Physiotherapy, Volume 97, Issue 1 (2011)

Physiotherapy VOLUME 97, NUMBER 1, 2011 Editor Editorial Office Michele Harms PhD MSc GradDipPhys MCSP Editor Kingston...

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Physiotherapy VOLUME 97, NUMBER 1, 2011 Editor

Editorial Office

Michele Harms PhD MSc GradDipPhys MCSP Editor Kingston University and St George’s, University of London, UK

Physiotherapy Editorial Office Elsevier Ltd, The Boulevard Langford Lane Kidlington Oxford OX5 1GB, UK Tel.: +44 (0)1865 843672 Fax: +44 (0)1865 843992 E-mail: [email protected]

Guest Editor Catherine Sykes MSc, MCSP, DipTP Professional Policy Consultant World Confederation for Physical Therapy (WCPT), London, UK

Associate Editors Claire Ballinger PhD MSc DipCOT Southampton General Hospital Southampton, UK

Gareth Noble PhD BSc(Hons) University of Wales Swansea, Wales

Richard Bohannon EdD, PT, NCS, FAHA, FAPTA University of Connecticut Connecticut, USA

Valerie Pomeroy PhD BA GradDipPhys FCSP University of East Anglia Norwich, UK

Tracy Bury MSc GradDipPhys MCSP WCPT Secretariat London, UK

Gabrielle Rankin PhD MSc GradDipPhys MCSP Chartered Society of Physiotherapy London, UK

Vinette Cross PhD MMedEd MCSP DipTP CertEd University of Wolverhampton Wolverhampton, UK Mike Hurley PhD GradDipPhys MCSP St George's University of London and Kingston University, London, UK Sallie Lamb DPhil MSc GradDipPhys MCSP University of Warwick Warwick, UK

International Advisory Board D. Bader (Queen Mary College, University of London, UK) C. Bithell (St George's, University of London and Kingston University, UK) K. Bø (Norwegian School of Sport Sciences, Oslo, Norway) M. O’Brien (McMaster University, Ontario, Canada) C. Cott (University of Toronto, Canada) R. de Bie (Maastricht University, The Netherlands) W. de Weerdt (University of Leuven, Heverlee, Belgium)

Patricia Roche PhD MSc BSc(Hons) MCSP Queen Margaret University College Edinburgh, Scotland Sally Singh PhD BSc MCSP Glenfield Hospital Leicester, UK Paul Watson PhD MSc GradDipPhys MCSP BSc(Hons) CertHSM PGCE DipPT University of Leicester Leicester, UK C. Eales (University of Witwatersrand, Johannesburg, South Africa) J. Hay Smith (University of Otago, Dunedin, New Zealand) S. Jenkins (Curtin University of Technology, Perth, Australia) G. Jensen (Creighton University, Nebraska, USA) R. Ladyshewsky (Curtin University, Perth, Australia) I. Nara (Kobe Gakuin University, Kobe, Japan) A. Nieuwboer (University of Leuven, Heverlee, Belgium) P. Pothongsunun (Chiang Mai University, Thailand) G. Wulf (University of Nevada, USA)

The journal of the Chartered Society of Physiotherapy Visit the journal website at www.intl.elsevierhealth.com/journals/phys

Amsterdam

• Boston • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis

Physiotherapy 97 (2011) 1–2

Guest Editorial

This issue of Physiotherapy brings together a number of articles in which the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) [1] plays an essential part in the research presented. Published in 2001 and followed by a derived version for children and youth (ICF-CY) in 2007, the ICF is becoming well accepted as a framework in which to explore the relationship between a health condition (usually recorded with an International Classification of Diseases code [2]) and the associated functioning at body (body function and structure/impairments), individual (activity/activity limitations) and societal (participation/participation restriction) levels, as well as the environmental factors affecting level of functioning either as facilitators or barriers. Important features of the ICF that are utilised by the authors in this special issue are the multifaceted and multidirectional nature of human function, the importance of recording the environment, and the aetiologically neutral stance that the classification takes in recording a person’s functioning regardless of the number and type of health conditions that may pertain. Over the 9 years since the ICF was published, the classification has been welcomed and used increasingly by the physiotherapy profession. The World Confederation for Physical Therapy endorsed the classification at its general meeting in 2003, and the American Physical Therapy Association adopted the classification more recently. This issue of Physiotherapy demonstrates a variety of uses of the ICF, not just as a conceptual framework but as a means of collating data from a variety of sources to enable comparisons of the experiences of functioning across the time course of a disease and across cultures and settings. This use of the classification by Myezwa et al. [3] in South Africa and Brazil demonstrates the benefit of a common language and definitions to bring together data to provide new information. The data from very different cohorts of people living with HIV/AIDS were brought together to give a picture of the experience of living with the disease in the two countries and at different stages in the course of the disease, despite the fact

that the studies did not follow a standard format. Despite the fact that the studies were conducted in different languages on different continents, it was possible to relate the data because the ICF provides the definitions and codes. A paradigm shift or change from one way of thinking to another takes time and is driven by agents of change [4]. Jelsma and Scott [5] have been such agents of change in the field of paediatric neurology. Physiotherapy students were introduced to the ICF early in their entry-level programmes, but it was not until the third year of study, when the ICF was required to be used as the systematic framework for assessment, that there were measurable changes in the quality of the assessments done by the students in terms of their holistic view of the paediatric patients, and their ability to see the child in the context of participation in age-appropriate activities. The study demonstrated the need to strengthen the links between the ICF in theory and practice. Although there were significant differences in the quality of the assessments and better planning was observed, it is not yet known whether this translates into better treatments and better outcomes for the children. Jones [6] considered the way in which the ICF can be introduced to students, and used a software product to make the ICF and a range of resources about the classification available to students. Using the learning resource enabled enquiry-based learning across the levels of physiotherapist entry-level education, and also facilitated interprofessional education by ensuring that all students and faculty have access to the resources. The study by Fairhall et al. [7] illustrates the benefit of having a conceptual framework in which to examine all aspects of functioning. The authors demonstrate how a suite of standardised assessment tools can be related to the components, domains and categories of the ICF to give a fuller picture of functioning, and perhaps importantly reveal the categories of functioning that are not usually addressed but may form important missing links, which, if addressed, can lead to better outcomes for the individuals concerned and better programme planning and development at the population level.

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.10.002

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Guest Editorial / Physiotherapy 97 (2011) 1–2

Another method of using the ICF is to select a subset relevant for a specific purpose from amongst the 1400+ categories. Selecting the lowest number of categories with the highest relevance can be a useful way of creating consistent and reliable data collections. The ‘core sets’ methodology [8] was used to develop such a subset of functioning categories that may be expected to be affected in breast cancer, which Glaessel et al. [9] have sought to validate from the perspective of physiotherapists. An a priori selection of relevant categories for a particular research question can enable the study to be replicated across settings and services, across regions or even nations. The articles in this special issue show different applications of the ICF and generally support the aims of the ICF as stated by the World Health Organization [1]. The classification has been used to provide the scientific basis for understanding the complexity that is human functioning in populations at either end of the age range. It has been used to establish a common language for describing functioning in order to improve communication between users, and has been used as a systematic coding scheme to permit comparison of data across countries, services and time. References [1] World Health Organization. The International Classification of Functioning, Disability and Health. Geneva: WHO; 2001.

[2] World Health Organization. The International Classification of Diseases and Related Health Problems. 10th edn. Version 2. Geneva: WHO; 2004. [3] Myezwa H, Buchalla CM, Jelsma J, Stewart A. HIV/AIDS: use of the ICF in Brazil and South Africa—comparative data from four cross-sectional studies. Physiotherapy 2011;97(1):17–25. [4] Kuhn TS. The structure of scientific revolutions. Chicago: University of Chicago Press; 1962. [5] Jelsma J, Scott D. Impact of using the ICF framework as an assessment tool for students in paediatric physiotherapy: a preliminary study. Physiotherapy 2011;97(1):47–54. [6] Jones LE. Introducing the ICF: the development of an online resource to support learning, teaching and curriculum design. Physiotherapy 2011;97(1):55–8. [7] Fairhall N, Sherrington C, Kurrle SE, Lord SR, Cameron ID. ICF Participation restriction is common in frail, community-dwelling older people: an observational cross-sectional study. Physiotherapy 2011;97(1):26–32. [8] Cieza A, Ewert T, Üstün TB, Chatterji S, Kostansjek N, Stucki G. ICF Core Sets development for patients with chronic conditions. J Rehab Med 2004;44(Suppl.):9–11. [9] Glaessel A, Kirchberger I, Stucki G, Cieza A. Does the Comprehensive International Classification of Functioning. Disability and Health (ICF) Core Set for Breast Cancer capture the problems in functioning treated by physiotherapists in women with breast cancer? Physiotherapy 2011;97(1):33–46.

Catherine Sykes (MSc, MCSP, DipTP) Professional Policy Consultant World Confederation for Physical Therapy (WCPT), London, UK E-mail address: [email protected]

Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 3–16

Validation of the Comprehensive ICF Core Set for Osteoarthritis: the perspective of physical therapists Tanja Bossmann a , Inge Kirchberger a , Andrea Glaessel b , Gerold Stucki a,b,c , Alarcos Cieza a,b,∗ a

ICF Research Branch of the WHO CC FIC (DIMDI), Institute for Health and Rehabilitation Sciences, Ludwig-Maximilian University, Munich, Germany b Swiss Paraplegic Research, Guido A. Zäch Institute, Nottwil, Switzerland c Seminar of Health Sciences and Health Policies, University of Lucerne, Lucerne, Switzerland

Abstract Background and purpose Osteoarthritis is a common chronic disease associated with functional impairments and activity limitations, as well as participation restrictions. The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Osteoarthritis is an application of the ICF and represents the typical spectrum of problems in functioning of patients with osteoarthritis. Objective To validate the Comprehensive ICF Core Set for Osteoarthritis from the perspective of physical therapists. Methods Physical therapists experienced in the treatment of patients with osteoarthritis were asked about patients’ problems, resources and aspects of the environmental factors treated by physical therapists in patients with osteoarthritis in a three-round, electronic-mail survey using the Delphi technique. Responses were linked to the ICF. Results Seventy-two experts from 22 countries named 744 meaningful concepts that covered all ICF components. One hundred and fifty-two ICF categories were linked to these answers, 32 concepts were linked to the not-yet-developed personal factors component, and 14 issues were not covered by a single ICF category. Twelve ICF categories were not represented in the Comprehensive ICF Core Set for Osteoarthritis, although at least 75% of the participants rated them as important. Discussion and conclusion The content validity of the ICF was widely supported by the physical therapists. However, several issues were raised that were not covered and need to be investigated further. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: International Classification of Functioning, Disability and Health; ICF core sets; Rehabilitation; Osteoarthritis; Delphi method

Introduction Osteoarthritis is a common chronic disease associated with functional impairments such as pain, morning stiffness and limitation of joint motion [1–7]. Such impairments often lead to limitations of physical activities and restrictions in daily activities and participation. Osteoarthritis also imposes a considerable economic burden on the healthcare system as well as the individual [5]. Physical therapy is frequently used in patients with osteoarthritis and has been recommended by the American College of Rheumatology and the European League against Rheumatism [1,8]. Numerous treatment modes are ∗ Corresponding author at: ICF Research Branch of the WHO CC FIC (DIMDI), Institute for Health and Rehabilitation Sciences, LudwigMaximilian University, Munich, Germany. E-mail address: [email protected] (A. Cieza).

used, including manual therapy, knee taping, exercise, massage, education and guidance regarding handling of assistive devices (e.g. walking aids) [9,10]. Central aims of the therapeutic process are facilitation of the patients’ functioning, activities and level of participation, and encouragement to deal with limitations of physical activities and restrictions in daily activities and participation in an adequate way. Furthermore, the adoption of a behavioural approach is relevant in patients with inadequate pain behaviour, and therefore patients’ coping strategies should be taken into account by physical therapists [11]. The International Classiﬁcation of Functioning, Disability and Health A proper understanding of patients’ functioning and health status is needed to optimise interventions aimed at maintaining function and minimising disability [12].

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2009.11.011

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T. Bossmann et al. / Physiotherapy 97 (2011) 3–16

Fig. 1. Structure of the International Classification of Functioning, Disability and Health (ICF).

The World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) provides a useful framework for classifying the aspects of health and the consequences of disease. It aims to provide a unified language for the description of health conditions in rehabilitation and a common framework for all health professions [13]. According to the ICF, the problems associated with a disease may concern body functions and structures as well as the performance of activities and participation in life situations. Health conditions and the development of disability are modified by contextual factors such as environmental and personal factors [13]. The ICF is structured into two parts – (a) functioning and disability, and (b) contextual factors – each of which has two components (see Fig. 1). Within functioning and disability, the body component consists of body functions and body structures, and the activities and participation component covers chapters of functioning from both individual and social perspectives. In contrast to other disability models, the ICF not only includes but also classifies contextual factors that may either facilitate or hinder functioning and, therefore, affect the development of disability. The two components of the contextual factors are environmental factors (i.e. factors in the physical, social or attitudinal world) and personal factors (i.e. age, gender, habits, lifestyle, coping style, etc.); the latter is not currently classified. Within the body functions and structures, activities and participation, and environmental factors components, all items in the classification are arranged hierarchically (see Fig. 1). The units of the ICF are ICF categories (e.g. b280 Pain). Both the content and the structure of the ICF point out their potential value for clinical and rehabilitation practice

in general and specifically for physical therapists [14]. The World Confederation of Physical Therapy emphasises the impact of the ICF, and is aiming to gain wider use of the ICF by physical therapists [15]. The common language of the ICF crosses professions and health disciplines. ICF data can be communicated effectively between the members of rehabilitation teams (e.g. physical therapists, physicians, nurses, psychologists and occupational therapists). Furthermore, application of the ICF will be valuable for the standardisation of rehabilitation research data around the world. Although the ICF does not prescribe measures and interventions that are used in physical therapist practice, it can be used as a basis from which selection of tests and interventions can be standardised [16]. The ICF Core Set for Osteoarthritis Despite its value, the ICF as a whole – including more than 1400 categories – is not feasible for use in clinical practice. In order to facilitate the implementation of the ICF into clinical practice, ICF core sets have been developed for a number of health conditions, including osteoarthritis [12,17,18]. The Comprehensive ICF Core Set for Osteoarthritis includes a set of categories from the whole ICF which is intended to cover the typical spectrum of problems in functioning in patients with osteoarthritis [19]. It was developed in a formal decision-making and consensus process, integrating evidence gathered from preparatory studies by experts experienced in the treatment of patients with osteoarthritis [19]. Preparatory studies included a Delphi exercise, a systematic review and an empirical data collection [20]. At present, the Comprehen-

T. Bossmann et al. / Physiotherapy 97 (2011) 3–16

sive ICF Core Set for Osteoarthritis is undergoing worldwide testing and validation using a number of approaches, including international multicentre field studies and validation from the patients’ perspective. One key aspect is validation from the users’ perspective, for whom the Comprehensive ICF Core Set for Osteoarthritis was developed in the first place (i.e. physical therapists, physicians, nurses, psychologists and occupational therapists). Since not all health professions were involved in the decision-making and consensus process, it is necessary to evaluate whether their perspective has been considered sufficiently. Furthermore, the preparatory studies and consensus process did not explicitly address the interventions applied by health professionals. Since ICF core sets should serve as a standard for multiprofessional assessment and evaluation in clinical trials, it is important to determine whether the categories included in the Comprehensive ICF Core Set for Osteoarthritis cover patients’ problems addressed by the specific intervention of health professionals. Consensus methods Achieving group consensus is difficult. The more complex the issue, the more prolonged the discussion [21]. Consensus methods are employed to help enhance effective decisionmaking and several methods have been described, such as the nominal group technique and the Delphi technique [22]. The Delphi method has a flexibility which allows considerable diversity in its application, and it is not affected by bias which can occur in comparable techniques (e.g. group discussion) [23]. There are various reasons why a researcher may choose the Delphi approach. One reason is that the time, cost and logistics would make frequent meetings of all the subjects unfeasible [24]. Therefore, in this study, the Delphi method was considered to be an appropriate approach for worldwide validation from the users’ perspective. Study objective The objective of this study was to validate the Comprehensive ICF Core Set for Osteoarthritis [19] from the perspective of physical therapists. The specific aims were to identify patients’ problems, resources and aspects of the environment treated by physical therapists in patients with osteoarthritis, and to examine whether the patients’ problems, resources and aspects of environments mentioned by physical therapists are represented by the current version of the Comprehensive ICF Core Set for Osteoarthritis.

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topic [24]. These informed persons are commonly titled ‘experts’. The Delphi method is a multistage process where each stage is based on the results of the previous stage, and a series of rounds is used to gather and provide information about a particular subject. The technique is characterised by its anonymity, thus avoiding group dominance; iteration, which allows panel members to change their opinions in subsequent rounds; and controlled feedback showing the distribution of the group response as well as the individual’s previous response [25]. Consideration must also be given to the level of consensus, but an universally agreed proportion does not exist. The percentage of recommended agreement ranges from 51% to 80% [22]. However, the authors decided to accept 75% agreement in the third round as consensus based on experience from previous studies [26]. The research group for this project consisted of two physical therapists and one psychologists. The study protocol was approved by the Ethics Committee of Philipps-University Marburg. Recruitment of participants The authors aimed to form a panel with a wide spectrum of experience for the Delphi study. Therefore, different recruitment strategies were used. In the preparatory phase of the study, national and international associations of physical therapists as well as universities and partners of the Institute for Health and Rehabilitation Sciences at Ludwig-Maximilian University Munich were contacted. In addition, literature searches and personal recommendations were used to identify physical therapists experienced in the treatment of patients with osteoarthritis. For a wide range of countries and different clinical settings, the participants were selected using a maximum variation sampling strategy [27]. To ensure that the participants of the study were informed about the treatment of patients with osteoarthritis, the letter of enquiry noted that participants should be ‘physical therapists with experience in the treatment of patients with osteoarthritis’. Furthermore, the letter of enquiry included brief information about the ICF Core Set for Osteoarthritis and a link to the study homepage to provide guidance regarding knowledge and understanding of the ICF. The first contact included an invitation to participate and a detailed description of the project targets, the Delphi process and the expected timeline. Only individuals who agreed to participate were included in the sample and received the questionnaire for the first Delphi round. Delphi process

Methods A consensus-building, three-round, electronic-mail survey was conducted with physical therapists from all six world regions defined by WHO using the Delphi technique [21–23]. The Delphi technique aims to gain consensus from a panel of individuals who have knowledge of the investigated

The questions for Rounds 1 to 3 were generated and developed in previous studies [26]. The process and verbatim questions of the electronic-mail survey using the Delphi technique are specified in Fig. 2. In Round 1 of the Delphi exercise, an informational letter including instructions and an Excel file containing an open-ended questionnaire were sent

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T. Bossmann et al. / Physiotherapy 97 (2011) 3–16

Fig. 2. Delphi process. ICF, International Classification of Functioning, Disability and Health.

to all participants. In the questionnaire, the participants were requested to list all the patients’ problems, patients’ resources and aspects of the environment treated by physical therapists in patients with osteoarthritis. Additionally, the participants were asked to complete questions on demographic characteristics and professional experience. The incoming

mails were assigned with identification numbers to assure anonymity. Responses were collected and linked to the ICF [28]. In the second Delphi round, the participants received a list of ICF categories linked to the responses of the first round. The categories were ordered according to the structure of the ICF.

T. Bossmann et al. / Physiotherapy 97 (2011) 3–16

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Table 1 Example linking process. Response of participant

Meaningful concepts

ICF code

ICF category title

Functional limitations, including activities of daily living such as difficulty walking, transferring, recreational, etc.

Functional limitations: activities of daily living Functional limitations: walking Functional limitations: transferring

d d450 d410 d420 d920

Component: activities and participation Walking Changing basic body position Transferring oneself Recreation and leisure

Functional limitations: recreational ICF, International Classification of Functioning, Disability and Health.

The responses that could not be linked to an existing ICF category were categorised by the research group and listed. The participants were asked to agree or disagree about whether the respective ICF category represented patients’ problems, patients’ resources and aspects of the environment treated by physical therapists in patients with osteoarthritis. In the third Delphi round, the participants received a list of ICF categories including the proportion and the identification numbers of the participants who agreed that the categories represented patients’ problems, patients’ resources and aspects of the environment treated by physical therapists in patients with osteoarthritis. The participants were asked to answer the same question taking into account the responses of the group as well as their own previous response.

IL, USA). Descriptive statistics were used to characterise the sample and frequencies of responses. Furthermore, the authors analysed inter-rater reliability of the linking process [28]. Statistical Analysis System (SAS) for Windows Version 8 (SAS Institute Inc., Cary, NC, USA) was used to perform kappa statistics with bootstrapped confidence intervals in order to describe the agreement between the two physical therapists who performed the linking [31,32].

Linking the responses to the ICF

1. All meaningful concepts, represented by participants’ answers in the first round, were identified separately by the two trained physical therapists of the research group [29,30]. 2. The two versions of meaningful concepts were compared. In cases of disagreement, a discussion was held between the two physical therapists and the psychologist in the research group. Based on this discussion, a joint decision was made. 3. The agreed list of meaningful concepts was linked separately by the two trained physical therapists of the research group to the most precise ICF categories (Table 1). The linkage was performed on the basis of 10 linking rules established in former studies [28]. 4. Consensus between the physical therapists was used to decide which ICF category should be linked to each response. In cases of disagreement between the two physical therapists, the suggested categories were discussed by the two physical therapists and the psychologist of the research group. Based on this discussion, a joint decision was made.

Ninety-six associations of physical therapists and 11 additional relevant associations (e.g. Osteoarthritis Research Society International and the American Academy of Physical Medicine and Rehabilitation) were contacted. Twenty-four participants were recruited using this strategy. Additionally, 74 universities from 34 different countries were addressed and yielded two more participants. One hundred and sixtysix partners of the Institute for Health and Rehabilitation Sciences at Ludwig-Maximilian University Munich were contacted, and nine physical therapists agreed to cooperate in the Delphi process. Based on the literature search, 62 physical therapists were identified and invited to participate; 23 of them were registered as Delphi panel members. On the basis of personal recommendations of other participants, 19 individuals agreed to participate in the project. Although the letter of enquiry noted that participants should be ‘physical therapists with experience in the treatment of patients with osteoarthritis’, two scientists involved in osteoarthritis research projects but without practical knowledge were recommended by another participant. The authors decided to include them because of their outstanding research expertise in the field of osteoarthritis. After the recruitment phase, a total of 77 physical therapists from 23 different countries representing all six WHO regions agreed to participate in the Delphi survey.

Statistical methods

Delphi process

Statistical analysis was performed using Statistical Package for the Social Sciences Version 12.0 (SPSS Inc., Chicago,

Seventy-two of 77 participants (94%) completed the first round questionnaire. The demographic and professional

Each response of the first Delphi round was analysed in four steps:

Results Recruitment and participants

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Table 2 Attrition of participants between the Delphi rounds, demographics and professional experience of participants in Round 1. WHO region

Round 1 (n)

Round 2 (n)

Round 3 (n)

Female (%)

Professional experience (years)

Osteoarthritis experience (years)

Self-rating expertise in osteoarthritisa

Median (range)

Median (range)

Median (range)

Median (range)

Mainly treating patients in acute situationsb (n)

Mainly treating patients in early-postacute situationsb (n)

Mainly treating patients in chronic situationsb (n)

Africanc Eastern Mediterraneand Europeane Americasf South East Asiag Western Pacifich

4 3 29 16 3 17

3 3 26 16 3 16

3 2 24 16 3 13

25% 100% 48% 50% 33% 65%

46 (33 to 52) 41 (26 to 44) 39 (29 to 59) 49 (28 to 60) 37 (33 to 54) 42 (27 to 51)

22 (7 to 30) 15 (4 to 15) 13 (5 to 35) 25 (5 to 36) 17 (8 to 20) 20 (7 to 28)

20 (6 to 30) 5 (4 to 5) 10 (0 to 28) 19 (5 to 31) 15 (8 to 17) 15 (6 to 25)

4 (3 to 5) 3 (2 to 4) 4 (3 to 5) 4 (3 to 5) 4 (4 to 4) 5 (4 to 5)

2 0 7 3 0 9

2 1 17 8 2 11

4 3 25 16 2 17

Total

72

67

61

53%

42 (26 to 60)

16 (4 to 36)

13 (0 to 31)

4 (2 to 5)

21

41

67

a b c d e f g h

1 = low, 5 = excellent. Multiple responses possible. Nigeria. Iran. Denmark, Germany, Hungary, Netherlands, Norway, Romania, Sweden, Switzerland, Turkey, UK. Canada, Chile, USA. India, Taiwan, Thailand. Australia, New Zealand, Singapore, Japan, South Korea.

T. Bossmann et al. / Physiotherapy 97 (2011) 3–16

Age (years)

T. Bossmann et al. / Physiotherapy 97 (2011) 3–16

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Table 3 Body functions component. ICF code 1st level

ICF category 2nd level

3rd level

4th level

b1301 b134 b1342 b152 b180 b260 b280 b28010 b28013 b28014 b28015 b28016 b410 b415 b420 b435 b455 b4550 b4551 b4552 b530 b640 b710 b7100 b715 b7150 b730 b7304 b735 b740 b755 b760 b7602 b7603 b770 b780 b7800 b7801

Round 3 n = 61 % yes

Motivation Sleep functions Maintenance of sleep Emotional functions Experience of self and time functions Proprioceptive function Sensation of pain Pain in head and neck Pain in back Pain in upper limb Pain in lower limb Pain in joints Heart functions Blood vessel functions Blood pressure functions Immunological system functions Exercise tolerance functions General physical endurance Aerobic capacity Fatiguability Weight maintenance functions Sexual functions Mobility of joint functions Mobility of a single joint Stability of joint functions Stability of a single joint Muscle power functions Power of muscles of all limbs Muscle tone functions Muscle endurance functions Involuntary movement reaction functions Control of voluntary movement functions Coordination of voluntary movements Supportive functions of arm or leg Gait pattern functions Sensations related to muscles and movement functions Sensation of muscle stiffness Sensation of muscle spasm

89% 34% 38% 57% 75% 97% 100% 93% 98% 98% 100% 100% 62% 48% 30% 20% 100% 100% 98% 97% 98% 18% 100% 100% 100% 100% 100% 100% 90% 100% 90% 97% 97% 97% 100% 98% 100% 87%

Bold text indicates International Classification of Functioning, Disability and Health (ICF) categories included in the Comprehensive ICF Core Set for Osteoarthritis, and regular text indicates ICF categories linked to participants’ responses but not included in the Comprehensive ICF Core Set for Osteoarthritis. Percentage of participants who considered the respective ICF category as relevant in the third round.

characteristics of the participants are shown in Table 2. Sixtyseven of 72 physical therapists (93%) returned the second round questionnaire. The third round questionnaire was completed by 61 of 67 participants (91%). Detailed information including the percentage agreement between participants is presented in Tables 3–6. Linking the responses to the ICF In the first Delphi round, 744 different meaningful concepts were identified which covered all ICF components. One hundred and fifty-two ICF categories were linked to these answers. Five fourth-level categories, 12 third-level categories and 21 second-level categories of the body function

component were linked. Seven fourth-level categories, eight third-level categories and seven second-level categories of the body structures component were linked. In the activities and participation component, 38 third-level categories, 22 second-level categories and one chapter were linked. Regarding the environmental factors component, the analysis resulted in 11 third-level categories and 20 second-level categories. Thirty-two identified concepts were considered to be linked to the personal factors component (e.g. coping, health behaviour, self-efficacy and health conditions such as obesity and osteoporosis). Fourteen issues were not covered by a single ICF category (e.g. alignment, malalignment and posture). The kappa statistic for linking was 0.61 with a bootstrapped confidence interval of 0.58 to 0.65.

