= 0.70) with shoulder-specific questionnaires, reaches acceptable benchmarks (rho > 0.80) for its reliability coefficients, and is responsive (effect sizes and standardized response mean > 0.80) for detecting improvement after intervention in a variety of shoulder pathologies. DISCUSSION This systematic review provides evidence to support the use of the Constant-Murley score for specific clinical and research applications but underscores the need for greater standardization and precaution when interpreting scores. Methods to improve standardization and measurement precision are needed. Responsiveness has been shown to be excellent, but some properties still need be evaluated, particularly those related to the absolute errors of measurement and minimal clinically important difference. CONCLUSION Given the widespread acceptance for usage of the Constant-Murley score in clinical studies and early indications that the measure is responsive, studies defining more rigid standardization of the tools/procedures are needed. LEVEL OF EVIDENCE Level 1.

Changes in muscle mass, muscle strength, and power but not physical function are related to testosterone dose in healthy older men.

OBJECTIVES: To examine the effect of graded doses of testosterone on physical function and muscle performance in healthy, older men.

A treadmill ramp protocol using simultaneous changes in speed and grade.

INTRODUCTION A treadmill exercise test requiring a low initial metabolic rate that then increments the work rate linearly to reach the subjects limit of tolerance in approximately 10 min would have significant advantages for exercise testing and rehabilitation of subjects with impaired exercise tolerance. METHODS We developed such a treadmill protocol that uses a linear increase in walking speed coupled with a curvilinear increase in treadmill grade to yield a linear increase in work rate. RESULTS Twenty-two healthy, sedentary subjects performed both this new treadmill protocol and a standard cycle ergometry ramp protocol eliciting similar work rate profiles. The low initial treadmill speed and grade resulted in a low initial metabolic rate, commensurate with unloaded pedaling on a cycle ergometer (average [OV0312]O2 = 0.54 +/- 0.16 vs 46 +/- 0.12 l x min(-1)). This combination of simultaneous increase in speed and grade yielded a linear work rate and its oxygen uptake response (R2 = 0.96 +/- 0.03) with a slope of 11.4 +/- 2.4 ml x min(-1) x W(-1)-slightly, but significantly, higher than on the cycle (9.6 +/- 2.0 ml x min(-1) x W(-1)). This difference was attributed to unmeasured work associated, for example, with additional limb movements and frictional losses. As previously demonstrated, both the peak oxygen uptake and the estimated lactate threshold were higher on the treadmill than for cycle ergometry (averaging 23% and 27%, respectively, in these subjects). CONCLUSION This treadmill protocol provides a linear profile of work rate as is currently standard for cycle ergometry and is appropriate for testing of subjects with low exercise tolerance.

Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review

BackgroundThe convergence of rising health care costs and physician shortages have made health care transformation a priority in many countries resulting in the emergence of new models of care that often involve the extension of the scope of practice for allied health professionals. Physiotherapists in advanced practice/extended scope roles have emerged as key providers in such new models, especially in settings providing services to patients with musculoskeletal disorders. However, evidence of the systematic evaluation of advance physiotherapy practice (APP) models of care is scarce. A systematic review was done to update the evaluation of physiotherapists in APP roles in the management of patients with musculoskeletal disorders.MethodsStructured literature search was conducted in 3 databases (Medline, Cinahl and Embase) for articles published between 1980 and 2011. Included studies needed to present original quantitative data that addressed the impact or the effect of APP care. A total of 16 studies met all inclusion criteria and were included. Pairs of raters used four structured quality appraisal methodological tools depending on design of studies to analyse included studies.ResultsIncluded studies varied in designs and objectives and could be categorized in four areas: diagnostic agreement or accuracy compared to medical providers, treatment effectiveness, economic efficiency or patient satisfaction. There was a wide range in the quality of studies (from 25% to 93%), with only 43% of papers reaching or exceeding a score of 70% on the methodological quality rating scales. Their findings are however consistent and suggest that APP care may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction.ConclusionsThe emerging evidence suggests that physiotherapists in APP roles provide equal or better usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. There is a need for more methodologically sound studies to evaluate the effectiveness APP care.

Androgen effects on body composition

Androgens are known to have a role in the body fat, muscle size, muscle performance and physical function differences seen between hypogonadal and eugonadal men. The results of investigations into effects of testosterone on body composition, fat metabolism and muscle anabolism are reviewed here. Testosterone dose-response relationships are presented in studies of the effects of physiologic and supraphysiologic doses with and without exercise in young hypogonadal men, older men with low testosterone levels and in chronic illness states.

Patients Are Satisfied with Advanced Practice Physiotherapists in a Role Traditionally Performed by Orthopaedic Surgeons

PURPOSE To measure and compare patient satisfaction with follow-up care in advanced practice physiotherapist (APP) and orthopaedic surgeon clinics for patients following total hip or knee replacement. METHOD Consecutive patients attending either an APP-led or a surgeon-led review clinic were surveyed using a modified nine-item satisfaction questionnaire based on the Visit-Specific Satisfaction Instrument (VSQ-9). Chi-square analyses were used to examine differences in patient characteristics and type of visit. Independent t-tests were used to examine potential differences in patient satisfaction. RESULTS Of the 123 participants, more than half were aged 65 years or older. Chi-squared analyses revealed no significant difference in participant characteristics (gender, age, and overall health status) between the two different types of clinics. There was a significant difference (χ(2) (4)=12.49, p=0.014) in the distribution of the timing of follow-up appointments. There was no significant difference between the groups in mean overall patient satisfaction scores on the modified VSQ-9 (p=0.34) nor in the mean of the sum of the seven items related to the service provider (p=0.85). Satisfaction scores for most of the service-provider items were above 90/100. CONCLUSION Patients are highly satisfied with the care provided by APPs in follow-up clinics after joint replacement. Evaluation of the patient perspective is essential to any new role involving a shift in traditional practice boundaries.

A Scoping Review of Strategies for the Prevention of Hip Fracture in Elderly Nursing Home Residents

Background Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear. Objective We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes. Methods We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate. Findings We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7 - vitamin D (n = 12,875 participants), 2 - sunlight exposure (n = 522), 1 - alendronate (n = 327), 1 - fluoride (n = 460), 4 – exercise or multimodal interventions (n = 8,165), and 5 - hip protectors (n = 2,594). Vitamin D, particularly vitamin D3 ≥800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC. Conclusions The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.