New ligands for melanocortin receptors.

Named originally for their effects on peripheral end organs, the melanocortin system controls a diverse set of physiological processes through a series of five G-protein-coupled receptors and several sets of small peptide ligands. The central melanocortin system plays an essential role in homeostatic regulation of body weight, in which two alternative ligands, alpha-melanocyte-stimulating hormone and agouti-related protein, stimulate and inhibit receptor signaling in several key brain regions that ultimately affect food intake and energy expenditure. Much of what we know about the relationship between central melanocortin signaling and body weight regulation stems from genetic studies. Comparative genomic studies indicate that melanocortin receptors used for controlling pigmentation and body weight regulation existed more than 500 million years ago in primitive vertebrates, but that fine-grained control of melanocortin receptors through neuropeptides and endogenous antagonists developed more recently. Recent studies based on dog coat-color genetics revealed a new class of melanocortin ligands, the beta-defensins, which reveal the potential for cross talk between the melanocortin and the immune systems.

Nutrition in the elderly.

Nutrition is a prime concern for the optimal health of older persons. Nutritional requirements for older persons must take into account the physiologic changes that occur with aging. The gastrointestinal tract is the site of key structural and functional changes that affect nutrient intake and assimilation. A working knowledge of nutritional screening, assessment, and interventions can assist the practitioner in providing quality care for the older patient.

Development and initial validation of the back pain functional scale.

STUDY DESIGN: A prospective repeated-measures design was applied. OBJECTIVES: To examine the measurement properties of the Back Pain Functional Scale (BPFS) and the Roland-Morris Questionnaire (RMQ) and to formulate hypotheses and sample size estimates for a subsequent comparison study. SUMMARY OF BACKGROUND DATA: Although there are numerous functional status measures for patients with low back pain, most have been conceived of and validated with a group rather than an individual patient as the unit of interest. Also, little has been done to formally compare-this includes the generation of a priori hypotheses, followed by statistical hypotheses testing-the many competing measures. METHODS: Subjects were 77 patients with low back pain who were referred by physicians to 10 outpatient physical therapy clinics located in Canada and the United States. The questionnaires were administered at patients' initial visits, within 48 hours of the initial visit, and at 1-, 2-, and 3-week follow-up visits. Reliability, cross-sectional validity, and longitudinal validity (sensitivity to change) coefficients were calculated. RESULTS: Test-retest reliability estimates of 0.81 and 0. 88 were obtained for the RMQ and BPFS, respectively. The measures demonstrated similar levels of cross-sectional validity. Correlations of 0.56 and 0.65 were noted between a prognostic rating of change and the RMQ and BPFS, respectively. The RMQ demonstrated a ceiling effect. Approximately 180 patients are needed for a subsequent head-to-head comparison study of the measures. CONCLUSIONS: The BPFS appears to have sound measurement properties, and a formal head-to-head comparison study with the RMQ is warranted.

A comparison study of the back pain functional scale and Roland Morris Questionnaire. North American Orthopaedic Rehabilitation Research Network.

OBJECTIVE: To determine whether the measurement properties of the Back Pain Functional Scale (BPFS) are superior to the Roland-Morris Questionnaire (RMQ). METHODS: The BPFS and RMQ were administered on multiple occasions to 153 patients with low back pain attending physical therapy. Eleven Canadian clinics and 8 American clinics participated in the study. Ceiling effects, internal consistency, test-retest reliability, cross sectional discriminant validity, and sensitivity to change were investigated. Error estimates in scale points were obtained. RESULTS: A ceiling effect was noted for 6 patients' RMQ scores compared to 3 patients' BPFS scores. Internal consistency for the RMQ and BPFS were 0.87 and 0.93, respectively. The error (95% CI) for a patient's score was +/- 15.5% of the scale range for the RMQ and +/- 10.5% for the BPFS. The test-retest reliability was 0.79 for the RMQ and 0.82 for the BPFS. The error associated with a patient's change score (95% CI) was 27.7% of the scale range for the RMQ and 22.2% for the BPFS. The measures showed similar levels of discriminant validity with respect to physical findings, work status, and education level. The BPFS was more adept at detecting different amounts of change in patients with back pain of less than 2 weeks' duration compared to patients with back pain of 2 or more weeks' duration. CONCLUSION: The BPFS is a competitive functional status measure for patients with low back pain.

The relation between dietary change and rising US obesity.