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Table 4 Body structure component. ICF code 1st level

ICF category 2nd level

3rd level

4th level

s140 s150 s720 s730 s73001 s73011 s7302 s750 s75001 s75002 s75010 s75011 s7502 s760 s7600 s76000 s7601 s770 s7700 s7701 s7702 s7703

Round 3 n = 61 % yes

Structure of sympathetic nervous system Structure of parasympathetic nervous system Structure of shoulder region Structure of upper extremity Elbow joint Wrist joint Structure of hand Structure of lower extremity Hip joint Muscles of thigh Bones of lower leg Knee joint Structure of ankle and foot Structure of trunk Structure of vertebral column Cervical vertebral column Muscles of trunk Additional musculoskeletal structures related to movement Bones Joints Muscles Extra-articular ligaments, fasciae, extramuscular aponeuroses, retinacula, septa, bursae

28% 25% 87% 92% 87% 88% 90% 93% 97% 98% 75% 98% 92% 84% 93% 93% 98% 98% 72% 98% 98% 97%

Bold text indicates International Classification of Functioning, Disability and Health (ICF) categories included in the Comprehensive ICF Core Set for Osteoarthritis, and regular text indicates ICF categories linked to participants’ responses but not included in the Comprehensive ICF Core Set for Osteoarthritis. Percentage of participants who considered the respective ICF category as relevant in the third round.

Representation of the physical therapists’ responses in the Comprehensive ICF Core Set for Osteoarthritis Eleven ICF categories of the body functions component are represented in the Comprehensive ICF Core Set for Osteoarthritis [19] at the same level of classification, and one additional category is represented by a higher-level category, linked to the responses of the Delphi panel. Four categories of the body structures component and 14 categories of the activities and participation component are represented in the Comprehensive ICF Core Set for Osteoarthritis [19] at the same level of classification. Two more ICF categories of the activities and participation component are represented by four higher-level categories, linked to the responses of the participants. From the environmental factors component, 13 categories are represented in the Comprehensive ICF Core Set for Osteoarthritis [19] at the same level of classification, and one additional category is represented by a higher-level category. Fourteen concepts are not covered by a single ICF category. Ten ICF categories at the same level of classification, one higher-level category and one chapter with agreement among participants of more than 75% in the third round are not represented in the Comprehensive ICF Core Set for Osteoarthritis [19].

Discussion The results show that physical therapists have a comprehensive appreciation of functioning of an individual with osteoarthritis. Seven hundred and forty-four identified meaningful concepts linked to 152 ICF categories, including all ICF components, reflect this holistic perception of physical therapists which has been supported by several studies [3,4,8–11,33–35]. A total of 46 categories of the Comprehensive ICF Core Set for Osteoarthritis were confirmed by the Delphi panel, many of them with high agreement. However, the study findings identified some ICF categories with agreement of more than 75% among the participants in the third round that were not represented in the Comprehensive ICF Core Set for Osteoarthritis [19] (Table 7). Body functions More than 90% of the participants agreed that the ICF categories b260 Proprioceptive function and b755 Involuntary movement reaction functions are important in the treatment of patients with osteoarthritis, and the literature underlines this result [36–40]. Individuals with knee osteoarthritis often

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Table 5 Activity and participation component. ICF code 1st level

ICF category 2nd level

3rd level

d1 d2401 d410 d4100 d4101 d4102 d4103 d4104 d4152 d4153 d4154 d420 d4201 d430 d4300 d440 d445 d450 d4500 d4501 d4502 d455 d4551 d4600 d4601 d4602 d465 d470 d4700 d4701 d4702 d475 d4750 d540 d5402 d570 d5701 d5702 d6200 d630 d640 d6400 d6401 d6402 d6500 d6501 d6505 d7400 d760 d770 d7702 d820 d845 d850 d910 d920 d9201 d9203 d9204 d9205 d930

4th level

Round 3 n = 61 % yes

Chapter 1: learning and applying knowledge Handling stress Changing basic body position Lying down Squatting Kneeling Sitting Standing Maintaining a kneeling position Maintaining a sitting position Maintaining a standing position Transferring oneself Transferring oneself while lying Lifting and carrying objects Lifting Fine hand use Hand and arm use Walking Walking short distances Walking long distances Walking on different surfaces Moving around Climbing Moving around within the home Moving around within buildings other than home Moving around outside the home and other buildings Moving around using equipment Using transportation Using human-powered vehicles Using private motorised transportation Using public motorised transportation Driving Driving human-powered transportation Dressing Putting on footwear Looking after one’s health Managing diet and fitness Maintaining one’s health Shopping Preparing meals Doing housework Washing and drying clothes and garments Cleaning cooking area and utensils Cleaning living area Making and repairing clothes Maintaining dwelling and furnishings Taking care of plants, indoors and outdoors Relating with persons in authority Family relationships Intimate relationships Sexual relationships School education Acquiring, keeping and terminating a job Remunerative employment Community life Recreation and leisure Sports Crafts Hobbies Socialising Religion and spirituality

87% 80% 100% 100% 100% 100% 100% 100% 90% 92% 100% 93% 90% 100% 100% 98% 97% 100% 100% 97% 98% 93% 97% 93% 92% 93% 93% 80% 48% 64% 71% 80% 84% 90% 92% 92% 93% 90% 46% 57% 84% 82% 79% 82% 66% 66% 62% 18% 21% 16% 21% 10% 30% 57% 53% 95% 92% 57% 46% 49% 25%

Bold text indicates International Classification of Functioning, Disability and Health (ICF) categories included in the Comprehensive ICF Core Set for Osteoarthritis, and regular text indicates ICF categories linked to participants’ responses but not included in the Comprehensive ICF Core Set for Osteoarthritis. Percentage of participants who considered the respective ICF category as relevant in the third round.

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Table 6 Environmental factors component. ICF code 1st level

ICF category 2nd level

3rd level

4th level

e1100 e1101 e115 e1150 e1151 e120 e1201 e135 e140 e150 e1500

e155 e1551

e1552

e165 e225 e310 e315 e340 e355 e450 e465 e540 e555 e570 e575 e580 e5800 e5801 e5802 e590

Round 3 n = 61 % yes

Food Drugs Products and technology for personal use in daily living General products and technology for personal use in daily living Assistive products and technology for personal use in daily living Products and technology for personal indoor and outdoor mobility and transportation Assistive products and technology for personal indoor and outdoor mobility and transportation Products and technology for employment Products and technology for culture, recreation and sport Design, construction and building products and technology of buildings for public use Design, construction and building products and technology for entering and exiting buildings for public use Design, construction and building products and technology of buildings for private use Design, construction and building products and technology for gaining access to facilities in buildings for private use Design, construction and building products and technology for way finding, path routing and designation of locations in buildings for private use Assets Climate Immediate family Extended family Personal care providers and personal assistants Health professionals Individual attitudes of health professionals Social norms, practices and ideologies Transportation services, systems and policies Associations and organisational services, systems and policies Social security services, systems and policies General social support services, systems and policies Health services, systems and policies Health services Health systems Health policies Labour and employment services, systems and policies

21% 28% 79% 61% 89% 92% 97% 80% 87% 46% 44%

44% 46%

30%

12% 15% 56% 23% 82% 95% 89% 39% 61% 34% 45% 74% 90% 92% 75% 69% 25%

Bold text indicates International Classification of Functioning, Disability and Health (ICF) categories included in the Comprehensive ICF Core Set for Osteoarthritis, and regular text indicates ICF categories linked to participants’ responses but not included in the Comprehensive ICF Core Set for Osteoarthritis. Percentage of participants who considered the respective ICF category as relevant in the third round.

report episodes of knee instability during activities of daily living, and consider this to be a limiting factor in their ability to perform functional tasks. This should be addressed specifically in rehabilitation programmes, and knee stability should be trained in a controlled manner to ensure that the neuro-

muscular system has been prepared when needed to carry out daily activities [37]. Almost all participants agreed that the ICF categories b455 Exercise tolerance function and b530 Weight maintenance functions are relevant intervention targets of physical ther-

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Table 7 International Classification of Functioning, Disability and Health (ICF) categories (2nd level) linked to participants’ responses with more than 75% agreement in the third round but not included in the Comprehensive ICF Core Set for Osteoarthritis. ICF code (2nd level)

ICF category

Body functions b180 b260 b455 b530 b755

Experience of self and time functions Proprioceptive functions Exercise tolerance functions Weight maintenance functions Involuntary movement reaction functions

Body structure s760

Structure of trunk

84%

Activity and participation d420 d465 d570

Transferring oneself Moving around using equipment Looking after one’s health

93% 93% 92%

Products and technology for culture, recreation and sport

87%

Environmental factors e140

apists although they are not included in the Comprehensive ICF Core Set for Osteoarthritis. Obesity is an important prognostic factor for osteoarthritis. Although diet programmes are outside the scope of practice of physical therapists, they might encourage a person to seek advice and can provide helpful treatment strategies to promote weight loss (e.g. training programmes) [41–43]. The combination of a moderate diet programme plus exercise provides better improvements in self-reported measures of function and pain than one intervention alone [42]. Thus, interprofessional management is needed in patients with osteoarthritis and obesity. Furthermore, 75% of the participants agreed that the not-yet-included category b180 Experience of self and time functions represents a problem treated by physical therapists. Encouraging patients to find an adequate way to deal with the limitations of physical activities and restrictions in daily activities and participation is a central aim of the therapeutic process [11,34]. Although the awareness of one’s identity and body image is a basic requirement for this goal, there is no evidence that it is a problem that is addressed by specific physical therapy interventions. It could be that some participants did not only consider the intervention targets of physical therapists, but considered patients’ problems in general.

Body structures For the body structures component, only the category s760 Structure of trunk represents an item at the same level of classification that is not included in the Comprehensive ICF Core Set for Osteoarthritis, although degenerative changes also occur in the spine [44,45].

Round 3 n = 61 % yes 75% 97% 100% 98% 90%

Activities and participation Many of the patients’ problems treated by physical therapists were represented by categories assigned to the activities and participation component, and most are considered in the current version of the Comprehensive ICF Core Set for Osteoarthritis [19]. In patients who experience their limitations of physical activities and restrictions in daily activities and participation as being threatening, stress management is an important goal. Physical therapists must encourage patients to gain sufficient control over their state of health [11,34]. Thus, it is not surprising that the ICF category d2401 Handling stress was considered relevant by 80% of all participants. Furthermore, maintaining patients’ compliance with treatment is an important task of physical therapists, which is addressed by the category d570 Looking after one’s health. However, neither of these ICF categories are included in the Comprehensive ICF Core Set for Osteoarthritis. The categories d420 Transferring oneself and d465 Moving around using equipment were considered to be important by more than 90% of the participants. Although these single ICF categories are not included in the current version of the Comprehensive ICF Core Set for Osteoarthritis, the corresponding chapter d4 Mobility is represented by nine categories. The high number of mobility categories may be necessary to record the situation for people with osteoarthritis in different joints. Since a selection of categories is necessary to ensure that the ICF Core Set for Osteoarthritis remains feasible for clinical practice, further investigations are needed to decide whether these categories should be included. Respective core sets for upper limb and lower limb could be a possible option for future revision of the Comprehensive ICF Core Set for Osteoarthritis.

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Environmental factors Regarding the environmental factors component, only the not-yet-included category e140 Product and technology for culture, recreation and sport reached considerable agreement between the participants. The Comprehensive ICF Core Set for Osteoarthritis contains six categories that belong to chapter e1 Products and technology. Thus, this domain is already sufficiently covered by the Comprehensive ICF Core Set for Osteoarthritis. Personal factors A large number of participants’ responses were identified as personal factors according to ICF language, such as coping styles, fear-avoidance beliefs and psychosocial factors [13]. However, these aspects are not classified in the ICF. The importance of coping strategies, protective factors and health resources has been described by several authors [46–50]. The present results are consistent with the literature and corroborate that physical therapists are aware of the impact of personal factors on rehabilitation outcomes, and aim to influence these facets of an individual, for instance by trying to facilitate an active coping style of a patient with osteoarthritis. Therefore, it would be most helpful for physical therapists if the ICF also provided a classification of personal factors which may potentially influence functioning. Not classiﬁed in the ICF Fourteen aspects that were not covered by a single ICF category contain important items for physical therapists, such as alignment, malalignment and posture. However, the ICF is worded in neutral terms and requires a qualifier to represent the negative aspects. A qualifier denotes a magnitude of the level of health (e.g. severity of the problem). The concepts alignment, malalignment and posture can be coded using the relevant body structure category with a qualifier, but they were not covered by a single ICF category. Several studies have already demonstrated that posture cannot be described precisely using the available ICF categories [51]. These results should be considered for further development of the ICF as a whole. Methodological considerations The Delphi technique proved to be an appropriate method for this study. In contrast to the mean attrition rate of 50% or more from round to round reported in the literature, response rates between the rounds exceeding 90% were achieved in this study [52]. However, there are some limitations regarding the external validity of this study. Recruitment strategies included several approaches. While 74 universities were contacted, only two physical therapists were recruited. Furthermore, 166 partners of the Institute for Health and Rehabilitation Sciences at

Ludwig-Maximilian University Munich were contacted and only nine physical therapists agreed to participate. These recruitment strategies were ineffective compared with successful recruitment gains from a literature search and personal recommendations. Although the authors were successful in recruiting participants from all six WHO regions, the distribution among regions is disparate. The African region, Eastern Mediterranean region and South East Asia region are comparatively under-represented. Against the background of successful recruitment gains from the literature search, the considerable variation in the origins of participants is possibly based upon retrieval bias. Therefore, this sample does not represent the worldwide spectrum of physical therapists experienced in the treatment of patients with osteoarthritis. Since no database is available that includes the target population, random sampling was not possible. However, the impossibility of random sampling characterises qualitative research methods in general and the Delphi method in particular [22,23]. Kappa statistics showed that the agreement between the two health professionals who performed the linking was better than that occurring by chance, but it remains unclear whether this would be true for other individuals. However, the linking process is complex and special training is needed. The Delphi method was an appropriate approach to validate the Comprehensive ICF Core Set for Osteoarthritis [19] from the perspective of physical therapists worldwide. Further results on the validity of the Comprehensive ICF Core Set for Osteoarthritis will be available from ongoing or future studies involving other health professionals such as physicians and occupational therapists. In addition to the health professionals’ perspective, the Comprehensive ICF Core Set for Osteoarthritis will be evaluated from the patients’ perspective in an ongoing study using individual interviews and focus groups. Although some restrictions of the current version of the Comprehensive ICF Core Set for Osteoarthritis were detected in this study, the content validity of the Comprehensive ICF Core Set for Osteoarthritis was widely supported by the participating physical therapists.

Conclusions The ICF provides a universal and standardised language and framework that extends beyond disease [53], and the potential benefits of applying the Comprehensive ICF Core Set for Osteoarthritis in physical therapy may be concluded from this study. This Delphi study shows that physical therapy is not limited to body functions, and therefore all ICF components need to be considered in assessment and outcome evaluations. As emphasised by Kirchberger et al. [16], ICF core sets and profession-specific systems, such as the Guide to Physical Therapist Practice [54], may complement each other in a very useful manner. The ICF Core Set for Osteoarthritis could be used to document the change

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in functioning associated with physical therapy treatment, improving both interprofessional and international communications. The ICF core sets can provide a common platform for different professionals to start discussing their assessments, treatment goals and interventions. The ICF core sets do not specify how to assess the different ICF categories. This guidance is provided by other systems such as the Guide to Physical Therapist Practice [54], which declares the appropriate tools for measuring ICF categories, such as joint mobility, pain, walking, doing housework, or recreation and leisure. Finally, as the Comprehensive ICF Core Set for Osteoarthritis defines ‘what to measure’ but not ‘how to measure’, future studies should focus on the operationalisation of the ICF categories to increase reliability [55]. Important steps toward the operationalisation of ICF categories are the development of ICF-based measures and ICF manuals [55], as developed by the American Psychological Association [56] and the Australian Institute of Health and Welfare [57]. The findings of this study, as well as future results of other validation projects, will further elucidate the validity of the Comprehensive ICF Core Set for Osteoarthritis from the different perspectives. The findings of all validation studies will potentially result in a modified version of the Comprehensive ICF Core Set for Osteoarthritis.

Acknowledgements The authors wish to thank the participants of the Delphi exercise for their valuable contribution and time spent responding to the demanding questionnaires. Ethical approval: Ethics Committee of Philipps-University Marburg (File Number: 20/07). Conﬂict of interest: None declared.

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Physiotherapy 97 (2011) 17–25

HIV/AIDS: use of the ICF in Brazil and South Africa – comparative data from four cross-sectional studies H. Myezwa a,∗ , C.M. Buchalla b , J. Jelsma c , A. Stewart a a

Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Park Town 2093, Johannesburg, South Africa b School of Public Health, University of Sao Paulo, Sao Paulo, Brazil c Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Abstract Introduction Human immunodeficiency virus (HIV) is a serious disease which can be associated with various activity limitations and participation restrictions. The aim of this paper was to describe how HIV affects the functioning and health of people within different environmental contexts, particularly with regard to access to medication. Method Four cross-sectional studies, three in South Africa and one in Brazil, had applied the International Classification of Functioning, Disability and Health (ICF) as a classification instrument to participants living with HIV. Each group was at a different stage of the disease. Only two groups had had continuing access to antiretroviral therapy. The existence of these descriptive sets enabled comparison of the disability experienced by people living with HIV at different stages of the disease and with differing access to antiretroviral therapy. Results Common problems experienced in all groups related to weight maintenance, with two-thirds of the sample reporting problems in this area. Mental functions presented the most problems in all groups, with sleep (50%, 92/185), energy and drive (45%, 83/185), and emotional functions (49%, 90/185) being the most affected. In those on long-term therapy, body image affected 93% (39/42) and was a major problem. The other groups reported pain as a problem, and those with limited access to treatment also reported mobility problems. Cardiopulmonary functions were affected in all groups. Conclusion Functional problems occurred in the areas of impairment and activity limitation in people at advanced stages of HIV, and more limitations occurred in the area of participation for those on antiretroviral treatment. The ICF provided a useful framework within which to describe the functioning of those with HIV and the impact of the environment. Given the wide spectrum of problems found, consideration could be given to a number of ICF core sets that are relevant to the different stages of HIV disease. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: ICF; HIV/AIDS; Function; Disability

Introduction Human immunodeficiency virus (HIV) is a major concern in developing and middle-income countries such as South Africa and Brazil. In South Africa, the HIV/acquired immunodeficiency syndrome (AIDS) epidemic has claimed thousands of lives and continues with little signs of abating. In 2008, it was estimated that just over 5 million people out of a population of 46 million were living with HIV, resulting in a total population prevalence rate of 18% [1]. The large majority of those with HIV/AIDS are heterosexual. In contrast, the ∗

Corresponding author. Tel.: +27 117173702; fax: +27 117173719. E-mail address: [email protected] (H. Myezwa).

number of people in Brazil with infection is much lower (estimated 630 000 people) and infection is more prevalent within the homosexual community (21% of those infected) [2]. In addition, Brazil differs from South Africa in that a very active free programme to provide antiretroviral therapy was started in 1991 [3], and this has resulted in the number of deaths per 100 000 inhabitants decreasing from 9.7 in 1995 to 6.0 in 2005 [2]. In contrast, South Africa only began to roll out universally available antiretroviral therapy in 2004 [4], and is still in the process of instituting treatment for those who are in need. The virus has many complex effects on the body and can be expected to have a marked impact on the functioning of individuals in everyday life [5]. The health-related quality

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.08.015

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of life (which includes the ability of an individual to function) of people living with HIV/AIDS in South Africa [6] and elsewhere [7] has been found to be severely compromised. The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization (WHO) in 2001 [8], and has increasingly become the standard classification of disability and functioning [9]. The ICF, which classifies impairments, activity limitations and participation restrictions and the environment as components that all play an important role in disability, is regarded as the most comprehensive model available for describing and understanding disability and functioning [10]. As such, it is a complex instrument intended to cover all aspects of human functioning. In principle, it is possible to assign unique codes to 1424 items [8]. In practice, the entire set of codes is seldom utilised, and WHO has produced a short version of the ICF [11] which still comprises a large number of codes. It is expected that a subset of codes will be chosen to meet the purpose, setting and expertise of the users. The user might, for example, use the 34 one-digit level codes, the 362 twolevel items or a combination of different levels, with up to four-level precision for specialist areas. In addition, a checklist has been developed which presents what is considered to be the most useful subset of codes for general clinical use [12]. Physiotherapists are key contributors to understanding health and disability, and the ICF is used increasingly as a biopsychosocial framework by this group of professionals. In addition, the definition of any intervention’s ‘success’ has changed with this shift to a biopsychosocial approach. It is no longer enough to reduce impairments with education, medication and exercise regimens at the level of body structure and function. It is therefore important to utilise the ICF to frame problems experienced not only at an impairment level but also at an activity and participation level, as well as to interpret the effect of all interventions. As an important function of a classification system is to provide comparable data across settings, clients and countries, it would seem necessary to use a similar set of codes during data collection in order to allow comparisons. In

response to the need for abbreviated but standard ‘core sets’ for specific conditions, several papers have been published detailing the process and final identification of core sets, such as those for chronic widespread pain [13], depression [14] and rheumatoid arthritis [15]. An attempt has also been made to identify a generic core set based on the regression analysis of data collected from 1039 patients using the ICF checklist [16]. It appears that there is a need to develop an ICF core set for documenting the health and functional consequences of HIV. Three studies in South Africa [17–19] and a study in Brazil [3] applied the ICF as a classification instrument to participants living with HIV. Although the studies did not follow a standard format, the amalgamation of the data gave the researchers a unique opportunity to compare the functioning of people living with HIV across different settings and different stages of the disease. This data set may also form the basis of further studies to identify basic core sets for HIV. Within the context of HIV, this paper presents an example of how the ICF can be used to describe health and healthrelated states, and is an example of a pragmatic starting point for physiotherapists. The specific objectives of this study were to present a preliminary set of codes which encompass the functional limitations of those living with HIV, and to investigate how these functional limitations vary within very different contexts.

Methods The methods of the four studies have been published elsewhere and are briefly described below. The specific objectives of each of the four studies are not outlined in this paper; however, the common methodology of each study entailed a description of health and health-related states using the ICF. The results of the four studies have been amalgamated into a single data set (Tables 1–4). The WHO classification [20] of the different stages of disease impact was used post hoc to categorise the different groups into an asymptomatic group (in terms of AIDS-defining diseases) (I/II), a symptomatic group

Table 1 Demographic characteristics of the study samples. Demographics

South Africa, Sample 1 n = 12

South Africa, Sample 2 n = 51

South Africa, Sample 3 n = 80

Brazil, Sample 4 n = 42

WHO Stage of disease

II/III

I/II

Ill/IV

Males Females Age in years, median (range) Description of patient setting

2 10 31 (20 to 49) Outpatients attending an HIV clinic

50 1 45 (32 to 52) Employed by a mining company

23 57 37 (28 to 46) Inpatients in a general hospital

Antiretroviral therapy

No

Yes, if necessary

Mixed

Post long-term antiretroviral treatment 28 14 38 (29 to 52) Outpatients attending an HIV clinic Yes, 59% for >4 years

WHO, World Health Organization; HIV, human immunodeficiency virus.

Table 2 Participants reporting problems in the domain of body functions. Domain

All categories under domains expressed as n in Samples 1 to 4 Mental functions (b1) % (n) reporting problems in most affected category of the four samples b130 Energy and drive functions b134 Sleep functions b144 Memory b152 Emotional functions b1801 Body image

Sample 1 n = 12

Sample 2 n = 51

Sample 3 n = 80

Sample 4 n = 42

Total of all four samples n = 185% (n)

50 (6)

35 (18)

74 (59)

93 (39)

6 0 5 6 nc

18 12 11 10 nc

59 56 24 49

nc 24 nc 25 39

45 (83) 50 (92) 22 (40) 49 (90) 21 (39) 54 (100)

% (n) reporting problems in most affected category b280 Pain

67 8

55 28

80 64

0 nc

Functions of cardiovascular and respiratory systems (b4)

% (n) reporting problems in most affected category b410 Heart functions b420 Blood pressure functions b430 Haematological system functions b435 Immunological system functions b440 Respiration (breathing) b4552 Fatigability

58 (7) nc nc nc nc 7 nc

33 (17) 6 9 17 6 14 nc

58 (46) 31 27 46 13 46 nc

55 (23) 14 20 23 17 nc 8

28 (51) 30 (56) 47 (86) 20 (36) 36 (60) 4 (8)

% (n) reporting problems in most affected category b515 Digestive b5153 Tolerance to food b525 Defaecation b530 Weight maintenance b535 Sensations associated with the digestive system b5350 Sensation of nausea b540 General metabolic functions b5403 Fat metabolism b555 Endocrine gland functions

58 (7) 4 nc 4 7 0 nc nc nc nc

63 (32) 8 nc 6 32 6 nc nc nc 0

75 (60) 34 nc 36 60 13 nc nc nc 8

57 (24) 18 7 12 24 19 15 18 16 20

35 (64) 4 (7) 31 (56) 67 (123) 21 (38) 28 (15) 10 (18) 9 (16) 15 (28)

% (n) reporting problems in most affected category b640 Sexual functions b650 Menstruation functions b6500 Regularity of menstrual cycle b670 Sensations associated with genital and reproductive functions b6700 Discomfort associated with sexual intercourse

8 (1) 1 nc nc nc

22 (11) 11 nc nc nc

16 (13) 13 nc nc nc

76 (32) 32 13 5 11

31 (57) 7 (13) 3 (5) 6 (11)

nc

nc

nc

26

14 (26)

% (n) reporting problems in most affected category b710 Mobility of joint b730 Muscle power

42 (4) 5 4

24 (12) 3 12

75 (60) 23 60

0 nc nc

17 (31) 41 (76)

% (n) reporting problems in most affected category b8 Skin functions b840 Sensation related to the skin

42 (5) 5 nc

18 (9) 9 nc

38 (30) 30 nc

38 (16) nc 16

24 (43) 9 (16)

Functions of the digestive system (b5)

Reproductive functions (b6)

Neuromusculoskeletal and movement related functions (b7)

Functions of the skin (b8)

19

nc, data not collected under this code.

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

Sensory functions and pain (b2)

20

Table 3 Participants reporting problems with either activities or participation. Domain

Sample 1 n = 12

Sample 2 n = 51

Sample 3 n = 80

Sample 4 n = 42

Total % (n)

% (n) reporting problems in most affected category

17 (2)

2 (1)

55 (44)

0

Mobility (d4)

d430 Lifting and carrying objects d440 Fine hand use d450 Walking d465 Moving around using equipment d470 Using transportation d475 Driving

2 0 1 0 1 0

1 0 1 0 0 0

10 7 44 8 21 4

nc nc nc nc nc nc

7 (13) 4 (7) 25 (46) 4 (8) 12 (22) 2 (4)

Self-care (d5)

% (n) reporting problems in most affected category d510 Washing oneself d520 Caring for body parts d530 Toileting d540 Dressing d550 Eating d560 Drinking d570 Looking after one’s health d5701 Managing diet and fitness

0 0 0 2 0 0 1 0 0

0 0 0 0 0 0 0 0 0

35 (28) 28 13 20 27 14 7 21 0

0 0 0 0 0 0 0 0 21

15 (28) 7 (13) 12 (22) 15 (27) 8 (14) 4 (8) 11 (21) 11 (21)

% (n) reporting problems in most affected category d620 Acquisition of goods and services d630 Preparation of meals d640 Doing housework d660 Assisting others

17 (2) 1 1 2 1

39 (26) 20 0 3 0

64 (51) 51 47 50 25

0 0 0 0 0

39 (72) 26 (48) 30 (52) 14 (26)

% (n) reporting problems in most affected category d710 Basic interpersonal interactions d720 Complex interpersonal interactions d760 Family relationships d770 Intimate relationships d7702 Sexual relationships

33 (4) 3 3 4 3 nc

10 (5) 0 0 5 5 nc

25 (19) 20 19 19 10 nc

64 (27) 0 0 0 24 27

12 (23) 12 (21) 15 (28) 23 (42) 15 (27)

% (n) reporting problems in most affected category d845 Acquiring, keeping and terminating a job d850 Remunerative employment d870 Economic self-sufficiency

33 (4) nc 4 nc

12 (6) nc 6 0

50 (40) nc 40 38

43 (18) 5 18

3 (5) 27 (50) 30 (56)

% (n) reporting problems in most affected category d920 Recreation and leisure d9201 Sports d930 Religion and spirituality d950 Political life and citizenship d999 Community, social and civic life, unspecified

0 nc nc nc nc nc

10 (5) 5 nc 1 0 nc

54 (43) 36 nc 43 21 nc

52 (22) 6 21 22 13 11

25 (47) 11 (21) 36 (66) 18 (34) 6 (11)

Domestic life (d6)

Interpersonal interactions and relationships (d7)

Major life areas (d8)

Community, social and civic life (d9)

nc, data not collected under this digit level code.

