Is the Berg Balance Scale an effective tool for the measurement of early postural control impairments in patients with Parkinson's disease? Evidence from Rasch analysis.

BACKGROUND: It is unclear whether the BBS is an effective tool for the measurement of early postural control impairments in patients with Parkinson's disease (PD). AIM: The aim of this paper was to evaluate BBS' content validity, internal construct validity, reliability and targeting in patients with PD within the Rasch analysis framework. DESIGN: Observational, cross-sectional study. SETTING: Outpatient Rehabilitation Unit. POPULATION: A sample of 285 outpatients with PD. METHODS: The content validity of the BBS was assessed using standard linking techniques. The BBS was administered by trained physiotherapists. The data collected then underwent Rasch analysis. RESULTS: Content validity analysis showed a lack of items assessing postural responses to tripping and slips and stability during walking. On Rasch analysis, the BBS failed the requirements of monotonicity, local independence, unidimensionality and invariance. After rescoring 7 items, grouping of locally dependent items into testlets, and deletion of the static sitting balance item because mistargeted and underdiscriminating, the Rasch-modified BBS for PD (BBS-PD) showed adequate internal construct validity (χ(2)24=39.693; P=0.023), including absence of differential item functioning (DIF) across gender and age, and was, as a whole, sufficiently precise for individual person measurement (PSI=0.894). However, the scale was not well targeted to the sample in view of the prevalence of higher scores. CONCLUSION: This study demonstrated the internal construct validity and reliability of the BBS-PD as a measurement tool for patients with PD within the Rasch analysis framework. However, the lack of items critical to the assessment of postural control impairments typical of PD, affected negatively the targeting, so that a significant percentage of patients was located in the higher ability range of the measurement continuum, where precision of measurement is reduced. CLINICAL REHABILITATION IMPACT: These findings suggest that the BBS, even if modified, may not be an effective tool for the measurement of early postural control in patients with PD.

Enhancing the usefulness of the Mini-BESTest for measuring dynamic balance: a Rasch validation study.

BACKGROUND: Recently, a new balance scale, the Mini-BESTest, was introduced. This scale can be administered in about 15 min, and focuses on "dynamic balance". In spite of the recently increased use of this scale, further psychometric studies seem called for to enhance confidence in its use in different fields of clinical practice and research. AIM: To re-examine through Rasch analysis the metric properties of the Mini-BESTest and provide a nomogram that allow to quickly transform raw scores of the scale into linear estimates of dynamic balance. DESIGN: Observational cross-sectional study. SETTING: Rehabilitation hospital. POPULATION: A total of 234 patients were consecutively admitted with a variety of neurological diseases causing balance impairment. METHODS: Internal construct validity was assessed by determining how well data fit the Rasch model. Reliability was estimated for both persons and items. Scale unidimensionality and local independence of items were analysed performing a principal component analysis (PCA) on the standardized residuals. Also, a differential item functioning (DIF) analysis was run to assess the stability of item calibration across subsamples of patients. RESULTS: All 14 items of Mini-BESTest fitted the "dynamic balance" construct, i.e., the mean of the squared residuals for both the infit and outfit was between 0.8 and 1.2. The person abilities-item difficulty matching was very good. The reliability indices of the Mini-BESTest were as follows: person separation index=3.24 and person reliability=0.91; item separation index=12.00 and item reliability=0.99. The PCA of standardized residuals showed that the variance attributable to the Rasch factor was good (68%) and the eigenvalue of the unexplained variance in the first contrast was just 1.9, thus confirming the unidimensionality of the scale. No DIF was found across gender and age groups. CONCLUSION: The reliability indexes confirmed their high values, giving a high degree of confidence in the consistency of both person-ability and item-difficulty estimates. Results allowed to transform the ordinal summed raw scores of the Mini-BESTest into interval-level measurements using a nomogram. Since no significant local dependence between items was found, this means that each Mini-BESTest item is appropriate for measuring the variable of interest (dynamic balance) and not redundant. DIF analysis showed the stability of item hierarchy and difficulty among subsamples of patients of different gender and age. CLINICAL REHABILITATION IMPACT: This study further increases confidence in use of the Mini-BESTest for clinical assessment of dynamic balance in patients undergoing rehabilitation.

Hematuria in a runner after treatment with whole body vibration: a case report.

