Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain.

PURPOSE: To compare the work-related limitations assessed using self-report, clinical examination and functional testing in patients with chronic low back pain (CLBP). METHODS: Work-related limitations of 92 patients were assessed using self-report, clinical examination and functional testing. To obtain the assessed limitations the patient (self-report), the physician (clinical examination) and a trained evaluator (functional testing) completed a scorings form about the work-related limitations of the patient. The Isernhagen Work Systems Functional Capacity Evaluation (IWS FCE) was used to obtain the functional testing results. A kappa value of more than 0.60, absolute agreement of more than 80% and ICC of more than 0.75 were considered as acceptable. RESULTS: Little agreement and correlation among self-report, clinical examination and functional testing were found for the assessment of work-related limitations. Self-reported limitations were considerably higher than from those derived from clinical examination or functional testing. Additionally, the limitations derived from the clinical examination were higher than those derived from the IWS FCE. CONCLUSION: Comparing self-report, clinical examination and functional testing for assessing work-related limitations in CLBP patients showed large considerable differences in limitations. Professional health care workers should be aware of these differences when using them in daily practice.

Reliability and stability of the Roland Morris Disability Questionnaire: intra class correlation and limits of agreement.

PURPOSE: To analyse test-retest reliability and stability of the Dutch language version of the Roland Morris Disability Questionnaire (RMDQ) in a sample of patients (n = 30) suffering from Chronic Low Back Pain (CLBP). METHOD: Patients filled out the Dutch language version of the RMDQ questionnaire twice, before starting the rehabilitation programme, with a 2-week interval. Intra Class Correlations (ICC), (one way random) was used as a measure for reliability and the limits of agreement were calculated for quantifying the stability of the RMDQ. An ICC of 0.75 or more was considered as an acceptable reliability. No criteria for limits of agreement were available. However, smaller limits of agreement indicate more stability because it indicates that the natural variation is small. RESULTS: The Dutch RMDQ showed good reliability, with an ICC of 0.91. Calculating limits of agreement to quantify the stability, a large amount of natural variation ( +/- 5.4) was found relative to the total scoring range of 0 to 24. CONCLUSION: The Dutch RMDQ proves to be a reliable instrument to measure functional status in CLBP patients. However, the natural variation should be taken into account when using it clinically.

Test-retest reliability of the Isernhagen Work Systems Functional Capacity Evaluation in patients with chronic low back pain.

The aim of this study was to investigate test-retest reliability of the Isernhagen Work System Functional Capacity Evaluation (IWS FCE) in a sample of patients (n = 30) suffering from Chronic Low Back Pain (CLBP) and selected for rehabilitation treatment. The IWS FCE consists of 28 tests that reflect work-related activities like lifting, carrying, bending, etc. In this study, a slightly modified IWS FCE was used. Patients were included in the study if they were still at work or were less than 1 year out of work because of CLBP. Participants' mean age was 40 years, the duration of low back pain ranged between 5 and 10 years. Fifteen patients (50%) were out of work for a mean of 17 weeks, and they all received financial compensation. Two FCE sessions were held with a 2-week interval in between. Means per session, 95% confidence intervals of the mean difference, one-way random Intra Class Correlations (ICC), limits of agreement, Cohen's kappa and percentage of absolute agreement were calculated where appropriate. An ICC of 0.75 or more, a kappa value of more than 0.60 and a percentage of absolute agreement of 80% were considered as an acceptable reliability. Tests of the IWC FCE were divided into tests with and tests without an acceptable test-retest reliability on the basis of the kappa values, the percentage of absolute agreement and the ICC values. Fifteen tests (79%) showed an acceptable test-retest reliability based on Kappa values and percentage of absolute agreement. Eleven tests (61%) showed an acceptable test-retest reliability based on ICC values.

The reliability of determining effort level of lifting and carrying in a functional capacity evaluation.