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

All categories under domains expressed as n in Samples 1 to 4

Table 4 Participants reporting barriers or facilitators in the environmental domain. Code

Sample 3 n = 80

Sample 4 n = 42

Total n = 185 % (n)

Facilitators

Barriers

Facilitators

Barriers

Facilitators

Barriers

Facilitators

0-

0

1

*32

11

21

nc

nc

6 (13)

29 (53)

0

0

2

30

17

23

nc

nc

10 (19)

29 (53)

4

0

9

5

27

0

nc

nc

22 (38)

3 (5)

0

12

3

27

10

*58

nc

nc

7 (13)

52 (97)

2 3

7 5

1 1

12 11

15 14

*57 *34

nc nc

nc nc

10 (18) 10 (18)

41 (76) 27 (50)

0 0

11 9

4 1

*26 *35

10 5

18 12

nc nc

nc nc

8 (14) 3 (6)

30 (55) 30 (56)

0 0

12 12

1 2

47 *44

5 6

*66 27

nc nc

nc nc

3 (6) 4 (8)

68 (125) 45 (83)

e410 Individual attitudes of immediate family members

0

11

2

28

6

*58

nc

nc

4 (8)

52 (97)

e420 Individual attitudes of friends e440 Individual attitudes of personal care providers and personal assistants e445 Individual attitudes of strangers e450 Individual attitudes of health professionals e455 Individual attitudes of health-related professionals e460 Societal attitudes

3 0

7 10

1 0

16 *16

18 5

*48 14

nc nc

nc nc

12 (22) 3 (5)

38 (71) 22 (40)

0 0

0 11

4 1

nc 46

nc 5

nc *59

9 nc

nc nc

9 (9) 3 (6)

0 63 (116)

0

11

1

47

7

*24

nc

nc

4 (8)

44 (82)

1

7

4

*39

38

16

14

nc

31 (57)

34 (62)

e5550 Associations and organisational services e570 Social security services, systems and policies e575 General social support services, system and policies e580 Health services, systems and policies e590 Labour and employment services, systems and policies

nc

nc

nc

nc

nc

nc

10

nc

5 (10)

0

nc

nc

7

*37

23

27

18

nc

26 (48)

35 (64)

nc

nc

1

*33

23

23

13

nc

20 (37)

30 (56)

nc

nc

2

*42

27

30

9

nc

21 (38)

39 (72)

nc

nc

3

24

*45

3

15

nc

34 (63)

15 (27)

Facilitators

21

*Most affected category. nc, data not collected under this digit level code.

Barriers

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

Domain Services, systems and policies

Sample 2 n = 51

Barriers All categories under domains expressed as n in Samples 1 to 4 Products and technology (e1) e110 Products and technology for personal consumption e120 Products and technology for use in indoor and outdoor mobility Domain e250 Sound Natural environment and human made changes to environment (e2) Domain e310 Immediate family Support and relationships (e3) e320 Friends e325 Acquaintances, peers, colleagues, neighbours and community members e330 People in position of authority e340 Personal care providers and personal assistants e355 Health professionals e360 Health-related professionals Domain Attitudes (e4) % reporting barriers or facilitators in most affected category

Sample 1 n = 12

22

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

(III) and a group who were acutely ill (IV). WHO does not include a post-antiretroviral therapy group and, consequently, the Brazilian sample, all of whom were receiving antiretroviral therapy, did not fit into this classification system. Sample 1: South Africa, Stage II/III [17] A small self-selected convenience sample of people living with HIV (n = 12) and attending an HIV clinic was used. All subjects who could speak English and who were prepared to be interviewed by researchers who were not members of their clinical management team were included in the study. The five researchers attended a 2-day training workshop on use of the ICF. An expanded English version of the ICF checklist was used. The section on impairments of body structures was not included, although body function impairments were included. Piloting of the procedure was undertaken, and the initial interviews were conducted in the presence of all the interviewers in order to standardise the manner in which questions were asked. After piloting, an expanded version of the ICF checklist questionnaire was drawn up in order to standardise the way the questions were asked by each interviewer. Interviews were conducted in a private venue within the clinic. Interviews lasted between 45 and 60 minutes depending on the amount of information disclosed by the patient. Sample 2: South Africa, Stage I/II [18] A cross-sectional study design was used and the participants consisted of 51 outpatients working for a mining company. A professional translation company was contracted to translate the ICF checklist into SeSotho and isiZulu, two local and commonly understood languages in Gauteng Province. The full checklist was used with its codes and qualifiers. Training was undertaken for two researchers. The training aimed to specify how each area was coded and subsequently qualified. The two researchers collected the data for this study. A combination of interviews and examinations was used to complete the ICF checklist. Impairments were determined by direct observation and questioning the patient, and were assessed through standardised tests. Although qualifiers were used to describe the different components, for the purpose of this paper, only the presence or absence of the component was noted. Performance (functioning within the participants’ personal context) was analysed. Body structure and function was coded using three qualifiers (extent, nature and location of the impairment) and then scaled. Environmental factors were coded as facilitators or barriers. Sample 3: South Africa, Stages III/IV [19] The study design was the same as that for Sample 2 except that the participants were 80 hospitalised patients with HIV. Data collection involved evaluation and interviews as above.

Sample 4: Brazil, post long-term antiretroviral treatment [3] The sample consisted of volunteers who were patients at a reference centre for sexually transmitted diseases and AIDS in Sao Paulo, Brazil. There were 42 participants, 28 of whom were men. Their ages ranged from 29 to 52 years, with a median of 38 years. The time on antiretroviral therapy ranged from 1.2 to 13 years, with 24/42 (59%) receiving therapy for more than 4 years. A systematic review was conducted as the preparatory phase to develop an AIDS core set, following the methodology of Stucki et al. (2002) [21]. The systematic review, which included the key words ‘HAART’ and ‘quality of life’, identified a total of 31 studies. An analysis of these studies identified 87 concepts; 66 of which could be identified as ICF categories. These comprised the interview questions. Data analysis Descriptive statistics were used to describe the data. Percentages, means and ranges for the different domains and subdomains were calculated. A comparison of the different groups from the studies was made in a table format. Ethical considerations For each study, ethical permission was obtained from the relevant authorities in each country.

Results Table 1 summarises the demographic profiles of the different samples. A wide spectrum of participants was represented, from those attending outpatient clinics or recruited from a work site to those hospitalised as a result of HIV. Sample 1 had not had access to antiretroviral treatment as it had not yet been made available. Participants in Sample 2 were receiving antiretroviral drugs from the mining company if their CD4 count warranted treatment. Sample 3 would have had access to antiretroviral treatment if necessary, and all of Sample 4 were receiving treatment and had done so for periods ranging from 1.2 to 13 years. The lists of problems reported in the tables are not strictly comparable as, in some instances, the Brazilian study allowed for the use of three digit codes. The number of participants reporting problems in the body function domain is listed in Table 2. For the categories, the data given are the actual numbers. Percentages are given for the most affected categories and for the problem out of the total sample in the last column. The most commonly experienced problem in all groups related to weight maintenance, with two-thirds of the sample reporting problems in this area. Other common domains in which problems were encountered included pain, sleep, energy and drive functions, and muscle power. Mental functions presented the most problems in all groups, with sleep

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

(50%, 92/185), energy and drive (45%, 83/185) and emotional functions (49%, 90/185) being the most affected. In those on long-term therapy, body image affected 93% (39/42) and was a major problem. All of the groups in Stages II to IV reported that pain was a problem, whereas Sample 4 did not seem to have a problem in this area. Cardiopulmonary functions were affected in all groups, being the least affected in Sample 1. A similar percentage of each group reported problems with the digestive system (range 57 to 62%), apart from Sample 3 who had a 75% prevalence of problems in this area. Sample 4 reported more problems than the other groups with reproductive functions, and Sample 3 were the most affected with regard to neuromuscular functions. Those groups likely to be receiving antiretroviral drugs reported more problems with regard to skin functions. With the exception of Sample 3, few subjects reported problems in the domains of mobility (d4) and self-care (d5). With regard to major life areas (d6), Sample 3 reported the most problems, although the 20 respondents in Sample 2 reported problems with acquisition of goods and services. All groups reported problems with interpersonal interactions and relationships (d7), with more than 60% of Sample 4 reporting problems with sexual and intimate relationships, and Sample 3 reporting the most problems with interpersonal interaction and family relationships. With regard to major life areas (d8), remunerative employment and economic self-sufficiency emerged as the major area of concern, particularly for Sample 3. (It is to be noted that Sample 2 were all employed.) In the domain of community, social and civic life (d9), Sample 3 reported the most problems with recreation, religion and political life, followed by Sample 4 who reported the most problems with recreation, sport, religion and spirituality. Samples 2 and 3 reported products and technology (e1) to be facilitators, as illustrated by the results in e110 and e120 codes (these groups had some access to medication), but Sample 3 reported barriers in this domain (access was not universal). These samples also reported support and relationships (e3) to be a facilitator of function, particularly the support received from immediate family (e310) (72%, 58) and health-care professionals (e355) (87%). The similar categories in the attitudes (e4) domain were also seen to provide facilitation. Sound emerged as a barrier to function in the South African samples. Seventy-three codes with three digits or more are presented in Tables 1 to 3. As the full checklist has a total of 128 codes, this represents 57% of the ICF checklist codes.

Discussion Previous studies that have aimed to identify categories that pertain to areas of difficulty in impairments, activity and participation used retrospective data or literature reviews to identify categories that could be related to the ICF [22–24]. In contrast, this paper is based on prospec-

23

tively gathered data and compares the results of studies that sought to describe and identify the problems experienced by people living with HIV using the ICF. Although the different methods and settings of data collection make strict comparability across the groups impossible, the use of ICF codes allowed for the amalgamation of the results. The researchers could then produce a description of both the problems across different stages of HIV and different geographical settings. The ICF model emphasises the importance of contextual factors in mediating and altering the functional impact of any health conditions [25]. This stance is well supported by the results of this paper. It is obvious that at each stage of the disease, the picture presented by the participants was very different, and these differences arose directly out of the different environmental factors which were brought to bear on each group. As a result of these environmental factors, particularly the availability of antiretroviral therapy, the groups were at different stages of the continuum of an episodic disability framework, and the majority of the checklist codes were utilised. The number of second-level categories used (i.e. 73) is comparable to that for core sets for low back pain (78 second-level categories) [26] and rheumatoid arthritis (76 second-level categories) [27], and considerably less than the 130 second-level categories identified for stroke patients. It would therefore appear that the production of a core ICF set for HIV is feasible, although the possibility of producing different core sets for different stages of HIV (acute episodic illness, remission and chronic HIV disease with people on antiretroviral drugs) could be explored. It would be necessary to establish which categories are common across the different stages of a patient’s health status and which categories are peculiar to each stage. Subjects in Sample 3 were at Stages II and III, and were clearly the most affected at an impairment and activity limitation level. Many of these subjects did not have prior access to antiretroviral drugs, due in part to the South African Government’s prior policy of restricting antiretroviral drugs and only providing treatment to those who had a very low CD4 count. The majority of these participants reported problems with energy, drive, pain and muscle weakness. These impairments are commonly treated with physiotherapy interventions. The subjects in Sample 2, who were at Stage I/II, were all in fulltime employment and receiving free antiretroviral drugs from the mining company. Although many reported impairments of function, these impairments did not appear to affect their activity and participation levels. With regard to participation and environmental factors, this group appeared to suffer the least from the impact of the disease. In contrast, economic self-sufficiency and participation in community life were reported as problems in almost equal numbers by both Sample 3 and Sample 4. Sample 4 reported relatively more problems in the area of participation; a finding that concurs with other studies [28], and particularly with Dos Santos et al. (2007) [29] who stated that although the health-related quality of life of people living with AIDS was better than that of

24

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

other patients, their social relationships were most affected by the stigma of the disease. The limited and recent accessibility to antiretroviral therapy in South Africa was reflected particularly in the environment factors, in the facilitation of functioning reported in products and technology, and in the attitude of health professionals, who were very supportive of the antiretroviral therapy roll-out in South Africa. It was noteworthy that generally more people in South Africa reported that support, relationships and attitudes, particularly those of family and friends, were facilitatory. All samples experienced these barriers with societal attitudes. Sample 4, however, reported more problems with intimate relationships and with body image, and it is not clear if this is an artefact of cultural difference or the effect of long-term use of antiretroviral drugs (which does result in lipodystrophy and alteration in the distribution of body fat [30]). With regard to the concern with body image, healthcare providers may need to pay attention to interventions for cosmetic purposes, especially where facial lipodystrophy is common. These results will help physiotherapists to understand HIV within a biopsychosocial framework, and illustrate that the role of physiotherapists will change and is dependent on the state of the immune system. By using the ICF, physiotherapists can better define the points in episodic HIV disease at which they can intervene. Specific problems that manifest due to a myriad of effects that are pathophysiological-, environment- and person-related become easier to define and relate to the philosophy of treatment used by physiotherapists. Physiotherapists therefore need to be aware of the spectrum of problems and plan holistic interventions which address not only impairments, but also the other components of the ICF. Furthermore, use of the ICF to code data provides an opportunity for the examination of common global population health issues through an international lens. Conclusion In summary, the spectrum of functional problems moved from problems in the areas of impairment and activity limitation in those at the more advanced stages of HIV, through to more limitations in the area of participation in those on treatment. The ICF provides a useful framework within which to describe the functioning of those with HIV and the impact of the environment. In addition, as the classification is presented in codes, it becomes possible to compare results directly across different languages and cultures. A single core set for the ICF may be a viable option. Consideration could be given to a number of core sets collected under the ICF that are relevant to the different stages of HIV disease. Clarity on linking the data to existing measures and how to take account of different contexts are areas for further study. Ethical approval: Samples 2 and 3, University of the Witwatersrand Human Research Ethics Committee (Medical)

(Ref. No. M050206); Sample 1, University of Cape Town Medical Research Ethics Committee (Ref. No. 051/2002); Sample 4, School of Public Health, University of Sao Paulo Human Research Ethics Committee (Ref. No. 1193). Funding: Samples 2 and 3, Carnegie Foundation and Medical Research Council of South Africa. Conﬂict of interest: None declared.

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[17]

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Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 26–32

ICF participation restriction is common in frail, community-dwelling older people: an observational cross-sectional study N. Fairhall a,b,∗ , C. Sherrington a , S.E. Kurrle c , S.R. Lord d , I.D. Cameron b a

The George Institute for Global Health, The University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia b Rehabilitation Studies Unit, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia c Division of Rehabilitation and Aged Care, Hornsby Ku-ring-gai Hospital, Hornsby, Sydney, NSW, Australia d Prince of Wales Medical Research Institute, Sydney, NSW, Australia

Abstract Objectives To determine the extent of participation restriction in a sample of frail older people, and to identify the domains of participation that are most restricted. A secondary aim was to determine which health and demographic factors were associated with participation restriction. Design An observational cross-sectional study. Setting Adults recently discharged from an aged care and rehabilitation service in Australia who were enrolled in a clinical trial. Participants One hundred and eighty-one community-dwelling adults aged over 70 years (mean age 84, standard deviation 5.7) who met the Cardiovascular Health Study criteria for frailty, had a Mini Mental State Examination score over 18 and a predicted life expectancy exceeding 12 months. Main outcome measures Participation restriction was evaluated using the Reintegration to Normal Living Index. Results Eighty percent of subjects reported participation restriction in at least one aspect of their life. Restricted participation was most prevalent in the areas of work in the home or community (114/181, 63%) and community mobility (92/181, 51%), and least common with regard to interpersonal relationships (9/181, 5%). Multivariate regression analysis showed that grip strength, mood, number of medical conditions and mobility were independently and significantly (P < 0.05) associated with participation restriction, and explained 29% of the variance in participation restriction. Cognition and living alone were not significantly associated with participation restriction. Conclusions Participation restriction was common in this sample of frail, community-dwelling older people. It was associated with factors from multiple levels of the International Classification of Functioning, Disability and Health. Further research is suggested to investigate the causes and treatment of participation restriction. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: ICF; International Classification of Functioning, disability and Health; Participation restriction; Frail elderly

Introduction Participation (i.e. involvement in a life situation) is a key component of function, as defined by the International Classification of Functioning, Disability and Health (ICF). Conversely, participation restriction is a problem experienced by an individual regarding his or her involvement in life situations [1]. The ICF describes disability as an umbrella term ∗ Corresponding author at: The George Institute for Global Health, The University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia. Tel.: +61 400303626; fax: +61 2 9657 0301. E-mail address: [email protected] (N. Fairhall).

for problems at any of the levels of the body (impairment), individual (activity limitation) or individual in society (participation restriction). Participation restriction is presented in the ICF as the consequence of interactions between an individual’s health condition and personal and environmental contextual factors [2]. The majority of older adults experience participation restriction in their daily life [3]. Participation outcomes are valued by the individual [4], are of more concern than impairments or activity limitations [5], and have the potential to improve in spite of irreversible health conditions, impairments and activity limitations [6]. However, outcomes at the level of participation are seldom evaluated in older people.

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.06.008

N. Fairhall et al. / Physiotherapy 97 (2011) 26–32

In both clinical and research settings, outcomes are predominantly conceptualised at the ICF levels of body function and activity, or using broader measures such as quality of life. Frailty, a syndrome whereby cumulative decline of many physiological systems results in decreased reserve, is independently predictive of worsening mobility and function, institutionalisation and death [7]. The features that define the frailty syndrome, empirically derived from the Cardiovascular Health Study, are weight loss, weakness, self-reported exhaustion (measured using depression questionnaire items), slow gait and low activity. As participation restriction in older people is independently associated with a number of these factors [8], it is likely that the prevalence of participation restriction is increased in the frail population. To enhance understanding and treatment of participation restriction in frail older people, information regarding the extent and nature of the problem is needed. This information may provide the basis for development of interventions to decrease participation restriction in frail older people. The research questions for this study were: (1) what is the extent of participation restriction in a sample of community-dwelling frail older people? (2) What domains of participation are most restricted? (3) Which health and demographic factors are associated with participation restriction in the frail older person?

Method Study sample Baseline data from the Frailty Intervention Trial, collected between February 2008 and November 2009, were analysed for this observational cross-sectional study. The Frailty Intervention Trial is a single-centre randomised controlled trial being conducted in Sydney, Australia (Clinical Trial Registration Number ACTRN12608000250336). Ethical approval for the study was granted by the Northern Sydney & Central Coast Health Human Research Ethics Committee, and the study protocol has been published elsewhere [9]. Clinicians working in the Division of Rehabilitation and Aged Care Services at Hornsby Ku-ring-gai Health Service, Sydney, Australia were asked to screen all patients who were living in the community at discharge from either the hospital or the community arm of the service. The majority (75%) of referrals came from the Rehabilitation Discharge Team (a home-based rehabilitation team) following admission to hospital or presentation to the emergency department. To be eligible for inclusion in the study, people were aged 70 years or older, did not usually reside in a residential aged care facility, did not have severe cognitive impairment (defined as a Mini Mental State Examination [10] score of 18 or less) and had a likely life expectancy of more than 12 months, estimated by a score of three or less on a modified version of the Implicit Illness Severity Scale [11]. In addition, they were defined as frail according to frailty criteria used in the

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Cardiovascular Health Study [7] by meeting predetermined cut-points for at least three of the following criteria: weight loss, weakness, self-reported exhaustion, poor endurance and low activity [9]. Following eligibility screening, all subjects underwent self-report and physical assessments. All subjects gave informed consent. Descriptive measures Person-perceived participation was measured using the Reintegration to Normal Living Index [12]. This instrument has high internal consistency [12,13], acceptable temporal reliability [14] and correlates strongly with the Participation Survey Mobility; an instrument developed to assess participation, based upon the ICF [15]. Nine of the 11 original items measure participation, covering eight dimensions of life and five ICF domains [16]. The nine items were included and the question phrasing was modified to increase comprehension, as validated by Daneski et al. [17] (see Table 1). The nine declarative statements were scored using a five-point scoring system (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree), yielding a total score from 0 to 36 with a higher score reflective of greater participation. Personal factors obtained were age, gender and years of education. Environmental context was considered by asking whether the individual lived alone or with another person, and whether they mobilised with a walking aid. The number of health conditions present was measured using the Functional Comorbidity Index [18] with seven additional diagnoses considered, offering a count of 0 to 25 comorbidities. Body mass index was calculated using height (derived from knee height, using gender- and age-specific equations [19]) and weight (using scales). Mood was evaluated using the 15-point Geriatric Depression Scale short form (GDS) [20], and degree of frailty was evaluated using the number of frailty criteria met, as has been described previously [9]. Impairment was measured in four areas. The Physiological Profile Assessment was used as a composite measure of risk of falling. This tool is a validated battery of five measures of physiological functioning: visual contrast sensitivity, lower limb proprioception, quadriceps strength, reaction time and postural sway [21]. Muscle strength (in kg) was measured as peak isometric grip using hand-held dynamometry (Saehan Dynamometer, model SH5001, Saehan Corporation, South Korea) and peak isometric knee extension, measured in the dominant leg with subjects seated and the hip and knee at 90◦ angles. The best of three trials was recorded [21]. The Mini Mental Status Examination was used to assess cognitive function on a scale of 0 to 30 [10], and postural sway was measured using a swaymeter to quantify body displacement at waist level [22]. The activity dimension of the ICF was evaluated using both performance and self-report measures. Performance data were collected according to the Short Physical Performance Battery [23], measuring fastest time to stand up

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Table 1 Modified Reintegration to Normal Living Index: declarative statements and relationship with International Classification of Functioning, Disability and Health (ICF). Statement on modified Reintegration to Normal Living Index

Participation domain measureda

ICF Code measureda

I get around my house as I need to I get out of the house as I need to I make longer trips if I need to (e.g. outside local area) I am happy with the way I manage my personal needs (such as eating, dressing, washing and going to the toilet) I am able to do work that is important to me (such as paid or voluntary work, housework and studying) I am able to do things that I enjoy (e.g. watching television, knitting, hobbies, games, computer, bingo, gardening, etc.) I socialise with friends and family as much as I want I still feel that I am an important member of the family I am happy with the way I get on with people who are important to me

Mobility

Self-care

d4600 d460 d4602 Chapter 5

Major life areas

d810–d859

Community, social and civic life

d920

Interpersonal interactions and relationships

d9205 d760 d730–d799

a ICF Code as applied by Perenboom and Chorus (Perenboom RJ, Chorus AM. Measuring participation according to the International Classification of Functioning, Disability and Health. Disabil Rehabil. 2003;25:577–87).

five times and to walk 4 m, plus timed balance tasks (feet together, one foot in front and one foot directly in front of the other). The composite Lower Extremity Continuous Summary Performance Score (CSPS) was calculated using the methodology described by Onder et al. [24], and gait velocity was also included as a separate variable. Activity was measured by self-report using the 100-point Barthel Index [25]. Data analysis Descriptive statistics were used to illustrate the subjects’ baseline characteristics. Participants were defined as experiencing participation restriction in an area of life if they answered ‘disagree’ or ‘strongly disagree’ to a question on the Reintegration to Normal Living Index. Differences between males and females in each of the areas of life affected by participation restriction were tested using a χ2 test. Univariate linear regression analysis was used to determine the relationship between the continuous measure of participation and 19 health and demographic factors which had been found to correlate with participation in older people [8] or were suggested contributors [26]. Variables independently and significantly (P < 0.05) associated with participation restriction were entered into a multivariate regression analysis to examine which participant characteristics and measures best explained participation. A backward elimination approach was used, with the least significant variable removed and a further model fitted, and the procedure was repeated until all remaining variables were significant at the P < 0.05 level. A three-point increase in the Reintegration to Normal Living Index score was considered indicative of participation in one extra area of life. Degree of frailty and Physiological Profile Assessment were not entered into the multivariate regression analysis, as these multidimen-

sional instruments contain elements considered in the other measures. The sample size allowed for the inclusion of 17 explanatory variables in the multivariate regression analysis, with at least 10 cases per independent variable [27]. Due to dysphasia, one subject had missing data for mood and cognition, and therefore was excluded for multivariate regression analysis. Analysis of the residuals showed that the assumptions for multiple regression analysis were met. Statistical analyses were conducted using PASW Statistics version 18.0 (Predictive Analytics SoftWare, IBM SPSS, New York, USA).

Results Participants in this study were the first 181 people recruited to the Frailty Intervention Trial. The mean (standard deviation, SD) age was 84 (5.7) years and 70% (127/181) were female (Table 2). The majority (105/181, 58%) of participants did not live alone. They had an average of 5.8 doctor-diagnosed medical conditions (SD 2.3), and most rated their health as fair (60/181, 33%) or good (63/181, 35%). Seventy percent (127/181) had fallen in the past year (range zero to four falls), mean gait speed was 0.44 m/second (SD 0.18 m/second, range 0.06 to 0.98 m/second) and 75% (136/181) of participants used a walking aid. Eighty percent (145/181) of subjects reported participation restriction in at least one area of their life. The majority had participation restriction in one to three areas of their life (103/181, 57%), whilst 20% (36/181) of participants were restricted in four to six areas and 3% (5/181) were restricted in seven to nine areas. The nature of participation restriction is presented in Fig. 1. Participation was most commonly restricted in the areas of work in the home or community (114/181, 63%) and

N. Fairhall et al. / Physiotherapy 97 (2011) 26–32

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Table 2 Characteristics of the study participants and their relationship with participation restriction measured using the Reintegration to Normal Living Index [mean 22.2, standard deviation (SD) 4.31]. Characteristic

n = 181

Personal factors Age (years), mean (SD) Gender, n female (%) Education (years), mean (SD) Environmental factors Living alone, n yes (%) Uses walking aid, n (%) Measures of health condition, mean (SD, range) Medical conditionsa Body mass index (kg/m2 ) Geriatric Depression Scaleb Meet four to five frailty criteria, n (%) Measures of impaired body form/function, mean (SD, range) Mini Mental State Examinationb Grip strength (kg) Quadriceps strength (kg) Sway (mm)c Physiological Profile Assessment Vision impaired, n yes (%) Hearing impaired, n yes (%) Measures of activity limitation, mean (SD, range) Barthel Index Gait velocity (m/second) Lower Extremity Continuous Summary Performance Score a b c

Relationship with participation restriction Unstandardised regression coefficients

R2

Standardised coefficients (β)

84 (6) 127 (70) 10 (3)

−0.06 −0.82 0.08

0.007 0.008 0.004

−0.08 −0.09 0.06

0.28 0.24 0.41

77 (42) 137 (75)

−0.10 −1.75

0.0001 −0.01 0.03 −0.18

0.88 0.02

5.8 (2.3, 0 to 12) 25.5 (5.4, 14.0 to 46.7) 5 (3.3, 0 to 14) 66 (37)

−0.53 −0.05 −0.52 −3.0

0.08 0.004 0.18 0.11

−0.29 −0.06 −0.42 −0.34

<0.001 0.41 <0.001 <0.001

26 (3.0, 18 to 30) 15 (7, 0 to 38) 15 (5.7, 4 to 30) 1966 (1637, 20 to 11 008) 2.7 (1.55, −0.4 to 7.1) 89 (49) 75 (41)

0.11 0.14 0.12 −0.001 −0.79 −0.53 −0.89

0.006 0.05 0.02 0.05 0.08 0.005 0.01

0.10 0.23 0.15 −0.22 0.20 −0.07 −0.10

0.29 0.002 0.04 0.003 <0.001 0.35 0.17

91.5 (13.9, 40 to 100) 0.44 (0.18, 0.06 to 0.98) 1.61 (0.69, −0.72 to 2.59)

0.09 4.09 1.86

0.09 0.03 0.09

0.30 0.17 0.30

<0.001 0.03 <0.001

P-Value

Self-reported, doctor-diagnosed medical conditions. Missing data for Mini Mental State Examination (n = 1) and Geriatric Depression Scale (n = 1). Millimetre squares traversed by swaymeter in 30 seconds.

community mobility (92/181, 51%), followed by socialising with family and friends (67/181, 37%), outdoor mobility (58/181, 32%) and family role (34/181, 19%). Participation restriction was least commonly perceived in leisure activities (27/181, 15%), personal needs (24/181, 13%), indoor mobility (16/181, 9%) and interpersonal relationships (9/181, 5%). There was no evidence of an association between gender and any area of life in which participation was restricted (P > 0.05 for all areas of life). The measure of participation restriction, the Reintegration to Normal Living Index, had a mean (SD) score of 22.2 (4.31). The associations between participation restriction and factors within each dimension of the ICF are shown in Table 2.