OBJECTIVE: To determine if the source from which food is obtained has contributed to the increased obesity of the US population, while controlling for demographic, lifestyle and regional factors. METHODS: Multiple regression was used to estimate the effect of food source on body mass index (BMI) while accounting for other factors which have been shown to affect obesity in a nationally representative sample of the US population. SAMPLE: This study used secondary data from the 1994-1996 Continuing Survey of Food Intake by Individuals (CSFII). The CSFII is a nationally representative sample of 16,103 individuals, obtaining for each respondent 24 h recalls of all food intake on two nonconsecutive days as well as demographics and information on lifestyle choices. RESULTS: For a large number of demographic and lifestyle factors, our results support those which have previously been found to contribute to increased overweight. Our contribution is to examine whether the source from which food is obtained also contributes to increased overweight. Our evidence suggests that this is the case. The average height for males in our sample was 1.77 m. For two such males, one who ate food away from home (FAFH) during the previous 24 h period and the other who did not, results suggest that the first will be about 1 kg heavier, all other factors being equal. For two females of average height (1.63 m) the same is true for those who ate fast food, but not at restaurants. In all cases, except females who ate at restaurants, the effects are significant in the regression (P<0.05). CONCLUSION: The trends in both increased US obesity and in increased consumption of FAFH are unlikely to be coincidental. FAFH, and particularly fast food consumption, are likely to be contributing factors to increased obesity.

Applying the results of self-report measures to individual patients: an example using the Roland-Morris Questionnaire.

Information concerning a patient's functional status is often obtained by asking the patient about activities that cannot be assessed directly in the clinical setting. This information is usually acquired through a verbal exchange between the clinician and patient. The measurement properties of the verbal exchange are unknown. An alternate method of obtaining this information is when patients self-report their functional status. The measurement properties of self-report questionnaires are well known; however, these measures are used infrequently for the evaluation of functional status, progress, and outcome in the clinic. Two reasons are possible for the infrequent use of self-report questionnaires: (1) values obtained from self-report measures have not been used to guide the care of the patient, and (2) a perception exists that these measures take a great deal of time to administer and score. The purpose of this clinical commentary was to describe the application, scoring, and use of a functional status measure (the Roland-Morris Questionnaire) for persons with low back pain and to illustrate how this questionnaire can be efficiently incorporated into clinical practice to aid decision making concerning individual patients. Three patient scenarios are used to illustrate the issues raised in this paper.

Error estimates in novice and expert raters for the KT-1000 arthrometer.

STUDY DESIGN: Single group repeated measures with multiple raters. OBJECTIVES: To determine the inter-rater reliability of KT-1000 measurements of novice and experienced raters and to provide error estimates for these raters. BACKGROUND: The KT-1000 arthrometer is often used clinically to quantify anterior tibial displacement. Few data have been documented, however, about the relative reliability of KT-1000 measurements obtained by novice compared with experienced users. METHODS AND MEASURES: Two novice and two experienced KT-1000 users performed measurements on 29 knees of 25 patients after anterior cruciate ligament (ACL) reconstruction or with a diagnosis of ACL deficiency. Measurements were performed at 131 N. Interrater and intertrial reliability coefficients (interclass correlation coefficient; ICC) and the standard error of measurement were calculated for expert and novice raters. RESULTS: The interrater ICC for novices was 0.65 and the interrate error was +/- 3.52 mm (90% confidence interval [CI]). The interrater ICC for experts was 0.79 and the interrater error was +/- 2.94 mm (90% CI). CONCLUSIONS: These results suggest that experience in using the KT-1000 is related to the interrater error of measurements and that training is an important consideration when using the KT-1000 arthrometer.

