Marcella Ottonello

Psychometric properties of the Rivermead Mobility Index in Italian stroke rehabilitation inpatients

Objective: To examine the internal consistency, validity, responsiveness and test scalability of the Rivermead Mobility Index (RMI) in Italian rehabilitation inpatients recovering from stroke. Design: Seventy-three stroke inpatients undergoing rehabilitation were assessed at admission (T 0) and five weeks later (T 1), using RMI, the motor (motFIM) and cognitive (cognFIM) subscales of the Functional Independence Measure, the ‘leg’ section of the Motricity Index and Trunk Control Test. Results: Cronbachs alpha of the RMI was 0.92. The item-to-total correlation coefficients (r rb) ranged from 0.36 to 0.83, all p < 0.003. All correlations between RMI scores and the other instruments, both at T 0 and T 1, were statistically significant (r 3 0.49, all p < 0.0001), except those with cognFIM. The difference in RMI scores over the testing period was statistically significant (sign test: z = 7.1, p < 0.0001) and the effect size was 0.89. The coefficient of reproducibility was 0.95 at T 0 and 0.93 at T 1, and both coefficients of scalability were 0.67. Conclusions: The study confirms the internal consistency, construct validity and responsiveness of the RMI, according to the classic psychometric indexes. However, some minor concerns arise regarding: (a) a floor effect of RMI in subacute rehabilitation stroke inpatients at admission and; (b) one item (‘bathing’) that seems sensitive to cultural and environmental factors. Moreover, even though RMI met the scaling criteria, the item hierarchy is not coincident with the one originally postulated. So, RMI should be considered only as a summated index with ordinal properties, and not a hierarchically ranked scale.

Life satisfaction index: Italian version and validation of a short form

The Life Satisfaction Index-version A (LSIA) is a 20-item questionnaire providing a cumulative score acknowledged as a valid index of quality of life. In the present study, an Italian version was produced through validated procedures of repeated back-translations. The final Italian version (LSIA.it) was administered to 90 healthy subjects (55 women; aged 40-65 yr, median 51). Cronbach alpha was 0.74, in agreement with previous studies on English, Greek, and Spanish versions, suggesting satisfactory internal consistency of the scale. Also in agreement with previous studies, factor analysis identified three factors (mood tone, zest for life, and congruence between desired and achieved goals), with eigenvalues of 2.80, 1.72, and 1.34, respectively. Nine of the original 20 items were dropped because of inconsistency with the overall scale and/or because of ambiguous loading onto the extracted factors. The resulting 11-item short form (LSI-11) had alpha = 0.69 and Kaiser-Meyer-Olkin measure of sample adequacy = 0.65. In our sample, the mean score of LSIA.it was almost the same as that previously reported in the literature for LSIA, and the correlation between LSIA and LSI-11 was very high (r = 0.91). In a test-retest trial, the cumulative score of LSI-11 showed a percentage of agreement ranging from 73.9 to 100 and Cohens k statistic for reliability ranging from 0.51 to 1. The individual items of the LSI-11 presented substantial (k > 0.6) to excellent (k > 0.8) levels of agreement. The responsiveness of LSIA and LSI-11 during a hospital stay for 30 consecutive inpatients for medical rehabilitation programs, as measured by effect size, was 0.57 and 0.63, respectively. The results suggest that (1) the LSIA it has cultural equivalence with the English LSIA and that (2) the 11-item short form of LSIA is not only simpler but also more valid from a psychometric standpoint.

Rasch analysis of the Fatigue Severity Scale in Italian subjects with multiple sclerosis.

OBJECTIVE To perform a psychometric analysis of the Fatigue Severity Scale (FSS) using Rasch analysis in a sample of Italian subjects with multiple sclerosis. METHODS The 9-item FSS was administered to 156 Italian-speaking subjects with multiple sclerosis. Responses were assessed using Cronbachs alpha, item-remainder correlations, factor analysis and Rasch analysis. RESULTS The FSS showed good internal consistency (Cronbachs alpha = 0.95), but presented problems in the rating categories and failed to fit the Rasch model. After re-coding and deletion of item 1 (infit mean-square (MnSq) = 1.65; outfit MnSq = 1.72), the 8-item version fitted the latent construct that the scale was intended to measure and showed satisfactory reliability indices. The scale was not optimally targeted to the sample, but no sex or age bias was found. CONCLUSION The 8-item FSS shows better psychometric properties than the 9-item version. However, a significant ceiling effect emerged in our sample of Italian adults with multiple sclerosis and, consequently, there is a targeting problem for patients with low-level disability. To consider this a valid tool for use in clinical practice and research, further studies with a larger sample of subjects with multiple sclerosis are needed.

Rasch analysis of the 22 knee injury and osteoarthritis outcome score-physical function items in Italian patients with knee osteoarthritis.