Personal factors, cognitive status and cohabitation were not associated with participation restriction. Mood (measured using the GDS), degree of frailty, number of medical conditions, grip strength, quadriceps strength, sway, use of a walking aid, Physiological Profile Assessment and both performance (CSPS and gait velocity) and self-report (Barthel Index) measures of activity were independently and significantly associated with participation restriction (P < 0.05). In the multivariate model, four variables were found to be significantly associated with participation restriction: grip strength (P = 0.04), mood (P ≤ 0.001), number of medical conditions (P = 0.003) and CSPS (P = 0.006). This model accounted for 29% of the variance in participation restriction (Table 3).

Table 3 Unstandardised regression coefficients (95% confidence interval), standardised regression coefficients and P-values from the multivariate analysis with participation restriction as the dependent variable, and proportion of variance explained by the model. Explanatory variables

Unstandardised coefficients (95% confidence intervals)

Standardised coefficients (β)

P-Value

Geriatric Depression Scale Medical conditionsa Grip (kg) Lower Extremity Continuous Summary Performance Score Constant R2 = 29%

−0.43 (−0.59 to −0.26) −0.35 (−0.59 to −0.12) 0.08 (0.01 to 0.16) 1.13 (0.32 to 1.93)

−0.34 −0.20 0.14 0.19

<0.001 0.003 0.04 0.006

a

24 (21 to 26)

Self-reported, doctor-diagnosed medical conditions.

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N. Fairhall et al. / Physiotherapy 97 (2011) 26–32

Fig. 1. Proportion of subjects reporting participation restriction by area of life.

Appraisal of standardised coefficients (the number of SDs of change in participation restriction for every SD of change in the predictor variable) found that GDS (␤ = −0.34) had a greater contribution to participation restriction than the other variables of grip strength (␤ = 0.14), CSPS (␤ = 0.19) and number of health conditions (␤ = −0.20).

Discussion Information about participation restriction in older people is sparse and, to the authors’ knowledge, no previous research has investigated participation restriction specifically in the frail population. The vast majority of frail older people living in the community following discharge from an aged care service are unable to be involved in their life roles as they wish. In light of research that participation restriction increases with age [3,28], it is not surprising that the study population had greater participation restriction than a sample of people aged over 50 years recruited from general practice registers (mean age 63 years), in which 51% reported participation restriction [3]. The areas of life most affected by participation restriction were work and community mobility. Difficulty mobilising outside the home is widely acknowledged as a primary problem in older people [3] and those with disability [29]. Work was defined broadly, primarily addressing the ‘major life areas’ domain of the ICF. Respondents rated their capacity to do the work that was important to them, using the examples of voluntary and paid work, housework and study. The measurement instrument did not enable evaluation of the relative restriction between these elements; however, Wilkie et al. found that participation restriction was not prevalent in areas of work or education, yet it posed a problem in terms of looking after the home [3]. The areas of participation least affected were interpersonal relationships, indoor mobility, self-care and leisure. It is possible that these are the aspects of participation restriction most frequently addressed by carers (paid and unpaid) and aged care support services in the community. The present study found participation restriction to be associated with factors from other dimensions of the ICF:

health condition, impairment of body form/function and activity limitation. These results concur with previous reports that participation is multifactorial in aetiology [28], yet unlike previous studies, neither personal factors (such as age and gender) nor environmental factors (such as living alone) were significantly associated with participation [3,28]. There is very strong evidence of a relationship between mood and participation, in agreement with previous findings that older people with depression have considerably higher odds of participation restriction [8]. In the final multivariate model, mood makes the largest unique contribution to the variance in participation restriction, although number of medical conditions, grip strength and the mobility measure (CSPS) also make statistically significant contributions. After controlling for the other variables in the final model, mood had the greatest influence on participation with a 1.3 point increase in the 15-point GDS related to participation restriction in one extra area of life. Wilkie et al. found that older people with a higher probability of depression [Hospital Anxiety and Depression Scale (HADS) score of 11 to 21] were more than four times as likely (odds ratio 4.7) to report participation restriction compared with those with lower scores on a depression scale (HADS score of 0 to 7), after adjusting for nine potentially confounding variables [8]. Depression is treatable in frail older people, and studies are warranted to investigate the predictive value of mood and the effect of targeting it during interventions aimed at increasing participation. Multiple variables reflecting impaired body form/function and activity limitation were found to be important. Both grip and quadriceps strength were independently and significantly associated with participation. Quadriceps strength is associated with mobility [30], while grip is a powerful marker of frailty [31], disability and morbidity [32]. Interestingly, grip strength provided a greater contribution to the variance in participation and was included in the final model, indicating the importance of overall vigor on participation. A 240-g decrease in grip strength was associated with participation restriction in one extra area of life. The roles of balance and mobility in participation are suggested by the significant association with each of postural sway, gait speed, use of a walking aid and the measures of lower extremity function (CSPS) and falls risk (Physiological Profile Assessment). Inclusion of sway and omission of CSPS in an alternative multivariate model was able to account for as much variance in predicting participation restriction, suggesting that balance is a key limiting factor in terms of the impact of mobility on participation. Participation restriction, viewed by the ICF as an aspect of disability, was found to be significantly associated with degree of frailty and number of concurrent medical conditions. Research by Fried et al. showed that disability, comorbidity and frailty are distinct, yet overlapping, entities in older people [33]. They defined disability as substantial limitation of one or more major life activities, which included activities of daily living, tasks necessary to live indepen-

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dently and pursuits important to an individual’s quality of life. Disability therefore related primarily to the ICF concept of activity limitation, although it is possible that participation restriction was also captured in Fried et al.’s study. Despite a variety of factors being considered, 71% of the variance in participation restriction was not explained by the multivariate model. To comprehensively explain participation restriction, future research should consider variables previously associated with participation, such as environmental barriers [34], self-esteem [28] and pain [8], plus the effect of psychological factors that influence mobility, such as fear of falling [35]. The design of this study does not permit conclusions about the cause or treatment of participation restriction; however, the multifactorial nature of participation suggests that intervention should target problems at the ICF levels of functioning (including impairment and activity limitation) and health conditions, as well as considering contextual factors such as the environment. Physiotherapists are well placed to address participation, in conjunction with colleagues from other disciplines. The limitations of this study should be acknowledged. The assessment tool used to measure participation examined five of the possible nine domains of participation outlined in the ICF. It has been suggested that the omitted domains (learning and applying knowledge, general tasks and demands, communication and domestic life), along with self-care, in fact relate to activity [36], yet how to differentiate measurement of activity and participation remains contentious and requires ongoing evaluation [34,36,37]. There are four reasons why this sample may not be representative of the broader population of frail older people. All subjects were referred to, and agreed to participate in, a trial, potentially resulting in selection bias given that they may be a different sample than the general population. They had recently been discharged from a rehabilitation and aged care service, with the majority gaining access to the service following hospitalisation or presentation to the emergency department. Finally, the sample resided in urban areas of Northern Sydney, Australia, and did not have severe cognitive impairment. Insight into the extent and nature of participation restriction in frail older people is important in our ageing society. The findings of this study suggest that the majority of community-dwelling, frail older Australians enrolled in the Frailty Intervention Trial experience participation restriction. Considering the incidence of participation restriction, longitudinal studies are warranted to understand the causes of participation restriction and changes in participation restriction in frail older people over time, and to evaluate whether participation can be increased with intervention. Ethical approval: (For the Frailty Intervention Trial) Northern Sydney & Central Coast Health Human Research Ethics Committee (Protocol Number: 0709-191M). Funding: The Frailty Intervention Trial is funded by an Australian National Health and Medical Research Council Health Services Research Grant Number 402791. A Physio-

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therapy Research Foundation Tagged National Gerontology Group Research Grant enabled collection of participation data. The funding bodies did not contribute to the content of this paper. Conﬂict of interest: None declared. References [1] World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001. [2] Stucki G, Cieza A, Ewert T, Kostanjsek N, Chatterji S, Ustun TB. Application of the International Classification of Functioning, Disability and Health (ICF) in clinical practice. Disabil Rehabil 2002;24: 281–2. [3] Wilkie R, Peat G, Thomas E, Croft P. The prevalence of personperceived participation restriction in community-dwelling older adults. Qual Life Res 2006;15:1471–9. [4] Hammel J, Magasi S, Heinemann A, Whiteneck G, Bogner J, Rodriguez E. What does participation mean? An insider perspective from people with disabilities. Disabil Rehabil 2008;30:1445–60. [5] Reichstadt J, Depp CA, Palinkas LA, Folsom DP, Jeste DV. Building blocks of successful aging: a focus group study of older adults’ perceived contributors to successful aging. Am J Geriatr Psychiatry 2007;15:194–201. [6] Harwood RH, Prince M, Mann A, Ebrahim S. Associations between diagnoses, impairments, disability and handicap in a population of elderly people. Int J Epidemiol 1998;27:261–8. [7] Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146–56. [8] Wilkie R, Peat G, Thomas E, Croft P. Factors associated with participation restriction in community-dwelling adults aged 50 years and over. Qual Life Res 2007;16:1147–56. [9] Fairhall N, Aggar C, Kurrle SE, Sherrington C, Lord S, Lockwood K, et al. Frailty Intervention Trial (FIT). BMC Geriatr 2008;8:27. [10] Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98. [11] Holtzman J, Lurie N. Causes of increasing mortality in a nursing home population. J Am Geriatr Soc 1996;44:258–64. [12] Wood-Dauphinee SL, Opzoomer MA, Williams JI, Marchand B, Spitzer WO. Assessment of global function: the Reintegration to Normal Living Index. Arch Phys Med Rehabil 1988;69:583–90. [13] Stark SL, Edwards DF, Hollingsworth H, Gray DB. Validation of the Reintegration to Normal Living Index in a population of communitydwelling people with mobility limitations. Arch Phys Med Rehabil 2005;86:344–5. [14] Steiner A, Raube K, Stuck AE, Aronow HU, Draper D, Rubenstein LZ, et al. Measuring psychosocial aspects of well-being in older community residents: performance of four short scales. Gerontologist 1996;36:54–62. [15] Gray DB, Hollingsworth HH, Stark SL, Morgan KA. Participation survey/mobility: psychometric properties of a measure of participation for people with mobility impairments and limitations. Arch Phys Med Rehabil 2006;87:189–97. [16] Perenboom RJ, Chorus AM. Measuring participation according to the International Classification of Functioning, Disability and Health (ICF). Disabil Rehabil 2003;25:577–87. [17] Daneski K, Coshall C, Tilling K, Wolfe CD. Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients. Clin Rehabil 2003;17:835–9. [18] Groll DL, To T, Bombardier C, Wright JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol 2005;58:595–602.

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[19] Chumlea WC, Guo S. Equations for predicting stature in white and black elderly individuals. J Gerontol 1992;47:M197–203. [20] Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982;17:37–49. [21] Lord SR, Menz HB, Tiedemann A. A physiological profile approach to falls risk assessment and prevention. Phys Ther 2003;83:237– 52. [22] Lord SR, Clark RD, Webster IW. Physiological factors associated with falls in an elderly population. J Am Geriatr Soc 1991;39:1194–200. [23] Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med 1995;332:556–61. [24] Onder G, Penninx BW, Lapuerta P, Fried LP, Ostir GV, Guralnik JM, et al. Change in physical performance over time in older women: the Women’s Health and Aging Study. J Gerontol A Biol Sci Med Sci 2002;57:M289–93. [25] Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. MD State Med J 1965;14:61–5. [26] Keysor JJ, Jette AM, Coster W, Bettger JP, Haley SM. Association of environmental factors with levels of home and community participation in an adult rehabilitation cohort. Arch Phys Med Rehabil 2006;87:1566–75. [27] Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373–9. [28] Chau JP, Thompson DR, Twinn S, Chang AM, Woo J. Determinants of participation restriction among community dwelling stroke survivors: a path analysis. BMC Neurol 2009;9:49.

[29] Mayo NE, Wood-Dauphinee S, Cote R, Durcan L, Carlton J. Activity, participation, and quality of life 6 months poststroke. Arch Phys Med Rehabil 2002;83:1035–42. [30] Ferrucci L, Guralnik JM, Buchner D, Kasper J, Lamb SE, Simonsick EM, et al. Departures from linearity in the relationship between measures of muscular strength and physical performance of the lower extremities: the Women’s Health and Aging Study. J Gerontol A Biol Sci Med Sci 1997;52:M275–85. [31] Syddall H, Cooper C, Martin F, Briggs R, Aihie Sayer A. Is grip strength a useful single marker of frailty? Age Ageing 2003;32:650–6. [32] Bassey EJ, Harries UJ. Normal values for handgrip strength in 920 men and women aged over 65 years, and longitudinal changes over 4 years in 620 survivors. Clin Sci (Lond) 1993;84:331–7. [33] Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol Series A Biol Sci Med Sci 2004;59:255–63. [34] Cott C, Aimone E, Blanchard G, Carswell A, Cook L, Cuthbertson T, et al. Conceptualising and measuring participation. Toronto: St John’s Rehabilitation Hospital, The Toronto Rehabilitation Institute, University Health Network and University of Toronto; 2005. [35] Delbaere K, Crombez G, van Haastregt JC, Vlaeyen JW. Falls and catastrophic thoughts about falls predict mobility restriction in community-dwelling older people: a structural equation modelling approach. Aging Ment Health 2009;13:587–92. [36] Australian Institute of Health and Welfare. ICF Australian user guide. Version 1.0. Canberra: AIWH; 2003. [37] Jette AM, Tao W, Haley SM. Blending activity and participation subdomains of the ICF. Disabil Rehabil 2007;29:1742–50.

Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 33–46

Does the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Breast Cancer capture the problems in functioning treated by physiotherapists in women with breast cancer? Andrea Glaessel a,b , Inge Kirchberger b,c , Gerold Stucki a,b,d,∗ , Alarcos Cieza a,b,c b

a Swiss Paraplegic Research (SPF), Nottwil, Switzerland ICF Research Branch of WHO Collaborating Centre for the Family of International Classiﬁcations in German, Nottwil, Switzerland and Munich, Germany c Institute for Health and Rehabilitation Sciences, Research Unit for Biopsychosocial Health, Ludwig-Maximilians Universität, Munich, Germany d Department of Health Sciences and Health Policy, University of Lucerne and SPF, Nottwil, Switzerland

Abstract Objective The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Breast Cancer is an application of the ICF, and represents the typical spectrum of problems in functioning and contextual factors that may influence functioning of patients with breast cancer. The objective of this study was to examine the content validity of this ICF core set from the perspective of physiotherapists. Design Physiotherapists from around the world experienced in the treatment of patients with breast cancer were interviewed about patients’ problems, patients’ resources and environmental aspects that physiotherapists take care of in a three-round survey using the Delphi technique. The responses were linked to the ICF. The degree of agreement was calculated by means of the Kappa statistic. Participants Physiotherapists experienced in breast cancer treatment. Results Fifty-nine physiotherapists from 19 countries named 769 problems treated by physiotherapists in patients with breast cancer. One hundred and sixty-six ICF categories were linked to these answers. Nineteen ICF categories reached >75% agreement among the physiotherapists but are not represented in the Comprehensive ICF Core Set for Breast Cancer. Ten concepts were linked to the not-yetclassified personal factors component. Eleven concepts are not covered by the ICF. The Kappa coefficient for the agreement between the two persons who performed the linking was 0.66 (95% bootstrapped confidence interval 0.63 to 0.68). Conclusions The content validity of the Comprehensive ICF Core Set for Breast Cancer was largely supported by the physiotherapists. However, several issues were raised which were not covered and these need to be investigated further. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Comprehensive ICF Core Set for Breast Cancer; International Classification of Functioning; Disability and Health (ICF); Physiotherapy; Rehabilitation; Breast cancer; Delphi technique

Background Breast cancer is the most common type of cancer among women worldwide [1]. The projected mortality from breast cancer in women worldwide in 2010 is 437 000 [2], and ∗ Corresponding author at: Swiss Paraplegic Research, Guido A. Zäch Str. 4, 6207 Nottwil, Switzerland. Tel.: +41 41 939 6570; fax: +41 41 939 6577. E-mail address: [email protected] (G. Stucki).

approximately 1 million women are diagnosed with breast cancer each year. However, incidence and mortality rates vary widely in different countries; they are high in most industrialised countries (except Japan), intermediate in Eastern and Southern Europe, and low in central and tropical South America, Africa and Asia [3]. Due to advances in the treatment of breast cancer, including the combined use of surgical intervention, radiation therapy and chemotherapy, cancer survival rates have

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.08.010

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A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

Fig. 1. Structure of the International Classification of Functioning, Disability and Health.

increased to 50% [4]. However, breast cancer is associated with a wide range of functional impairments. Pain, limited range of motion and lymphoedema of the affected arm can result from primary surgical treatment [5–7]. Untreated lymphoedema gradually worsens with time [8]. Anxiety, depression, loss of energy or fatigue, and sleeping problems are common responses to stressors [9,10]. A significant proportion of women also suffer from disturbances in body image and self-concept [10,11]. Moreover, social isolation and disruptions in family and sexual relationships are related to fears of recurrence and death [10–13]. Finally, the side-effects of treatment, as well as inactivity secondary to treatment, can impair activity and participation, decrease independence and affect quality of life [10,14]. Taking the diversity of consequences of breast cancer into account, a multidisciplinary approach seems appropriate. Rehabilitation after breast cancer requires a multiprofessional team including physicians, psychologists, nurses, social workers and, particularly, physiotherapists [9,10]. Physiotherapists are part of the multiprofessional team to prevent and restrict physical sequelae. In order to reach these rehabilitation goals, physiotherapists use different systemic treatment approaches and advise patients regarding prevention or how to apply compensation strategies [15,16]. To optimise interventions aimed at maintaining functioning and minimising disability, a proper understanding of the patient’s functioning and health status is needed. The International Classification of Functioning, Disability and Health (ICF) provides a useful framework for achieving this understanding, and constitutes a common language among the different health professionals [17]. According to the ICF, the problems associated with a disease may concern body functions and body structures, activities and participation in

life situations. Health states and the development of disability are modified by contextual factors such as environmental and personal factors [17]. The ICF is structured into two parts: functioning and disability, and contextual factors; each of which has two components (Fig. 1). Within functioning and disability, the body part consists of two domains: body functions and body structures. Chapters within these two domains are organised according to body systems. Activities and participation covers domains of functioning from both an individual and a societal perspective. In contrast to other disability models, the ICF classifies contextual factors that may either facilitate or hinder functioning, and therefore influence potential disability. These contextual factors consist of two components: environmental factors, including factors in the physical, social or attitudinal world; and personal factors, including age, habits, lifestyle, coping style, etc. The personal factors component is not yet classified. Both the content and the structure of the ICF point out their potential value for rehabilitation professions, especially physiotherapists. Physiotherapists may use the ICF to assess the patient’s functional status, which is the basis for intervention planning [18]. In contrast to professionspecific guides, such as the ‘Guide to Physical Therapists Practice’ of the American Physical Therapy Association [18], the common language of the ICF crosses professions and health disciplines. Therefore, ICF data can be communicated effectively between all members of the rehabilitation team. However, the ICF as a whole, with more than 1400 categories, is not feasible for use in clinical routine. To facilitate the implementation of the ICF into clinical practice, so-called ‘ICF core sets’ have been developed for a number

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

of chronic health conditions, including breast cancer [19,20]. The development of the ICF core sets followed a standard approach that included a formal decision-making and consensus process among experienced health professionals, integrating evidence gathered from preparatory studies. Preparatory studies included a Delphi exercise, a systematic review and empirical data collection [21–23]. The current version of the Comprehensive ICF Core Set for Breast Cancer includes 80 ICF categories, which cover the typical spectrum of problems in functioning and contextual factors that may influence functioning of patients with breast cancer in the chronic situation (after completion of primary treatment) [21]. From the 80 ICF categories, 26 can be assigned to body functions, nine to body structures, and 22 to activities and participation. Additionally, the Comprehensive ICF Core Set for Breast Cancer contains 23 environmental factors that may facilitate or hinder functioning. Based on this list of ICF categories, physiotherapists can comprehensively describe the functioning of a determined patient, and create a profile which can serve as a reference for follow-up and can be used to demonstrate treatment effects. To report the extent of problems in specific ICF categories, ICF qualifiers can be used as a rating scale from 0 (no problem) to 4 (complete problem). The judgement is based on various information sources including patient, health professionals, examination and tests, and clinical data. Supplementary to the ICF core sets, ICF-based documentation tools have been developed to be used in multidisciplinary rehabilitation management [24]. In addition, an ICF-based documentation template based on the ‘Guide to Physical Therapists Practice’ was suggested by Escorpizo et al. (2010) to be used specifically by physiotherapists [25]. The Comprehensive ICF Core Set for Breast Cancer is currently undergoing worldwide testing and validation using a number of approaches, including international multicentre field studies and validation from the consumer’s perspective as well as from the user’s (health professional’s) perspective. Content validity from the consumer’s perspective means that all aspects of functioning relevant for patients with breast cancer should be covered by the ICF Core Set for Breast Cancer. In contrast, content validity from the health professional’s perspective has a narrower frame. It means that at least those problems in functioning which are substantial targets of the specific interventions applied by health professionals are represented in the ICF Core Set for Breast Cancer. This is a prerequisite for implementation of the ICF Core Set for Breast Cancer in clinical practice. To give an example, if joint mobility is a main intervention target of physiotherapists, it is essential that physiotherapists are able to document the extent and change of joint mobility problems in a determined patient during the treatment course using the ICF Core Set for Breast Cancer. Consequently, if the corresponding ICF category for joint mobility is not included in the current version of the ICF Core Set for Breast Cancer, the core set is lacking content validity from the perspective of physiotherapists.

35

Consequently, the purpose of this study was to examine the content validity of the Comprehensive ICF Core Set for Breast Cancer from the perspective of physiotherapists. The study aimed to identify all aspects of functioning of patients with breast cancer, including patients’ problems, patients’ resources and environmental factors treated by physiotherapists, and to analyse whether these aspects are represented in the current Comprehensive ICF Core Set for Breast Cancer. Methods A three-round e-mail survey of physiotherapists using the Delphi technique was conducted [26–29]. The Delphi technique aims to gain consensus from a group of individuals who have knowledge of the investigated topic [30]. These informed persons are commonly titled ‘experts’ [31]. The Delphi method is a multistage process with each stage building on the results of the previous stage, and a series of rounds are used to both gather and provide information about a particular subject. The technique is characterised by: anonymity, to avoid the dominance of single individuals in a group; iteration, which allows panel members to change their opinions in subsequent rounds; and controlled feedback, which shows the distribution of the group’s responses as well as each individual’s previous responses [32]. Ethical approval was not required as no patients were included in this study. Recruitment of participants In the preparatory phase of the study, national and international associations of physiotherapists, as well as universities and collaborative partners of the Institute for Health and Rehabilitation Sciences at Ludwig-Maximilian University, Munich all over the world were contacted. In addition, a literature search and personal recommendations were used to identify physiotherapists experienced in the treatment of breast cancer. The experts were selected using a maximumvariation sampling strategy for clinical setting and country [33]. To ensure that the study participants were experienced in the treatment of patients with breast cancer, the initial letter stated that participants should be ‘physiotherapists with experience in the treatment of patients with breast cancer’. The first contact included an invitation to cooperate and a detailed description of the project targets, the Delphi process and the expected timeline. Only individuals who agreed to participate were included in the expert sample and received the questionnaire for the first round of the Delphi procedure. Delphi process The process and verbatim questions of the e-mail survey using the Delphi technique are specified in Fig. 2. In the first round of the Delphi procedure, an information letter including instructions and an Excel file containing an open-ended ques-

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A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

FIRST ROUND

Activities of study group

Activities of experts

The participants received an e-mail with general information, instructions and a questionnaire with the following open-ended question: ‘What are the patients’ problems, patients’ resources and environmental aspects treated by physiotherapists in patients with breast cancer?’

Creating a list of patients’ problems, patients’ resources and environmental aspects treated by physiotherapists in patients with breast cancer

• Linking of responses to ICF categories

SECOND ROUND

The experts received an e-mail with instructions and the questionnaire for the second round with the following question: ‘Do you agree that these ICF categories represent patients’ problems, patients’ resources or environmental aspects treated by physiotherapists in patients with breast cancer?’

Judgement (yes/no) whether the listed ICF categories reflect the treatment given by physiotherapists to patients with breast cancer

• Calculation of frequencies (% yes responses) • Feedback of individual judgement • Feedback of group answer

THIRD ROUND

The experts received an e-mail with instructions and the questionnaire for the third round with the following question: ‘Taking into account the answers of the group and your individual answer in the second round, do you agree that these ICF categories represent patients’ problems, patients’ resources or environmental aspects treated by physiotherapists in patients with breast cancer?’

Judgement (yes/no) whether the listed ICF categories reflect the treatment given by physiotherapists to patients with breast cancer

• Calculation of frequencies (% yes responses) Fig. 2. Delphi process.

tionnaire were sent to all participants. In the questionnaire, the participants were asked to list all patients’ problems, patients’ resources and environmental aspects treated by physiotherapists in patients with breast cancer. The phrasing of this question aimed to encourage the participants to

consider not only problems in functioning but also resources and environmental factors, which are included as contextual factors (personal factors, environmental factors) in the ICF model. Additionally, the participants were asked to complete questions on demographic characteristics and professional

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

experience. Responses were collected and linked to the ICF [34,35]. In the second round of the Delphi procedure, the participants received a list of the ICF categories linked to the responses of the first round. The responses that could not be linked to an existing ICF category were categorised by the research team and listed. The participants were asked to agree or disagree whether the respective ICF categories represent patients’ problems, patients’ resources or environmental aspects treated by physiotherapists in patients with breast cancer. In the third round of the Delphi procedure, the participants received a list of ICF categories including the proportion and the identification numbers of the participants who agreed that the categories represented patients’ problems, patients’ resources and environmental aspects treated by physiotherapists in patients with breast cancer. The participants were asked to answer the same question, taking into account the responses of the group as well as their previous response. Linking the responses to the ICF Each response of the first Delphi round was analysed in four steps. First, a qualitative analysis was conducted. All meaningful concepts contained in the participants’ answers in the first round were extracted independently by two physiotherapists [34,35]. A meaningful concept is a specific unit of the statement comprising a common theme [36]. The physiotherapists were trained in the ICF and the linking process. Second, the meaningful concepts extracted by the two physiotherapists were compared and, in case of disagreement, were discussed by a team consisting of two physiotherapists and a psychologist. Based on this discussion, a joint decision was made. Third, the agreed list of meaningful concepts was linked separately by the two physiotherapists to the most precise ICF categories. To give an example, a participant’s response ‘Pain in lower limb and trunk’ includes two meaningful concepts: ‘Pain in lower limb’, which was linked to ‘b28014 Pain in lower limb’; and ‘Pain in trunk’, which was linked to ‘b2801 Pain in body part’. Concepts not represented in the ICF were coded as ‘Not covered’, and concepts addressing personal factors according to the ICF definition were coded as ‘Personal factors’. The linkage was performed on the basis of 10 linking rules established in previous studies [35]. Fourth, consensus between the physiotherapists was used to decide which ICF category should be linked to each response. In case of disagreement between the two physiotherapists, the suggested categories were discussed by a team consisting of two physiotherapists and a psychologist. Based on this discussion, a joint decision on the final linking was made. Statistical methods Statistical analysis was performed using SAS for Windows Version 8 (SAS Institute Inc., Cary, NC, USA). Descrip-

37

tive statistics were calculated to characterise the sample and frequencies of responses. Kappa statistics with bootstrapped confidence intervals were used to describe the agreement between the two physiotherapists who performed the linking [37,38]. Values of the Kappa coefficient generally range from 0 to 1, where 1 indicates perfect agreement and 0 indicates no additional agreement beyond what is expected by chance. The percentage of participants who agreed with the question in the second and third Delphi rounds was calculated. Lacking a universally accepted definition of ‘consensus’ [39], 75% agreement among the participants was considered sufficiently high based on experiences from former studies [39].

