Are performance-based measures sufficiently reliable for use in multicenter trials? Musculoskeletal Impairment (MSI) Study Group.

BACKGROUND: The literature contains few reports of the test-retest reliability of performance-based measures. The purpose of this study was to determine the test-retest reliability of a battery of seven timed, performance-based measures used to assess the functional limitations of frail, older adults. METHODS: One hundred and five frail, elderly subjects were twice administered a battery of timed tests approximately 2 weeks apart: 8-foot walk, get-up-and-go test, stair climb, single and repetitive standing from a chair, and single and repetitive 10-pound lifts with the upper limbs. Agreement between the mean times recorded for accomplishing each task at the two administrations was assessed. RESULTS: Intraclass correlation coefficients ranged from .25 for the single chair stand to .79 for the 8-foot walk. Only the time taken for the single 10-pound lift was significantly greater at the first administration as compared with the second. CONCLUSIONS: Timed performance-based measures have a wide range of test-retest reliability. Performance-based protocols that reflect familiar tasks with discrete starting and ending points may achieve higher reliability than tasks that are unfamiliar to subjects or may have ambiguous elements in them.

Effect of different forms of transcutaneous electrical nerve stimulation on experimental pain.

The purpose of this study was to compare the effects of five different types of transcutaneous electrical nerve stimulation on experimentally induced pain threshold and tolerance in healthy subjects. Fourteen subjects received the following treatments on different days: low frequency TENS, burst frequency TENS, hyperstimulation TENS, high frequency TENS with a low voltage galvanic stimulator, and high frequency TENS with a high voltage galvanic stimulator to the left upper extremity. Pain threshold and tolerance were tested with electric current on a fingertip of the left upper extremity before each treatment, immediately after each treatment, and 20 minutes after the end of each treatment. Data were analyzed using separate two-by-five analyses of variance with repeated measures for pain threshold and tolerance. No significant effects of treatment or time for pain threshold or tolerance were found. A significant interaction between treatment and time for pain threshold was found. Further study is needed to compare the effects of these treatments in patients with clinical pain.

Physiological effects of exercise in the diabetic.

Physical therapists frequently assess and treat patients with diabetes mellitus. Because exercise is often a component of the prescribed program, the physical therapist should have some understanding of the possible responses a diabetic may have to exercise. Diabetics can benefit from exercise and training, but exercise can have deleterious effects in some instances. This paper provides a review of the literature on the physiological effects of exercise and training in the diabetic. Effects of exercise and training on the cardiovascular and muscular systems are reviewed, and the role of insulin in regulating the production, mobilization, and utilization of energy substrates during exercise is examined. Additionally, this paper provides suggestions on the clinical relevance of the physiological findings in planning exercise programs and education for the diabetic patient.

The relationship of cardiovascular and psychological impairments to the health status of patients enrolled in cardiac rehabilitation programs.

BACKGROUND AND PURPOSE: Understanding the causes of differences in disability among individuals is an important research focus for rehabilitation professionals. The purpose of this study was to examine the relationship between health status and the impairments commonly associated with cardiovascular pathophysiology. SUBJECTS: The subjects were patients (N=789) enrolled in 13 cardiac rehabilitation programs in Massachusetts. METHODS: Data were collected on psychological and physiological impairments, demographic characteristics, and health status. Multivariate analyses were used to determine which measures of impairment and patient characteristics were related to health status. RESULTS: Psychological impairment was related to all scales of the MOS 36-item Short-Form Health Survey (SF-36). Very few measures of physiological impairment and individual characteristics were related to SF-36 scores. The models accounted for 16% to 57% of the variability of the instrument's scales. CONCLUSION AND DISCUSSION: In patients entering cardiac rehabilitation, psychological distress is related to poor health in both the physical and psychological dimensions. Variability in health status is not well explained by traditional measures of impairment or demographic characteristics. Physical therapists working to address their patients' health needs must consider collecting data, setting goals, and devising interventions that address psychological impairment.

Health status of individuals entering a cardiac rehabilitation program as measured by the medical outcomes study 36-item short-form survey (SF-36).

