Application of the Rasch measurement model in rehabilitation research and practice: early developments, current practice, and future challenges.

The application of the Rasch measurement model in rehabilitation is now well established. Both its dichotomous and polytomous forms provide for transforming ordinal scales into interval-level measures, consistent with the requirements of fundamental measurement. The growth of applying the model in rehabilitation spans 30 years, during which both the protocol has steadily developed and several software packages have emerged that provide for analysis, together with the "R" language that has an increasing set of codes for applying the model. This article reviews that development and highlights current practice requirements, including those for providing the relevant information for the methods, and what is expected of the analysis. In addition, this provides a worked example and looks at the remaining issues and current developments of its application.

Rehabilitation interventions in osteoarthritis.

The goals of the management of osteoarthritis (OA) are to relieve joint pain and stiffness, maintain or increase joint mobility and stability, improve activities and participation, and enhance quality of life. The first step in the management is to make a comprehensive holistic assessment to understand the impact of the disease on the individual. Then, an individualized management plan can be set via a shared-decision making process between the patient and the clinician taking into account all components of functioning affected by the disease. Rehabilitation interventions serve as the basis of OA management whereas pharmacological modalities are usually administered for additional symptom control. This study aimed to overview the rehabilitation interventions used for people with OA with an update of the recent evidence. First, core management approaches that include patient education, physical activity and exercises, and weight loss were addressed; then adjunctive treatments including biomechanical interventions (e.g. orthoses, assistive devices) and physical modalities were overviewed.

Development of simple descriptions of the ICF Generic-30 Set in different languages: laying the foundation for an ICF-based clinical tool for Europe.

BACKGROUND: Functioning is considered a third indicator of health and a key outcome in rehabilitation. A universal practical tool for collecting functioning information is essential. This tool would be ideally based on the International Classification of Functioning, Disability and Health. AIM: To report the results of the development of country/language-specific versions of an ICF-based clinical tool in six European countries. DESIGN: Consensus process. SETTING: Expert conferences. POPULATION: Multi-professional group of rehabilitation professionals in six European countries. METHODS: 1) Developed an initial proposal by translating the published English-language version of the simple descriptions into the targeted language; 2) conducted a multi-stage consensus conference to finalize the descriptions; 3) employed a three-stage multi-professional expert panel translation back to English. The consensus conference model was modified for geographically large countries. RESULTS: Croatian, Flemish/Dutch, Greek, Polish, and Turkish versions were produced. CONCLUSIONS: The creation of the country/language-specific simple descriptions is a significant part of the "system-wide implementation of the ICF" initiative that will pave the way for the implementation of the ICF in national health systems. CLINICAL REHABILITATION IMPACT: The practical ICF-based clinical tool with country/language specific versions for standardized reporting of functioning will serve as a means of integrating functioning information in national health systems and additionally for monitoring the effects of rehabilitation interventions.

Overview of Cochrane Systematic Reviews of rehabilitation interventions for persons with rheumatoid arthritis: a mapping synthesis.