Results Recruitment and participants One hundred and thirty-seven associations of physiotherapists were contacted, including the World Confederation of Physical Therapy (WCPT), members of the European region of the WCPT and different national physical therapy associations. Nineteen experts were recruited by this strategy. Additionally, 565 international universities were contacted which named 68 experts, of whom four agreed to participate. One hundred and ninety-one experts in lymphoedema treatment were contacted. Thereof, 13 physiotherapists agreed to cooperate in the Delphi process. Based on a literature search, 340 potential experts were identified and invited to participate. Twenty were registered as Delphi panel members. On the basis of personal recommendations of other participants, 16 individuals agreed to participate in the project. After the recruitment phase, a total of 72 physiotherapists from 20 different countries representing all six World Health Organization regions had agreed to participate in the Delphi survey. Delphi process Fifty-nine out of 72 (82%) physiotherapists who agreed to participate in the study filled in the first-round questionnaire. The demographic and professional characteristics of these participants are shown in Table 1. Fifty-two of the 59 firstround participants (72% of the original sample) returned the second-round questionnaire. The third-round questionnaire was completed by 50 of the 59 first-round participants (69% of the original sample). Linking the responses to the ICF In the first Delphi round, 769 different meaningful concepts were identified and 166 ICF categories were linked to these. Five fourth-level categories, 24 third-level categories and 22 second-level categories of the body function component were linked. Six fourth-level categories, 19 third-

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Table 1 Attrition of participants between the Delphi rounds, demographics and professional experience of the first-round participants. World Health Organization region

Round 1 (n)

Round 2 (n)

Round 3 (n)

Europeb Americasc Eastern Mediterraneand Africae South East Asiaf Western Pacificg

25 15 1 4 3 11

22 14 1 4 2 9

21 14 1 3 2 9

Total

59

52

50

a b c d e f g

Female (%)

Age (years) median (range)

Professional experience (years) Median (range)

Breast cancer experience (years) Median (range)

Self-rated breast cancer expertisea Median (range)

88 100 0 75 33 100

46 (29 to 55) 44 (32 to 59) 51 48 (35 to 63) 30 (27 to 33) 43 (29 to 56)

21 (6 to 35) 19 (8 to 38) 28 24 (9 to 40) 7 (1 to 11) 19 (4 to 34)

13 (5 to 25) 10 (1 to 26) 7 13 (6 to 20) 4 (1 to 6) 10 (1 to 26)

4 (3 to 5) 4 (3 to 5) 4 4 (3 to 5) 4 (3 to 4) 4 (3 to 5)

88

44 (27 to 63)

11 (1 to 40)

11 (1 to 26)

4 (3 to 5)

1 = low, 5 = excellent. Austria, Belgium, Denmark, Germany, Finland, Israel, Netherlands, Sweden, Switzerland. Canada, USA. Egypt. South Africa, Uganda. India, Bangladesh. Australia, China, New Zealand.

level categories and 11 second-level categories of the body structures component were linked. In the activities and participation component, 37 third-level categories and 20 second-level categories were linked. For the environmental factors component, 11 third-level categories and 11 secondlevel categories were linked. Ten identified concepts were linked to the not-yetdeveloped personal factors component (e.g. coping strategies, lymphoedema management, scar and pain management). Eleven concepts are not covered by the ICF (e.g. perform an activity over head or posture). The Kappa statistic for linking was 0.66 with a bootstrapped confidence interval of 0.63 to 0.68. Representation of the physiotherapists’ responses in the Comprehensive ICF Core Set for Breast Cancer Fifty-one ICF categories of the body functions component were linked to the concepts identified in the participants’ responses. Seventeen ICF categories are represented in the Comprehensive ICF Core Set for Breast Cancer at the same level of classification (e.g. b152 Emotional functions; see Table 2 , line 8). Twenty-nine responses were linked to more detailed thirdand fourth-level categories and represented by the corresponding second-level category (e.g. b1300 Energy level, represented in the Comprehensive ICF Core Set for Breast Cancer by the second-level category b130 Energy and drive functions; see Table 2, line 4). Thirteen ICF categories are not represented in the Comprehensive ICF Core Set for Breast Cancer. Among these, nine ICF categories, including b270 Sensory functions related to temperature and other stimuli, b440 Respiration functions, b715 Stability of joint functions and b735 Muscle tone functions, reached >75% agreement (Table 2). For the body structures component, 36 ICF categories were linked to the participants’ responses. Among these,

seven categories are included in the Comprehensive ICF Core Set for Breast Cancer at the same level of classification and reached >75% agreement. The six ICF categories that reached >75% agreement but which are not represented in the Comprehensive ICF Core Set for Breast Cancer address the structures of respiratory system and head and neck region, and additional musculoskeletal structures related to movement (Table 3). Most of the ICF categories linked could be assigned to the activities and participation component. Of the 57 ICF categories linked to activities and participation, 26 were included at the same level of classification and 26 were more detailed third-level categories, represented by the corresponding second-level categories. Four ICF categories which reached >75% agreement are not represented in the Comprehensive ICF Core Set for Breast Cancer (Table 4). Of the environmental factors component, 22 categories were linked to the participants’ responses. Of these, 11 categories were included at the same level of classification, and 11 categories were represented at a different level of classification. Although three ICF categories are not included in the Comprehensive ICF Core Set for Breast Cancer, none of these reached >75% agreement among the participants (Table 5). Ten concepts were linked to the not-yet-developed personal factors component. Most addressed the patients’ abilities in managing his/her disease (e.g. coping strategies, pain and scar management, and disease knowledge) (Table 6). Eleven concepts extracted from the responses of the participants are not covered by the ICF (Table 6).

Discussion This study found that the categories of the current version of the Comprehensive ICF Core Set for Breast Cancer largely represent what physiotherapists agreed that they take care of in their interventions. Eighty-nine percent of the 166 ICF categories linked to the answers of the participants are

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39

Table 2 Body functions component. ICF Code Second level

Third level

Fourth level

b126 b1266 b130 b1300 b134 b1343 b144 b152 b180 b1801 b265 b270 b2702 b280 b2801 b28010 b28011 b28013 b28014 b28016 b2803 b2804 b410 b435 b4352 b4353 b440 b4402 b455 b4550 b4551 b4552 b530 b5350 b640 b650 b660 b670 b710 b7101 b715 b7151 b720 b7200 b730 b7300 b7301 b7305 b7306 b735 b7350 b7355 b740 b7402 b770 b780 b7800 b810

Body functions

Round 3 n = 50

Inclusion in ICF Core Set

ICF Category

% Agreement

for Breast Cancer

Temperament and personality functions Confidence Energy and drive functions Energy level Sleep functions Quality of sleep Memory functions Emotional functions Experience of self and time functions Body image Touch function Sensory functions related to temperature and other stimuli Sensitivity to pressure Sensation of pain Pain in body part Pain in head and neck Pain in chest Pain in back Pain in upper limb Pain in joints Radiating pain in a dermatome Radiating pain in a segment or region Heart functions Immunological system functions Functions of lymphatic vessels Functions of lymphatic nodes Respiration functions Depth of respiration Exercise tolerance functions General physical endurance Aerobic capacity Fatiguability Weight maintenance functions Sensation of nausea Sexual functions Menstruation functions Procreation functions Sensations associated with genital and reproductive functions Mobility of joint functions Mobility of several joints Stability of joint functions Stability of several joints Mobility of bone functions Mobility of scapula Muscle power functions Power of isolated muscles and muscle groups Power of muscles of one limb Power of muscles of the trunk Power of all muscles of the body Muscle tone functions Tone of isolated muscles and muscle groups Tone of muscles of trunk Muscle endurance functions Endurance of all muscles of the body Gait pattern functions Sensations related to muscles and movement functions Sensation of muscle stiffness Protective functions of the skin

51 62 42 54 28 51 94 80 84 90 96 100 88 100 88 100 98 92 90 45 63

90 92 96 92 88 96 71 31 25

100 98 98 98 98 100 100 100 98 83 94 94 92 94 76 71

98 80

Yes Yesa Yes Yesa Yes Yesa No Yes Yes Yes Yes No No Yes Yes Yesa Yesa Yesa Yesa Yesa Yesa Yesa No Yes Yes Yes No No Yes Yesa Yesa Yesa Yes Yesa Yes Yes Yes Yes Yes Yesa No No Yes Yesa Yes Yesa Yesa Yesa Yesa No No No Yes Yesa No Yes Yesa Yes

40

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Table 2 (Continued ) ICF Code Second level

Third level

Body functions Fourth level

b820 b840 b850

Round 3 n = 50

Inclusion in ICF Core Set

ICF Category

% Agreement

for Breast Cancer

Repair functions of the skin Sensation related to the skin Functions of hair

87 90 10

Yes Yes No

The table denotes the percentage of experts who considered the respective International Classification of Functioning, Disability and Health (ICF) category as relevant in the third Delphi round, and the correlation with the ICF Comprehensive ICF Core Set for Breast Cancer. ICF categories included in the Comprehensive ICF Core Set for Breast Cancer are printed in bold. a ICF category is represented in the Comprehensive ICF Core Set for Breast Cancer by its corresponding higher-level (second-or third-level) category.

Table 3 Body structures component. ICF Code Second level

Third level

Body structures

Round 3 n = 50

Inclusion in ICF Core Set

Fourth level

ICF Category

% Agreement

for Breast Cancer

13 35 58 15

s73001 s73002

Structure of brain Spinal cord and related structures Spinal nerves Structure of meninges Structure of immune system Lymphatic vessels Lymphatic nodes Thymus Lungs Thoracic cage Structure of reproductive system Breast and nipple Structure of head and neck region Structure of shoulder region Bones of shoulder region Joints of shoulder region Muscles of shoulder region Structure of upper extremity Structure of upper arm Elbow joint Muscles of upper arm Structure of forearm Wrist joint Structure of hand Bones of hand Structure of pelvic region Muscles of pelvic region Structure of lower extremity Structure of trunk Cervical vertebral column Thoracic vertebral column Muscles of trunk Bones Joints Muscles Extra-articular ligaments, fasciae, extramuscular aponeuroses, retinacula, septa, bursae, unspecified Structure of areas of skin Structure of hair

98 95 100 75 100 100 100 100 94 100 94 92 94 47 55 48 35 96 88 92 96 69 100 98 98

No No No No Yes Yes Yes Yesa No No Yes Yes No Yes Yesa Yesa Yesa Yes Yesa Yesa Yesa Yesa Yesa Yesa Yesa No No No Yes Yesa Yesa Yesa Yesa Yesa Yesa Yesa

98 10

Yes No

s110 s120 s1201 s130 s420 s4200 s4201 s4202 s4301 s4302 s630 s6302 s710 s720 s7200 s7201 s7202 s730 s7300

s7301 s73011 s7302 s73020 s740 s7402 s750 s760 s76000 s76001 s7601 s7700 s7701 s7702 s7703

s810 s840

100 100 8 92 96

The table denotes the percentage of experts who considered the respective International Classification of Functioning, Disability and Health (ICF) category as relevant in the third Delphi round, and the correlation with the ICF Comprehensive ICF Core Set for Breast Cancer. ICF categories included in the Comprehensive ICF Core Set for Breast Cancer are printed in bold. a ICF category is represented in the Comprehensive ICF Core Set for Breast Cancer by its corresponding higher-level (second- or third-level) category.

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

41

Table 4 Activities and participation component. ICF Code Second level

Third level

d177 d230 d240 d2401 d4100 d415 d4150 d4153 d430 d4300 d4302 d440 d445 d4451 d4452 d450 d4501 d455 d4551 d4554 d4702 d475 d4750 d4751 d510 d5101 d520 d5200 d5202 d530 d540 d5400 d5401 d550 d560 d570 d5701 d5702 d620 d6200 d630 d640 d6400 d6401 d6402 d6403 d650 d6505 d660 d6600 d710 d720 d750 d760 d770 d7702 d845 d8450 d8451

Fourth level

Activities and participation

Round 3 n = 50

Inclusion in ICF Core Set

ICF Category

% Agreement

for Breast Cancer

Making decisions Carrying out daily routine Handling stress or other psychological demands Handling stress Lying down Maintaining a body position Maintaining a lying position Maintaining a sitting position Lifting and carrying objects Lifting Carrying in the arms Fine hand use Hand and arm use Pushing Reaching Walking Walking long distances Moving around Climbing Swimming Using public motorised transportation Driving Driving human-powered transportation Driving motorised vehicles Washing oneself Washing whole body Caring for body parts Caring for skin Caring for hair Toileting Dressing Putting on clothes Taking off clothes Eating Drinking Looking after one’s health Managing diet and fitness Maintaining one’s health Acquisition of goods and services Shopping Preparing meals Doing housework Washing and drying clothes and garments Cleaning cooking area and utensils Cleaning living area Using household appliances Carrying for household objects Taking care of plants, indoors and outdoors Assisting others Assisting others with self-care Basic interpersonal interactions Complex interpersonal interactions Informal social relationships Family relationships Intimate relationships Sexual relationships Acquiring, keeping and terminating a job Seeking employment Maintaining a job

Yes Yes Yes 57 82 78 71 78 98 98 100 75 92 92 100 55 71 62 60 73 33 67 65 60 56 83 86 48 78 88 88 46 75 82 77 16 86 69 65 73 57 57

48 19

21 23 21 19 33

Yesa No No No No Yes Yesa Yesa No Yes Yesa Yesa No No No No No No No No No Yes Yesa Yes Yesa Yesa Yes Yes Yesa Yesa Yes Yes Yes Yesa Yesa Yes Yesa Yes Yes Yesa Yesa Yesa Yesa Yes Yesa Yes Yesa No Yes Yes Yes Yes Yesa No No No

42

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

Table 4 (Continued ) ICF Code Second level

Third level

d850 d855 d860 d910 d920 d9200 d9201 d9202 d9203 d9204 d9205

Activities and participation Fourth level

Round 3 n = 50

Inclusion in ICF Core Set

ICF Category

% Agreement

for Breast Cancer

Remunerative employment Non-remunerative employment Basic economic transactions Community life Recreation and leisure Play Sports Arts and culture Crafts Hobbies Socialising

25 19 8 14 79 27 78 25 65 43 25

Yes Yesa Yesa Yesa Yes Yesa Yesa Yesa Yesa Yesa Yesa

The table denotes the percentage of experts who considered the respective International Classification of Functioning, Disability and Health (ICF) category as relevant in the third Delphi round, and the correlation with the ICF Comprehensive ICF Core Set for Breast Cancer. ICF categories included in the Comprehensive ICF Core Set for Breast Cancer are printed in bold. a ICF category is represented in the Comprehensive ICF Core Set for Breast Cancer by its corresponding higher-level (second- or third-level) category.

represented in the Comprehensive ICF Core Set for Breast Cancer. However, 19 ICF categories considered by >75% of participants in the third Delphi round are not represented in the Comprehensive ICF Core Set for Breast Cancer [21]. The following discussion will focus on these ICF categories which indicate a lack of content validity from the perspective of physiotherapists. A high consensus among the participants was found concerning the ICF categories b270 Sensory functions related to temperature and other stimuli and b2702 Sensitivity to pressure, which are not represented in the Comprehensive ICF Core Set for Breast Cancer. In fact, in the literature, numbness associated with lymphoedema is described as a relevant complication after breast cancer treatment [40]. However, problems regarding sensory functions are already represented in the Comprehensive ICF Core Set for Breast Cancer by the corresponding ICF category b265 Touch function. Any further inclusion of ICF categories addressing sensory functions may be useful, on the one hand, because physiotherapists prefer specific information which they can use for treatment planning. On the other hand, the current version of the Comprehensive ICF Core Set for Breast Cancer already includes 80 ICF categories, and further extension could compromise its feasibility in clinical practice. The participants addressed almost the complete chapter of neuromusculoskeletal and movement-related functions, covering functions of joints, bones and muscles. However, the ICF categories b715 Stability of joint functions and b7151 Stability of several joints reached 98% agreement among the participants but are not included in the Comprehensive ICF Core Set for Breast Cancer. The loss of joint stability in the shoulder girdle is a meaningful problem after breast cancer due to changes in the humero-scapular rhythm as a consequence of surgery and radiotherapy [41]. This is often the main reason for shoulder pain which is treated by physiotherapists using different techniques [42–44].

Furthermore, >90% of the participants agreed that b735 Muscle tone functions and its corresponding third-level categories b7350 Tone of isolated muscles and muscle groups and b7355 Tone of muscles of trunk are problems commonly treated by physiotherapists. However, they are not included in the Comprehensive ICF Core Set for Breast Cancer. This indication is clearly supported by literature reporting a close relationship between breast cancer and hypertonic muscles and the incidence of shoulder pain following axillary lymph node dissection [43,44]. With regard to the body structures component, six ICF categories are not included in the current version of the Comprehensive ICF Core Set for Breast Cancer. Particularly regarding complications with oxygen supply, the ICF categories s4301 Lungs and s4302 Thoracic cage are relevant from the physiotherapist’s perspective as they apply breathing techniques preventing or following post-acute pulmonary infection [43,44]. This problem was addressed by the body functions b440 Respiration functions and b4402 Depth of respiration, which are not included in the Comprehensive ICF Core Set for Breast Cancer [45]. Problems in s710 Structure of head and neck region are consequences following changed posture and asymmetric body position, and are subjects of physiotherapeutic interventions in women with breast cancer [41]. Furthermore, the ICF categories s7701 Joints, s7702 Muscles and s7703 Extra-articular ligaments, fasciae, extramuscular aponeuroses retinacula septa, bursae, unspecified including bones, muscles and ligaments represent a main treatment area of physiotherapy after breast cancer including surgery and radiotherapy [41]. s7701 Joints addresses structures influenced by muscle imbalance in trunk and upper limbs (e.g. shoulder pain and restricted joint mobility after axillary lymph node dissection) [42,44]. Problems in joints like the shoulder are one of the major problems after breast cancer, followed by resultant problems in activities of daily living.

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

43

Table 5 Environmental factors component. ICF Code Second level

Third level

e110 e1101 e115 e1150 e1151 e1200 e165 e1650 e225 e2250 e310 e315 e320 e325 e330 e340 e355 e360 e410 e415 e420 e425 e430 e440 e450 e465 e540 e555 e570 e5700 e575 e5750 e580 e5800 e5801 e5802 e590

Fourth level

Environmental factors

Round 3 n = 50

Inclusion in ICF Core Set

ICF Category

% Agreement

for Breast Cancer

Products or substances for personal consumption Drugs Products and technology for personal use in daily living General products and technology for personal use in daily living Assistive products and technology for personal use in daily living General products and technology for personal indoor and outdoor mobility and transportation Assets Financial assets Climate Temperature Immediate family Extended family Friends Acquaintances, peers, colleagues, neighbours and community members People in positions of authority Personal care providers and personal assistants Health professionals Other professionals Individual attitudes of immediate family members Individual attitudes of extended family members Individual attitudes of friends Individual attitudes of acquaintances, peers, colleagues, neighbours and community members Individual attitudes of people in positions of authority Individual attitudes of personal care providers and personal assistants Individual attitudes of health professionals Social norms, practices and ideologies Transportation services, systems and polices Associations and organisational services, systems and polices Social security services, systems and polices Social security services General social support services, systems and polices General social support services Health services, systems and policies Health services Health systems Health policies Labour and employment services, systems and polices

25

Yes Yesa Yes Yesa

92

Yesa

31

Yesa

17

6 45 56 27 30 23 19 71 90 23

21 21

Yes Yesa Yes Yesa Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes

27 41 75 86 73 71

Yes Yesa Yes Yesa Yes Yesa Yesa Yesa Yes

The table denotes the percentage of experts who considered the respective International Classification of Functioning, Disability and Health (ICF) category as relevant in the third Delphi round, and the correlation with the ICF Comprehensive ICF Core Set for Breast Cancer. ICF categories included in the Comprehensive ICF Core Set for Breast Cancer are printed in bold. a ICF category is represented in the Comprehensive ICF Core Set for breast cancer by its corresponding higher-level (second- or third-level) category.

Regarding the activities and participation component, only the ICF category d440 Fine hand use was regarded as relevant by the participants but is not included in the Comprehensive ICF Core Set for Breast Cancer. Indeed, after breast cancer, patients show impairments such as swollen hands and fingers as a consequence of reduced lymph nodules or radiotherapy. As a result, this can lead to restrictions in fine hand use and the loss of handgrip strength [42]. This problem is represented in the Comprehensive ICF Core Set for Breast Cancer by three

ICF categories: d445 Hand and arm use, d4451 Pushing and d4452 Reaching. Since a selection of categories is necessary to assure that the Comprehensive ICF Core Set for Breast Cancer remains feasible for clinical practice, further studies are needed to decide whether inclusion of the category d440 Fine hand use is essential for physiotherapists. Furthermore, the Comprehensive ICF Core Set for Breast Cancer does not include any ICF category addressing the maintenance or change of body position and transfer. How-

44

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

Table 6 Responses that were linked to the personal factors component and not classified. Answer Personal factors Lymphoedema management Motivation of the patient Pain management Scar management Self-management strategies Knowledge of disease Lack of knowledge Coping strategies Apprehension regarding effects of further treatment Feelings of shame Not classified Contracture Assessment/exercise Mobility of the tissue Posture Perform an activity over head Abnormal nerve tension Instructing strategies Palliative care Neural sensitivity Problem with unbalance between the breasts Social barrier (e.g. attending beaches)

Round 3 n = 50 % Agreement 100 100 100 100 98 96 96 94 92 62 100 100 100 100 100 99 96 96 92 78 71

The table denotes the percentage of participants who considered the respective answer as relevant in the third round.

ever, the participants highly agreed on two ICF categories covering this issue: d415 Maintaining a body position and d4100 Lying down. Actually, moving the body can be impaired after post-mastectomy reconstruction of the breast using the latissimus dorsi musculocutaneous flap [46]. Consequently, this aspect should be considered in the final version of the Comprehensive ICF Core Set for Breast Cancer. Ten aspects – including lack of knowledge; motivation; and pain, scar and lymphoedema management – were linked to the not-yet-developed personal factors component. Knowledge about disease is a relevant part of treatment by physiotherapists [47]. Various studies and systematic reviews support the positive effects of patient education on selfmanagement [47] and coping with disease [48,49]. These results highlight the relationship between personal factors and a patient-centred approach, which is typical for the work of physiotherapists. Therefore, a classification of personal factors within the ICF would be helpful for physiotherapists. Eleven concepts were not covered by the ICF. These concepts include important items for physiotherapists, such as posture. Several studies have already demonstrated that posture cannot be described precisely using the available ICF categories [50]. Although the ICF category d415 Maintaining a body position covers the static aspects of posture, the dynamic aspects of posture are missing. Thus, it is crucial to consider these results for further development of the ICF.

The Delphi technique proved to be an appropriate method for this study objective. With a total response rate of 85%, the reported attrition rates of approximately 50% could be clearly surpassed [32,51]. However, some limitations regarding the reliability and external validity of this study should be considered. Participants from the six world regions defined by the World Health Organization were recruited, guaranteeing a wide range of expert opinion. However, the African Region and the Eastern Mediterranean Region were underrepresented, with only one to three participants, which may reflect a potential lack of physiotherapists experienced in the treatment of patients with breast cancer in these regions. Therefore, this sample does not represent the whole spectrum of physiotherapists experienced in the treatment of patients with breast cancer worldwide.

Conclusion Although some restrictions of the current version of the Comprehensive ICF Core Set for Breast Cancer were detected in this study, the categories largely represented what the physiotherapists in the study agreed that they take care of in their interventions. Demonstrating that physiotherapy is not limited to body functions, all ICF components need to be considered in assessment and outcome evaluations. As emphasised by Kirchberger et al. [52,53], ICF core sets and profession-specific classification systems, such as the ‘Guide to Physical Therapist Practice’ [18], may complement each other in a very useful manner. The ICF Core Set for Breast Cancer allows a comprehensive and systematic description and documentation of a client’s problems and resources. Such a profile could serve as the basis for the assignment of the core competences within the therapeutic team. The responsibilities for the treatment of a specific problem can be assigned to the team members according to the corresponding ICF categories. Therefore, role overlaps in the therapeutic team as well as treatment gaps can be detected [24,25,54,55]. Compared with the use of profession-specific assessment and documentation systems, the major advantage of the ICF Core Set for Breast Cancer is its common language that can be understood by all health professionals. Although the ICF Core Set for Breast Cancer provides basic standardised documentation, application of the ICF in clinical practice should also follow an individual approach. This means that any problem in functioning that is relevant for an individual patient but which is not part of the Comprehensive ICF Core Set for Breast Cancer can be selected from the ICF itself or from any other available ICF core set. The results of finalised or ongoing studies involving both health professionals and patients will further elucidate the validity of the Comprehensive ICF Core Set for Breast Cancer from the different perspectives. Based on the discussion of these results, a revised version of the ICF Core Set for Breast Cancer could be created. In the revision process,

A. Glaessel et al. / Physiotherapy 97 (2011) 33–46

it should be decided whether the ICF categories identified by the different health professions as not being represented in the current version should be added, or whether these additional profession-specific categories should comprise a profession-specific list of ICF categories that may be applied in addition to the Comprehensive ICF Core Set for Breast Cancer. However, a prerequisite for further expansion of the current Comprehensive ICF Core Set for Breast Cancer is that data on its feasibility are available and will be taken into account. Finally, as the Comprehensive ICF Core Set for Breast Cancer defines ‘what to measure’ but not ‘how to measure’, future studies could focus on the operationalisation of the ICF categories.

Acknowledgements The authors wish to thank Barbara Schurig for her great work in this study, and also all the participants in the Delphi exercise for their valuable contribution and their time spent responding to the demanding questionnaires. Ethical approval: None required. Funding: Institute for Health and Rehabilitation Sciences at the Ludwig-Maximilian-University Munich, Germany. Conﬂict of interest: None declared.

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Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 47–54

Impact of using the ICF framework as an assessment tool for students in paediatric physiotherapy: a preliminary study Jennifer Jelsma, Des Scott ∗ Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa

Abstract Objective To determine if clinical assessment of children with neurological conditions by physiotherapy students was improved through the overt use of the International Classification of Functioning, Disability and Health (ICF). Design and participants A retrospective, pragmatic audit of practice using written patient assessments completed by third-year physiotherapy students. Assessments completed by third-year students in 2008 were compared with assessments completed by third-year students in 2009. The assessment format used in 2008 was very loosely based on the ICF model, while the 2009 assessments made rigorous use of the ICF approach. Setting Two schools for children with special needs to which physiotherapy students from the Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, Division of Physiotherapy, University of Cape Town are sent for clinical exposure. Method A score sheet was drawn up to evaluate specific criteria in each assessment, using a five-point marking scheme. The mark sheet was tested for reliability. All assessments were evaluated independently using the score sheet by two external physiotherapists who were blind to the purpose of the exercise. Results There was a significant difference between the scores obtained on the score sheet for the 2008 group and the 2009 group. The 2009 group obtained a median score of 60, compared with a median score of 50 for the 2008 group (median difference between groups 9.2, 95% confidence interval 4.2 to 14.1). The overall impression mark given to the 2009 group was also higher than that given to the 2008 group, with a median difference between the groups of 5.9 (95% confidence interval 3.2 to 12.7). It would appear that the 2009 students, using the ICF framework for assessing patients, were able to include more function-related information in their assessments, resulting in a more holistic assessment. Conclusion Teaching students to use the ICF framework when assessing paediatric patients encourages clinical reasoning and an improved holistic approach to identifying the patient’s problems in context. This, in turn, enables the student to plan a more appropriate intervention treatment, to the patient’s benefit. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: ICF; Physiotherapy; Education; Clinical assessment

Introduction The training of health professionals is complex as different cognitive and handling skills need to be taught and then applied in a clinical context. This clinical reasoning is one of the most difficult skills that a physiotherapy student has to learn [1], and there are several theories regarding the methods utilised by physiotherapists [2]. In the training of physiotherapy students, various different clinical reasoning strategies are used. These include hypotheticodeductive reasoning [3], which arises from a cognitive science perspective and focuses on the accessibility of stored ∗

Corresponding author. Tel.: +27 21 4066401; fax: +27 21 4066323. E-mail address: [email protected] (D. Scott).

knowledge in the student’s memory; and narrative reasoning, which is used to understand the patient’s experiences of their disability and their needs, as explained by them [3]. In order to meet the needs of a patient, the student needs to know what the needs of the patient are, analyse these needs and the problems that are causing them, choose and apply suitable techniques, and assess whether or not the intervention has been effective [4]. Several models of the clinical process have been developed, but the most common model is a cyclical model in which assessment leads to appropriate treatment which then leads to changes in the condition of the patient [5]. These changes need to be assessed and the cycle begins once more. An example of this ‘rehab cycle’ has been presented by various authors [6,7].