The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the reliability, construct validity, and sensitivity to change of the Lower Extremity Functional Scale (LEFS). SUBJECTS AND METHODS: The LEFS was administered to 107 patients with lower-extremity musculoskeletal dysfunction referred to 12 outpatient physical therapy clinics. METHODS: The LEFS was administered during the initial assessment, 24 to 48 hours following the initial assessment, and then at weekly intervals for 4 weeks. The SF-36 (acute version) was administered during the initial assessment and at weekly intervals. A type 2,1 intraclass correlation coefficient was used to estimate test-retest reliability. Pearson correlations and one-way analyses of variance were used to examine construct validity. Spearman rank-order correlation coefficients were used to examine the relationship between an independent prognostic rating of change for each patient and change in the LEFS and SF-36 scores. RESULTS: Test-retest reliability of the LEFS scores was excellent (R = .94 [95% lower limit confidence interval (CI) = .89]). Correlations between the LEFS and the SF-36 physical function subscale and physical component score were r=.80 (95% lower limit CI = .73) and r = .64 (95% lower limit CI = .54), respectively. There was a higher correlation between the prognostic rating of change and the LEFS than between the prognostic rating of change and the SF-36 physical function score. The potential error associated with a score on the LEFS at a given point in time is +/-5.3 scale points (90% CI), the minimal detectable change is 9 scale points (90% CI), and the minimal clinically important difference is 9 scale points (90% CI). CONCLUSION AND DISCUSSION: The LEFS is reliable, and construct validity was supported by comparison with the SF-36. The sensitivity to change of the LEFS was superior to that of the SF-36 in this population. The LEFS is efficient to administer and score and is applicable for research purposes and clinical decision making for individual patients.

Sensitivity to change of the Roland-Morris Back Pain Questionnaire: part 1.

BACKGROUND AND PURPOSE: This study estimated the Roland-Morris Back Pain Questionnaire's (RMQ) change score that best classified patients as those who had achieved an important change and those who had not achieved an important change. The study also investigated whether the estimate of change was dependent on patients' initial scores. SUBJECTS AND METHODS: The RMQ was administered to 226 patients with low back pain of less than 6 weeks' duration during their initial visit for physical therapy and following 3 to 6 weeks of treatment. A global rating of change was used to classify patients as those who had changed an important amount and those who had not changed. Receiver operating characteristic curves were used to identify the RMQ change score that most accurately classified patients with respect to important change. This analysis was repeated for 5 overlapping subsamples of patients with initial scores 0 to 8, 5 to 12, 9 to 16, 13 to 20, and 17 to 24. RESULTS: The area under the receiver operating characteristic curves increased when patients' initial scores were taken into account. Estimates of important change were 2, 4, 5, 8, and 8 for the initial score intervals mentioned above. CONCLUSION AND DISCUSSION: Important change appears to be dependent on patients' initial RMQ scores. Subsequent inquiry using different hypotheses would add support to the estimates of important change found in this study.

Sensitivity to change of the Roland-Morris Back Pain Questionnaire: part 2.

BACKGROUND AND PURPOSE: One purpose of this study was to determine whether the Roland-Morris Back Pain Questionnaire (RMQ) could be used to detect clinically meaningful change in individual patients. The construct that served as the basis for this study was that RMQ change scores should be greater for patients meeting their treatment goals than for patients who did not meet their goals. The second purpose of the study was to determine whether sensitivity to change (STC) varies depending on the magnitude of the initial RMQ score. SUBJECTS AND METHODS: Of the 143 patients with low back pain who completed the study, 104 patients achieved their goals and 39 patients did not achieve their goals. Receiver operating characteristic (ROC) curve analysis and likelihood ratios were used to determine the RMQ change scores that best classify patients as having met or not met their goals. RESULTS: The area under the ROC curve for the entire RMQ scale was 0.68, while the curve areas for smaller RMQ intervals varied from 0.80 to 0.97. CONCLUSION AND DISCUSSION: The STC for the entire RMQ scale was poor for the construct examined in this study. The likelihood ratios for smaller RMQ intervals support the construct validity of the RMQ for assessing change in disability. Initial RMQ score magnitudes must be taken into account to improve the rate of making correct predictions about whether meaningful change in disability will occur following treatment.

The patient-specific functional scale: validation of its use in persons with neck dysfunction.

Self-report measures of disability are being used more frequently to assess patients' outcomes in clinical practice. This study examines the reliability, validity, and sensitivity to change of the Patient-Specific Functional Scale when applied to persons with neck dysfunction. The Patient-Specific Functional Scale and Neck Disability Index were applied at the initial visit, within 72 hours of the initial visit, and following 1-4 weeks of treatment in 31 patients with cervical dysfunction. At the time of the initial visit, the clinician made an estimate of patients' prognoses on a five-point scale. This estimate served as an priori construct for change: patients with better ratings would change more. The results demonstrate excellent reliability (R = .92) validity (r = .73-.83 compared with the Neck Disability Index, and r = .52-.64 compared with the prognosis rating), and sensitivity of change (r = .79-.83 compared with Neck Disability Index change scores, and r = .46-.53 compared with the prognosis rating). No difference was found between the Patient-Specific Functional Scale and Neck Disability Index in their ability to detect change over time. The results of this study are consistent with previous investigations which have concluded that the Patient-Specific Functional Scale is an efficient and valid measure for assessing disability and change in disability in persons with low back pain and knee dysfunction.