OBJECTIVES To replicate previous Rasch analysis (RA) that yielded the 7-item Physical Function Short Form of the Knee Injury and Osteoarthritis Outcome Score (KOOS-PS7) in order to verify the consistency of the item selection process, and to analyze its main psychometric properties in a sample of Italian patients with osteoarthritis (OA). DESIGN Methodological research on cross-sectional data from a convenience sample. SETTING University hospital. PARTICIPANTS Outpatients with symptomatic OA of the knee (N=200; women, 73%; mean age, 69.4y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The KOOS-PF22 (22 items comprising the 2 KOOS domains of activities of daily living and sport/recreation). Its dimensionality was investigated using exploratory factor analysis. RA was performed on KOOS-PF22, KOOS-PS7, and an item set (called KOOS-PS12) obtained by removing from KOOS-PF22 all misfitting items. RESULTS KOOS-PF22 showed a 2-factor structure, with the first one largely prevailing. Ten of its 22 items did not fit the Rasch model, while item dependency was present in 7 item pairs. Five of 7 KOOS-PS7 items and all KOOS-PS12 items showed acceptable fit to the Rasch model. The person separation reliability was .79 for KOOS-PS7 and .90 for KOOS-PS12; Cronbach alpha was .81 for KOOS-PS7 and .92 for KOOS-PS12. CONCLUSIONS RA was not able to replicate the selection process of the items included in KOOS-PS7. KOOS-PS7 reliability levels indicate that the instrument seems more useful for group decisions than for everyday clinical application in single patients. To achieve a short form of KOOS-PF22 valid for a wide spectrum of individuals with knee OA, further psychometric studies are warranted.

Psychometric properties of self-administered Lequesne Algofunctional Indexes in patients with hip and knee osteoarthritis: an evaluation using classical test theory and Rasch analysis

The aim of this study is to perform a psychometric analysis of the Lequesne Algofunctional Indexes (LAI) for the severity of osteoarthritis (OA) of the hip (LAI-hip) and knee (LAI-knee), using classical test theory (CTT) and Rasch analysis. Questionnaires were completed by 1,214 patients with symptomatic OA of the knee (n = 697) and hip (n = 517). Internal consistency was evaluated using Cronbach’s alpha and an item-to-total correlation. Dimensionality was investigated with a factor analysis. Raw scores underwent Rasch analysis. Cronbach’s alpha was 0.84 for LAI-hip and 0.82 for LAI-knee. LAI-hip resulted in unidimensionality according to the factor analysis, while LAI-knee supported both a single and a two-factor solution (items 1–6b and 7–10, respectively). At Rasch analysis, the rating categories of item ‘maximum distance walked’ did not comply with the criteria for category functioning in either LAI-hip or LAI-knee. A test of the residual correlation showed item dependency in both LAI-hip and LAI-knee. Misfitting items were present in both the scales. According to both CTT and Rasch analysis, in our two samples representing a wide spectrum of both hip and knee OA severity the LAI-hip and LAI-knee showed a series of drawbacks, which rendered both questionnaires inadequate in relation to their metric properties and severely limit their ability to perform, as a composite measure, in line with the main aims of their developers.

Motivation to change and posttreatment temptation to drink: a multicenter study among alcohol-dependent patients

Background An inpatient 28-day rehabilitation program for alcohol dependence is focused on detoxification, enhancing motivation to change, and coping strategies for the management of emotional distress and temptation to drink. The aims of the present study were to investigate 1) changes over time in motivation to change, anxiety, and depression in individuals undergoing residential rehabilitation treatment for alcohol addiction, and 2) which pretreatment factors are associated with posttreatment temptation to drink. Methods We assessed 432 patients diagnosed with alcohol dependence based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) consecutively recruited from seven residential rehabilitation centers in Northern Italy. Patients were assessed by means of self-report questionnaires at the beginning of rehabilitation (pretreatment) and before their hospital discharge (posttreatment) regarding motivation to change and self-efficacy (motivation assessment of change – alcoholism version), readiness to change and temptation to drink (visual analog scales), and depression and anxiety (cognitive behavioral assessment – outcome evaluation). Results Results showed an overall improvement in motivation to change and a significant reduction over time in depression and anxiety levels for the total sample, particularly patients with low baseline level of temptation to drink. Multivariate linear regression analysis revealed that significant predictors of posttreatment temptation to drink were polysubstance dependence (p<0.001), readiness to change (p=0.01), and self-efficacy (p=0.05). Conclusion Inpatients’ rehabilitation for alcohol dependence is associated with an overall improvement in motivation to change and a significant reduction of psychological distress. Treatments for alcohol-dependent patients should focus on motivation to change, negative moods, and relapse prevention strategies for the management of craving.

