On the use of a six-level scale for physical activity.

The 4-level questionnaire to assess leisure-time physical activity (PA) originally described by Saltin and Grimby has been extended to a 6 (or 7)-level questionnaire, especially for the elderly or other persons with a low level of PA, expanded to include household activities. There are currently two main versions, one used in Swedish, Danish, and Norwegian studies, and one with further modifications used in Finnish studies. In this review, predictive validity for mortality and different aspects of physical performance are demonstrated. In a study regarding concurrent validity in one of the Finnish versions, significant correlations with accelerometer-based PA variables are shown. The scale has been used in a number of studies concerning effects of different types of intervention, such as physical training and increased PA, or to describe the PA level in the studied cohort. In presenting and analyzing the data, different combinations of PA levels have been used. As there are major differences between the versions, validity studies cannot easily be transformed between them. Thus, it is suggested that a common consensus be reached with respect to details of the questionnaire.

The "Saltin-Grimby Physical Activity Level Scale" and its application to health research.

The use of a four-level questionnaire to assess leisure time physical activity (PA) and its validation is reviewed in this paper. This questionnaire was first published in 1968 and has then been used by more than 600,000 subjects, especially in different population studies in the Nordic countries. A number of modifications to the questionnaire have been published. These are mostly minor changes, such as adding practical examples of activities to illustrate the levels of PA. Some authors have also added duration requirements that were not included for all levels of PA in the original version. The concurrent validity, with respect to aerobic capacity and movement analysis using objective measurements has been shown to be good, as has the predictive validity with respect to various risk factors for health conditions and for morbidity and mortality.

La importancia de estudios de investigación en la rehabilitación / Importance of research studies in rehabilitation

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Developing research capacity in human functioning and rehabilitation research from the comprehensive perspective based on the ICF-model.

With the International Classification of Functioning, Disability and Health (ICF) the World Health Organization (WHO) has prepared the ground for a comprehensive understanding of Human Functioning and Rehabilitation Research integrating the biomedical perspective on impairment with the social model of disability. This poses a number of old and new challenges regarding the enhancement of adequate research capacity. Here the authors will summarize approaches to address these challenges with respect to three areas: the organization of Human Functioning and Rehabilitation Research into distinct scientific fields, the development of suitable academic training programs and the building of university centres and collaboration networks.

Content comparison of health-related quality of life measures used in stroke based on the international classification of functioning, disability and health (ICF): a systematic review.

OBJECTIVE: To examine and compare the contents of health-related quality of life (HRQoL) measures used in stroke, based on the ICF as the frame of reference. DESIGN: We conducted a systematic literature review to select current generic and condition-specific HRQoL measures applied in stroke. We examined the contents of the selected measures by linking the concepts within the instruments' items to the ICF. RESULTS: The systematic literature review resulted in the selection of six generic and seven stroke-specific HRQoL measures. Within the selected instruments we identified 979 concepts. To map these concepts, we used 200 different ICF categories. None of the ICF categories is contained in all of the instruments. The most frequently used category is 'b152 Emotional functions' contained in 53 items from 10 instruments. Stroke-specific measures more often address 'Mental functions', while the selected generic instruments more often include Environmental Factors. DISCUSSION: The present study provides an overview on current HRQoL measures in stroke with respect to their covered contents and provides valuable information to facilitate the selection of appropriate instruments for specific purposes in clinical as well as research settings.

Cross-diagnostic validity in a generic instrument: an example from the Functional Independence Measure in Scandinavia.

BACKGROUND: To analyse the cross-diagnostic validity of the Functional Independence Measure (FIM) motor items in patients with spinal cord injury, stroke and traumatic brain injury and the comparability of summed scores between these diagnoses. METHODS: Data from 471 patients on FIM motor items at admission (stroke 157, spinal cord injury 157 and traumatic brain injury 157), age range 11-90 years and 70 % male in nine rehabilitation facilities in Scandinavia, were fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM motor items was made prior to testing fit to the model. Categories were re-scored where necessary. Fit to the model was assessed initially within diagnosis and then in the pooled data. Analysis of Differential Item Functioning (DIF) was undertaken in the pooled data for the FIM motor scale. Comparability of sum scores between diagnoses was tested by Test Equating. RESULTS: The present seven category scoring system for the FIM motor items was found to be invalid, necessitating extensive rescoring. Despite rescoring, the item-trait interaction fit statistic was significant and two individual items showed misfit to the model, Eating and Bladder management. DIF was also found for Spinal Cord Injury, compared with the other two diagnoses. After adjustment, it was possible to make appropriate comparisons of sum scores between the three diagnoses. CONCLUSION: The seven-category response function is a problem for the FIM instrument, and a reduction of responses might increase the validity of the instrument. Likewise, the removal of items that do not fit the underlying trait would improve the validity of the scale in these groups. Cross-diagnostic DIF is also a problem but for clinical use sum scores on group data in a generic instrument such as the FIM can be compared with appropriate adjustments. Thus, when planning interventions (group or individual), developing rehabilitation programs or comparing patient achievements in individual items, cross-diagnostic DIF must be taken into account.