Problem-based learning in physical therapy: a review of the literature and overview of the McMaster University experience.

Problem-based learning (PBL), as implemented in the health sciences, is an educational method in which the focus of learning is a small-group tutorial in which students work through health care scenarios. The goals of the health care scenarios are to provide a context for learning, to activate prior knowledge, to motivate students, and to stimulate discussion. Learning is student-centered rather than faculty-centered, and self-directed learning is emphasized. The method was developed in the McMaster University medical school program and has since been adopted by many health care professional schools around the world. The theoretical basis and suggested advantages and disadvantages of PBL are outlined. Three approaches to PBL have been identified in the literature: completely integrated PBL curricula, transitional curricula, and a single-course approach. The advantages and disadvantages of each approach are addressed. The physical therapist (PT) program at McMaster University is a completely integrated problem-based curriculum. The history and process of PBL in general and in the PT program are reviewed. The implications of our experience for the development of other PBL courses and curricula are discussed. Evidence for proposed differences in students' performance and outcomes in PBL versus traditional curricula is critically reviewed. Recommendations are made for implementing PBL in PT curricula.

Measurement properties of the RM-18. A modified version of the Roland-Morris Disability Scale.

STUDY DESIGN: This investigation had two components: one was an item analysis that examined data obtained at the initial patient assessment, and the second was a validation study that used a pretest-posttest design. OBJECTIVES: The authors' goal, in this study, was to determine whether a shorter version of the Roland-Morris Questionnaire could be developed with measurement properties equal to or better than the original 24-item questionnaire. SUMMARY OF BACKGROUND DATA: The measurement properties of the Roland-Morris Questionnaire have been shown to be better than or equal to competing measures. A number of studies have reported modified versions of the Roland-Morris without providing the measurement properties of the modified tool. METHODS: The item analysis investigated endorsement frequency, interitem correlations, item-corrected item total correlations, and coefficient alpha with various combinations of items deleted. The validation study examined reliability, concurrent validity, and longitudinal validity (sensitivity to change). The analyses included comparisons with the Oswestry and Jan van Breeman Pain Questionnaires. RESULTS: The item analysis suggested than six items could be detected from the Roland-Morris Questionnaire. The validation study demonstrated that the shorter version, named the RM-18, has measurement properties that are equal to those of the longer version. CONCLUSIONS: The RM-18 can be used as an outcome measure in clinical trials or as a tool to aid in decision making concerning individual patients. In either case, its measurement properties are equal to those of the 24-item Roland-Morris Questionnaire.

The Patient-Specific Functional Scale: measurement properties in patients with knee dysfunction.

BACKGROUND AND PURPOSE: Assessing disability is important, and numerous interviewer-assisted and self-report questionnaires are used to accomplish this task. These questionnaires can be classified as being generic, condition or disease specific, or patient specific. The purpose of this study was to determine test-retest reliability, construct validity, and sensitivity to change of the Patient-Specific Functional Scale (PSFS) when applied to patients with knee dysfunction. SUBJECTS: Subjects were 38 physician-referred patients with knee dysfunction. METHODS: The PSFS and the Medical Outcomes Study 36-Item Short-Form Health Survey were administered at a patient's initial visit and following 2 to 3 weeks of treatment. An assessment of global change was also made by the patient and clinician at follow-up. These measures allowed the assessment of construct validity and sensitivity to change. To obtain an estimate of reliability, the PSFS was also administered within 72 hours of the initial assessment. RESULTS: Test-retest reliability and sensitivity to change were excellent (intraclass correlation coefficient [type 2,1] R = .84 and Pearson's r = .78, respectively). Validity was also confirmed. CONCLUSION AND DISCUSSION: Previous investigation on persons with low back pain suggested that the PSFS has promising measurement properties. The results of this study provide further evidence supporting the reliability, validity, and efficiency of the PSFS. Further investigation is needed to determine the extent to which the PSFS can be applied across a variety of conditions and age groups.

Health status measures: strategies and analytic methods for assessing change scores.