OBJECTIVES: To establish inter- and intra-rater reliability of observations in a functional capacity evaluation. BACKGROUND: Functional capacity evaluations are used to assess a person's functional capacity as it relates to work. Lifting and carrying are important aspects of a functional capacity evaluation. An evaluator determines the patient's levels of effort through standardized observations. Questions remain with regards to the reliability of these observations. METHODS: Four healthy subjects were videotaped while performing two lifts and four carries with progressive loads. The videotape was scrambled randomly and viewed twice by 3 physical therapists and 2 occupational therapists. The evaluators determined the amount of effort it required (light, medium, heavy, and maximum). The inter- and intra-rater reliability of the observations was expressed by means of percentage agreement. RESULTS: Inter-rater reliability ranged 87-96%, intra-rater reliability ranged 93-97%. CONCLUSION: The results indicate that by means of standardized observations, therapists can reliably determine effort level during lifting and carrying in healthy subjects, and thus affirm the findings of other studies of similar design.

Test-retest reliability of lifting and carrying in a 2-day functional capacity evaluation.

The objectives of this study were to establish test-retest reliability of lifting and carrying of a functional capacity evaluation (FCE) on two consecutive days and to verify the need for a 2-day protocol. A cohort of 50 patients (39 men, 11 women) with nonspecific low back pain were evaluated using a 2-day FCE protocol. Intraclass correlation coefficients (ICC) were calculated for weight lifted and carried. Predictive relationships between test and retest were explored by means of a regression analysis. The results of ICC were lifting low 0.87, lifting overhead 0.87, and carrying 0.77. Performances on day 2 were on an average 6-9% higher. Other than the amount of weight handled on day 1, no variable was found to predict performance on day 2. It was concluded that test-retest reliability of lifting and carrying was good, and the need for a 2-day protocol could not be confirmed.

Health complaints and disabilities in patients supplied with foot orthoses for degenerative foot disorders.

This exploratory study attempted to estimate the severity of health complaints and disabilities in patients supplied with foot orthoses for degenerative foot disorders in the Netherlands. Information on the severity and the distribution of the complaints in these patients is important to acquire insight in the problems which these patients experience, and moreover is essential for further research, especially for evaluating effects of patients undergoing foot orthosis treatment. Patients with degenerative foot disorders aged 18 years and over were recruited from nine orthopaedic workshops over a period of three months in 2000. One hundred and twenty-two (122) patients were included in the study. Two approaches were used to obtain data. Firstly, shoe technicians and orthotists inspected patients' feet and legs and interviewed them at their initial visit. Data on gender, age, height, weight, existing and prescribed orthotic devices were recorded on a report form. Secondly, patients were asked to fill in a questionnaire assessing type, location, frequency, intensity and duration of health complaints, and disability. Data indicate that females with degenerative foot disorders and foot orthoses are twice as common as men. Patients supplied with foot orthoses are twice as often overweight compared to subjects in the general population. Besides frequent and protracted pain there are also fatigue complaints, particularly in the feet and lower leg. Duration and frequency of the complaints suggest that these patients suffer from a chronic pain syndrome. In addition, the results indicate that the functional level of these patients is below that of the general population, in particular regarding physical activities.

Measuring maximum holding times and perception of static elevated work and forward bending in healthy young adults.

The objectives of this study were to investigate the maximum holding times (MHT) of two highly stressful postures: standing in a forward bend position and performing elevated work in a standing position. The relationship between perceived exertion and MHT was also studied. Subjects were 44 young adults, age 20-29 years (25 female, 19 male). A test-retest design was used to establish reliability. Mean maximum holding times for forward bending and elevated work were respectively 14.51 and 16.18 min with large interindividual variations. A logarithmic rather than a linear relation between perceived exertion and performance is found. It is not possible to reliably predict MHTs from subjective data. Test-retest correlation is high (n = 19, r = 0.716 and 0.813, p < 0.001), and the scores did not differ significantly (p < 0.005), indicating a reliable procedure. The average holding times of the population studied are higher than expected from literature. Neither generic formulas, curve estimations, or predictions can reliably predict an individual's MHT. An individual's MHTs are best tested through performance based testing.