The cross-cultural adaptation and psychometric validation of the MSSS-88 for use in Italian patients with multiple sclerosis

Abstract Purpose: To cross-culturally translate the Multiple Sclerosis Spasticity Scale into Italian and to evaluate its psychometric properties in patients with multiple sclerosis. Methods: The Italian version of Multiple Sclerosis Spasticity Scale was developed in accordance with international standards and subsequently administered to 232 Italian adults with multiple sclerosis. The following psychometric properties were analyzed: internal consistency through Cronbach’s α and item-to-total correlation, dimensionality with factor analysis, and convergent and criterion validity through hypotheses-testing, comparing the Multiple Sclerosis Spasticity Scale with other outcome measures (Fatigue Severity Scale, Multiple Sclerosis Quality of Life, Modified Ashworth Scale, Barthel Index, and Expanded Disability Status Scale) and analyzing related constructs. Finally, we correlated the MSSS-88 subscales with each other. Results: The final Multiple Sclerosis Spasticity Scale version was well-understood by all subjects. The internal consistency was good (Cronbach’s α ≥0.90). Factor analysis revealed that each subscale was unidimensional. Convergent and criterion validity were supported by acceptable correlations with other disease-specific questionnaires, according to the a priori expectations. Conclusions: The final Italian Multiple Sclerosis Spasticity Scale version showed robust psychometric properties. Therefore, it can be recommended as an assessment tool for clinical and research use to evaluate spasticity in Italian patients with multiple sclerosis. Implications for rehabilitation The Multiple Sclerosis Spasticity Scale was developed to measure patients’ perception of the impact of spasticity on life of subjects with multiple sclerosis. In a sample of Italian subjects with multiple sclerosis, the Multiple Sclerosis Spasticity Scale revealed good internal consistency and convergent and criterion validity. Factor analysis demonstrated that each subscale was unidimensional. Each subscale can be used to assess the impact of spasticity in Italian patients with multiple sclerosis.

Computational rehabilitation of neglect: Using state-space models to understand the recovery mechanisms

Unilateral spatial neglect is a neuropsychological syndrome often observed in right hemisphere stroke patients. The symptoms differ from subject to subject. A few rehabilitation approaches, e.g. prism adaptation, have demonstrated some effect in reducing the symptoms, but the underlying mechanisms are still largely unclear. Recently, neural models have been proposed to qualitatively describe cortical lesions, the resulting neglect symptoms and the effects of treatment. However, these predictions are qualitative and cannot be used to compare different hypotheses or to interpret symptoms at individual subjects level. Here we propose a computational model of the trial-by-trial dynamics of training-induced recovery from neglect. Neglect is modelled in terms of an impaired internal representation of visual stimuli in the left hemispace. The model assumes that recovery is driven by the mismatch between defective representations of visual stimuli and the corresponding hand positions. The model reproduces the main observations of prism adaptation experiments. Using standard system identification techniques, we fitted the model to data from a rehabilitation trial based on a novel rehabilitation approach based on virtual reality, involving reaching movements within an adaptive environment. Our results suggest that the model can be used to interpret data from individual subjects and to formulate testable hypotheses on the mechanisms of recovery and directions for treatment.

Development and validation of the Maugeri Sleep Quality and Distress Inventory (MaSQuDI-17)

Objectives The aim of this study was to develop and validate a questionnaire designed to measure the impact of sleep impairment on emotional distress in patients with various sleep disorders. Methods Five experts created an item data-bank pertaining to sleep-related psychological symptoms and somatic perceptions. Fifty patients in two focus groups examined each item for: a) word clarity (indicating any ambiguity of interpretation) and b) appropriateness for the target population. This process permitted to identify 36 appropriate items. Classical Test Theory and Rasch Analysis were used to further refine the questionnaire, yielding the final 17-item set. Concurrent validation of the new scale was tested with the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and the Anxiety and Depression questionnaires. Results Starting from the initial item data-bank, a 17-item questionnaire, the Maugeri Sleep Quality and Distress Inventory (MaSQuDI–17), was produced. Parallel Analysis on the MaSQuDI–17 confirmed the presence of a single dimension; exploratory factor analysis showed salient loading for each item, explaining 58.7% of total variance. Item-remainder correlation ranged from 0.72 to 0.39 and Cronbach alpha was 0.896. Rasch analysis revealed satisfactory psychometric properties of the new scale: the rating structure performed according to expectations, model fit was good and no item dependencies emerged. The scale presented good convergent validity and scores significantly distinguished healthy subjects from OSAS or Insomnia or BSD (p < 0.001). Conclusions MaSQuDI –17 shows good psychometric qualities, and can be used to assess the impact of sleep disorders such as Insomnia, OSAS, Central Hypersomnia and BSD on emotional stress.