Matthew Borgia

Development and evaluation of the activities measure for upper limb amputees.

OBJECTIVES (1) To develop a measure of activities for adults with upper limb amputation: the Activities Measure for Upper Limb Amputees (AM-ULA); and (2) to conduct initial psychometric evaluation of the measure. DESIGN This was a cohort study where the prototype measure was administered twice within 1 week. Tests were videotaped and graded by 2 independent raters. Interrater reliability, test-retest reliability, internal consistency, and minimal detectable change were estimated. Known group validity was examined using analyses of variance comparing scores of transradial, transhumeral, and shoulder level amputees. Convergent validity was examined by correlating AM-ULA scores with dexterity tests and self-reported function. SETTING Hospital outpatient. PARTICIPANTS Subjects (N=52) with upper limb amputation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Intraclass correlation coefficients (ICCs) for test-retest reliability were .88 to .91. ICCs for interrater reliability were .84 to .89. Cronbach alphas were .89 to .91. The minimal detectable change at the 90% confidence interval was 3.7 points. Subjects with more distal levels of limb loss had better scores than those with more proximal levels (P<.01). The AM-ULA was moderately correlated with most dexterity tests and self-reported function. CONCLUSIONS The AM-ULA is a new measure of activity performance for adults with upper limb amputation that considers task completion, speed, movement quality, skillfulness of prosthetic use, and independence in its rating system. It has good interrater reliability, test-retest reliability, and demonstrated known group validity.

Measurement of community reintegration in sample of severely wounded servicemembers

The Community Reintegration of Servicemembers (CRIS) is a new measure of community reintegration. The purpose of this study was to test the CRIS with seriously injured combat veterans. Subjects were 68 patients at the Center for the Intrepid. Each patient completed three CRIS subscales, the 36-Item Short Form Health Survey for Veterans (SF-36V), the Quality of Life Scale (QOLS), and two Craig Handicap Assessment and Reporting Technique subscales at visit 1 and the 3-month follow-up. Of the patients, 11 also completed the measures within 2 weeks of visit 1. We abstracted diagnoses and activities of daily living from the medical record. We evaluated test-retest reliability using intraclass correlation coefficients (ICCs). We evaluated concurrent validity with Pearson product moment correlations. We used multivariate analyses of variance to compare scores for subjects with and without posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and depression. Responsiveness analyses evaluated floor and ceiling effects, percent achieving minimal detectable change (MDC), effect size (ES), and the standardized response mean (SRM). CRIS subscale ICCs were 0.90 to 0.91. All subscales were moderately or strongly correlated with QOLS and SF-36V subscales. CRIS subscale scores were lower in PTSD and TBI groups (p < 0.05). CRIS Extent of Participation and Satisfaction with Participation subscales were lower for subjects with depression (p < 0.05). Of the sample, 17.4% to 23.2% had change greater than MDC. The ES ranged from 0.227 to 0.273 (SRM = 0.277-0.370), showing a small effect between visit 1 and the 3-month follow-up. Results suggest that the CRIS is a psychometrically sound choice for community reintegration measurement in severely wounded servicemembers.

New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model

OBJECTIVES We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. METHODS We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. RESULTS We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. CONCLUSIONS Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

Association of change in depression and anxiety symptoms with functional outcomes in pulmonary rehabilitation patients

OBJECTIVE Pulmonary rehabilitation (PR) has emerged over the last decade as an essential component of an integrated approach to managing patients with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD). We sought to examine how depression and anxiety symptom changes relate to disease-specific quality of life outcomes following PR. METHODS We performed a cohort study of 81 patients with COPD who completed PR at a Veterans Administration Medical Center. Pulmonary rehabilitation consisted of supervised exercise training and education twice weekly for 8 weeks. Beck Depression and Anxiety Inventories (BDI and BAI) assessed symptom burden at baseline and completion of PR. We measured change in disease-specific quality of life using the dyspnea, mastery, emotion and fatigue domains of the Chronic Respiratory Questionnaire Self-Reported (CRQ-SR) from baseline to completion of PR. RESULTS Participants were 69.8±9.1 years old and all male. Forced expiratory volume in 1 s (FEV1) was 1.23±0.39 L. The CRQ-SR scores improved significantly: dyspnea (P<.0001), mastery (P=.015) and fatigue (P=.017). The BDI scores improved significantly (13.1±10.5 to 10.8±9.9, P=.003; BAI: 13.1±10.1 to 12.1±11.7). Multivariate regression models controlling for age, FEV1, depression treatment and anxiety treatment showed that improvement in depressive symptoms were associated with improvement in fatigue (P=.003), emotion (P=.003) and mastery (P=.01). Anxiety symptom change was not significantly associated with change in disease-specific quality of life domains. CONCLUSION Addressing anxiety symptoms in PR patients may be indicated because disease-specific quality of life improvement appears to be associated with mood.