BACKGROUND AND PURPOSE: The goal of health care for individuals with chronic disease is the improvement of function and well-being. Although the individual's perception of his or her quality of life may be the best indicator of achievement of this goal, measurement of self-perceived quality of life, or health status, is not a routine component of evaluation. The purposes of this article are to describe the health status of individuals upon entry into a cardiac rehabilitation program and to demonstrate the use of a comprehensive, generic health status measure in this group. SUBJECTS: The subjects of this study were 789 men and women enrolled in one of 13 cardiac rehabilitation programs in the state of Massachusetts. METHODS: As part of a large database, subjects completed a 36-item generic questionnaire, Short Form 36 (SF-36), that examines eight health concepts. Scores range from 0% to 100%; a higher score is consistent with better health status. Results. Mean uncontrolled scores ranged from 26.6 to 70.8. Mean scores adjusted for sex, age, and education ranged from 27.1 to 70.9. In light of previously published data using a similar 20-item scale, our results show that cardiac disease is associated with reductions in health-related quality of life. CONCLUSION AND DISCUSSION: Health status measurement provides information that can supplement the usual measures of impairment in patients with cardiovascular disease. The findings of this study contribute to the understanding of health status of individuals who enroll in cardiac rehabilitation programs. The health status instrument used in this study has potential as a useful, practical measurement tool for use in the clinical setting.

Physical therapy and health outcomes in patients with spinal impairments.

BACKGROUND AND PURPOSE: Little is known concerning the effects of physical therapy on health outcomes in patients with spinal impairments. This research examined the pattern of health outcomes in patients with spinal impairments and the relationship of outcomes to the physical therapy provided. SUBJECTS: Data were obtained from 1,097 patients with spinal impairments who completed an episode of care in any of 68 physical therapy practices across the United States. METHODS: Data were derived from the Focus on Therapeutic Outcomes database during 1993 and 1994. Multivariate analyses were used to determine which of the treatment variables, controlled for baseline health status and relevant patient characteristics, were related to outcomes. RESULTS: Improvement occurred in nearly all health scales. Inclusion of endurance exercise was most consistently associated with better outcomes. Inclusion of heat or cold modalities was associated with poorer outcomes. CONCLUSION AND DISCUSSION: This study suggests that physical therapists take a broader view of patient-related goals and documentation of outcomes. It also provides evidence that the type of intervention is related to outcomes.

Physical therapy and health outcomes in patients with knee impairments.

BACKGROUND AND PURPOSE: Physical therapy is usually initiated with the belief that treatment will improve patients health, particularly the ability to perform daily activities and function in expected roles. The purpose of this report to describe health outcomes and related factors in patients with knee impairments receiving physical therapy. SUBJECTS: Data were obtained from a sample of 426 patients with knee impairments treated in 63 physical therapy practices across the United States. METHODS: Data were obtained during 1993 and 1994 from the Focus on Therapeutic Outcomes database. Health outcomes over an episode of physical therapy care were described using the SF-36 and the Lysholm Knee Rating Scale. Multivariate analyses were used to determine which patient and treatment characteristics were associated with these outcomes. RESULTS: The patients health improved, as measured by all but one of the SF-36 outcomes scales, with effect sizes ranging from 0.18 to 0.93 in scales in which change occurred. The patient and treatment characteristics that were studied accounted for 23% to 37% of the variability in health outcomes. CONCLUSION AND DISCUSSION: Patients who were older, had no surgery, were out of work because of their health, or were depressed were more at risk for poor health outcomes than were patients without these characteristics. These findings suggest a need for physical therapists to look for new approaches to identifying and treating patients with these characteristics.

Changes in sympathetic tone associated with different forms of transcutaneous electrical nerve stimulation in healthy subjects.

The purpose of this study was to determine the effect of four different forms of transcutaneous electrical nerve stimulation (TENS) on sympathetic tone in healthy subjects. Twelve subjects received high frequency, low frequency, burst frequency, and placebo stimulation to one upper extremity. Treatments were given on different days. Ipsilateral and contralateral fingertip skin temperatures were measured at three intervals for each treatment: 1) after a 25-minute rest period before stimulation, 2) after a 25-minute treatment, and 3) 25-minutes posttreatment. High, low, and burst frequency TENS significantly increased sympathetic activity in the ipsilateral extremity immediately after treatment. Similar trends in temperature change were seen on the contralateral side. The effects of the three nonplacebo treatments did not differ from each other. Further research is needed to assess sympathetic effects of TENS on patient groups. The results suggest that monitoring skin temperature as part of a TENS assessment may be warranted, especially in patients with distal vascular impairments.