The use of whole body vibration (WBV) for therapeutic purposes is far from being standardized and the training protocols reported in the literature vary considerably. Currently, the optimal threshold for a beneficial effect is undetermined, and caution regarding potential health risks due to WBV is always necessary. In this case report, we present a 34-year-old otherwise healthy elite athlete (steeplechase runner) who suffered two episodes of hematuria (HT) after WBV training. Shortly after the third WBV, he had an episode of bright red urine. Seven days later, following the next WBV session (and again before his daily running session), a reddish-colored urine reappeared. Our patient was advised to stop WBV training and to take fluid before and during exertion. He did not experience any episode of HT during a 1-year follow-up with periodic check-ups, in spite of the continuation of his sporting career. The concomitance of the two types of trauma - daily running and WBV - could have been critical in this case for producing HT. In particular, we think that platforms providing side-alternating vibration (such as the Galileo platform) may pose some health risks if the feet are positioned too far from the axis of rotation.

Writing a case report for the American Journal of Physical Medicine and Rehabilitation and the European Journal of Physical and Rehabilitation Medicine.

Case reports (CR) have led to the description and discovery of new diseases, syndromes, therapeutic complications or side-effects, and previously unknown potential benefits of pharmacologic agents. CRs may also be used as an effective training strategy for novice authors to develop the skills needed for medical writing. Yet, too often, CRs do not follow standards for excellence in scientific writing. Therefore, in this article, the American Journal of Physical Medicine and Rehabilitation (AJPMR) and the European Journal of Physical and Rehabilitation Medicine (EJPRM) collaborate with the purpose of providing guidance to authors in selecting CRs that might be appropriate for publication. In addition, we discuss different aspects of the preparation of a well-written CR in accordance with the mission and editorial views of both journals.

Choosing a scholarly journal during manuscript submission: the way how it rings true for physiatrists.

BACKGROUND: Research and publications are increasing in Physical and Rehabilitation Medicine (PRM). Hence, there appears to be a multifaceted and challenging turnover in our scientific niche involving authors, editors, publishers and readers in a complex interplay. AIM: To explore the manuscript submission process from the side of the authors, and to better understand their perceptions and preferences. DESIGN: A survey study. SETTING: E-mail and personal contact. POPULATION: European researchers working in the field of PRM. METHODS: A questionnaire was specifically prepared for this study. The first part included questions regarding personal and scientific background; in the second part the attendants rated 20 items (with respect to several journal characteristics) on a 4-point semantic differential scale; and the third part contained two open ended questions regarding additional factors that the authors considered during submission. RESULTS: Area of interest (mission and contents) of the journal within the "Rehabilitation" category, absolute impact factor of the journal, match between perceived "quality" of their study and journal impact factor were considered to be the three most important factors by the authors. CONCLUSION: In a scientific environment where the numbers of research and publication outlets alike are growing, it is important to understand how authors choose where to publish their papers. CLINICAL REHABILITATION IMPACT: We believe that editors, and publishers as well, would take into account our findings to best meet the needs of all actors in the competitive marketplace of scholarly publishing in PRM.

Patient satisfaction with hospital rehabilitation: validation of the SAT-16 questionnaire through Rasch analysis.

AIM: The SAT-16 is a 16-item self-administered questionnaire measuring patient satisfaction with the quality of care during stay in a rehabilitation unit. A comprehensive psychometric analysis of SAT-16 was performed using both classical test theory and Rasch analysis (RA) to examine its validity and metric properties, and provide further insights for its clinical use in rehabilitation settings. METHODS: A sample of 9458 patients, consecutively admitted to two Rehabilitation Centres, was examined with SAT-16. Factor (both explorative and confirmatory) analysis and RA were used to process the data in order to examine validity and metric properties of SAT-16. Dimensionality, item fit to the model, response category performance and internal construct validity were assessed. RESULTS: Two subscales were identified by factor analysis and expert review, respectively related to satisfaction with clinical care (items 1-9), and satisfaction with hospital organization and facilities ("hotel" aspects of care, items 10-16). Each subscale underwent a separate RA. Response categories were revised in both subscales of SAT-16, obtaining a new 3-level rating scale. Both subscales showed high internal consistency and internal validity. CONCLUSION: RA confirmed the appropriateness of SAT-16 and its usefulness in identifying areas for quality improvement. Overall, the questionnaire allows to assess patient satisfaction with the services through: 1) two sub-scores respectively specific for satisfaction with "clinical care" and "hotel aspects of care"; 2) additional information gathered in the optional open-ended questions.

Bibliometric indicators: a snapshot of the scientific productivity of leading European PRM researchers.