The aim of this paper was to provide an overview of Cochrane Systematic Reviews (CSRs), which synthesizes the quality and quantity of available evidence on the effectiveness of rehabilitation interventions in rheumatoid arthritis (RA). The World Health Organization (WHO) requested Cochrane Rehabilitation the CSRs search to develop the Package of Interventions in Rehabilitation (PIR). We searched the Cochrane Library using the terms "rheumatoid arthritis" and "rehabilitation." We screened the CSRs according to the search strategy based on the methodology developed for the WHO PIR. The search period for the data provided to WHO was between 1 September 2009 and 2019. We updated the search to 1 September 2022 for this paper. We summarized the CSRs identified after the screening process using an evidence map, grouping outcomes, and comparisons of included CSRs indicating the effect and the quality of evidence to provide a comprehensive view of current knowledge. We identified 10 CSRs, including 92 primary studies with 10,801 participants and 23 comparisons. They explored the effectiveness and/or safety of either non-pharmacological or pharmacological (for symptom control only) interventions. Outcomes were pain, muscle strength, grip/pinch strength, tender joints, swollen joints, fatigue, disease activity, radiological damage, physical function, hand function, participant adherence, clinical improvement, withdrawals, and adverse events. Our mapping synthesis indicates that physical activity and exercises in RA are effective non-pharmacological interventions for some outcomes, such as hand function, muscle strength and fatigue, without any deterioration of pain, disease activity and radiological involvement. Psychosocial interventions show a small beneficial effect on fatigue. Regarding pharmacological agents, celecoxib presents similar analgesic effects with traditional NSAIDs but fewer gastric adverse events. Current evidence supports physical activity and exercise programs for individuals with RA. However, well-designed studies will help document the exact effects of these programs on different outcomes and physiological mechanisms in RA. There were inconclusive results for some of the interventions due to low and very-low quality of evidence. Furthermore, due to the lack of CSRs on therapeutic patient education, orthoses, physical modalities and assistive devices in the search period, it was impossible to synthesise the evidence on those interventions.

Scale Banking for Patient-Reported Outcome Measures That Measure Functioning in Rheumatoid Arthritis: A Daily Activities Metric.

OBJECTIVE: Functioning is an important outcome for the management of rheumatoid arthritis (RA). Heterogeneity of respective patient-reported outcome measures (PROMs) challenges direct comparisons between their results. This study aimed to standardize reporting of such PROMs measuring functioning in RA to facilitate comparability. METHODS: Common-item nonequivalent group design with the Health Assessment Questionnaire (HAQ) as a common scale across data sets from various countries (including the UK, Turkey, and Germany) to establish a common metric was used. Other PROMs included are the physical function items of the Multidimensional HAQ (MDHAQ), the Disabilities of the Arm, Shoulder, and Hand questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the World Health Organization Disability Assessment Schedule II (WHODAS II), the Medical Outcomes Study Short Form 36 (SF-36) health survey, and 4 short forms (20, 10, 6, and 4 physical function items) from the Patient-Reported Outcomes Measurement Information System. As the HAQ includes mobility, self-care, and domestic life items, this study focuses on these 3 domains. PROMs were described using standard error of measurement (SEM) and smallest detectable difference (SDD). A Rasch measurement model was used to create the common metric. RESULTS: The range of the SEM was 0.2 (MDHAQ) to 7.4 (SF-36 health survey physical functioning domain). The SDD revealed a range from 9.7% (WOMAC rating scale) to 33.5% (WHODAS physical functioning domain). PROMs co-calibration revealed fit to the Rasch measurement model. A transformation table was developed to allow exchange between PROM scores. CONCLUSION: Scores between the daily activity PROMs commonly used in RA can now be compared. Factors such as SEM and SDD help to determine the choice of a PROM in clinical practice and research.

Use and detailed metric properties of patient-reported outcome measures for rheumatoid arthritis: a systematic review covering two decades.

INTRODUCTION: The importance of patient-reported outcome measures (PROMs) for rheumatoid arthritis (RA) clinical studies has been recognised for many years. The current study aims to describe the RA PROMs used over the past 20 years, and their performance metrics, to underpin appropriate tool selection. METHODS: The study included a systematic search for PROMs that have been in use over the period 2000-2019, with detailed documentation of their psychometric properties, and a user-friendly presentation of the extensive evidence base. RESULTS: 125 PROMs were identified with psychometric evidence available. The domains of pain, fatigue, emotional functions, mobility, physical functioning and work dominated, with self-efficacy and coping as personal factors. Domains such as stiffness and sleep were poorly served. The most frequently used PROMs included the Health Assessment Questionnaire Disability Index (HAQ), the Short Form 36 (SF-36), the EuroQoL and the Modified HAQ which, between them, appeared in more than 3500 papers. Strong psychometric evidence was found for the HAQ, and the SF-36 Physical Functioning and Vitality (fatigue) domains. Otherwise, all domains except stiffness, sleep, education and health utility, had at least one PROM with moderate level of psychometric evidence. CONCLUSION: There is a broad range of PROMs for measuring RA outcomes, but the quality of psychometric evidence varies widely. This work identifies gaps in key RA domains according to the biopsychosocial model.