Effect of intermittent, supine cervical traction on the myoelectric activity of the upper trapezius muscle in subjects with neck pain.

This study was undertaken to compare the myoelectric activity of the upper trapezius muscle before, during, and after intermittent, supine cervical traction. Twelve people with diagnosed disease or injury of the cervical spine served as subjects. Electromyographic recordings were taken from the upper trapezius muscle with bipolar surface electrodes. The subjects were treated with 20 minutes of intermittent, cervical traction at a force of 8% of their body weight. Recordings were taken with the subjects in the supine position before the traction, during one pull and release phase of the 10th and 20th minutes of traction, and after completion of the traction treatment. An analysis of variance with repeated measures showed no significant differences in the myoelectrical activity during the six time periods measured. The results of this study do not support the clinical use of intermittent, supine traction to produce cervical muscle relaxation.

Factors associated with burnout of physical therapists in Massachusetts rehabilitation hospitals.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the factors associated with burnout in physical therapists at rehabilitation hospitals. Burnout is a serious concern because it can lead to psychosomatic complaints, work-associated withdrawal behaviors, and a decreased quality of care. SUBJECTS: Full-time, nonadministrative, nonsupervisory, staff physical therapists working in inpatient settings in rehabilitation hospitals in Massachusetts were surveyed. METHODS: The survey included demographic data, the Maslach Burnout Inventory (MBI), and questions designed to address attributes of the work environment and individual personalities. The MBI scores were calculated according to instructions provided by publishers to determine the degree of burnout experienced by this group. Questions involving personality and work environment were submitted to factor analyses. Multivariate analyses were done to determine the factors related to burnout. RESULTS: Forty-six percent of the respondents scored high on the emotional exhaustion subscale of the MBI, 20% scored high on the depersonalization subscale, and 60% scored low on the personal accomplishment subscale. As a whole, the sample demonstrated moderate burnout. Three factors emerged from the factor analysis. The factors communication/connectedness, achievement, and time constraints accounted for 69% of the variability in emotional exhaustion and 73% of the variability in depersonalization and personal accomplishment. Burnout was not significantly associated with the therapists' number of years of practice, number of years on the job, or number of patients seen daily. CONCLUSION AND DISCUSSION: Recognition of factors contributing to burnout may prove to be instrumental in the prevention of burnout in physical therapists and the problems that arise from it.

The relationship of lower-limb muscle force to walking ability in patients with amyotrophic lateral sclerosis.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the level of muscle force associated with ability to walk in the community without assistance, in the community with assistance, or at home only in individuals with amyotrophic lateral sclerosis (ALS). SUBJECTS AND METHODS: Percentage of predicted maximal muscle force (%PMF) of lower-extremity muscles was determined, and walking ability was categorized in 118 patients with ALS during periodic visits to the Neuromuscular Research Unit. Data were derived from consecutive visits in which subjects demonstrated declines in walking ability. Means for %PMF of each muscle group and a limb average were calculated at each consecutive visit. RESULTS: The mean lower-extremity average %PMF was: (1) 54.01% (SD=12.76%) for subjects who walked independently in the community and 50.19% (SD=14.38%) during the next visit when these same subjects required assistance in the community (difference=3.82%, 95% confidence interval [CI]= 2.45-5.19);(2) 37.52% (SD=15.17%) during the last visit that subjects walked with assistance in the community and 32.18% (SD=13.83%) during the next visit when they walked only at home (difference=5.33%, 95% CI=3.61-7.06); and (3) 19.12% (SD=9.08%) during the visit when subjects were last able to ambulate at home versus 13.70% (SD=7.36%) when they became unable to walk (difference=5.42%, 95% CI=2.97-7.96). CONCLUSION AND DISCUSSION: The findings suggest there are required levels of lower-extremity muscle force for various categories of walking ability. Variations in forces within and between categories of walking ability, however, indicate the complexity of this relationship.

The disablement process in patients with pulmonary disease.