Factors related to successful job reintegration of people with a lower limb amputation.

OBJECTIVE: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. INTERVENTION: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. MAIN OUTCOME MEASURES: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. RESULTS: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. CONCLUSIONS: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration.

Analysis of handwriting of children during treatment for acute lymphoblastic leukemia.

BACKGROUND: Children treated for acute lymphoblastic leukemia (ALL) often complain about handwriting problems. PROCEDURE: Using a computerized writing task, we have prospectively studied the processes necessary for the production of handwriting movements in 11 children (5-12 years old) during treatment for ALL. Children were tested at time points closely related to the vincristine administration. RESULTS AND CONCLUSIONS: Children treated for ALL drew slower, with longer pause durations and increased drawing pressure. Children were able to overcome the problems, except for a consistently increased drawing pressure. This increased drawing pressure may be an attempt of the children to obtain sufficient kinesthetic information and thus can be seen as an adequate adaptation mechanism in case of peripheral neuropathy due to the neurotoxic effects of vincristine. However, neurotoxic effects of other cytostatic drugs cannot be excluded.

Short-term outcomes of a back school program for chronic low back pain.

OBJECTIVE: To assess the short-term outcome of a back school program for patients suffering from chronic, nonspecific low back pain (LBP). DESIGN: Quasi-experimental cohort study with a waiting list control group. SETTING: Dutch rehabilitation department. PARTICIPANTS: Experimental group (n = 14) participating in the back school program and a waiting list control group (n = 10). INTERVENTION: A back school program aimed to achieve optimal functional capacity and functional health status by teaching participants to react appropriately to overload signals. MAIN OUTCOME MEASURES: Functional capacity assessed by the RAND-36 instrument; functional health status assessed by the Roland-Morris Disability Questionnaire; and static and dynamic lifting capacity, endurance, and range of motion assessed by objective measures. RESULTS: The experimental group significantly improved in functional capacity and functional health status, with a large power, likely attributable to adequate reactions to signals of overload. Significant differences existed between the 2 groups, with large powers for the main outcomes. CONCLUSION: The back school program improved the functional capacity and functional health status of patients with chronic, nonspecific LBP.

Extensibility and stiffness of the hamstrings in patients with nonspecific low back pain.

OBJECTIVE: To investigate the extensibility and stiffness of the hamstrings in patients with nonspecific low back pain (LBP). DESIGN: An experimental design. SETTING: A university laboratory for human movement analysis in a department of rehabilitation medicine. PARTICIPANTS: Forty subjects, a patient group (20) and a healthy control group (20). INTERVENTIONS: Subjects laid supine on an examination table with a lift frame, with left leg placed in a sling at the ankle. Straight leg raising, pulling force, and activity of hamstring and back muscles were recorded with electrodes. Patients indicated when they experienced tension or pain. MAIN OUTCOME MEASURES: The lift force, leg excursion, pelvic-femoral angle, first sensation of pain, and the electromyogram of the hamstrings and back muscles measured in an experimental straight-leg raising set-up. RESULTS: The patient group showed a significant restriction in range of motion (ROM) and extensibility of the hamstrings compared with the control group. No significant difference in hamstring muscle stiffness can be assessed between both groups. CONCLUSION: The restricted ROM and the decreased extensibility of the hamstrings in patients with nonspecific LBP is not caused by increased muscle stiffness of the hamstrings, but determined by the stretch tolerance of the patients.

Employment status, job characteristics, and work-related health experience of people with a lower limb amputation in The Netherlands.

