Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder.

BACKGROUND: The influence of elevated fear-avoidance beliefs on change in functional status is unclear. OBJECTIVE: The purpose of this study was to determine the influence of fear-avoidance on recovery of functional status during rehabilitation for people with shoulder impairments. DESIGN: A retrospective longitudinal cohort study was conducted. METHODS: Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper-extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health-related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method. RESULTS: Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (Δ=1.37, P<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (Δ=5.52, P<.02). These differences were below the minimal detectable change. Limitations Information was not available on whether therapists used information on level of fear to implement treatment plans. CONCLUSIONS: The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments.

Examination of the factor structure of the Disabilities of the Arm, Shoulder, and Hand questionnaire.

OBJECTIVE: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a global scale evaluating the impact of upper-extremity disorders. We sought to validate or challenge the unidimensional factor structure of the DASH. METHOD: Secondary analysis was performed on data collected from outpatient clinics. Factor analysis was performed in two steps, exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA). To provide further support for unidimensionality, fit statistics were calculated using the Andrich Rasch rating-scale model. RESULTS: EFA revealed three potential factors (eigenvalues = 18.40, 1.56, and 1.54). CFA was performed fitting a three-factor model. Tucker-Lewis Index (.99) and standardized root mean square residual (.05) values indicated good fit. Comparative fit index (.89) and root mean square error of approximation (.13) did not. When divided into three constructs, only one item misfit. CONCLUSION: More research is needed to determine situations in which division of the DASH may enhance interpretability.

Development of an item bank for a computerised adaptive test of upper-extremity function.

PURPOSE: The purpose of this study was to determine the psychometric characteristics of an upper-extremity item bank as a precursor to developing a computer adaptive patient reported outcome instrument. The Activity dimension of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) provided the conceptual framework for the items. METHOD: Factor and Rasch analyses were used to evaluate the psychometric properties of the item bank, including: monotonicity, local independence, dimensionality, item difficulty hierarchy and match between sample ability and item difficulty. RESULTS: Monotonicity of the rating scale was supported. Nine item pairs were locally dependent, and thus one item from each pair was removed from subsequent analyses. There was evidence for two unidimensional constructs; gross upper-extremity and fine hand. Both constructs showed good internal consistency and person separation. In general, the order of item difficulty within each construct replicated the hypothesised item difficulty order. The fine hand construct had a ceiling effect. CONCLUSIONS: The above study of our newly developed upper-extremity item bank empirically verified the intended item difficulty order, identified separate constructs (i.e. gross upper-extremity and fine hand) and provided insights into eliminating the ceiling effect of one of the constructs. These findings are critical precursors to the development of upper-extremity components of the ICF Activity Measure, an ICF-based, CAT located on the web at: www.icfmeasure.phhp.ufl.edu.

Creating a clinically useful data collection form for the DASH questionnaire.

PURPOSE: We generated a clinically useful data collection form for the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This data collection form is designed to aid in measuring change and goal setting. METHOD: Rasch analysis was used to generate three data collection forms for constructs on the DASH (gross motor, fine motor, and symptoms; N = 960). A form was completed to represent the findings from 1 study participant. Admission and discharge data were illustrated for one of the three sections (gross motor activity). Possible goals were indicated on the admission form. The discharge form illustrates whether these goals have been achieved. RESULTS: Figures illustrate the utility of the forms in observing functional change from admission to discharge and how the forms aid in goal setting. CONCLUSION: Use of the data collection form has many positive implications. This type of form could aid in goal setting and treatment planning.

Ability to detect change in patient function: responsiveness designs and methods of calculation.

UNLABELLED: In hand clinics, the goal of enabling patient improvement is fostered by the use of assessments with the ability to detect change (responsiveness). Thus, for commonly used assessments, investigations are needed to determine a standardized change index, the amount of change exceeding error estimates (minimal detectable change or MDC), and the amount of change shown to make a clinically relevant difference (clinically important difference or CID). The purpose of study was to serve as an introduction for hand therapists to responsiveness designs and indices and to highlight their application within the clinical setting. The study design used was a narrative review. Method papers and research studies addressing responsiveness were selected and summarized. Currently, several good studies of responsiveness have been conducted. However, there is a need to move beyond the calculation of standardized change indices to include the calculation of clinically meaningful values. For many of the assessments used in hand clinics, there is still a call for investigation of the amount of change, which exceeds error estimates (MDC) and the amount of change shown to make a clinically relevant difference (CID). LEVEL OF EVIDENCE: N/A.

A comparison of the ability of two upper extremity assessments to measure change in function.

STUDY DESIGN: Retrospective Measurement Comparison. INTRODUCTION: Upper extremity musculoskeletal disorders affect millions, thus, discerning optimal assessments for measuring change in upper extremity function is critical. PURPOSE OF THE STUDY: To compare responsiveness (ability to measure change) of the Disabilities of Arm, Shoulder, and Hand (DASH) and Upper Extremity Functional Index (UEFI). METHODS: Statistical analyses included Rasch analysis to place the instruments on the same scale, analysis of variance to compare change scores, correlations to compare change scores with global ratings, and the use of receiver operating characteristic (ROC) curves to determine meaningful change scores and overall error. RESULTS: Change scores on the DASH and UEFI and correlations between change scores and global ratings were similar. Areas under the ROC curves for the DASH and UEFI were 67% and 65%, respectively. CONCLUSIONS: Neither assessment has a clear advantage over the other when measuring clinical change. LEVEL OF EVIDENCE: Not applicable.