Over the last 15 years, numerous self-report health status measures have appeared in the literature. An important parallel development has been the development of numerous strategies for assessing change in health status over time. The purpose of this article is to summarize and critique the more common design and analytic strategies for assessing the meaningfulness of change over time. Five commonly reported designs are presented, critiqued, and depicted using examples from the literature. Methods for analyzing results are reviewed and illustrated using two data sets. Insights into comparing competing health status measures are provided. In summary, the article suggests that some designs and analytic strategies are more adept than others at assessing change and that these methods should be considered when planning sensitivity-to-change studies.

Defining the minimum level of detectable change for the Roland-Morris questionnaire.

BACKGROUND AND PURPOSE: The Roland-Morris Questionnaire (RMQ) is a self-administered disability measure in which greater levels of disability are reflected by higher numbers on a 24-point scale. The RMQ has been shown to yield reliable measurements, which are valid for inferring the level of disability, and to be sensitive to change over time for groups of patients with low back pain. Little is known about the usefulness of this instrument in aiding decision making regarding individual patients. The purpose of this study was to determine the minimum level of detectable change when the RMQ is applied to individual patients. SUBJECTS: The study sample consisted of 60 outpatients with low back pain. METHODS: The RMQ was administered at the subjects' initial visit and again 4 to 6 weeks later. Conditional standard errors of measurement (CSEMs) were computed for initial and follow-up RMQ scores, and these values were used to estimate the minimum level of detectable change. Results. Minimum levels of detectable change at the 90% confidence level varied from 4 to 5 RMQ points. CONCLUSION AND DISCUSSION: The magnitude of CSEMs is sufficiently small to detect change in patients with initial scores in the central portion of the scale (4-20 RMQ points); however, the magnitude is too large to detect improvement in patients with scores of less than 4 and deterioration in patients who have scores greater than 20.

Interrater reliability of lumbar accessory motion mobility testing.

BACKGROUND AND PURPOSE: This study examined the interrater agreement, or reliability, of accessory motion mobility testing of the lumbar spine in patients with low back pain. SUBJECTS: Subjects were 18 patients with low back pain referred to the physical therapy outpatient department of a university teaching hospital. METHODS: Six orthopedic physical therapists evaluated the posterior-anterior (P-A) accessory motion mobility at each of six levels, L-1 to the sacral base, on each subject. The mobility was recorded on a nine-point scale, and reproduction of pain was noted. The physical therapists noted any level at which mobility or pain findings were of significance to treat. To evaluate agreement on the identification of spinal levels, therapists were asked to identify one spinous process, which was arbitrarily marked on each subject. Kappa analyses and intraclass correlation coefficients (ICCs) were calculated to evaluate agreement on the level of the marked segment and the mobility at that level, respectively. RESULTS: The ICC for determination of the marked level was R(2,1) = .69 (95% confidence interval = .53-.82). The ICC for mobility findings at the marked level was R(2,1) = .25 (95% confidence interval = 0-.44). A secondary Kappa analysis to determine agreement on treatment decision making demonstrated similarly low levels of agreement. CONCLUSION AND DISCUSSION: There is poor interrater agreement on determination of the segmental level of a marked spinous process. There is poor interrater reliability of P-A accessory mobility testing in the absence of corroborating clinical data. Caution should be exercised when physical therapists make clinical decisions related to the evaluation of motion at a specific spinal level using P-A accessory motion testing.

A review of the McMurray test: definition, interpretation, and clinical usefulness.

Clinicians frequently use the results of clinical diagnostic tests to make decisions concerning patients. The intent of this paper is to review the technical aspects and measurement properties of the McMurray test and, more globally, to illustrate the impact that indiscriminate test application has on test interpretation. The literature shows that diagnostic accuracy studies, which evaluate the test described by McMurray, yield remarkably similar estimates of sensitivity (about 26%) and specificity (about 94%). These test characteristics are applied to three case scenarios to illustrate the impact that history-specific prevalence (i.e., the likelihood a patient has the condition based on the history) has on the predictive values. The results show a high false positive rate when applied to patients who, based on the history, have a low pre-physical examination likelihood for the condition of interest and a higher false negative rate when applied to patients who have a high history-specific prevalence. Readers are warned that the exhaustive examination approach effectively lowers the prevalence and results in a high false positive rate. The impact that the exhaustive approach has on increasing the false positive rate is universal to all diagnostic investigations and is not unique to the McMurray test.