Is transcranial direct current stimulation (tDCS) effective for improving aphasia in adults with aphasia after stroke? - A Cochrane Review summary with commentary.

Missing.

Cross-diagnostic scale-banking using rasch analysis: Developing a common reference metric for generic and health condition-specific scales in people with rheumatoid arthritis and stroke.

OBJECTIVES: To develop a common reference metric of functioning, incorporating generic and health condition-specific disability instruments, and to test whether this reference metric is invariant across 2 health conditions. DESIGN: Psychometric study using secondary data analysis. Firstly, the International Classification of Functioning, Disability and Health (ICF) Linking Rules were used to examine the concept equivalence between the World Health Organization Disability Assessment Schedule (WHODAS 2.0), Health Assessment Questionnaire (HAQ) and Functional Independence Measure (FIMTM). Secondly, a scale-bank was developed using a reference metric approach to test-equating, based on the Rasch measurement model. PARTICIPANTS: Secondary analysis was performed on data from 487 people; 61.4% with rheumatoid arthritis and 38.6% with stroke. RESULTS: Three sub-domains of the WHODAS 2.0 and all items of the HAQ and FIMTM motor mapped on to the ICF chapters d4 Mobility, d5 Self-care and d6 Domestic life. Test-equating of these scales resulted in good model fit, indicating that a scale bank and associated reference metric across these 3 instruments could be created. CONCLUSION: This study provides a transformation table to enable direct comparisons among instruments measuring physical functioning commonly used in rheumatoid arthritis (HAQ) and stroke (FIMTM motor scale), as well as in people with disability in general (WHODAS 2.0).

Nonpharmacological treatment in established rheumatoid arthritis.

The goals in the management of established rheumatoid arthritis (RA) are to control pain and disease activity, prevent further joint damage, and enhance functioning and quality of life. Despite the fact that aggressive and the early use of biological and nonbiological disease-modifying antirheumatic drugs have been associated with substantial gains in clinical, radiological, and disability outcomes, a considerable proportion of patients still report significant problems of physical, emotional and social functioning, and unmet needs in established RA. Therefore, nonpharmacological treatments are also administered for patients with RA. The aim of this article is to overview the nonpharmacological, therapeutical, and rehabilitative interventions, to minimize the consequences of the disease in patients with established RA. First, the principles of functional assessment in RA will be addressed. Then nonpharmacological interventions including therapeutic patient education, exercise therapy, physical modalities, orthoses, assistive devices, dietary interventions, and balneotherapy will be reviewed in the light of evidence-based literature data.

Evidence-based position paper on Physical and Rehabilitation Medicine professional practice for persons with stroke. The European PRM position (UEMS PRM Section).

BACKGROUND: Stroke is a major cause of disability worldwide, with an expected rise of global burden in the next twenty years throughout Europe. This EBPP represents the official position of the European Union through the UEMS Physical and Rehabilitation Medicine (PRM) Section and designates the professional role of PRM physicians for people with stroke. The aim of this study is to improve PRM physicians' professional practice for persons with stroke in order to promote their functioning and enhance quality of life. METHODS: A systematic review of the literature including a ten-year period and a consensus procedure by means of a Delphi process has been performed involving the delegates of all European countries represented in the UEMS PRM Section. RESULTS: The systematic literature review is reported together with 78 recommendations resulting from the Delphi procedure. CONCLUSIONS: The professional role of PRM physicians for persons with stroke is to improve specialized rehabilitation services worldwide in different settings and to organize and manage the comprehensive rehabilitation programme for stroke survivors considering all impairments, comorbidities and complications, activity limitations and participation restrictions as well as personal and environmental factors.