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The problem lies in the amount of information that needs to be gathered. Some of it is not important and some ends up being essential. The inexperienced clinician needs to learn how to gather all relevant data, but not to waste time by gathering information that has no bearing on the planning of the patient’s management [8]. This is particularly difficult in paediatrics in which the health condition, impairments and activity limitations are mediated by the developmental stage that the child is undergoing and the associated alteration in relevant environmental factors [9]. A useful framework to manage the information gained during patient assessment is the International Classification of Functioning, Disability and Health (ICF) [10]. The ICF was published in 2001 by the World Health Organization. The purpose of the ICF is to ‘provide a unified and standard language and framework for the description of health and health-related states’. It defines health in terms of various health-related domains. These domains include areas of physiological function and anatomical structures, as well as actions, tasks and involvement in social situations. The domains are described from bodily, individual and societal perspectives within a given context [10]. The ICF defines health in terms of health domains of well-being (e.g. walking, self-care abilities, communication) and other domains of well-being (e.g. ability to learn, participation in social activities) [10]. The ICF can be used to describe all aspects of a patient’s functioning, disability and health. This information can be used to ensure a holistic approach to managing the patient [4]. The ICF is divided into two main categories: functioning and disability, and contextual factors. Under functioning and disability, there are body functions and structure, which are organised according to body system and include changes in the physiological and anatomical structures. Also in this category are activities and participation, both from an individual and societal perspective. These are interpreted by capacity and performance. The second category of the ICF classification includes environmental and personal factors. These can either facilitate or hinder functioning [10]. As the education of physiotherapists is increasingly based on the biopsychosocial approach to disability and management of health conditions, the ICF model can provide the conceptual linkages between management of disability (activity limitations and participation restrictions) and other basic, cognitive sciences taught in the curriculum as anatomical sciences (impairments), clinical sciences (health conditions), psychology (personal factors) and environmental sciences (socio-economic factors) [4]. Similarly, it can be used in conjunction with the rehab cycle as a clinical reasoning tool to guide students in bridging the gap between cognitive knowledge and interaction in the clinical setting, as the ICF approach is an interaction between the health condition and contextual factors [3], and to plan holistic management [7]. The advantage of teaching students to assess patients using the ICF approach is that it provides the student

with a conceptual framework which guides their questioning of a patient, assists them in organising the information gained from both subjective and objective assessments, and prompts them to integrate the information into the various components of the ICF [4]. In this way, clinical reasoning is enhanced to provide a full and complete picture of the patient in his/her own context [3]. This approach is also useful in generating outcome-based assessments which focus the student’s treatment interventions on improving function [11]. Palisano presented a very useful application of the ICF to the multidisciplinary management and treatment planning of children [12]. The process suggested entails the identification of all problems that the child experiences under the different components of the ICF. The next step is to use the ICF framework to map out the interrelationships and causal chains between these components. On this basis, treatment can be planned and monitored. Similar challenges in educating physiotherapy students are highlighted in an article which investigates the alignment of a South African physiotherapy curriculum and the expectations of the healthcare system [13]. Two main themes emerged: relating physiotherapy theory to practice, and interpersonal relationships around different cultural practices and caring. The author suggests that encouraging students to use the ICF approach might assist in overcoming these challenges as it is a valuable tool in linking theory to practice. The ICF also has 11 ethical provisions which can be divided into three main categories: respect and confidentiality, clinical use of ICF information and social use of ICF information [14]. Under social use, ICF information can be used to ‘develop social policy and political change to enhance and support the participation of individuals’ [14] as is needed to meet the healthcare expectations of post-apartheid South Africa. The ICF encourages users to determine an individual’s interpersonal, organisational and societal spheres of living [14]. With this understanding, people with a disability can be rehabilitated back into their own societal culture. Research setting and description of intervention In the third year of study, physiotherapy students attend clinical practice at sites which include special schools. The third-year students whose assessments were evaluated for this research were at two different primary schools for children with special needs. One school caters specifically for children with cerebral palsy, and the other school is for children with congenital abnormalities, muscular dystrophy and other physical conditions. The students are supervised by the same clinical educator who spends one morning per week with each group of students. The students are required to assess and treat the children assigned to them, and to write up a full assessment including treatment planning and functional goals of intervention. This written assessment is handed in to the clinical educator each week for marking and further input. At the end of each clinical block, the student is awarded a

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clinical mark based on his/her performance on the block and a clinical examination. Prior to 2008, the Division of Physiotherapy at the University of Cape Town subscribed rather loosely to the ICF framework as an underlying philosophical approach to underpin the assessment and intervention planning of paediatric patients. These students were given lectures on the ICF framework and an assignment in their second year in which they were required to apply the ICF analysis of disability and functioning to a paper patient, a case of a child with cerebral palsy. The article by Palisano [12] on application of the ICF to the collaborative model of decision making in children with movement disorders was referenced. The students from this cohort, who were in the paediatric clinics in 2008, were not actively encouraged to use the ICF framework, and objective assessment of function was not strongly linked to participation limitations. The emphasis of the assessments was mainly on impairments, with little or no focus on participation. The child’s input was also minimal and mainly focused on activities of daily living and home environment. A functional problem list was drawn up, with underlying reasons (impairments) being given for each problem. No actual links were made between the functional problems and any other aspect of the assessment, except for impairments. In 2008, lectures were given on the ICF to the new second-year students, but the approach to assessment in the theoretical lectures was structured along the lines of the ICF model. Students were given case studies and asked to identify which aspects of the child described could be classified under each ICF component. They were then required to analyse the causal and association links between the domains. The following year, in 2009, this group of students was required to overtly include the ICF framework as a basis for assessing and decision making in the clinic, and the clinical educator reinforced the use of the model in clinical tutorials. The assessment form (see Appendix B) was restructured to include sections on health condition, body functions and structures, activities, participation limitations, and environmental and personal factors. Once clinical data had been gathered under these components, the students were required to insert each problem into the framework and analyse inter-relationships and causal chains by drawing arrows between related components. At this point, final priority problem setting and goal setting was done. In order to achieve this, the students had to make use of all the information gained about the child’s disability and functioning. The aim of this study was to compare the quality and comprehensiveness of the written assessments submitted before and after introduction of the new assessment format. The expected outcome was that the students using the ICF approach to assessment would have a more holistic picture of the child’s participation limitations, and would be able to plan a more appropriate intervention plan than the students using the previous form of assessment.

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Methods A retrospective, pragmatic audit of practice was instituted. The sample consisted of the written assessments of third-year physiotherapy students produced during their paediatric clinical rotation in 2008 and 2009. In December 2008, the students who had been in the paediatric placements that year were asked to submit their assessments for review (2008 cohort). The assessments of the 2009 student cohort were collected from January to June 2009 during the students’ last week at the clinical placement. Instrumentation A form was developed to score the quality and scope of the students’ assessments and to gather basic information about diagnosis of the children. The information included in the initial rating form reflected the learning outcomes of assessment for the paediatric clinical block, and included grading the quality of the information that the student presented in their assessment (see Appendix A). The emphasis was not on whether the ICF had been applied, but rather on whether the student had approached the assessment holistically and identified the full range of problems that the children experienced. One of the investigators was the clinical educator and was in contact with all the children assessed, and therefore was aware of the problems experienced by them. Once the list of items had been compiled, a five-point marking scheme (1 = no information, 2 = some information, 3 = adequate information but lacks detail, 4 = complete and detailed information, 5 = outstanding) was applied. In addition to scoring individual items, the assessors were required to give an overall impression percentage of the assessment. The 23 assessments used were shuffled to achieve a random order before being evaluated. The researchers filled out three of the forms together to establish the scoring criteria. Subsequently, to ensure the reliability of application of criteria for mark allocation, a further 10 forms were assessed separately and the results were analysed using a two-way random model. Intra-class correlation (ICC) for absolute agreement for single measures was used. The correlation of the component items was also assessed. As two items in the initial criteria (identification of appropriate short- and long-term goals, problem list prioritisation) had low correlation, these were excluded; the overall ICC was 0.93 (95% confidence interval 0.76 to 0.98; P < 0.001). Procedure All patient names, student names, dates of assessments and feedback comments were removed from the assessments and recorded elsewhere. The assessments were then given to two independent assessors, both of whom were physiotherapists with postgraduate degrees who had been involved in the teaching of undergraduate students and who were experts in the field of paediatrics. They were asked to use the score sheet to grade the assessments, and to award an overall impression

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percentage mark. They were blinded to the students’ groups and were not informed of the purpose of the study. The ICF was not mentioned at any stage. Data analysis The data sets were small and non-parametric statistics were used throughout. Descriptive statistics were used to describe the frequencies. Chi-squared test was used to test if the two groups had had equal exposure to the two schools, because each student would only have attended one school. As there was a concern that only the more competent 2008 students might have submitted their assessments, the average clinical marks were compared, which included placements other than the paediatric placement, using the Mann–Whitney U-test. To test for internal validity, the Spearman’s correlation coefficient between the external assessors’ score based on the score sheet and their overall impression was calculated. In addition, Cronbach’s alpha was used to determine how well the set of items included in the questionnaire measured a single unidimensional latent construct, which was hypothesised to be quality of assessment. A high Cronbach’s alpha would allow for addition of the scores on the different items as they measure the same construct. The Mann–Whitney U-test was used to determine if there was a difference in the rank ordering of the total score and the impression mark awarded to each student.

Results Of the 2008 cohort, 12 students (out of a possible 23) responded and submitted a total of 16 assessments. One assessment per student was chosen at random. The other students in that cohort had not kept their assessments from the previous year, limiting the number. As the assessments were gathered after one semester from the 2009 cohort, only 15 students had attended these schools, and 11 assessments were gathered. For administrative reasons, assessments were not available for the remaining four students. There was no difference in the proportion of each cohort (approximately 50%) attending the two different clinical sites during the paediatric placement between 2008 and 2009 (χ2 = 0.381, df = 1, P = 0.537). The conditions which were treated by the students are listed in Table 1. In general, the distribution was similar, although the 2008 group treated more children with quadriplegic cerebral palsy and the 2009 group treated more children with paraplegia. There was no difference in the rank ordering of the clinical block performance of the two groups of students (Table 2). The characteristics of the students in the two years were similar regarding block performance, which takes clinical administration, application to work, communication, patient management and clinical competencies into account. There was a significant difference between the cohorts in the scores obtained on the score sheet (U = 18.50, P = 0.006),

Table 1 Conditions treated. Year

2008

2009

2 3 1 2 3 1 0

2 0 2 1 3 1 2

4 3 3 3 6 2 2

12

11

23

Hemiplegic cerebral palsy Quadriplegic cerebral palsy Diplegic cerebral palsy Spina bifida Muscular dystrophy Triplegic cerebral palsy Paraplegia Total

Both groups

90 80 70

Total %

50

60 50 40

Median 25%-75% Min-Max

30

2008

2009

Year Fig. 1. Overall scores given by the two assessors using the score sheet: median and quartiles of the mean (2008 n = 11, 2009 n = 12).

with a median score of 50.5 for the 2008 students compared with 58 for the 2009 students (median difference between groups 9.2, 95% confidence interval 4.2 to 14.1) (Figs. 1 and 2). Similarly, the difference in the overall impression marks was significant (U = 27.50, P = 0.032), with a median score of 58 for the 2008 students compared with 62.5 for the 2009 students (median difference between groups 5.9, 95% confidence interval 3.2 to 12.7).

Discussion Within the clinical context, the ICF was ‘intended for use in needs assessment, matching interventions to specific health states, rehabilitation and outcome evaluation’ [7]. This audit has demonstrated the utility of the ICF framework, in that physiotherapy students who overtly used the framework Table 2 Comparison of the clinical performance marks of the two student groups, excluding marks obtained on the paediatric block. Cohort

Valid n

Median %

Minimum %

Maximum %

2008 2009

12 11

69 67

61 62

73 79

Rank sum 2008

Rank sum 2009

U

Z

153

123

57

−0.55

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might have biased the results as the students would have had more exposure to clinical work in this group. However, this did not seem to influence the results, as the 2009 cohort who had only completed their first semester performed better. The impact of didactic teaching in the absence of overt use of the ICF in the clinic was minimal. The need to strengthen the links between theory and clinical practice is clear and has been identified by other authors [1]. Clinical reasoning only appears to occur once the student has applied the framework to assessment in a real situation.

90 85

Impression %

80 75 70 65 60 55 50 Median 25%-75% Min-Max

45 40

51

2008

Year

Conclusion

2009

Fig. 2. Impression scores given by the two assessors: median and quartiles of the mean (2008 n = 11, 2009 n = 12).

to gather information, analyse and plan interventions produced assessments of a higher quality than students who only applied the ICF concepts loosely. The second cohort were better able to recognise the relationships that exist between the different components of the ICF and, in particular, the interaction between activity limitations and participation restrictions as a result of the patient’s social situation, as suggested by Homa and Peterson [4]. Encouraging students to link theory to practice by communicating their thought processes while assessing and planning the management of each patient promotes clinical reasoning. Using clinical reasoning to determine how to make these daily activities easier through therapy, how to change the environment to facilitate the child’s performance, and being aware of personal factors which might impede or enhance this performance improved the students’ management of the patients. In addition to achieving higher scores on the score sheet, the 2009 cohort also performed better than the 2008 cohort in terms of overall impression. This implies that use of the ICF did not result simply in the inclusion of more relevant ICF data regarding the child’s participation in age-appropriate activities, but that the assessments were more comprehensive overall and better able to identify the extent of the children’s problems. This study was a pragmatic, retrospective audit of practice, and cannot be regarded as having proved a definitive causal link between the change in approach to clinical assessment and the quality of student assessments. In addition, such a design lends itself to bias in several ways. However, all the sources of bias described below would have favoured the 2008 cohort but, in fact, the 2009 cohort performed better. Not all the 2008 students complied with the request to submit their assessments, which might have resulted in the more conscientious students complying and their assessments may have been of a higher standard. However, as there was no difference in the clinical marks (over several assessments, settings and clinical educators) between the two cohorts, it would appear that the two groups were equivalent in terms of their clinical abilities. In addition, the inclusion of assessments from the second semester of study in the 2008 cohort

The ICF is a useful framework within which students can assess paediatric patients. With rigorous application of this format, students were able to assess the children holistically, identifying the extent of functional problems and activity limitations in the related setting. The ICF framework encouraged the students to form links between activity limitations and participation restrictions, and to analyse the children’s problems against a full contextual background, taking environment and personal factors into account, thus enhancing clinical reasoning. Once this has been achieved, students are better able to plan appropriate and holistic treatment interventions. This will ultimately improve the quality of students’ treatment interventions for children. Based on the results of this audit, the ICF appears to be useful as a framework for clinical assessment and treatment planning. Acknowledgements The contribution of Pam Versfeld and Mariette Burger to the study as external assessors is gratefully acknowledged. Ethical approval: Medical Research Ethics Committee of the University of Cape Town (Ref. No. 294/2009). Conﬂict of interest: None declared. Funding: No funding received. Appendix A. Data collection form Number of assessment Year of assessment Diagnosis of child (demographic data from student assessment) Items scored out of five • Medical history • Subjective assessment: interaction with family and friends • Subjective assessment: living environment • Objective examination: impairments, body structure and body function • Objective examination: functioning • Problem list: addresses all relevant aspects of child’s functioning • Problem list: analysis of problem • Comparable signs to monitor improvement • Treatment plan/intervention: addresses all aspects of child’s functional needs • Holistic approach to intervention Total % Impression % Overall mark for all clinical blocks, excluding this paediatric block

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Appendix B. Physiotherapy assessment form outline for paediatrics 2009

ICF Framework

Health condition (disorder)

Body function & structure

Activities

Environmental factors

1. Demographic details Name: Date of birth: Age: Diagnosis:

Participation

Personal factors

Assessed by: Date of assessment:

From folder: Birth history: Developmental history: Subsequent medical history: Surgical history – date and type Medication – type and what it is for Vital signs – if appropriate X-Ray findings – if appropriate 2. Subjective assessment a. Impairments •

• • • • • • •

Mental function Sight, hearing Speech Feeding Pain, sensory loss Respiratory and/or cardiac function Continence Skin condition

b. Activity limitations • • • •

Learning and applying knowledge, as appropriate for age Communication Self-care: dressing, bathing, brushing teeth, toileting Physical activity/mobility (an indication of highest level of activity and duration or distance)

J. Jelsma, D. Scott / Physiotherapy 97 (2011) 47–54 c. Participation • Domestic life (how does he spend his day?) • School life (what activities does he participate in at school?) • Interpersonal relationships with family, friends, staff, therapists • Community and social life regarding leisure time, sport, participation in family outings d. Environment • Appliances used • Transport to and from school • Accessibility in home (type of house; no. of rooms; no. of people sleeping per room; available amenities such as water, electricity, indoor toilet, space to move around in house with aids and type of outdoor surface areas) • Support of community and family involvement • Services (disability and child support grant) General observation How did child get to physiotherapy department? Is child in a buggy or wheelchair or walking, with or without appliances? Observe child undressing and comment 3. Objective assessment a. Activity • •

• •

Observe and describe posture in the highest functional level the child is capable of achieving Observe and describe all the functional activities the child is able to achieve in his highest functional level. Analyse what the child is doing and what function is difficult or can only be achieved with facilitation. Be aware of which functions are missing for his age Assess balance, if appropriate, in highest functional level, both static and dynamic Describe transitioning in and out of highest functional level

b. Impairments • • • • •

Respiratory Muscle tone Sensory loss Range of movement Muscle strength

4. Identification and analysis of problems Review ICF framework above before analysing problems. Draw and fill in diagram, making the appropriate connections with arrows 5. Problem list Document functional problems Prioritise the most important problems and analyse completely, using the following table Functional problems Usually activity or participation restrictions

Missing components Usually activity linked

Underlying Intervention reasons Usually Treatment plan impairment, could be environmental and/or personal

Indicator Objective measure

6. Short-term aims Must be functional aim (likely to be achieved in the next few treatment sessions. Give target times) 7. Long-term aim Think of one function you would like to improve in 6 months time 8. Soap notes

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References [1] Shoemaker MJ, Riemersma L, Perkins R. Use of high fidelity human simulation to teach physical therapist decision-making skills for the intensive care setting. Cardiopulm Phys Ther J 2009;20:13–8. [2] Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy 2002;88:258–68. [3] Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Med Educ 2004;84:312– 29. [4] Homa D, Peterson D. Using the international classification of functioning, disability and health (ICF) in teaching rehabilitation client assessment. Rehabil Educ 2005;19:119–28. [5] Smith M, Higgs J, Ellis E. Characteristics and processes of physiotherapy clinical decision making: a study of acute care cardiorespiratory physiotherapy. Physiother Res Int 2008;13:209–22. [6] Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther 2002;82: 1098–107.

[7] Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disabil Rehabil 2002;24:932–8. [8] Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology. Boston: Little, Brown and Company; 1985. [9] Peterson D, Kosciulek J. Introduction to the special issue of Rehabilitation Education: the international classification of functioning, disability and health (ICF). Rehabil Educ 2005;19:75–80. [10] World Health Organization. International classification of functioning, disability and health. Geneva: WHO; 2001. [11] Peterson B, Rosenthal DA. The international classification of functioning, disability and health (ICF): a primer for rehabilitation educators. Rehabil Educ 2005;19:81–94. [12] Palisano RJ. A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making. Phys Ther 2006;86:1295–305. [13] Ramklass S. An investigation into the alignment of a South African physiotherapy curriculum and the expectations of the healthcare system. Physiotherapy 2009;95:215–22. [14] Peterson D, Threats T. Ethical and clinical implications of the international classification of functioning, disability and health (ICF) in rehabilitation education. Rehabil Educ 2005;19:129–37.

Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 55–58

Discussion

Introducing the ICF: the development of an online resource to support learning, teaching and curriculum design Lester E. Jones ∗ School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Bundoora, Vic. 3086, Australia

Abstract The International Classification of Functioning, Disability and Health (ICF) was adopted as one of the key models to support early health professional learning across a suite of new preregistration health science courses. It was decided that an online resource should be developed to enable students, course designers and teaching staff, across all disciplines, to have access to the same definitions, government policies and other supporting information on disability. As part of the comprehensive curriculum review, enquiry-based learning was adopted as the educational approach. Enquiry-based learning promotes deeper learning by encouraging students to engage in authentic challenges. As such, it was important that the online resource was not merely a site for accessing content, but enabled students to make decisions about where else to explore for credible information about the ICF. The selection of a host location that all students and staff could access meant that the resource could not be located in the existing online learning management system. Construction using software being trialled by the library at La Trobe University allowed for the required access, as well as alignment with an enquiry-based learning approach. Consultation for the content of the online resource included formal and informal working groups on curriculum review. The published version included resources from the World Health Organization, examples of research completed within different disciplines, a test of knowledge and a preformatted search page. The format of the online resource allows for updating of information, and feedback on the utilisation of the software has been used to enhance the student experience. The key issues for the development of this online resource were accessibility for students and staff, alignment with the adopted educational approach, consultation with all disciplines, and ease of modification of information and format once published. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Classification; Interprofessional; Education; Disability

Introduction The International Classification of Functioning, Disability and Health (ICF) provides a framework that can be used by a broad range of health professionals [1]. In educational settings, where interprofessional education is seen as a way of promoting successful interprofessional working [2] and better health outcomes for patients, the ICF can be used to promote a shared understanding of the influences on functioning and disability. The establishment of a suite of new health professional courses, with a common first year, provided discussion and much debate about how to promote and optimise interprofessional learning. Understanding disability and a ∗

Tel.: +61 3 94795867; fax: +61 3 94795768. E-mail address: [email protected]

multidimensional view of health and functioning were seen as important topics, and the ICF was chosen as one model that aligned well with the different disciplines and therefore would promote interprofessional communication in learning activities. To ensure efficiency and consistency in the presentation of common concepts and themes across a number of disciplines and campuses, it was decided that the ICF should be the basis of an online resource that could be used by students, course designers and teaching staff from all disciplines.

Developing the online resource Accessibility for students and staff A number of host sites were considered for the ICF online resource. The online learning management system (LMS)

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L.E. Jones / Physiotherapy 97 (2011) 55–58

provided a faculty-specific location and would allow the resource to be embedded in an online learning environment, where other resources, such as lecture notes and online tests, could be easily linked and integrated. However, the LMS had limitations. The main issue was that students were only allowed access to subjects in which they were enrolled, and once they had completed the subject, they no longer had access. This would have been suitable if the only intention was for the resource to be used in the learning and teaching of a particular subject, and indeed this would have been fine for the year 1 subject where the ICF was introduced. However, the intention was that all students could also access the resource to support learning, including for non-directed learning activities; i.e. activities where, through the student’s own enquiry, the ICF and supporting resources became important. This reflected the educational approach, enquiry-based learning [3], adopted during a comprehensive curriculum review. The premise of enquiry-based learning is that students, through their response to authentic challenges, learn to explore, discover and critique a range of resources. Therefore, it was important that the online resource was available to all students, not just students who were directed to the resource through the structure of a particular subject. At the time of searching for a host location, the library at La Trobe University was trialling a software product for the purpose of creating a range of information guides. These guides could then be made available via a uniform resource locator (URL) address. The format provided by the software allowed for construction of a number of linked web pages, with a selection of page formats for text, pictures and links to other URL addresses. It was decided that this format was aligned with the access requirements, and was also appropriate for the structure and content of the resource. Structure and content Consultation about structure and content initially took place in the Curriculum Review Working Group (CRWG), an interdisciplinary forum for aligning curriculum development activity across the participating disciplines. CRWG members then alerted staff in their disciplines about developments, and so further comment was gained from a broader range of staff via email. A key challenge was to create a resource that could be used as an introduction to the ICF but also be suitable for students who were exploring the ICF, or functioning and disability, at a more sophisticated level. The resource had to meet the needs of the tasks that were set within the introductory subject, but also allow for students to explore around and beyond the content provided. In addition, the enquirybased learning approach emphasises student-driven enquiry, and therefore a resource that stimulates further enquiry is more aligned to this approach compared with a site with comprehensive information. The format allowed for six pages, and each page could be accessed on any of the other pages via a clearly labelled tab [4]. Table 1 indicates the page headings and a summary

Table 1 Page headings and content for online resource. Page headings

Summary of content

The model

• Introduction to online resource • Commonly used diagrammatic representation of the ICF demonstrating the interaction between ‘Health condition’, ‘Body structure and function’, ‘Activity’, ‘Participation’ and ‘Contextual factors’

Introduction

• Notes and definitions on the ICF • What is WHO? • What is UN?

WHO resources

• Links to a range of ICF resources from WHO website including: ◦ A beginner’s guide to the ICF ◦ Application and tools ◦ ICF checklist

Other resources

• Links to recent discipline-specific research • Links to a range of non-WHO resources on disability and the ICF including: ◦ Australian users’ guide ◦ Human Rights and Equal Opportunity Commission ◦ PRSP website – disability ◦ Victorian Disability Act ◦ What is disability? (Australian Government)

Check your knowledge

• Link to LMS quizzes and external quiz on attitudes to people with disability • Two preformatted search queries including CINAHL, PsychInfo, Medline and Google Scholar

Keeping up to date

ICF, International Classification of Functioning, Disability and Health; WHO, World Health Organization; UN, United Nations; LMS, Learning Management System; PRSP, Poverty Reduction Strategy Paper.

of the content for each page. The first page, ‘The model’, allowed those first accessing the resource a visual representation of the components of the ICF. The other pages provided introductory information such as definitions, and allowed for further exploration of existing external resources via URL links. One page contained quiz information in order for students to review their current knowledge about disability, and another page had preformatted search pages to encourage students to check for up-to-date resources. While the information provided in the resource was not comprehensive, there were direct links to some informative documents. ‘Towards a common language of functioning, disability and health’ [5] – also known as ‘A beginner’s guide to the ICF’ – is a 22-page document that presents the background of the classification, defines terms and presents the four underlying principles of the ICF: universality, parity, neutrality and environmental factors. The ‘ICF Australian users’ guide version 1.0’ [6] also provides a valuable introduction to the ICF, but importantly reflects a local context for Australian clinicians and students. It includes national examples of using health information, development of tools to assist assessment, and some context-specific and conditionspecific information.

L.E. Jones / Physiotherapy 97 (2011) 55–58

Total hits on WHO ICF Resource

2500 2000 1500 2009 1000

2010

500 0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Fig. 1. Comparison of frequency of hits on World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) resource for January 2009 to September 2010.

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would also suggest that staff are not incorporating it into their curriculum design. Another interpretation is that the resource serves its purpose for introduction to the ICF, and students then use other access points to information. These interpretations will only be verified by a comprehensive evaluation, which is yet to be implemented. In the future, this resource will need to accommodate a new online learning tool currently being developed by the World Health Organization. The current opinion is that this new learning tool will not replace the resource, as it is important to maintain a context that reflects the participating disciplines, and have a resource that makes reference to local strategies and policies. Conclusion

Access for staff and students The resource was published as part of La Trobe University Library’s collection of information guides. Additionally, students enrolled in the subject with directed activities that made reference to the ICF were able to access the web pages via a link embedded in the LMS site for that subject. The same students were made aware of the resource through lecture material that included screen grabs of the resource. An assessment task required the students to incorporate the ICF into their submission; in this case, a series of web pages about a health condition. Staff that were involved in curriculum development were made aware of the resource via the CRWG, and this included the recommendation to consider the resource for supporting and designing learning activities subsequent to the common first year.

Modiﬁcations and additions Since publication, a number of modifications and additions have been made to the resource. As would be expected, some URL addresses have changed or become non-functioning, and new resources have been created. This requires a flexible format that allows for easy modification of the resource. In addition, the collection of generic statistics about the usability of the format led to the adoption of a new URL address incorporating the terms ‘WHO’ and ‘ICF’. These statistics also indicated that students had not been using some of the links that were supplied in the page header ‘tabs’, so these will be relocated in the near future. Disappointingly, there has been no change in the profile of activity on the site across the 2 years that this resource has been available (Fig. 1). The timing of the high rate of access of the resource is associated with the assessment requirements of the introductory subject in the first semester of the common first year (February to June). This may suggest that students are not visiting the resource after the introduction, which

This paper describes the development of an online resource to support early health professional education about functioning, disability and health. The ICF reflects the multidimensions of functioning, disability and health in a model that has relevance across a range of health disciplines, and has the potential to provide a common language in interprofessional education. A number of key issues were identified during development. First, the resource should not be limited to those enrolled in a particular subject at a particular time. Second, the resource had to align with the enquiry-based learning approach, and therefore provide scaffolding for students to find their own way to significant resources and information, but not provide that information. Third, in order for the resource to have relevance across the Faculty of Health Sciences, a process of consultation involving all disciplines was essential in development, and also to ensure it is relevant for future use. Finally, in response to user activity statistics, and also because information changes over time, the resource needs to be updated regularly and have the functionality to do this easily. Ultimately, student and staff evaluation is necessary to verify the best way forward. Ethical approval: Faculty of Health Sciences Human Ethics Committee, La Trobe University, Australia (submitted and approved by Chair as negligible risk not requiring review). Conﬂict of interest: None declared.