Self-reported and performance-based outcomes using DEKA Arm

Mechanical properties of the DEKA Arm and associated engineering innovations are easy to observe. What is less clear is how these advances translate into functional benefits for the user with amputation. Study aims were to (1) quantify outcomes including dexterity, performance of daily activities, and prosthetic skill and spontaneity of users of the DEKA Arm and (2) compare outcomes when using the DEKA Arm with scores using the existing prosthesis. This was a quasi-experimental study. Descriptive analyses examined outcomes by DEKA Arm configuration level. Of the 39 subjects fit with a DEKA Arm, 32 were trained in use and completed end-of-study testing. Data from 26 prosthetic users were used to compare outcomes using existing prostheses with outcomes with the DEKA Arm. Dexterity and activity performance with the DEKA Arm varied by amputation level (p < 0.01). Self-reported function and number of activities performed using the prosthesis were similar across levels. Comparisons with existing prostheses showed the effect on dexterity varied by level. Activity performance and spontaneity of prosthetic use improved for users of the shoulder configuration level, while use of the prosthesis to perform activities and perceived difficulty performing self-selected tasks improved for all levels.

Reliability and Validity of Outcome Measures for Upper Limb Amputation

ABSTRACT Objective: Studies of outcome measures for adults with upper limb amputation are lacking. Our purpose was to examine the measurement properties of the Modified Box and Block Test of Manual Dexterity (BB), the Jebsen-Taylor Test of Hand Function (JTHF), the Upper Extremity Functional Scale (UEFS), the satisfaction scale from the Trinity Amputation and Prosthetics Experience Scale measure (TAPES), and the Patient-Specific Function Scale (PSFS). Specifically we aimed to 1) estimate test-retest reliability, 2) calculate minimum detectable change (MDC), and 3) examine known group validity. Methods: Subjects were 73 adults with upper limb amputation from four study sites. We estimated test-retest reliability using intraclass correlation coefficient (ICC) (3,1), calculated standard error of the measurement, and MDC; assessed scale score distributions; and compared scores by level of amputation using analyses of variance. Results: The ICCs were 0.91 for BB, 0.68 to 0.92 for the JTHF subtests, 0.80 for the UEFS summary, 0.65 for UEFS use, and 0.86 for the TAPES. The MDC was 6.5 items for BB, 0.09 to 0.18 items per second for the JTHF subtests, 12 points for the UEFS summary, 0.39 for UEFS use, and 0.79 for TAPES. Floor effects were observed for the JTHF page turning, small items, and feeding subtests. Subjects with more distal amputation had better dexterity (p < 0.001), better self-reported function on the PSFS (p = 0.01), and greater prosthetic satisfaction (p < 0.05) as compared with persons with higher levels of amputation. Scores on the UEFS did not vary by amputation level. Discussion and Conclusion: The BB, JTHF, and TAPES are reliable and valid for use with adults with upper limb amputation. Further research is needed to examine the test-retest reliability of the PSFS. The UEFS was reliable, but summary scores do not take prosthetic usage into account. Further validation work is needed for this measure. Findings can be used to assist clinicians and researchers in choosing appropriate measures and in interpreting changes in scores with repeat administration.

Reliability, validity and administrative burden of the community reintegration of injured service members computer adaptive test (CRIS-CAT)"

BackgroundThe Computer Adaptive Test version of the Community Reintegration of Injured Service Members measure (CRIS-CAT) consists of three scales measuring Extent of, Perceived Limitations in, and Satisfaction with community integration. The CRIS-CAT was developed using item response theory methods. The purposes of this study were to assess the reliability, concurrent, known group and predictive validity and respondent burden of the CRIS-CAT.The CRIS-CAT was developed using item response theory methods. The purposes of this study were to assess the reliability, concurrent, known group and predictive validity and respondent burden of the CRIS-CAT.MethodsThis was a three-part study that included a 1) a cross-sectional field study of 517 homeless, employed, and Operation Enduring Freedom / Operation Iraqi Freedom (OEF/OIF) Veterans; who completed all items in the CRIS item set, 2) a cohort study with one year follow-up study of 135 OEF/OIF Veterans, and 3) a 50-person study of CRIS-CAT administration. Conditional reliability of simulated CAT scores was calculated from the field study data, and concurrent validity and known group validity were examined using Pearson product correlations and ANOVAs. Data from the cohort were used to examine the ability of the CRIS-CAT to predict key one year outcomes. Data from the CRIS-CAT administration study were used to calculate ICC (2,1) minimum detectable change (MDC), and average number of items used during CAT administration.ResultsReliability scores for all scales were above 0.75, but decreased at both ends of the score continuum. CRIS-CAT scores were correlated with concurrent validity indicators and differed significantly between the three Veteran groups (P < .001). The odds of having any Emergency Room visits were reduced for Veterans with better CRIS-CAT scores (Extent, Perceived Satisfaction respectively: OR = 0.94, 0.93, 0.95; P < .05). CRIS-CAT scores were predictive of SF-12 physical and mental health related quality of life scores at the 1 year follow-up. Scales had ICCs >0.9. MDCs were 5.9, 6.2, and 3.6, respectively for Extent, Perceived and Satisfaction subscales. Number of items (mn, SD) administered at Visit 1 were 14.6 (3.8) 10.9 (2.7) and 10.4 (1.7) respectively for Extent, Perceived and Satisfaction subscales.ConclusionThe CRIS-CAT demonstrated sound measurement properties including reliability, construct, known group and predictive validity, and it was administered with minimal respondent burden. These findings support the use of this measure in assessing community reintegration.