OBJECTIVES: To describe the occupational situation of people with lower limb amputations in The Netherlands and to compare the health experience of working and nonworking amputee patients with a nonimpaired reference population. DESIGN: Cross-sectional study in which patients completed a questionnaire about their job participation, type of job, workplace adjustments to their limb loss, their position in the company, and a general health questionnaire. SETTING: Orthopedic workshops in The Netherlands with a population of lower limb amputees. PATIENTS: Subjects were recruited from orthopedic workshops in the Netherlands. They ranged in age from 18 to 60 years (mean, 44.5yr) and had a lower limb amputated at least 2 years (mean, 19.6yr) before this study. MAIN OUTCOME MEASURES: A self-report questionnaire, with 1 part concerning patient characteristics and amputation-related factors, and the other concerning job characteristics, vocational handicaps, work adjustments, and working conditions; and a general health questionnaire (RAND-36) to measure health status. RESULTS: Responses were received from 652 of the 687 patients (response rate, 95%) who were sent the questionnaire. Sixty-four percent of the respondents were working at the time of the study (comparable with the employment rate of the general Dutch population), 31% had work experience but were not presently working, and 5% had no work experience. After their amputations, people shifted to less physically demanding work. The mean delay between the amputation and the return to work was 2.3 years. Many people wished their work was better adjusted to the limitations presented by their disability and they mentioned having problems concerning possibilities for promotion. Seventy-eight percent of those who stopped working within 2 years after the amputation said that amputation-related factors played a role in their decision. Thirty-four percent said that they might have worked longer if certain adjustments had been made. The health experience of people who were no longer working was significantly worse than that of the working people with amputations. CONCLUSIONS: Although amputee patients had a relatively good rate of job participation, they reported problems concerning the long delay between amputation and return to work, problems in finding suitable jobs, fewer possibilities for promotion, and problems in obtaining needed workplace modifications. People who had to stop working because of the amputation showed a worse health experience than working people.

Functional capacity evaluation: Ecological validity of three static endurance tests.

Functional Capacity Evaluation's (FCE's) are designed to measure the functional capacity of injured workers. Static endurance tests are integrated aspects of FCE's. Little is known about the validity of the tests. In this study, three static endurance tests (overhead work, crouching and kneeling) of the Isernhagen Work Systems FCE are studied for ecological validity. By manipulating the environment in an experiment using three different conditions (normal, loud noise, high production requirement), the ecological validity of the tests was investigated. Results: the different conditions did not seem to influence the holding times, the perceived exertion and the productivity of the subjects. The results are discussed and it is concluded that the three static endurance tests meet conditions of ecological validity. In order to be able to state that the tests of the IWS FCE are ecologically valid, more research is needed to enable a generalization.

Assessment and treatment of chronic work-related pain disorders in an outpatient university rehabilitation setting in The Netherlands.

Points of view of the assessment and treatment of chronic work-related disorders in a Dutch university rehabilitation setting are described. After a general introduction in which the basic philosophy is outlined, medical issues as well as issues regarding two treatment programs and the evaluation of functional capacity are described. The article ends with a brief description of current and future research programs.

Mild axonal neuropathy of children during treatment for acute lymphoblastic leukaemia.

Neurophysiological functioning was studied prospectively in children treated for acute lymphoblastic leukaemia with a low dose vincristine regime (8 x 1.5 mg/m2/dose), to obtain more insight into vincristine neuropathy. A WHO neurotoxicity score was estimated and vibration sense and electrophysiological measurements were taken at standardized times during vincristine treatment. The WHO neurotoxicity score showed decreased or disappearance of Achilles tendon reflexes, and mild sensory disturbances, but a grade 3-4 neurotoxicity was not demonstrated by any of the children. Vibration perception thresholds increased progressively during treatment and amplitudes of action potentials of peroneal and sensory ulnar and median nerves decreased, whereas nerve conduction velocities stayed unchanged. Both vibration perception thresholds and the electrophysiological findings hardly exceeded the limits of normality. We conclude that children treated for acute lymphoblastic leukaemia with a low dose vincristine regimen have mild axonal neuropathy which may be responsible for the motor problems in these children.

The Timed "up and go" test: reliability and validity in persons with unilateral lower limb amputation.