Cross-cultural validity of FIM in spinal cord injury.

OBJECTIVE: To analyse cross-culture validity of the Functional Independence Measure (FIM) in patients with a spinal cord injury using a modern psychometric approach. SETTINGS: A total of 19 rehabilitation facilities from four countries in Europe. PARTICIPANTS: A total of 647 patients at admission, median age 46 years, 69% male. METHODS: Data from the FIM, collected on inpatient admission, was fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM items was undertaken before to testing fit to the model. Categories were rescored where necessary. Fit to the model was assessed initially within country, and then in the pooled data. Analysis of differential item functioning (DIF) was undertaken in the pooled data for each of the FIM motor and social cognitive scales, respectively. Final fit to the model was tested for breach of local independence by principle components analysis (PCA). RESULTS: The present scoring system for the FIM motor and cognitive scales, that is a seven category scale, was found to be invalid, necessitating extensive rescoring. Following this, DIF was found in a number of items within the motor scale, requiring a complex solution of splitting items by country to allow for the valid pooling of data. Five country-specific items could not be retained within this solution. The FIM cognitive scale fitted the Rasch model after rescoring, but there was a substantial ceiling effect. CONCLUSIONS: Data from the FIM motor scale for patients with spinal cord injury should not be pooled in its raw form, or compared from country to country. Only after fit to the Rasch model and necessary adjustments could such a comparison be made, but with a loss of clinical important items. The FIM cognitive scale works well following rescoring, and data may be pooled, but many patients were at the maximum score.

Scoring alternatives for FIM in neurological disorders applying Rasch analysis.

OBJECTIVE: The Functional Independence Measure (FIM) is an internationally widely used outcome measure. The aim of this study was to evaluate the structural properties of FIM using the Rasch model, with regard to scoring within rehabilitation centres in Scandinavia. MATERIALS AND METHODS: FIM data from 1660 patients with stroke, traumatic brain injury and spinal cord injury were analysed. The best models with respect to person separation were determined, together with person reliability, item separation, disordered categories, distance of more than 1.4 logits between categories and item fit to the model. RESULTS: Analysis showed disordering using seven categories in all three diagnoses. After collapsing of categories a four-category scale was the best solution. CONCLUSIONS: Decreasing the categories from seven to four may be one way of dealing with problems of disordered thresholds. Further studies are also needed in order to try the suggested scale in clinical settings and to compare it with the original FIM scale.

31P MRS evaluation of fatigue in anterior tibial muscle in postpoliomyelitis patients and healthy volunteers.

Changes in concentration of high energy phosphates and pH were studied during rest, exercise and subsequent recovery in the anterior tibial muscle of 10 patients with late effects of poliomyelitis and 10 age- and sex-matched healthy volunteers using 31P MRS. The exercise was dynamic and isometric, and the force levels were individually adapted to each subject and stepwise increased. In general, there were no differences in metabolite changes between the groups, except for lower Pi and Pi/PCr for the volunteers during the recovery phase, also reflected by shorter recovery half-time for Pi. The interindividual variation was much higher for the patient group. Some of the patients showed deviating results probably because of differences in muscle fibre type.

GH is needed for the maturation of muscle mass and strength in adolescents.

The postpubertal period and the early years of adulthood may be of importance for continuing tissue maturation of importance in adulthood and aging. An example of this is the peak bone mass. This study has evaluated the importance of GH for lean mass and muscle strength in adolescents and young adults. GH treatment was discontinued in 40 adolescents aged 16-21 yr with GH deficiency of childhood onset. Measurements of isometric and isokinetic knee-extensor and flexor strength, handgrip strength, lean body mass, fat-free mass, and total body nitrogen were performed annually for 2 yr. Two hundred fifty healthy adolescents were randomly selected for prospective measurements of lean mass and handgrip strength between the ages of 17 and 21 yr. In the adolescents with continuing GH deficiency, lean body mass decreased, compared with the patients defined as having sufficient endogenous GH. The isometric strength in knee flexors increased in the sufficient endogenous GH group and was unchanged in the GH deficiency group during the 2 yr off GH treatment (between group, P < 0.05). The mean and peak handgrip strength increased on average by 9-15% in the group with sufficient endogenous GH and was unchanged in those with GH deficiency (P < 0.05). Lean body mass and handgrip strength (both, P < 0.001) increased in both the healthy boys and girls who were followed for 4 yr with a more marked increase in the boys. The mean increase in handgrip between the age of 17 and 21 yr was 7-9%. The increased lean mass and improved muscle performance seen in healthy adolescents did not occur in adolescents with GH deficiency. These findings suggest that GH is of importance for the maturation of lean mass and muscle strength in adolescents and young adults.

Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground.

OBJECTIVE: To compare the effect of walking training on a treadmill with body weight support (BWS) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke. DESIGN: Randomized controlled experimental study. SETTING: Multicentre design; three departments of rehabilitation medicine. SUBJECTS: Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were randomized into a treatment group and a control group. INTERVENTIONS: The treatment group received walking training on a treadmill with BWS for 30 minutes, 5 days a week. The control group received walking training according to the Motor Relearning Programme (MRP) on the ground for 30 minutes 5 days a week, not including treadmill training. During the time in the rehabilitation department (about two months), all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM), walking velocity for 10 m, Functional Ambulation Classification (FAC), Fugl-Meyer Stroke Assessment and Berg's Balance Scale. The assessments were performed at admission, at discharge and at 10-month follow-up. RESULTS: There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM, walking velocity, FAC, Fugl-Meyer Stroke Assessment, and Berg's Balance Scale. Patients in both groups improved in these variables from admission to the 10-month follow-up. CONCLUSIONS: Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground.

Ability and perceived difficulty in daily activities in people with poliomyelitis sequelae.

Polio involvement and its relation to ability in terms of independence and perceived difficulty in activities in daily living (ADL) were studied in outpatients (median age 57 years) with poliomyelitis sequelae (n = 133). The use and need of assistive devices and housing conditions were recorded. The subjects had a high degree of independence in personal ADL, whereas more than 50% were dependent on cleaning, shopping and transportation. A considerable number of subjects independent in ADL reported difficulties in daily activities. The majority of interventions in the form of housing adaptation and assistive devices were provided for persons severely weakened by polio. Ratings of perceived difficulty indicated need of interventions to prevent overload and increased dependence in ADL. However, about half of the recommended mobility assistive devices were rejected. The results indicate that polio subjects try to maintain their independence despite perceived difficulties and may be reluctant to use assistive devices.

Distress in everyday life in people with poliomyelitis sequelae.

The prevalence of distress in aspects of perceived health and its relation to involvement of poliomyelitis sequelae were studied with the Nottingham Health Profile (NHP) in 113 outpatients (mean age 57 years). The leisure and employment situation was also recorded. Most distress was found in the NHP dimensions physical mobility, pain and energy, and least distress in social isolation. Most health-related problems were reported in housework, employment and leisure. Three-quarters of the persons were satisfied with their leisure, although many of them had problems. Fifty-nine per cent of the subjects of working age were in gainful employment, and no difference in employment rate due to the distribution of polio involvement was found. In comparison with norm values for the respective age groups, the subjects with poliomyelitis sequelae aged below 45 and 45-65 years had more distress in a larger number of NHP dimensions than older subjects.

Muscular effects in late polio.

New or increased muscular weakness, fatigue and muscle and joint pain with neuropathic electromyography (EMG) changes in a person with a confirmed history of polio constitute the cardinal symptoms of the post-polio syndrome. Unusual tiredness or fatigue is a common complaint in late polio subjects as is intolerance to cold. Fatigue in polio subjects can have several explanations: emotional fatigue, central nervous system fatigue, 'general' fatigue and/or neuromuscular fatigue. Some studies indicate central fatigue, but it is unclear how often and to which degree there will be a central muscular fatigue. Polio patients are known to be deconditioned (reduced function because of low activity level), and aerobic power is reduced. Defects in the neuromuscular transmission may be present but are not seen in all post-polio subjects with reduction in force and increased fatigability. The fatigue experienced by late polio patients is most likely an augmented peripheral muscle fatigue. Possible explanations may be an imperfection in the sarcoplasmatic reticulum with altered calcium release mechanisms (activation) or in sliding filament function (contractile properties). This may be a secondary effect to the enlarged muscle fibres. However, the prolonged subjective feeling of fatigue reported despite unchanged maximal voluntary contraction (MVC) remains unexplained.

Reliability of an interview approach to the Functional Independence Measure.