AIM: The aim of this paper was to explore the validity and practical usefulness of a set of bibliometric indicators with a focus on the scientific production of influential European researchers in Physical and Rehabilitation Medicine (PRM). METHODS: We randomly selected 24 European PRM specialists from the list of invited lecturers or chairpersons at the 17th ESPRM Congress in 2010. Using the time window 1996-2010, we recorded the number of papers published, total number of citations, and h-index from Web of Science (WoS) and Publish or Perish (PoP) databases. We also noted the journals in which the papers were published. Ranking the 24 authors into two groups according to higher vs. lower research productivity, we compared the frequency of Editorial Board membership of at least one of the 5 most influential journals in PRM. RESULTS: Median values (WoS, PoP) for papers, citations, and h-index were respectively: (31, 46); (171, 317); and (6.5, 8.5). High correlations were found among different indicators, and also between the same indicators calculated in the two different databases. However, the Bland-Altman plot indicated that the two databases could not be considered interchangeable. Twelve PRM specialists were Editorial Board members: 11 of them were in the first 10 ranking positions for at least one of the 6 indicators analysed. CONCLUSION: There is need to better understand the characteristics of bibliometric indicators and we retain that the information they provide is insufficiently valid to justify their use as the sole objective criterion for career assessment.

Animal-assisted interventions in internal and rehabilitation medicine: a review of the recent literature.

While conventional wisdom has always affirmed the value of animals in promoting human well-being, only recently has their therapeutic role in medicine become the focus of dedicated research. Therapeutic modalities that use animals as a tool for improving the physical, emotional, cognitive and/or social functioning of humans are called animal-assisted interventions (AAI), and are classified into: animal-assisted activities (AAA); animal-assisted therapy (AAT); and service animal programs (SAP). The aim of this review is to analyze the papers published between 2001 and 2010 in the most influential medical journals dealing with AAI, and discuss their findings in the light of what may be of interest for internal medicine and rehabilitation. A total of 35 articles met the strict inclusion criteria for this review: 18 papers dealing with AAA, 8 with AAT, and 9 with SAP. The therapeutic outcomes associated with AAA are: enhancement of socialization; reduction of stress, anxiety and loneliness; improvement in mood and general well-being; and development of leisure/recreation skills. Regarding AAT, horses are often used as a complementary strategy to facilitate the normalization of muscle tone and improve motor skills in children with cerebral palsy and persons with lower limb spasticity. Finally, most SAP utilize dogs, that assist people with various disabilities in performing everyday activities, thus reducing their dependence on other persons. Further studies are needed to better define the fields and programs for the therapeutic use of animals and to increase their utilization in medicine, as a promising, complementary and natural means to improve both functional autonomy and quality of life.

Trinity amputation and prosthesis experience scales: a psychometric assessment using classical test theory and rasch analysis.

OBJECTIVE: To perform a detailed psychometric analysis using both classical test theory and Rasch analysis of the three main scales of the Trinity Amputation and Prosthesis Experience Scales (TAPES) in people with a lower-limb amputation. DESIGN: A sample of 498 persons who were prosthesis users with a lower-limb amputation was retrospectively studied, pooled from a number of studies undertaken across the United Kingdom and Ireland in the past decade in which the TAPES had been completed as part of a postal survey. Both factor analysis techniques and Rasch analysis were performed on TAPES data. Dimensionality, item fit to the model, response category performance, and internal construct validity were assessed. Category collapsing and item removal were considered to improve the questionnaire. RESULTS: The analyses suggested to restructure the TAPES as follows: (a) three psychosocial adjustment subscales with a four-point rating scale (and a reworded item); (b) an activity restriction scale based on ten items with their original three-point rating scale; and (c) two satisfaction with the prosthesis subscales using a three-point rating scale. All scales and subscales showed acceptable internal consistency and ability to define a distinct hierarchy of persons along the measured construct. CONCLUSIONS: This study empirically identified a revised version of the TAPES (TAPES-R) with a simplified general structure and psychometrically suitable for assessing the complex experience of amputation and adjustment to a lower-limb prosthesis. Additional studies are needed to confirm and further explore its measurement properties in other samples, thereby adding clinical validity to the instrument.

[Treadmills in rehabilitation medicine: technical characteristics and selection criteria]. / Il treadmill in medicina riabilitativa: caratteristiche tecniche e criteri di selezione.

The treadmill is a commonly used means of testing and training patients with cardiopulmonary diseases. There is growing interest in the use of the treadmill also for rehabilitation of patients with orthopaedic and neurological diseases. Commercially available treadmills show wide differences in terms of structure and function that have a direct impact on the specific rehabilitation protocols. The aims of this paper are: a) to briefly review the physiology and biomechanics of treadmill exercise as compared to overground walking; b) to point out the technical specifications of treadmills suitable for rehabilitation settings; c) to provide guidelines for treadmill selection in the different categories of rehabilitation patients. First, the different physiological and biomechanical characteristics of walking on a treadmill and overground are discussed. Uphill and downhill walking as well as backward walking are also presented together with the spin-offs for rehabilitation practice. Then, the technical features of treadmills (treadbelt, frame, bars, deck, rollers, shock absorption, elevation motor, drive motor, flywheel, display) are described and the specific requisites for the different patient categories undergoing rehabilitation are discussed in detail. Finally, guidelines and a flow-chart for identifying the main technical requisites for appropriate treadmill selection in the different disabilities are provided. A summary table of the technical specifications of the commercially available rehabilitation treadmills is also included.