Reliability, Validity, and Responsiveness of the QuickDASH in Patients With Upper Limb Amputation

OBJECTIVES To examine the internal consistency, test-retest reliability, validity, and responsiveness of the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire in persons with upper limb amputation. DESIGN Cross-sectional and longitudinal. SETTING Three sites participating in the U.S. Department of Veterans Affairs Home Study of the DEKA Arm. PARTICIPANTS A convenience sample of upper limb amputees (N=44). INTERVENTIONS Training with a multifunction upper limb prosthesis. MAIN OUTCOME MEASURES Multiple outcome measures including the QuickDASH were administered twice within 1 week, and for a subset of 20 persons, after completion of in-laboratory training with the DEKA Arm. Scale alphas and intraclass correlation coefficient type 3,1 (ICC3,1) were used to examine reliability. Minimum detectable change (MDC) scores were calculated. Analyses of variance, comparing QuickDASH scores by the amount of prosthetic use and amputation level, were used for known-group validity analyses with alpha set at .05. Pairwise correlations between QuickDASH and other measures were used to examine concurrent validity. Responsiveness was measured by effect size (ES) and standardized response mean (SRM). RESULTS QuickDASH alpha was .83, and ICC was .87 (95% confidence interval, .77-.93). MDC at the 95% confidence level (MDC95%) was 17.4. Full- or part-time prosthesis users had better QuickDASH scores compared with nonprosthesis users (P=.021), as did those with more distal amputations at both baseline (P=.042) and with the DEKA Arm (P=.024). The QuickDASH was correlated with concurrent measures of activity limitation as expected. The ES and SRM after training with the DEKA Arm were 0.6. CONCLUSIONS This study provides evidence of reliability and validity of the QuickDASH in persons with upper limb amputation. Results provide preliminary evidence of responsiveness to prosthetic device type/training. Further research with a larger sample is needed to confirm results.

Needing Primary Care But Not Getting It: The Role of Trust, Stigma and Organizational Obstacles reported by Homeless Veterans

We describe data from a multi-center community-based survey of homeless veterans who were not accessing available primary care to identify reasons for not getting this care as well as for not seeking health care when it was needed. Overall, 185 homeless veterans were interviewed: The average age was 48.7 years (SD 10.8), 94.6% were male, 43.2% were from a minority population. The majority identified a recent need for care and interest in having a primary care provider. Reasons for delaying care fell into three domains: 1) trust; 2) stigma; and 3) care processes. Identifying a place for care (OR 3.3; 95% CI: 1.4–7.7), having a medical condition (OR 5.5; 95% CI 1.9–15.4) and having depression (OR 3.4; 95% CI: 1.4–8.7) were associated with receiving care while not being involved in care decisions was associated with no care (OR 0.7; 95% CI 0.5–0.9). Our findings support the importance of considering health access within an expanded framework that includes perceived stigma, inflexible care systems and trust issues.

User ratings of prosthetic usability and satisfaction in VA study to optimize DEKA Arm

The Department of Veterans Affairs study to optimize the DEKA Arm provided feedback to inform optimization of the gen 2 (second-generation) prototype and evaluate the gen 3 (third-generation) prototype. This article summarizes recommendations to improve gen 2 and reports satisfaction and usability ratings of gen 2 and gen 3. Data were collected from 39 subjects; 37 subjects were included in this analysis. Of the subjects, 24 were fit with gen 2 (8 radial configuration [RC], 6 humeral configuration [HC], and 10 shoulder configuration [SC]), 13 were fit with gen 3 (4 RC, 5 HC, and 4 SC), and 5 were fit with both. Usability and satisfaction were evaluated using the Trinity Amputation and Prosthesis Experience Scale (TAPES) and study-specific usability and satisfaction scales. Descriptive statistics were examined and prototypes compared using Wilcoxon rank-sum. Results were stratified by configuration level and outcomes compared by prototype. Satisfaction and usability were greater for gen 3 than gen 2. Overall TAPES scores were similar; however, scores of the TAPES aesthetic satisfaction subscale were higher for gen 3. Compared with gen 2 users, gen 3 users were more satisfied with appearance, grips, and doffing and rated overall usability higher. Features of gen 3, including weight, external cables and wires, hand covering, and fingernails, would benefit from further optimization.