OBJECTIVE: To establish the reliability of an interview approach to the Functional Independence Measure (FIM). DESIGN: Two raters were present at the same time during the interviews in the home and did independent ratings of the 18 FIM items. The interview procedure was repeated within a week by another two raters in the clinic. SUBJECTS: Sixty-three stroke survivors (median age 63 years, range 18-71 years) were studied approximately two years after onset. RATERS: Three occupational therapists and one nurse. METHODS: Reliability was calculated as unweighted kappa statistics, percentage agreement (PA), and intraclass correlation coefficient (ICC). RESULTS: Best agreement was found in the motor items of FIM. The kappa statistics showed good to excellent inter-rater values during the same interview except for the Social interaction item. The ICCs based on sum-score for motor (0.92) and social-cognitive items (0.75) respectively, were similar to those reported in the literature. The repeated interview by different raters showed less stable agreement according to kappa values for the items dealing with transfers, locomotion and social-cognition. CONCLUSIONS: FIM assessments showed high inter-rater agreement for the same interview setting (home as well as clinic), but the stability of the measure over time with a repeated interview by different raters was somewhat less satisfactory.

Dynamic water exercise in individuals with late poliomyelitis.

OBJECTIVE: To evaluate the specific effects of general dynamic water exercise in individuals with late effects of poliomyelitis. DESIGN: Before-after tests. SETTING: A university hospital department. PARTICIPANTS: Twenty-eight individuals with late effects of polio, 15 assigned to the training group (TG) and 13 to the control group (CG). INTERVENTION: The TG completed a 40-minute general fitness training session in warm water twice weekly. Assessment instruments included the bicycle ergometer test, isokinetic muscle strength, a 30-meter walk indoors, Berg balance scale, a pain drawing, a visual analog scale, the Physical Activity Scale for the Elderly, and the Nottingham Health Profile (NHP). MAIN OUTCOME MEASURES: Peak load, peak work load, peak oxygen uptake, peak heart rate (HR), muscle function in knee extensors and flexors, and pain dimension of the NHP. RESULTS: The average training period was 5 months; compliance was 75% (range, 55-98). No negative effects were seen. The exercise did not influence the peak work load, peak oxygen uptake, or muscle function in knee extensors compared with the controls. However, a decreased HR at the same individual work load was seen, as well as a significantly lower distress in the dimension pain of the NHP. Qualitative aspects such as increased well-being, pain relief, and increased physical fitness were reported. CONCLUSIONS: A program of nonswimming dynamic exercises in heated water has a positive impact on individuals with late effects of polio, with a decreased HR at exercise, less pain, and a subjective positive experience. The program was well tolerated (no adverse effects were reported) and can be recommended for this group of individuals.

The use of outcome measures in physical medicine and rehabilitation within Europe.

The aim of the study was to survey the use of outcome measures in rehabilitation within Europe. It was envisaged that this would provide the basis for further studies on the cross-cultural validity of outcome measures. A postal questionnaire was distributed in November 1998 to 866 units providing rehabilitation. In total, 418 questionnaires were returned, corresponding to a response rate of 48%. These 418 centres treated an estimated 113,000 patients annually, undertaking 360,000 assessments. The survey focused on nine diagnostic groups: hip and knee replacement, low back pain, lower limb amputees, multiple sclerosis, neuromuscular disorders, rheumatoid arthritis, spinal cord lesions, stroke and traumatic brain injury. It identified a relatively small number of dominant outcome assessments for each diagnostic group and some variation in the preference for measures across regions. A large number of measures, however, are being used in one or a small number of locations and with relatively few patients. For rehabilitation of orthopaedic patients the majority of assessments undertaken are at the impairment level. For patients with neurological disorders the emphasis is mostly upon measures of disability.

Dependence and perceived difficulty in activities of daily living in adults with cerebral palsy and spina bifida.

PURPOSE: The purpose of this study was to identify differences between two groups of subjects: one with cerebral palsy, the other with spina bifida in their dependence and their perceived difficulty in performing daily activities according to the Functional Independence Measure (FIM) and the Instrumental Activity Measure (IAM), and to compare these findings with the reported use of assistance. METHOD: Community-living persons. 53 with cerebral palsy and 20 with spina bifida, aged 20 to 39 years, participated in semistructured interviews in their homes, where rating was performed using items from FIM and IAM. RESULTS: Differences were found for the reported use of assistance and the dependence rated according to FIM and IAM. Significant differences for dependence were found between the CP and SB subjects concerning Eating, Bladder and Bowel items and for perceived difficulty concerning toileting, bladder and bowel. There was close overall agreement between dependence and perceived difficulty, except for the item walk/wheelchair. CONCLUSIONS: Subjects in both groups needed help in basic and instrumental ADL. The ability of spina bifida subjects was more influenced in toileting, bladder, bowel than the cerebral palsy subjects and tended also to be so in mobility instrumental tasks. FIM and IAM do not cover all aspects of significance in community-living adults. Further items have to be developed, covering personal care and occupational as well as leisure domains.