Rasch psychometric validation of the Impact on Participation and Autonomy questionnaire in people with Parkinson's disease.

AIM: The aim of this study was to assess the psychometric properties of the Impact on Participation and Autonomy (IPA) questionnaire, in its two scales: IPA-I, perceived limitations in participation and autonomy; IPA-II, perceived problems in participation. METHODS: The IPA data underwent Rasch analysis for rating scale diagnostics and a reliability and validity study. The work and education domain was left out of the analysis due to its low applicability to our subjects. A convenience sample of 100 patients with Parkinson's disease (PD) (41 male, 59 female; mean age 72+/-7 years) were consecutively observed at our Rehabilitation Clinic. RESULTS: According to Rasch analysis, two response categories of IPA-I were collapsed into one and 1 item (''intimate relationship'') was deleted. The remaining 24 items fitted the unidimensional construct that the scale was intended to measure. IPA-I demonstrated good reliability (person separation = 0.93, item separation = 0.97) and internal construct validity. All six IPA-II items proved to belong to the same construct. For IPA-II, item separation = 0.97, person separation = 0.71. The targeting and spread of item difficulty and the quite low person separation reliability of IPA-II made it possible only to differentiate people with low vs high level of problems in participation. Both scales showed the expected correlation with PD-specific clinical and quality of life measures. CONCLUSIONS: IPA-I shows promise as a tool for measuring participation in people with PD. IPA-II has acceptable psychometric characteristics for measuring perceived problems in participation. Additional steps to improve their metric properties and further studies in people with different kinds of health conditions need to be carried out.

[Cycle ergometers in rehabilitation medicine: technical characteristics and selection criteria]. / I cicloergometri in medicina riabilitativa: caratteristiche tecniche e criteri di selezione.

The cycle ergometer is a commonly used means of testing and training patients with energetic disabilities (particularly in the area of cardiopulmonary diseases). Recent evidence suggests that cycle ergometers can also be useful in patients with subacute and chronic stroke, brain injury, chronic degenerative neurological conditions, and in spinal cord injury. Commercially available cycle ergometers show wide differences in terms of structure and function that have a direct impact on the specific rehabilitation protocols. The aims of this review paper are: a) to briefly review the physiology and biomechanics of exercise on a cycle ergometer; b) to review and discuss the technical specifications of the cycle ergometers suited to rehabilitation settings; c) to provide guidelines for selecting appropriate cycle ergometers for the different categories of rehabilitation patients. First, the physiology of exercise on the cycle ergometer and its biomechanical features are discussed, including the patterns of muscular activity during down- and up-stroke. Upright and recumbent ergometers and their specific clinical indications are compared. Finally, the technical characteristics of the cycle ergometers (load, motor, resistance, flywheel, belt, resilience, pedals, frame, display) are described and the specific requisites for the different patient categories undergoing rehabilitation are discussed in detail. Finally, guidelines are offered for identifying the main technical requisites for appropriate cycle ergometer selection in the different disabilities.

The influence of comorbidities and complications on discharge function in stroke rehabilitation inpatients.

AIM: The aims of this prospective study were: 1) to assess the frequency, type and severity of comorbidities (COMs) and complications (COMPLs) in acute stroke patients, according to the weighted comorbidity index (w-CI) of Liu et al. and 2 new indices, respectively COM severity index (COM-SI) and COMPL severity index (COMPL-SI); 2) to separately analyse the interference of COMs and COMPLs with functional status and recovery during stroke rehabilitation treatment; 3) to compare the ability of COM-SI and COMPL-SI to predict functional independence at discharge with that of w-CI. METHODS: Eighty-five stroke rehabilitation inpatients participated in the study. The type, incidence and severity of COM at admission and of COMPL during the whole hospital stay were studied prospectively. The Functional Independence Measure (FIM) scale was administered at both admission and discharge. RESULTS: About 1/3 suffered from some significant COM and another 1/3 developed COMPLs needing specific medical treatment and/or clinical monitoring. The most frequent COMs and COMPLs were cardiovascular and psychiatric/psychological diseases. The odds of having a high efficiency in the daily functional gain (FIM score) were greater for patients without any COM (3.5) and/or COMPL (4.6). Similarly, the odds of having a high FIM score at discharge were greater (3.5) for patients without COM or COMPL. The COM-SI demonstrated a higher predictive capacity of the FIM score at discharge (5%) than w-CI (4%), and COMPL-SI (1%). CONCLUSIONS: COM-SI resulted as the most interesting predictive index of functional outcome at discharge, after accounting for the functional status at admission.