Is physical rehabilitation effective for Wernicke-Korsakoff syndrome? A case report.

Wernicke-Korsakoff syndrome is a type of brain disorder caused by the lack of thiamine, most commonly because of chronic alcohol misuse. It consists of two separate conditions including Wernicke's encephalopathy and Korsakoff syndrome. Various levels of cognitive impairments are associated with the severity of the syndrome. Although the effectiveness of thiamine replacement in the early phases of the syndrome is proven, the efficacy of subsequent treatments, which mainly include rehabilitation protocols after the development of Korsakoff syndrome, is not clear. This is the first report showing the positive effects of physical rehabilitation in a 48-year-old male patient with Wernicke-Korsakoff syndrome.

The role of Interdisciplinary Teams in Physical and Rehabilitation Medicine.

The increasing complexity of healthcare provision and medical interventions requires collaboration between large numbers of health professionals. The nature of the interactions between team members determines whether the pattern of working is described as multi-, inter- or trans-disciplinary. Such team-working is an important part of the specialty of Physical and Rehabilitation Medicine. Grounded in group behaviour theory, team-working demonstrates that joint aims, trust and willingness to share knowledge, can improve patient outcomes, including mortality. The synthesis of individual skills and knowledge and working to common patient goals, has shown benefit in many conditions. This evidence base is perhaps best in stroke, but has been demonstrated in many other conditions, including acquired brain injury, back pain, mental health, cardiopulmonary conditions, chronic pain and hip fracture. There are also considerable benefits to staff and health organizations in terms of outcome and staff morale. This review paper examines the evidence for the benefit of such team-working and for the recommendations of team-working in rehabilitation services.

Patient-reported outcome measures in osteoarthritis: a systematic search and review of their use and psychometric properties.

INTRODUCTION: Patient-reported outcome measures (PROM) or self-completed questionnaires have been used to report outcomes in osteoarthritis (OA) for over 35 years. Choices will always need to be made about what should be measured and, if relevant, what would be the most appropriate PROM to use. The current study aims to describe the available PROMs used in OA and their performance quality, so that informed choices can be made about the most appropriate PROM for a particular task. METHODS: The study included a systematic search for PROMs that have been in use over 17 years (period 2000-2016), and to catalogue their psychometric properties, and to present the evidence in a user-friendly fashion. RESULTS: 78 PROMs were identified with psychometric evidence available. The domains of pain, self-care, mobility and work dominated, whereas domains such as cleaning and laundry and leisure, together with psychological and contextual factors, were poorly served. The most frequently used PROMs included the Western Ontario McMaster Osteoarthritis Index, the Short Form 36 and the Knee Disability and Osteoarthritis Outcome Score which, between them, appeared in more than 4000 papers. Most domains had at least one PROM with the highest level of psychometric evidence. CONCLUSION: A broad range of PROMs are available for measuring OA outcomes. Some have good psychometric evidence, others not so. Some important psychological areas such as self-efficacy were poorly served. The study provides a current baseline for what is available, and identifies the shortfall in key domains if the full biopsychosocial model is to be explored.

Kinaesthetic ability training improves unilateral neglect and functional outcome in patients with stroke: A randomized control trial.

OBJECTIVE: To investigate the effects of kinaesthetic ability training with the Kinesthetic Ability Trainer (KAT) on unilateral neglect and functional outcomes in stroke patients. STUDY DESIGN: An assessor-blinded, randomized controlled, clinical trial. METHODS: A total of 64 stroke patients with unilateral neglect (mean age 61 (standard deviation (SD) 12) years, 60.4% male, mean time since stroke 6.4 (SD 10.4) months, left hemiplegia 92.5%) were randomly assigned to a conventional rehabilitation programme (control group, n = 32) or KAT plus a conventional rehabilitation programme (KAT group, n = 32) for 4 weeks. Patients were assessed with the Behavioral Inattention Test (BIT) and Functional Independence Measure (FIM) before and after therapy. RESULTS: Both groups showed significant improvements in all subscales of the BIT (conventional and behavioural) (p < 0.001) and the FIM motor scale (p < 0.001) after therapy. Recovery from neglect was assessed, based on the BIT cut-off scores. The recovery rate for behavioural BIT was 40% in the KAT group and 17.9% in the control group (p = 0.07), whereas recovery rates according to the conventional BIT were 16% and 10.7% in the KAT and control groups, respectively. CONCLUSION: Kinaesthetic ability training provides clinically meaningful improvement in stroke patients with unilateral neglect. It may be useful as an adjunctive therapy for rehabilitation in these patients.