References [1] World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2010. Available at: http://www.who.int/classifications/icf/en/ (last accessed 23.05.10). [2] Barr H. Interprofessional education – today, yesterday and tomorrow. London: Higher Education Academy; 2005. Available at: http://www.health.heacademy.ac.uk/publications/occasionalpaper/occp1revised.pdf (last accessed 23.05.10).

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[3] University of Manchester. What is enquiry-based learning? Manchester: University of Manchester; 2006. Available at: http://www.campus. manchester.ac.uk/ceebl/resources/guides/studentguide july06.pdf (last accessed 23.05.10). [4] La Trobe University Library. LibGuides WHO ICF. Melbourne: La Trobe University; 2010. Available at: http://latrobe.libguides.com/who icf (last accessed 23.05.10). [5] World Health Organization. Towards a common language for functioning, disability and health. Geneva: World Health Organiza-

tion; 2002. Available at: http://www.who.int/classifications/icf/training/ icfbeginnersguide.pdf (last accessed 23.05.10). [6] Australian Institute of Health and Welfare. ICF applications – examples, ICF Australian user guide version 1.0. Canberra Australian Institute of Health and Welfare; 2003. Available at: http://www.aihw.gov.au/publications/dis/icfaugv1/icfugv1-c06.pdf (last accessed 24.05.10).

Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 59–64

Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study Kate Trainor a,b,∗ , Mark A. Pinnington a b

a Directorate of Physiotherapy, School of Health Sciences, University of Liverpool, Liverpool, UK Aintree University Hospitals NHS Foundation Trust, Physiotherapy Department, University Hospital Aintree, Liverpool, UK

Abstract Objectives It has been proposed that neurodynamic examination can assist differential diagnosis of upper/mid lumbar nerve root compression; however, the diagnostic validity of many of these tests has yet to be established. This pilot study aimed to establish the diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression in subjects with suspected lumbosacral radicular pain. Design Two independent examiners performed the slump knee bend test on subjects with radicular leg pain. Inter-tester reliability was calculated using the kappa coefficient. Slump knee bend test results were compared with magnetic resonance imaging findings, and diagnostic accuracy measures were calculated including sensitivity, specificity, predictive values and likelihood ratios. Setting Orthopaedic spinal clinic, secondary care. Participants Sixteen patients with radicular leg pain. Results All four subjects with mid lumbar nerve root compression on magnetic resonance imaging were correctly identified with the slump knee bend test; however, it was falsely positive in two individuals without the condition. Inter-tester reliability for the slump knee bend test using the kappa coefficient was 0.71 (95% confidence interval 0.33 to 1.0). Diagnostic validity calculations for the slump knee bend test (95% confidence intervals) were: sensitivity, 100% (40 to 100%); specificity, 83% (52 to 98%); positive predictive value, 67% (22 to 96%); negative predictive value, 100% (69 to 100%); positive likelihood ratio, 6.0 (1.58 to 19.4); and negative likelihood ratio, 0 (0 to 0.6). Conclusions Results indicate good inter-tester reliability and suggest that the slump knee bend test has potential to be a useful clinical test for identifying patients with mid lumbar nerve root compression. Further investigation is needed on larger numbers of patients to confirm these findings. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. MeSH terms: Nerve compression syndromes; Radiculopathy; Physical examination Keywords: Slump knee bend; Diagnostic accuracy; Neurodynamics

Introduction Accurate clinical diagnosis of upper/mid lumbar nerve root compression (L2 to L4) is highly desirable to ensure that appropriate surgical candidates are identified and referred on for diagnostic imaging. The slump knee bend neurodynamic test is not pathognomonic but is suggested to be useful in the diagnosis of lumbar radicular pain among other pathologies [1,2]. The diagnostic validity of this test for specific levels ∗ Correspondence: Directorate of Physiotherapy, School of Health Sciences, Thompson Yates Building, University of Liverpool, Brownlow Hill, Liverpool L69 3GB, UK. Tel.: +44 0151 794 5742; fax: +44 0151 794 5740. E-mail address: [email protected] (K. Trainor).

of spinal nerve/nerve root compression remains unclear, and this has implications for all clinicians who use it to assist with differential diagnosis. The slump knee bend test [1] or femoral slump test [2] is an extension of the standard prone knee bend test [1] or femoral nerve stretch test [3]. The prone knee bend test has been shown to place a load on the upper/mid lumbar nerve roots (L2 to L4) via movement of the femoral nerve during knee flexion [3]. The slump knee bend test differs from the prone knee bend test in that it is performed in side lying, and combines knee flexion and hip extension with thoracic and cervical flexion to further load the nervous system [1]. Cervical extension is used when symptoms are reproduced to ‘unload’ the nervous system and assist with structural dif-

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.05.004

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ferentiation [1]. The addition of a spinal flexion component to the slump knee bend test gives it suggested superiority over the standard prone knee bend test in differentiation between symptoms arising from neural and non-neural tissues [1]. The prone knee bend and slump knee bend tests are thought to be particularly useful to evoke symptoms in middle and upper lumbar radiculopathy, but it is also suggested that they may have a role in the assessment of sensitive lower lumbar radiculopathy [1]. Both tests are also advocated to assist in the differential diagnosis of other disorders including femoral-nerve-related pathologies [2]. An electronic search was performed of AMED (1985 to 2008), CINAHL (1982 to 2008), EMBASE (1980 to 2008), Medline (1980 to 2008) and PEDro (1980 to 2008). The search terms used were deliberately kept broad to allow for the lack of literature relating to neurodynamic testing, and were as follows: prone knee bend, crossed prone knee bend, femoral nerve stretch test, slump knee bend, straight leg raise, neurodynamics, adverse neural tension, thoracolumbar radiculopathy, lumbar radiculopathy and lumbar nerve root compression. The search was further refined by adding additional terms including ‘and Physiotherapy’, ‘and Physi*therapy’, ‘and validity’, ‘and reliability’ and ‘and diagnosis’. The prone knee bend test [4–8] and crossed prone knee bend test [9,10] have been investigated in relation to their ability to diagnose upper/mid lumbar disc herniation, low thoracic disc herniation and upper/mid lumbar radiculopathy (L2 to L4 spinal levels), but these papers are descriptive and do not report calculations of diagnostic accuracy. To the authors’ knowledge, no published studies have investigated the diagnostic validity of the slump knee bend test. This paper reports the diagnostic validity of the slump knee bend test for the diagnosis of L4 nerve root compression in conjunction with other levels of nerve root compromise in patients with radicular pain. Magnetic resonance imaging (MRI) was used as the gold standard for diagnosis [11–14]. The inter-tester reliability of the slump knee bend test is also reported.

Methods Convenience sampling was used to recruit 16 patients from an orthopaedic spinal clinic in an acute National Health Service trust over a 6-month period. Participants were included if they had symptoms synonymous with lumbosacral radicular pain, defined as having the following features: • intermittent or constant pain radiating into one or both legs distal to the groin or gluteal crease; or • distribution of pain in all or part of the dermatomal area of one or two adjacent lumbosacral nerve roots (L1 to S2 levels). Participants were only recruited if they were awaiting MRI of the lumbar spine or returning to the spinal clinic following

MRI of this region. Exclusion criteria included pain in the cervical or thoracic region likely to be exacerbated by spinal slump, a history of central nervous system pathology, systemic illness or symptoms indicating possible serious spinal pathology or ‘red flags’ [15]. The neurodynamic test performed in the study is presumed to load the nervous system; for this reason, the presence of any of these characteristics may have subjected the study participants to an unacceptable level of risk. Patients with recent quadriceps injury (in the last 6 months) and participants unable to lie in the test position were also excluded. Finally, participants were excluded if the anticipated wait for MRI was more than 6 weeks or if their previous MRI was obtained more than 6 weeks previously. Informed consent was obtained from suitable participants who were then screened for the presence of serious spinal pathology or ‘red flags’ [15]. Any participants found to have signs of widespread neurology or other red flags were highlighted to the medical team and withdrawn from the study. The slump knee bend test was performed once on each participant by two investigators, both experienced physiotherapists who had been working in the field of musculoskeletal physiotherapy for over 10 years. The first author was named as the principal investigator. Tests were performed with random examiner order. Repeated movement of a joint to the end of its range during serial measurement may itself change the range of movement available at that joint; for this reason, each neurodynamic test was only carried out once by each investigator. Any interval between repeated testing was kept deliberately small (a few minutes), and individual investigators were blinded to each other’s findings. Investigators were also blinded to any previous MRI scan results to avoid any conscious or subconscious ascertainment bias. The slump knee bend test protocol was adapted from a previously described protocol [1] and is shown in Figs. 1 and 2. The slump knee bend test was performed in an attempt to reproduce symptoms or to identify any changes occurring in existing symptoms. Unnecessary pain provocation was avoided by using sensitising manoeuvres to reduce rather than increase symptoms [2]. Each test was determined to be either normal (negative) or abnormal (positive) for each subject. No adequate criteria were found in the literature to describe normal or abnormal participant responses to the slump knee bend test using the specific end-test measures chosen in this study, so criteria were established by the authors. These criteria are shown in Boxes 1 and 2 and were based on the suggestions of experts in the field of neurodynamics [1,2]. The point of evoked symptoms, submaximal pain or the onset of firm resistance (R1) were used as endtest measures. The reliability of these end-test measures has not been investigated previously for the slump knee bend test. Following neurodynamic testing, participants underwent MRI if this had not been performed previously. All MRI scans were evaluated routinely by hospital radiologists, and these

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Box 1: Classiﬁcation of a normal response (negative result) to the slump knee bend neurodynamic test. • Symptoms of stretching or discomfort on the side being tested. • These symptoms may be felt in the anterior thigh area. • These normal symptoms may either decrease in intensity or remain the same when cervical extension is performed. • Range of movement and normal symptom response is the same on both sides.

Box 2: Classiﬁcation of an abnormal response (positive result) to the slump knee bend neurodynamic test.

Fig. 1. Protocol for the slump knee bend neurodynamic test. Adapted from: [1].

Fig. 2. The slump knee bend neurodynamic test. Reproduced with permission from Claire Molyneux, Senior Physiotherapist, Aintree University Hospitals NHS Foundation Trust.

• All or part of the subject’s reported symptoms are reproduced or increased during the test procedure (when testing on either or both sides). The symptoms should be the same usually experienced by the subject (e.g. pain, paraesthesia previously reported). The provoked symptoms should diminish when the subject’s cervical spine is extended. OR • Associated symptoms (but not the subject’s reported symptoms) are reproduced during the test procedure. If the associated symptoms are not in a normal distribution and symptoms diminish when the subject’s cervical spine is extended, this can be considered a positive test. If the associated symptoms are in a normal distribution, there must be evidence of asymmetry between sides, and the symptoms should diminish when extending the subject’s cervical spine. OR • The onset of firm resistance is perceived to occur earlier in range during the testing procedure when one side is tested compared with the other. This may or may not be accompanied by symptom reproduction or associated symptom production. There should be a decrease in perceived resistance at the hip when extending the subject’s cervical spine.

written reports were reviewed to establish: • the presence of any spinal nerve/nerve root compression and the level(s) it occurred in the lumbosacral spine; and • the type of pathology present causing the spinal nerve/nerve root compromise. The radiologists evaluating the scans were not aware that a research project was taking place. MRI was chosen as the gold standard for diagnosis and is routinely ordered in the spinal clinic where this study was undertaken if nerve root compres-

sion is suspected. It is a reliable and valid tool for diagnosing lumbosacral nerve root compression and intervertebral disc injury [11,12], and determination of nerve root compromise by MRI appears to be well correlated with surgical findings [13]. The sensitivity, specificity, accuracy, and positive and negative predictive values for standard MRI and nerve root compression have been shown to be 81%, 100%, 82%, 100% and 25%, respectively, when following the protocol used in this study [14].

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Data analysis Inter-tester reliability for the slump knee bend neurodynamic test was calculated using the kappa coefficient [16–18]. Strength of agreement was ascertained using standards proposed by Brennan and Silman [19]. The diagnostic validity of the slump knee bend test was established for upper/mid lumbar nerve root compression (L2 to L4) by calculating sensitivity, specificity, and positive and negative predictive values. Positive and negative likelihood ratios were also calculated, defined as how many times more (or less) likely patients with the disease are to have a particular result than patients who do not have the disease [20]. All diagnostic accuracy measurements were calculated using data collected by the principal investigator, and 95% confidence intervals were calculated for each value to establish the precision of the estimates [21,22].

Results The study sample was taken from an area of the North West of the UK. Of the 16 patients approached, all agreed to participate. Nine females (56%) and seven males (44%) were recruited, aged between 35 and 72 years with a mean age of 49 years (standard deviation 12.6). Symptom duration was reported as subacute (between 3 weeks and 3 months) for 11 participants (69%) and chronic (more than 3 months) for the remaining five participants (31%). Reliability testing For the slump knee bend test, kappa was 0.71 (95% confidence interval 0.33 to 1.0). This indicates that the strength of agreement using the kappa coefficient was ‘good’ for this test (between 0.61 and 0.8) using guidelines suggested by Brennan and Silman [19]. MRI results MRI findings can be found in Table 1. Four of the 16 participants had mid lumbar nerve compression on MRI, with only two of these participants showing L4 compression in isolation. Diagnostic validity of the slump knee bend test for upper/mid lumbar nerve root compression Neurodynamic test findings were reported as either positive or negative, and all positive tests reproduced symptoms or associated symptoms in test participants (Boxes 1 and 2). These findings were compared with MRI findings as the gold standard, and the results are shown in Table 2. The slump knee bend test correctly confirmed or negated the presence of mid lumbar nerve root compression in 14 of the 16 participants (88%). Diagnostic validity calculations for the slump

knee bend test (95% confidence intervals) were: sensitivity, 100% (40 to 100%); specificity, 83% (52 to 98%); positive predictive value, 67% (22 to 96%); negative predictive value, 100% (69 to 100%); positive likelihood ratio, 6.0 (1.58 to 19.4); and negative likelihood ratio, 0 (0 to 0.6).

Discussion Inter-tester reliability was found to be ‘good’ for the slump knee bend test using the kappa coefficient. This suggests that clinicians can reliably agree on the findings of this test using the operational definitions described. All subjects with mid lumbar nerve root compression confirmed on MRI had a positive slump knee bend test, and over 80% of participants without the disorder had a negative test. The slump knee bend test had some clinical value in predicting the disorder, and was found to be excellent at negating the disorder. The rate of MRI-confirmed cases being correctly diagnosed with a positive slump knee bend test was found to be six times greater than that of negative MRI cases being incorrectly diagnosed with a positive slump knee bend test. The lower confidence interval of the positive likelihood ratio for the slump knee bend test is greater than 1 (1.6), so it can therefore be suggested with 95% confidence that a patient classified with a positive slump knee bend test is more likely to have mid lumbar nerve root compression than to be falsely positive for the disorder. The authors were unable to find any published literature investigating the diagnostic validity of the slump knee bend test in relation to any pathology; for this reason, no direct comparison can be made with other work in this particular area. The only work previously undertaken in this area has been in relation to the standard [4–8] and crossed [9,10] versions of the prone knee bend/femoral nerve stretch tests. Only one paper was found that reported the diagnostic validity of these tests for L2 to L4 nerve root compression rather than disc pathology [10]. This paper cannot be used for comparison with the present research as it only details two case studies, and the data presented were insufficient for the calculation of sensitivity, specificity or predictive values for diagnostic accuracy. Bias can potentially limit diagnostic validity studies, so attempts were made to eliminate this where possible. Interpretation biases, which can occur when the results of the test under investigation are known when the diagnosis is made using the gold standard (diagnostic review bias) or vice versa (test review bias) [23], were eliminated by the blinding of investigators. Observer variability bias [23], which can have an adverse effect on external validity if not adequately controlled, was controlled for using a highly experienced tester using standardised protocols for all neurodynamic testing. Similarly, potential bias arising from the order in which the tests were performed was controlled for by the random testing procedure. As the participants in this study were patients referred to a spinal clinic due to the suspicion of lumbosacral

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Table 1 Magnetic resonance imaging results indicating level and cause of spinal nerve/nerve root compression. Subject

Levels of SN/NR compression evident with MRI

Significant pathology present causing spinal SN/NR compression

1 2 3 4 5 6 7

No SN/NR compression No SN/NR compression Compression of the left L4 and L5 nerve roots Compression of the left L5 nerve root Compression of the left L5 nerve root Compression of the right L5 nerve root L4 nerve root compression

8 9

No SN/NR compression Compression of the right S1 nerve root

10 11 12 13 14

No SN/NR compression No SN/NR compression Compression of the left S1 nerve root No SN/NR compression Compression of the left L4 and L5 nerve roots

15 16

Compression of the L4 nerve root Compression of the S1 nerve root

N/A N/A Disc herniation Degenerative disc disease with herniation Disc herniation Disc herniation L3/L4 disc bulge, L4/L5 right lateral recess stenosis and narrowing of the left neuroforamina N/A Narrowing of the L4/L5 and L5/S1 discs, and small disc prolapse at L5/S1 N/A N/A Disc herniation N/A L3/L4 disc dehydration. Posterior and lateral disc bulging together with facet joint hypertrophy causing a degree of anteroposterior and transverse canal stenosis and narrowing of the lateral recess exit foramina. Minor disc bulge at L4/L5 impinging on the left exit foramina Disc degeneration and bulging Disc herniation

SN/NR, spinal nerve/nerve root; MRI, magnetic resonance imaging; N/A, not applicable.

nerve root compression, an element of patient cohort bias may have been present (in particular, population bias). The authors acknowledge that this homogenous sample may affect the external validity of the findings to the general population, but suggest that the findings remain valid for individuals who would be likely to undergo these tests in clinical practice (i.e. patients with suspected radicular pain). Clinicians should be aware that predictive values are dependent on the prevalence of disease in a study population, whereas sensitivity and specificity findings are not. Increasing prevalence of disease makes it more likely that a person with a positive test result has the disease, and less likely that a positive result is a false positive. It should therefore be emphasised that clinicians may not be able to apply these predictive test values directly to their own patient populations unless disease prevalence is similar. Other limitations to the study are in relation to the operational definitions and protocol for the slump knee bend test. The use of R1 as an end-test measure is contentious in the neurodynamic literature, both in relation to its reliability and its

validity [24]. All positive slump knee bend tests in this study reproduced symptoms or associated symptoms; for this reason, the use of R1 would not have affected the internal validity of the study findings. The use of M1, the onset of reflex muscle activity, may be a more valid end-test measure for future neurodynamic research. However, it remains unclear whether clinicians can ascertain M1 reliably during clinical testing. Longer time intervals between repeated tests on individuals would have allowed any symptoms and potential biomechanical effects on tissues to settle, as this could have affected the validity of the results. Both intra- and inter-tester reliability could also have been established for the individual test measures used within the protocols. The wide confidence intervals presented for the slump knee bend test mean that further data are needed from a larger sample in order to clarify the usefulness of the test for this disorder. In particular, more patients with upper lumbar nerve root compression (L2 to L3) would have strengthened the conclusions, as this study has only shown the slump knee bend test to be valid for L4 spinal nerve/nerve root compres-

Table 2 Accuracy of the slump knee bend test for the diagnosis of L2 to L4 spinal nerve/nerve root compression using data collected by the principal investigator.

Slump knee bend positive Slump knee bend negative Total number of subjects

L2 to L4 SN/NR compression confirmed with MRI

L2 to L4 SN/NR compression negated with MRI

Total number of subjects

4 True positives 0 False negatives 4

2 False positives 10 True negatives 12

6 10 16

SN/NR, spinal nerve/nerve root; MRI, magnetic resonance imaging.

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sion. The practicalities of MRI waiting times in the National Health Service trust for non-urgent imaging resulted in a time delay between neurodynamic testing and scanning. Times between testing and MRI would ideally have been shorter to strengthen the study’s internal validity.

Conclusion The results of this study suggest that the slump knee bend test has value in predicting the presence or absence of L4 lumbar nerve root compression, and as such, may be useful to assist with the differential diagnosis of leg pain suspected to be due to this condition. It should be highlighted, however, that the individuals correctly identified with this level of nerve root compromise also had concurrent lower lumbar nerve root pathology. It therefore remains unclear whether the slump knee bend test can identify L4 nerve root pathology reliably in the absence of other levels of nerve root pathology. It also remains unclear whether the test can identify L2 and L3 levels of nerve root compression, as these levels were not found to be affected in the study participants. A larger study would help to confirm the diagnostic usefulness of the slump knee bend test more definitively. Further research should also investigate the diagnostic value of clusters of tests for upper/mid lumbar nerve root compression, including the slump knee bend test, as this is how it is likely to be used clinically.

Acknowledgements The authors would like to thank the Orthopaedic Department at Aintree University Hospitals NHS Foundation Trust for allowing the collection of data, and Margaret Beswick, Extended Scope Physiotherapy Practitioner for her assistance with data collection. Thanks are extended to Dr Hilary Chatterton at Manchester Metropolitan University for her advice and support during this project. Permission was obtained from Claire Molyneux, Senior Physiotherapist, Aintree University Hospitals NHS Foundation Trust for the use of her image in Fig. 2. Ethical approval: Manchester Metropolitan University Ethics Committee and Sefton Local Research Ethics Committee (Ref. No. 04/Q1501/20). Conﬂict of interest: None declared.

References

[2] Shacklock MS. Clinical neurodynamics: a new system of musculoskeletal treatment. London: Butterworth Heinemann; 2005. [3] Kobayashi S, Suzuki Y, Asai T, Yoshizawa H. Changes in nerve root motion and intraradicular blood flow during intraoperative femoral nerve stretch test. Report of four cases. J Neurosurg 2003;99(Suppl):298–305. [4] Epstein NE. Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures. Spinal Cord 2002;40:491–500. [5] Christodoulides AN. Ipsilateral sciatica on femoral nerve stretch test is pathognomonic of an L4/5 disc protrusion. J Bone Joint Surg Br 1989;71:88–9. [6] Porchet F, Fankhauser H, de Tribolet N. Extreme lateral lumbar disc herniation: clinical presentation in 178 patients. Acta Neurochir (Wien) 1994;127:203–9. [7] Asquier C, Trousssier B, Chirossel JP, Chardonnet E, Mouries D, Juvin R, et al. Femoral neuralgia due to degenerative spinal disease. A retrospective clinical and radio-anatomical study of one hundred cases. Rev Rhemat English Ed 1996;63:278–84. [8] Tokuhashi Y, Matsuzaki H, Uematsu Y, Oda H. Symptoms of thoracolumbar junction disc herniation. Spine 2001;26:512–8. [9] Kreitz BG, Cote P, Yong-Hing K. Crossed femoral stretching test. A case report. Spine 1996;21:1581–6. [10] Nadler SF, Malanga GA, Stitik TP, Keswani R, Foye PM. The crossed femoral nerve stretch test to improve diagnostic sensitivity for the high lumbar radiculopathy: 2 case reports. Arch Phys Med Rehabil 2001;82:522–3. [11] Kim KY, Kim YT, Lee CS, Kang JS, Kim YJ. Magnetic resonance imaging in the evaluation of the lumbar herniated intervertebral disc. Int Orthop 1993;17:241–4. [12] Schellhas KP, Pollei SR, Gundry CR, Heithoff KB. Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine 1996;21:79–86. [13] Pfirrmann CW, Dora C, Schmid MR, Zanetti M, Hodler J, Boos N. MR image-based grading of lumbar nerve root compromise due to disk herniation: reliability study with surgical correlation. Radiology 2004;230:583–8. [14] Chawalparit O, Churojana A, Chiewvit P, Thanapipatsir S, Vamvanij V, Charnchaowanish P. The limited protocol MRI in the diagnosis of lumbar disc herniation. J Med Assoc Thail 2006;89:182–9. [15] Greenhalgh S, Selfe J. Red flags: a guide to identifying serious pathology of the spine. Edinburgh: Churchill Livingstone; 2009. [16] Sim J, Wright C. Research in health care: concepts, designs and methods. Cheltenham: Stanley Thornes (Publishers) Ltd; 2000. [17] Tooth LR, Ottenbacher KJ. The Kappa statistic in rehabilitation research: an examination. Arch Phys Med Rehabil 2004;85:1371–6. [18] Sim J, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 2005;85:257–68. [19] Brennan P, Silman A. Statistical methods for assessing observer variability in clinical measures. BMJ 1992;304:1491–4. [20] Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. BMJ 2004;329:168–9. [21] Petrie A, Sabin C. Medical statistics at a glance. 3rd ed. Oxford: Wiley Blackwell; 2009. [22] Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with confidence. 2nd ed. London: BMJ Books; 2000. [23] Whiting P, Rutjes AWS, Reitsma JB, Glas AS, Bossuyt PMM, Kleijnen J. Sources of variation and bias in studies of diagnostic accuracy: a systematic review. Ann Intern Med 2004;140:189–202. [24] Hall T, Zusman M, Elvey R. Adverse mechanical tension in the nervous system? Analysis of straight leg raise. Man Ther 1998;3:140–6.

[1] Butler DS. The sensitive nervous system. Adelaide: Noigroup Publications; 2000. p. 303–304.

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Ankle positioning and knee perturbation affect temporal recruitment of the vasti muscles in people with patellofemoral pain Elton C.T. Ng, Mara P.Y. Chui, Aggie Y.K. Siu, Vaniel W.N. Yam, Gabriel Y.F. Ng ∗ Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

Abstract Objectives To compare the temporal recruitment of the vastus medialis obliquus (VMO) and vastus lateralis (VL) during voluntary ankle movements and perturbed standing in people with patellofemoral pain, and to determine the effects of different reflex and voluntary postural exercise tasks on VMO facilitation. Design Repeated-measures design. Participants Twenty-three subjects with patellofemoral pain. Interventions Quadriceps reflex contraction in response to postero-anterior knee perturbations was measured with three crural muscle contraction conditions and three postural exercises (semi-squatting, tip-toeing and heel standing). Main outcome measures The electromyographic (EMG) onset time of the VMO and VL during each task was measured and compared across the different tasks. Results The mean EMG onset time of the VMO was later than that of the VL in the voluntary tasks such as tip-toeing (VMO 95.3 ms vs VL 36.4 ms, mean difference 58.9 ms, 95% confidence interval −33.7 to 151.5 ms), whereas earlier VMO activation was found in the perturbation tests such as toe standing (VMO 17.6 ms vs VL 22.9 ms, mean difference −5.3 ms, 95% confidence interval −25.3 to 14.7 ms). Conclusion These findings suggest the potential benefits of unexpected perturbation activities for facilitating VMO activation. The clinical applications of perturbation tasks in rehabilitation exercise programmes and the underlying mechanisms warrant further investigation. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Knee; Patella; Postural balance; Rehabilitation

Introduction Patellofemoral pain syndrome (PFPS) is characterised by diffuse pain in the retropatellar region, exacerbated by daily activities such as stair climbing, prolonged sitting, squatting and kneeling. It is one of the most common conditions in athletes, especially for sports involving repetitive loading to the lower limbs such as running [1,2]. The aetiology of PFPS is not fully understood, but the most popular theory is abnormal tracking of the patella [3]. The mechanisms for abnormal patella tracking could be due to changes in muscle activities or passive restraining forces around the patella [4]. Atrophy of the vastus medialis obliquus (VMO) would lead to strength imbalance between the medial and lateral heads of the quadriceps muscle, result∗

Corresponding author. Tel.: +852 27666721; fax: +852 23305642. E-mail address: [email protected] (G.Y.F. Ng).

ing in a larger lateral pulling force on the patella [1]. Even in the absence of a strength deficit, a biomechanical modelling study has revealed that if the neural drive to the VMO is decreased or inappropriately timed, a lag of as little as 5 ms behind that of the vastus lateralis (VL) could result in significant lateral patellar shifting and thus abnormal loading to the patellofemoral joint [5]. Clinically, management of PFPS aims to restore normal patella tracking by releasing the tight capsular structures such as the lateral patellar retinaculum, strengthening the VMO, synchronising the neuromotor control of the knee musculature, and strengthening the hip muscles. Techniques such as patella taping, pelvic control exercises, and stretching of the hamstrings and hip muscles have been advocated [3,6–11]. The relative onset timing of the VMO and the VL has been studied by various researchers, and findings have differed between reports [12]. However, a number of studies have demonstrated that temporal activation of the VMO in peo-

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ple with PFPS was delayed compared with activation of the VL [1,2,13,14], which has led to emphasis on neuromuscular training for the VMO in rehabilitation exercises. An important aim for the treatment of PFPS is balancing the medial and lateral pulling forces on the patella, and there is evidence that VMO and VL activities are affected by postural control of the lower limb. Studies have shown that muscles of adjacent body segments have a pattern of pre-movement activation to provide stability to the body segments [15,16]. Anticipatory or ‘feed-forward’ activation of the leg and thigh muscles has been reported in voluntary ankle movements, such that the quadriceps muscle contracts either simultaneously or up to 100 ms before the ankle muscles [17,18]. According to Nardone and Schieppati [17], the anticipatory phenomena were considered to be postural adjustments because they only appeared in the free-standing situation, and induced a body sway in the appropriate direction to counteract the destabilising thrust due to the voluntary contraction of the leg muscles. Cowan et al. [19] examined activation of the VMO and VL with ankle movements in healthy subjects, and found co-activation between the VMO and VL when stability of the knee was challenged. The authors explained that such co-activation of the VMO and VL was needed in order to guide the patella movement smoothly along the femoral groove. They proposed that the VMO and VL co-activation was associated with ankle movements to be part of the feedforward postural response in standing. This thus forms the theoretical basis for studying the postural effect on muscle co-activation for PFPS. This study examined the onset timing of electromyographic (EMG) activity in the VMO and VL in people with PFPS during voluntary ankle movements and knee perturbation to explore the effects of these motor tasks on the temporal co-ordination of these muscles. If a relationship is found between postural control tasks and VMO/VL activities, this will have implications for the design of rehabilitation exercises for patients with PFPS.