BACKGROUND AND PURPOSE: The purposes of this study were (1) to describe the disabilities of patients with pulmonary disease and (2) to examine the relationships among impairments, functional limitations, and disability, as described by the disablement process model. SUBJECTS: Subjects were 154 patients with chronic pulmonary disease (64% female, 36% male; mean age = 59 years, SD = 14, range = 24-86). METHODS: Information was abstracted from physical therapy records, including measurements of pulmonary impairment, 6-minute walk distance (6MWD), and Functional Status Questionnaire (FSQ) scores. Multivariate analyses were used to examine the relationships among measurements of impairment, 6MWD, and FSQ scores. RESULTS: Mean FSQ scores ranged from 52.6 for instrumental activities of daily living to 83.3 for basic activities of daily living, where 100 represents the highest level of ability. Fifty percent of patients were not working because of health problems. Percentage of predicted 1-second forced expiratory volume (FEV1), oxyhemoglobin saturation, and the ratio of FEV1 to forced vital capacity were related to 6MWD but not to FSQ scores. The 6MWD was associated with scales of the FSQ, including basic activities of daily living (R2 = .24), instrumental activities of daily living (R2 = .35), and social activity (R2 = .26). CONCLUSION AND DISCUSSION: Patients entering a pulmonary rehabilitation program have clinically important disabilities. The results support the use of the disablement process model and suggest that different and important information is obtained from measurements of impairment, functional limitation, and disability in patients with pulmonary disease.

Health status assessment in the occupational health setting.

This article discusses the conceptual roots of measuring health- related outcomes based on a biopsychosocial model of health. The selection and applicability of instruments for measurement of health status are discussed and suggestions are made concerning how health-status instruments may be used in the occupational- health setting. The potential value of measuring health status in the occupation-health setting is explored with a brief review of current literature and an example from one investigation in which measurements of health status were used to examine outcomes of common musculoskeletal impairments.

Professional uncertainty and treatment choices by physical therapists.

OBJECTIVE: To determine patient, clinician, and practice setting characteristics associated with physical therapists' treatment choices in patients with knee, lumbar, and cervical impairments. DESIGN: Secondary analysis of data from the Focus on Therapeutic Outcomes (FOTO) database. SETTING: Data from 132 physical therapy practices owned by five United States outpatient rehabilitation companies. PATIENTS: The database contained information on 5,061 patients with knee, lumbar, or cervical impairments seen in these practices in 1993 and 1994 and agreeing to participate in data collection. Our sample consisted of 2,491 patients, treated by 462 physical therapists, who had complete data on the variables of interest. RESULTS: Physical therapists' treatment choices relied on factors other than the patient's clinical status when the impairment was likely to result in professional uncertainty as to diagnosis and consequences of treatments. For patients with spinal impairments, the clinical status of the patient was associated only with the choice of endurance exercises and modalities. Patient's clinical status was associated with every treatment type in patients with knee impairments. Educational level of the physical therapist, patient load, and payer were associated with a variety of treatment choices across the impairment types. CONCLUSION: In conditions of professional uncertainty, physical therapy practice may be influenced by many idiosyncratic factors.

Lower extremity muscle force measures and functional ambulation in patients with amyotrophic lateral sclerosis.

OBJECTIVE: To examine the relation between lower extremity muscle force production and functional ambulation in patients with amyotrophic lateral sclerosis (ALS). DESIGN: Retrospective analysis of data collected from 1979 to 1995. PATIENTS: Two hundred forty ALS patients referred to the New England Medical Center Neuromuscular Research Unit. MAIN OUTCOME MEASURES: Muscle force production during a maximum, voluntary isometric contraction of ankle dorsiflexors, knee flexors, knee extensors, hip flexors, and hip extensors was calculated as percent predicted maximal force (PPMF). Functional ambulation status was classified as unable, home, or community. RESULTS: The probability of community ambulation compared with home increased with progressively higher PPMF for all muscle groups. Subjects with knee flexion strength greater than 75% PPMF were 395 times more likely to ambulate in the community. Subjects with hip extension strength over 50% PPMF showed improved chance of ambulation at home. CONCLUSION: Lower extremity PPMF is a critical factor determining functional ambulation in patients with ALS. Knee flexors play an important role in community ambulation while the hip extensors are important for home ambulation.