Adaptation of the osteoarthritis-specific quality of life scale (the OAQoL) for use in Germany, Hungary, Italy, Spain and Turkey.

The Osteoarthritis Quality of Life scale (OAQoL) is specific to individuals with osteoarthritis. The present study describes the adaptation of the OAQoL for use in the following five European languages: German, Hungarian, Italian, Spanish and Turkish. The study involved three stages in each language; translation, cognitive debriefing (face and content validity) and validation. The validation stage assessed internal consistency (Cronbach's alpha), reproducibility (test-retest reliability using Spearman's rank correlations), convergent and divergent validity (correlations with the Health Assessment Questionnaire, The Western Ontario and McMaster Universities Index of osteoarthritis and Nottingham Health Profile) and known group validity. The OAQoL was successfully translated into the target languages with minimal problems. Cognitive debriefing interviewees found the measures easy to complete and identified few problems with content. Internal consistency ranged from 0.94 to 0.97 and test-retest reliability (reproducibility) from 0.87 to 0.98. These values indicate that the new language versions produce very low levels of measurement error. Median OAQoL scores were higher for patients reporting a current flare of osteoarthritis in all countries. Scores were also related, as expected, to perceived severity of osteoarthritis. The OAQoL was successfully adapted for use in Germany, Hungary, Italy, Spain and Turkey. The addition of these new language versions will prove valuable to multinational clinical trials and to clinical practice in the respective countries.

Adaptation and validation of the Ankylosing Spondylitis Work Instability Scale (AS-WIS) for use in Turkey.

The Ankylosing Spondylitis Work Instability Scale (AS-WIS) is a recently developed 20-item measure to assess work instability in AS. This study aimed to adapt the AS-WIS to Turkish and to test its reliability and validity. After the translation process, 132 AS patients were assessed by the AS-WIS, Bath AS Disease Activity Index, Bath AS Functional Index and the AS Quality of Life Questionnaire. Reliability was tested by internal consistency, person separation index (PSI) and intra-class correlation coefficient (ICC); internal construct validity by Rasch analysis; external construct validity by associations with comparator scales and cross-cultural validity by comparison with the original UK data. Reliability of the Turkish AS-WIS was good with Cronbach's α and PSI of 0.88 and test-retest ICC of 0.91. Data showed good fit to Rasch model [mean item fit: -0.477 (SD 1.047), Chi-square interaction: 60.9 (df = 40, p = 0.018)]. There was no differential item functioning by age, gender, disease duration or work type. The scale was strictly unidimensional. 51 % of the patients were at moderate risk, and 9 % were at high risk of having to give up their work. External construct validity was confirmed by expected correlations with comparator scales, and a clear gradient of disease activity and functional status across increasing levels of risk. Cross-cultural validity showed some differences in item locations, but this cancelled out at the test level. Turkish version of the AS-WIS is reliable, valid and available for use in routine clinical setting to identify patients who are at risk of having to give up their current job.

The reliability and validity of the World Health Organization Disability Assessment Schedule (WHODAS-II) in stroke.