OBJECTIVE: To determine the interrater and intrarater reliability and the validity of the Timed "up and go" test as a measure for physical mobility in elderly patients with an amputation of the lower extremity. DESIGN: To test interrater reliability, the test was performed for two observers at different times of the same day in an alternating order. To test intrarater reliability, the patients performed the test for one observer on two consecutive visits with an interval of 2 weeks. To test validity, the results of the Timed "up and go" test were compared with the results on the Sickness Impact Profile, 68-item version (SIP68), and the Groningen Activity Restriction Scale (GARS). PATIENTS: Thirty-two patients, age 60 yrs or older, with unilateral transtibial or transfemoral amputation because of peripheral vascular disease. RESULTS: The Timed "up and go" test showed good intrarater and interrater reliability (r = .93 and .96, respectively). A moderate relationship exists between the Timed "up and go" test and the GARS, a good relationship exists with the "physical subscales" of the SIP68, and there is no relationship with the "mental subscales" of the SIP68. CONCLUSIONS: The Timed "up and go" test is a reliable instrument with adequate concurrent validity to measure the physical mobility of patients with an amputation of the lower extremity.

Repeated passive stretching: acute effect on the passive muscle moment and extensibility of short hamstrings.

OBJECTIVE: To examine the response of short hamstring muscles to repeated passive stretching. DESIGN: A repeated measures design. SETTING: A university laboratory for human movement analysis in a department of rehabilitation. SUBJECTS: Students (7 men, 10 women) from the Department of Human Movement Sciences. MAIN OUTCOME MEASURES: The lift force, range of motion, pelvic-femoral angle, first sensation of pain, and electromyogram of the hamstrings were measured. RESULTS: Comparison of the data of the test group (n = 17) after five successive passive stretch tests by means of an instrumental straight-leg raising test showed no significant change of the variables passive muscle stiffness and extensibility (p>.05). CONCLUSION: The acute effect of repeated passive stretching of short hamstring muscles is negligible. With an instrumental straight-leg raising test, the relevant muscle variables can be examined noninvasively.

Fine motor and handwriting problems after treatment for childhood acute lymphoblastic leukemia.

Motor skills were investigated in 18 children 2 years after treatment for acute lymphoblastic leukemia (ALL). Gross and fine motor functioning were examined with the Movement Assessment Battery for Children. Handwriting as a specific fine motor skill was studied with a computerized writing task. We conclude that 2 years after cessation of treatment motor problems in ALL survivors were still present. Dysfunctions were mainly pronounced in handwriting and fine motor skills.

Sport stretching: effect on passive muscle stiffness of short hamstrings.

OBJECTIVE: To evaluate the effects of one 10-minute stretch on muscle stiffness in subjects with short hamstrings. DESIGN: Randomized control trial. SETTING: Laboratory for human movement sciences in the department of rehabilitation of a university hospital. SUBJECTS: Sixteen students from the Department of Human Movement Sciences participated with informed consent in the experiment. Subjects were limited to men and women without a history of neurological and orthopedic disorders. To select subjects with short hamstrings, the finger-ground distance had to be greater than 0cm (unable to touch the floor when bending forward) and the manual leg lifting was not to exceed 80 degrees. One group of 10 subjects performed static stretching exercises during 10 minutes interspersed with relaxing, whereas the untreated group of 6 subjects was used as a control. MAIN OUTCOME MEASURES: The instrumental straight-leg-raising set-up enables the measurement of the force needed to lift the leg, range of motion (ROM), pelvic-femoral angle, and the electromyogram of the hamstrings. These variables provide information about the stiffness, elongation, and state of activity of the hamstring muscles. RESULTS. One 10-minute sport stretch resulted in a significant increase in passive muscle moment, ROM, and elongation of the hamstrings. There was no significant change in the course of the passive muscle stiffness curve with respect to the prestretch stiffness curve. CONCLUSIONS: One session of static stretching does not influence the course of the passive muscle stiffness curve. The increased ROM, i.e., the extensibility of the hamstrings, results from an increase in the stretch tolerance.