PURPOSE: Psychometric properties of the World Health Organization Disability Assessment Schedule (WHODAS-II) in stroke have received some attention recently, mostly using classical approaches, but there is still an absence of investigation from a modern psychometric perspective. This study aimed to test the reliability and validity of the WHODAS-II in stroke, using modern psychometric analysis. METHODS: A total of 188 community-dwelling poststroke patients were recruited. Internal construct validity was assessed by Rasch analysis, reliability by internal consistency and person separation index (PSI), and external construct validity by associations with Functional Independence Measure (FIM(™)). RESULTS: Rasch analysis indicated that total score (based upon 32 items, omitting the work-related items) was satisfactory, after adjustment for local dependency. The proposed "activities" and "participation" components also satisfied Rasch model expectations. An existing short form was problematic due to inclusion of a work-related item, but an alternative 10-item version was acceptable. Cronbach's α for the WHODAS-II, its domains and components varied between 0.83 and 0.99 and PSI between 0.70 and 0.95. External construct validity was confirmed by expected correlations with FIM(™). CONCLUSIONS: WHODAS-II provides a reliable and valid instrument for measuring disability and components of "activities" and "participation" in stroke survivors. Various combinations of the item set may provide a range of scales to suit most research needs.

Reliability, construct validity and measurement potential of the ICF comprehensive core set for osteoarthritis.

BACKGROUND: This study aimed to investigate the reliability and construct validity of the International Classification of Functioning, Disability and Health (ICF) Comprehensive Core Set for osteoarthritis (OA) in order to test its possible use as a measuring tool for functioning. METHODS: 100 patients with OA (84 F, 16 M; mean age 63 yr) completed forms including demographic and clinical information besides the Short Form (36) Health Survey (SF-36®) and the Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC). The ICF Comprehensive Core Set for OA was filled by health professionals. The internal construct validities of "Body Functions-Body structures" (BF-BS), "Activity" (A), "Participation" (P) and "Environmental Factors" (EF) domains were tested by Rasch analysis and reliability by internal consistency and person separation index (PSI). External construct validity was evaluated by correlating the Rasch transformed scores with SF-36 and WOMAC. RESULTS: In each scale, some items showing disordered thresholds were rescored, testlets were created to overcome the problem of local dependency and items that did not fit to the Rasch model were deleted. The internal construct validity of the four scales (BF-BS 16 items, A 8 items, P 7 items, EF 13 items) were good [mean item fit (SD) 0.138 (0.921), 0.216 (1.237), 0.759 (0.986) and -0.079 (2.200); person item fit (SD) -0.147 (0.652), -0.241 (0.894), -0.310 (1.187) and -0.491 (1.173) respectively], indicating a single underlying construct for each scale. The scales were free of differential item functioning (DIF) for age, gender, years of education and duration of disease. Reliabilities of the BF-BS, A, P, and EF scales were good with Cronbach's alphas of 0.79, 0.86, 0.88, and 0.83 and PSI's of 0.76, 0.86, 0.87, and 0.71, respectively. Rasch scores of BF-BS, A, and P showed moderate correlations with SF-36 and WOMAC scores where the EF had significant but weak correlations only with SF36-Social Functioning and SF36-Mental Health. CONCLUSION: Since the four different scales derived from BF-BS, A, P, and EF components of the ICF core set for OA were shown to be valid and reliable through a combination of Rasch analysis and classical psychometric methods, these might be used as clinical assessment tools.

Strategies for assessment and outcome measurement in physical and rehabilitation medicine: an educational review.

The aim of this educational review, which is based upon expert opinion, is to describe to clinicians training in Physical and Rehabilitation Medicine and research students training to work in the field, the appropriate attributes and standards required for assessment and outcome measurement. "What to assess" is discussed in the context of the conceptual framework provided by the International Classification of Functioning, Disability and Health, supplemented with quality of life as an additional construct. The reasons for making the assessment, and the context in which the assessment will be used, are then considered. Examples of recommendations of some international organizations regarding what and how to assess are presented. Suggestions are made about the selection of assessment tools, including examples from two diagnostic groups: stroke and rheumatoid arthritis. Finally, the basic psychometric standards required for any assessment tool, and additional requirements for outcome assessment, are explained.