Fig. 1. Electrode placements for surface electromyogram recordings of the vastus medialis obliquus (VMO) and vastus lateralis (VL).

cal injuries, spinal referred pain and traction apophysitis as evidenced by X-ray or diagnosed clinically by the referring physician. This study was approved by the research committee of the Department of Rehabilitation Sciences, Hong Kong Polytechnic University, and all subjects gave written informed consent before being tested. Procedure

Methods This study adopted a cross-sectional, within-subject, repeated-measures design with six testing conditions. Twenty-three subjects (11 females, 12 males) with clinically diagnosed unilateral PFPS were recruited from a local running club. Subjects were included if they had patellofemoral pain while engaging in at least two of the following activities: prolonged sitting, climbing stairs, squatting, running, kneeling, hopping and jumping. A patellar grinding test was performed by a qualified physiotherapist before the study to confirm the symptoms. Subjects were excluded if they had acute knee traumas or pathologies that required medical treatment, sick leave of more than 2 days within the last year due to knee problems, signs of quadriceps or hamstring muscle atrophy, patellar subluxation, radiological evidence of knee joint degeneration, history of ligamentous or menis-

Recordings of VMO and VL activities were made with a surface EMG system (Bagnoli-2 EMG system, Delsys Inc., Boston, MA, USA) with an in-built band width of 20 to 450 Hz and amplification by a factor of 1000. The amplified signals were input to an AD converter (National Instrument, Model DAQPAD 6020E, Austin, Texas, USA) which sampled at 1000 Hz, and output to a personal computer with LabView Version 7.0 software (National Instrument) for data collection and analysis. Bipolar electrodes with conduction gel were applied over the mid-point of the VMO and VL. The VMO electrode was placed with an angle of 55◦ to the vertical, 4 cm superior and 3 cm medial to the superomedial border of the patella measured from the mid-point of the electrode. The VL electrode was placed with an angle of 15◦ to the vertical, 10 cm superior and 8 cm lateral to the superior border of the patella [20].

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Table 1 Summary of the six different tasks for electromyographic (EMG) activity analysis and comparisons between the different conditions. Testing condition

Mean VMO onset time (ms)

Mean VL onset time (ms)

Mean difference in VMO onset minus VL onset (95% confidence interval)

Pair-wise comparison

1: perturbation in normal standing 2: perturbation with toe standing 3: perturbation with heel standing 4: voluntary semi-squat 5: voluntary tip-toeing 6: voluntary heel standing

25.9 17.6 30.1 46.8 95.3 113.5

28.1 22.9 37.9 45.4 36.4 55.8

−2.2 (−17.4 to 13.0) −5.3 (−25.3 to 14.7) −7.8 (−31.4 to 15.8) 1.4 (−6.8 to 9.6) 58.9 (−33.7 to 151.5) 57.7 (−14.6 to 130.0)

n.s. P = 0.0033 vs condition 6 P = 0.0033 vs conditions 5 and 6 n.s. P = 0.0033 vs condition 3 P = 0.0033 vs conditions 2 and 3

VMO, vastus medialis obliquus; VL, vastus lateralis; n.s., not significant.

The ground electrode was placed over the fibula head (Fig. 1). Prior to electrode placement, the skin was shaved, cleaned with alcohol and gently abraded with superfine sandpaper to reduce skin impedance. Intervention In order to examine the involuntary and voluntary postural control actions of the lower leg on VMO and VL activation, each subject performed six tasks (three reflex contractions and three voluntary contractions) in a single test session. Subjects stood unsupported on a low platform with arms by their sides, feet approximately 20 cm apart. Two bathroom scales were placed on the platform to ensure a difference in weight bearing of less than 1 kg between the two legs. A 3kg medicine ball was suspended with a sling from the ceiling above the subject. The examiner pulled the ball back until the sling made an angle of approximately 60◦ to the vertical behind the subject. Upon release of the ball, it exhibited a pendulum swing and hit the back of the subject’s symptomatic knee to trigger a stretch reflex in the quadriceps [21] (Fig. 2). According to the authors’ calculation, the energy of the impact of the pendulum was approximately 30 J, which was sufficient to perturb the knee. The subjects were informed of the perturbation before the tests but they did not know when the perturbation would be applied. During the tests, their ears were shielded so that they could not hear the release of the pendulum. An accelerometer (Model 8772A10, Kistler Instrument Corp., Amherst, NY, USA) was attached to the tibial tuberosity and synchronised with the EMG recordings to demarcate the instance of perturbation. A previous study has reported good reliability for this method of assessment (intraclass correlation coefficient: 0.775 to 0.884) [22]. The perturbation tests were performed in three conditions in random order, namely: (1) normal standing, (2) standing on the forefoot with the rearfoot unsupported, and (3) standing on the heels with the forefoot off the edge of a low stool so that the triceps surae or tibialis anterior muscles contracted, respectively, to maintain balance. During conditions 2 and 3, the subjects moved as far forwards or backwards on the supporting platform as possible without having to contract their dorsi/plantar flexors so that the ankle could be maintained in relatively neutral dorsi/plantar flexion. Thus, the base of

Fig. 2. Experimental set-up for the perturbation test.

support was reduced but the dorsi/plantar flexors were not excessively shortened in either condition. In addition to the reflex testing conditions, the subjects also performed three voluntary contraction tests, namely: (4) semi-squat, (5) rise on the toes, and (6) rock on the heels by lifting the toes as quickly as possible in response to verbal commands (Table 1). These testing positions were chosen in consideration of the ease of standardising and monitoring them during the tests. The order of all the tests was randomised and a 2-minute rest was given between each testing condition. Outcome measures The EMG signals were full wave rectified and low pass filtered at 10 Hz for smoothing. The mean activity at 500 ms before perturbation was recorded as the resting EMG signal. The onset of VMO and VL activity was defined as a signal that differed by 3 standard deviations (SD) from the resting level which lasted for more than 25 ms [13,14].

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Fig. 3. Tracing of the electromyogram recording with perturbation. The arrows represent the moment of perturbation (accelerometer) and the subsequent activities of the vastus lateralis (VL) and vastus medialis obliquus (VMO).

The difference in onset timing of the VMO and VL was calculated for each of the testing conditions by subtracting the VL onset time from that of the VMO. As such, a positive value indicated earlier onset of the VL and a negative value indicated the opposite. These differences in onset timing were used for statistical analysis. Statistical analysis The data were analysed using Statistical Package for the Social Sciences Version 11.0 (SPSS Inc., Chicago, IL, USA). As the EMG data of the subjects revealed a skewed distribution, a non-parametric Friedman test was used to analyse the within-subject difference. If the result of the Friedman test was significant, multiple comparisons were performed using the Wilcoxon Signed Ranks test to identify which testing conditions were significantly different from the others. Since 15 comparisons were made, Bonferroni’s correction was applied with α adjusted from 0.05 to 0.0033 to control for type I error.

the six tests are shown in Table 1. All three perturbation tasks showed negative values, and the three voluntary tasks showed positive values. The Friedman test revealed a significant difference (Table 1). Wilcoxon Signed Ranks test found that four of the pair-wise comparisons had significant differences (P < 0.0033) (Table 1). As the mean differences in EMG onset timing of all perturbation tasks had negative values and the voluntary contraction tasks had positive values, this indicated that the perturbation tasks had earlier VMO onset relative to VL than the voluntary tasks. In particular, the heel standing task (condition 6) had a significantly later VMO onset than conditions 2 and 3 (P = 0.001), and this approached significance (P = 0.004) in comparison with condition 1. The toe standing task also resulted in a significantly later VMO onset than the heel standing task.

Discussion Results The mean (SD) ages of the female and male subjects were 31.6 (3.9) and 29.1 (6.3) years, respectively, and the mean (SD) body height and weight of the subjects were 169 (5.2) cm and 65 (3.3) kg, respectively. All subjects had been experiencing PFPS symptoms for more than 2 months before the study, and the level of pain ranged from 3 to 6 out of 10 in the visual analogue scale during resisted knee extension. All subjects had positive results with the patella grinding test, but none of them complained of pain during the actual testing sessions. All subjects were involved regularly in running, and had run more than 10 km per week in the 3 months prior to the study. A sample EMG trace of a perturbation task is shown in Fig. 3, and the mean differences in EMG onset (VMO-VL) of

The objectives of this study were to explore VMO and VL activities in people with PFPS during voluntary ankle movements and knee perturbation to explore the effects of these motor tasks on the temporal co-ordination of these muscles. The results revealed a general pattern that the VMO had longer activation latency than the VL during the voluntary tasks of semi-squat, toe standing and heel standing, and the VL had longer latency than the VMO during reflex contractions. This concurred with previous reports [13,14] that EMG onset of the VL occurred before that of the VMO in symptomatic subjects when performing body rising and rocking tasks. However, the mechanism of change in the activation pattern of the muscles is not clear. According to Cowan et al. [14], changes in VMO and VL onset timing can be due to fatigue, change in nerve conduction velocity, motor neurone inhibition or reflex inhibition.

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Clinically, muscle inhibition can be induced by pain. However, Stokes and Young [23] found that inhibition could be dissociated from pain. They tested patients receiving local anaesthesia after knee surgery to control postoperative pain, and found that the quadriceps inhibition pattern was not changed by anaesthesia. In the present study, pain was not reported by the subjects during the test, so the finding that VMO onset was later than VL onset in the voluntary tasks was not likely to be pain induced. However, it could not be ruled out that other non-pain-related pathological changes in PFPS might lead to muscle inhibition. Spencer et al. [24] reported that the VMO was more prone to reflex inhibition than the VL and rectus femoris, possibly due to the small muscle size and the oblique fibre orientation of the VMO. More recently, Alrowayeh et al. [25] studied the H-reflex of the vastus medialis in healthy subjects and found that this muscle was facilitated during knee flexion in standing. An increase in excitability of the alpha motor neurones of this muscle could have masked the presynaptic inhibition, which may explain the facilitation of the H-reflex while performing knee flexion in healthy subjects. However, the present study did not find that voluntary semi-squatting could facilitate VMO activity. This could be because Alrowayeh et al.’s [25] findings were in normal subjects but the subjects in the present study had PFPS. Activity of the quadriceps has been found to either happen simultaneously or up to 100 ms before activity of the lower leg muscles [15–18]. More recently, Cowan et al. [19] studied co-ordination of the VMO and VL in ankle movements in healthy subjects, and found an anticipatory co-activation of the medial and lateral muscles when stability of the knee was compromised, such as during toe or heel standing. However, this type of pre-planned recruitment of the quadriceps by the central nervous system was different from the present tests. It is not known why this anticipatory response in the quadriceps was altered in subjects with PFPS. It could be because the excitatory projection to quadriceps motor neurones was suppressed in these subjects. It has been reported that activity in the soleus produces a discharge in Ia and Ib fibres, not only to its motor neurones but also to the quadriceps motor neurones [26]. Ia fibres have excitatory projections to both soleus and quadriceps motor neurones, whereas Ib afferents have inhibitory projections to these motor neurones. However, the mechanism of how to maintain equilibrium between excitation and inhibition in these motor neurones is still not clear. Apart from the voluntary testing conditions, the reflex muscle testing revealed that VMO activation happened earlier than VL activation with reflex contractions. Perturbation challenges the balance mechanism, thus the body responds with a reactive motor control strategy rather than pre-planned muscle activity. When the subject’s knee was perturbed, the mechanoreceptors could be stimulated by the impact and vibration wave of the medicine ball which excited the Ia afferent fibres. Also, the protective short-latency responses were triggered to regulate joint stiffness by co-contraction of

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the muscles around the joint [27]. Earlier VMO contraction may be beneficial in preventing lateral patellar tracking and hence protecting the patellofemoral joint. The present results showed that the VMO contracted earlier than the VL with the perturbation test. Before applying the findings, it is necessary to consider the clinical significance and the likely errors of this study. Despite the statistical significance found, the small differences and the fact that tests were performed in a quasi-static manner, it is not known if the speed of movements could overcompensate the muscle firing order of the VMO and VL during dynamic activities. During the tests, the subjects were standing on both legs with equal weight distribution prior to perturbation, but perturbation was only applied to the symptomatic knee. Therefore, there could have been a shift of body weight to the asymptomatic leg at the time of perturbation. In testing conditions 2 and 3, subjects were asked to stand as far forwards or backwards as possible on the platform without contracting the dorsi/plantar flexors to maintain balance. However, non-contraction of these muscles was only determined by observation and there was no EMG monitoring. Clinically, the aims of rehabilitation of people with PFPS are to strengthen the VMO in a functional position, correct any patellar maltracking, improve pelvic control and reduce soft tissue tightness in the knee [3,6,7,13,14]. Given that delayed activation of the VMO could result in abnormal patella tracking [5], any strategies to facilitate activation of the VMO could improve patella tracking and prevent abnormal stresses. The present finding that unexpected perturbations resulted in earlier VMO activation may have the potential for use as a rehabilitation strategy, but this would need to be tested further. The concept rests on the assumption that responses to unexpected perturbations can lead to improved functioning during daily voluntary activities. Besides the above, the pattern of VMO/VL activation alone cannot explain the whole picture of PFPS; pelvic control and gluteal muscle activation should also be investigated. Furthermore, this study only investigated the VMO/VL firing pattern in six conditions; it is not known if other testing conditions would have similar effects.

Conclusion This study found a delay in VMO activation compared with VL activation in runners with PFPS on voluntary semisquat, toe standing and heel standing activities, but the temporal activation sequence of the two muscles was reversed during reflex activities elicited by knee perturbation. These findings suggest a potential benefit of including a postural challenge task in the rehabilitation exercises for people with PFPS to facilitate activation of the VMO. Ethical approval: Departmental Research Committee of Rehabilitation Sciences, Hong Kong Polytechnic University. Conﬂict of interest: None declared.

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References [1] Cowan DN, Jones BH, Frykman PN, Polly DW, Harman EA, Sosenstein RM, et al. Lower limb morphology and risk of overuse injury among male infantry trainees. Med Sci Sports Exerc 1996;28:945–52. [2] Rauth MJ, Koepsell TD, Rivara FP, Margherita AJ, Rice SG. Epidemiology of musculoskeletal injuries among high school cross-country runners. Am J Epidemiol 2006;163:151–9. [3] McConnell J. The management of chondromalacia patellae: a long term solution. Aust J Physiother 1986;32:215–23. [4] Wong YM, Ng GYF. The relationships between the geometrical features of patellofemoral joint and patellar mobility in able-bodied subjects. Am J Phys Med Rehabil 2008;87:134–8. [5] Neptune RR, Wright IC, Van den Bogert AJ. The influence of orthotic devices and vasti medialis strength and timing on patellofemoral loads during running. Clin Biomech 2000;15:611–8. [6] Gilleard W, McConnell J, Parsons D. The effect of patellar taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 1998;78:25–31. [7] Harrison EL, Sppard MS, McQuarrie AM. A randomized controlled trial of physical therapy treatment programs in patellofemoral pain syndrome. Physiother Can 1999;54:93–100. [8] Ng GY, Cheng MF. The effect of patellar taping on pain and neuromuscular performance in subjects with patellofemoral pain syndrome. Clin Rehabil 2002;16:821–7. [9] Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. J Orthop Sport Phys Ther 2003;33:647–60. [10] Crossley KM, Cowan SM, McConnell J. Physical therapy improves knee flexion during stair ambulation in patellofernoral pain. Med Sci Sports Exerc 2005;37:176–83. [11] Cowan SM, Hodges PW, Crossley KM. Patellar taping does not change the amplitude of electromyographic activity of the vasti in a stair stepping task. Br J Sports Med 2006;40:30–4. [12] Chester R, Smith TO, Sweeting D, Dixon J, Wood S, Song F. The relative timing of VMO and VL in the aetiology of anterior knee pain: a systematic review and meta-analysis. BMC Musculoskel Dis 2008;9:64–78. [13] Cowan SM, Bennell KL, Crossley KM, Hodges PW, McConnell J. Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome. Med Sci Sports Exerc 2002;34:1879–85.

[14] Cowan SM, Hodges PW, Bennell KL, Crossley KM. Altered vasti recruitment when people with patellofemoral pain syndrome complete a postural task. Arch Phys Med Rehabil 2002;83:989–95. [15] Cordo PJ, Nashner LM. Properties of postural adjustments associated with rapid movements. J Neurophysiol 1982;47:287–308. [16] Massion J. Movement, posture and equilibrium: interaction and coordination. Prog Neurophysiol 1992;38:35–56. [17] Nardone A, Schieppati M. Postural adjustments associated with voluntary contraction of leg muscles in standing man. Exp Brain Res 1988;69:469–80. [18] Kasai T, Kawai K. Quantitative EMG analysis of anticipatory postural adjustments of voluntary contraction of leg muscles in standing man. Electroencep Clin Neurophysiol 1994;93:184–7. [19] Cowan SM, Hodges PW, Bennell KL. Anticipatory activation of vastus lateralis and vastus medialis obliqus occurs simultaneously in voluntary heel and toe raises. Phys Ther Sport 2001;2:71–9. [20] Wong YM, Ng GYF. Surface electrode placement affects the EMG recordings of the quadriceps muscles. Phys Ther Sport 2006;7: 122–7. [21] Ng GYF. Patellar taping does not affect the onset of activities of vastus medialis obliquus and vastus lateralis before and after muscle fatigue. Am J Phys Med Rehabil 2005;84:106–11. [22] Fong SM, Ng GY. The effects on sensorimotor performance and balance with Tai Chi training. Arch Phys Med Rehabil 2006;87:82–7. [23] Stokes M, Young A. Investigations of quadriceps inhibition: implications for clinical practice. Physiotherapy 1984;70:425–8. [24] Spencer J, Kayes K, Alexander I. Knee joint effusion and quadriceps reflex inhibition in man. Arch Phys Med Rehabil 1984;65: 171–7. [25] Alrowayeh HN, Sabbahi MA, Etnyre B. Soleus and vastus medialis H-reflexes: similarities and differences while standing or lying during varied knee flexion angles. J Neurosci Method 2005;144:215– 25. [26] Pierrot-Deseilligny E. Control of human locomotion by group I reflex pathways from ankle extensor. In: Struppler A, Weindi A, editors. Electromyography and evoked potential. Berlin: Springer-Verlag; 1985. p. 50–5. [27] Schillings AM, Van Wezel BMH, Mulder TH, Duysens J. Widespread short-latency stretch reflexes and their modulation during stumbling over obstacles. Brain Res 1999;816:480–6.

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Physiotherapy 97 (2011) 71–77

Discrete-event computer simulation methods in the optimisation of a physiotherapy clinic J.R. Villamizar, F.C. Coelli, W.C.A. Pereira, R.M.V.R. Almeida ∗ Biomedical Engineering Program, COPPE – Federal University of Rio de Janeiro, Caixa Postal 68510 Cidade Universitária, Rio de Janeiro 21941-970, Brazil

Abstract Objective To develop a computer model to analyse the performance of a standard physiotherapy clinic in the city of Rio de Janeiro, Brazil. Design and setting The clinic receives an average of 80 patients/day and offers 10 treatment modalities. Details of patient procedures and treatment routines were obtained from direct interviews with clinic staff. Additional data (e.g. arrival time, treatment duration, length of stay) were obtained for 2000 patients from the clinic’s computerised records from November 2005 to February 2006. Methods and main outcome measures A discrete-event model was used to simulate the clinic’s operational routine. The initial model was built to reproduce the actual configuration of the clinic, and five simulation strategies were subsequently implemented, representing changes in the number of patients, human resources of the clinic and the scheduling of patient arrivals. Results Findings indicated that the actual clinic configuration could accept up to 89 patients/day, with an average length of stay of 119 minutes and an average patient waiting time of 3 minutes. When the scheduling of patient arrivals was increased to an interval of 6.5 minutes, maximum attendance increased to 114 patients/day. For the actual clinic configuration, optimal staffing consisted of three physiotherapists and 12 students. According to the simulation, the same 89 patients could be attended when the infrastructure was decreased to five kinesiotherapy rooms, two cardiotherapy rooms and three global postural reeducation rooms. Conclusions The model was able to evaluate the capacity of the actual clinic configuration, and additional simulation strategies indicated how the operation of the clinic depended on the main study variables. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Simulation; Resource allocation; Modelling

Introduction Worldwide, health services face the challenge of growing population demands, which put pressure on infrastructure limits and impose the need for cost-containment strategies [1–4]. There is a need for development of new planning and programming tools in order to integrate information on resource supplies and patient demands into suitable, useful models that can work as tools for planning and management. In this context, computer simulation appears to be a viable alternative, with clear time and cost advantages over more traditional statistical methods. These techniques have been used in the planning of surgery, emergency, radiology and anaesthesiology departments [5–10], as well as in the anal∗

Corresponding author. E-mail address: [email protected] (R.M.V.R. Almeida).

ysis of patient flow in health units [11–14]. Such tools are particularly relevant to enable hospitals, clinics and other health providers to better adjust to demand and technology changes, which involve characteristics such as complex and non-linear interactions which cannot be represented in typical ‘analytical’ models. Discrete-event models are among the most promising of these strategies, and can be defined as computer techniques that represent sequential events describing the behaviour of a system [15,16]. Originally developed for industrial and aeronautical applications, this simulation methodology is thus named due to the discrete nature of its variables (e.g. the number of patients arriving at a clinic). In Brazil, patients are usually referred to physiotherapy by a physician, who makes the initial clinical diagnosis. Physiotherapeutic treatments are exclusively proposed, supervised and performed by physiotherapists, but physiotherapists

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Fig. 1. Clinic model and patient flow. In this discrete-event model, the routes of patients inside the system are fully known. For instance, a patient arrives at reception and is taken by a physiotherapist to the preparation room, where the patient changes. The patient is then taken to a treatment room and treated for a certain length of time. Afterwards, the patient is taken back to the reception area and leaves the clinic. All times (e.g. waiting time and duration of treatment) and event rates (e.g. number of patient arrivals) follow defined probability distributions, therefore allowing for the modelling of changes in the variables of interest. In the figure, locations are identified by stars, and arrows indicate the direction of patient flow.

cannot prescribe medication. Students work under the supervision of physiotherapists (ratio 6:1) in teaching hospitals. The objective of this work was to construct and analyse a computational discrete-event model for a standard physiotherapy clinic in the city of Rio de Janeiro, Brazil. The analysis involved optimisation of the number of patients attending the clinic and their waiting times, taking into account the scheduling of patient arrivals and the human and physical resources of the clinic. It was hoped that this analysis would help the clinic to determine whether its available resources were sufficient to handle an increase in patient numbers.

Methods Clinic description The study clinic is associated with a university, and is a ‘model’ unit in the sense that its physical design is used by other clinics that offer the same services. Only physiotherapy services are offered. The clinic receives an average of 80 patients/day and offers 10 treatments [acupuncture, mechanical therapy, kinesiotherapy, cardiotherapy, cryotherapy, global postural reeducation (GPR), hydrotherapy, electrotherapy, neurotherapy and pilates]. The clinic is open on Mondays and Wednesdays from 7 a.m. to 10 p.m., and on Saturdays from 8 a.m. to 1 p.m. In total, the clinic has 14 patient rooms, including treatment rooms, waiting rooms and a patient reception area (Fig. 1). The number

of sessions for each patient is dependent on each specific treatment. Computerised records are kept for all consultation data, including patient follow-up and treatment notes. Data Information about procedures and patient attending routines were obtained from semi-structured interviews with clinic staff and by direct data collection from November 2005 to February 2006. Data on length of stay and type of treatment were obtained from the computerised records of 2000 patients for the study period. Questionnaires were completed in private by clinic staff, with no supervision. Staff confidentiality was guaranteed. Patient confidentiality was also guaranteed by anonymising the patient names in the database made available for the study. These procedures and the study were approved by the clinic’s director in charge of patient safety. Other information, such as the average duration of treatment according to treatment modality, was also obtained by direct measurement and interviews with staff. The main concern of the clinic administration was that the clinic was nearing its maximum operating capacity. Patient ﬂow Patient flow, defined as the route taken by patients inside the clinic, was defined according to treatment modalities, and enabled estimation of the transit times for patients and staff. Fig. 1 shows the patient flow routes. Patient flow can be summarised as: the patient arrives in reception and stays

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Table 1 Model variables and parameters for the computer simulation of a physiotherapy clinic. These values were used in a discrete-event model to estimate changes in the number of patients attended, length of stay, waiting time and service time (model outputs). Model components Inputs

Ranges (inputs) and values (parameters) Range of change

Patient arrivals (patients/day) Patient scheduling (patients/day) Available human resources (n physiotherapists) Available human resources (n students) Patient beds (n kinesiotherapy, cardiotherapy, global postural reeducation)

80–90 80–114 3–5 10–20 7–5, 4–2, 5–3

Model components Parameters

Ranges (inputs) and values (parameters) Values

Locations (i.e. treatment rooms, waiting rooms, other) (n) Human resources (n students/physiotherapists) Processes (e.g. specific treatments) (n) Treatment modalities (n) Average and standard deviation of patient arrivals (minutes) Number of patients/day Patient walking speed (m/minute) Simulation

36 15/5 20 10 8.8, 5.5 (log-normal) 80 60 30 replications of a working day

‘Range of change’ refers to the range of the input values analysed in the simulation.

in a waiting area until they are called by a physiotherapist; the physiotherapist accompanies the patient to a preparation room, where the patient changes; the physiotherapist then accompanies the patient to the appropriate treatment room; and finally, the physiotherapist returns with the patient to the waiting area. At this point in time, the physiotherapist is free for the next task, and the patient can either use a changing cubicle or leave immediately. The same door is used to enter and exit the clinic. Model construction and variables used A discrete-event simulation model was developed to simulate the clinic’s operation routine. In general terms, these models are based on the concepts of resources, entities, locations, processes and attributes. Thus, resources act on entities (e.g. physiotherapists treat patients), locations are the rooms where resources operate, processes are the routines that connect locations, and attributes are the possible states of resources and entities (e.g. ‘in use’ or ‘not in use’). These concepts, together with the probability distributions with which events of interest occur and with the physical layout of the system, allow for representation of the actual operating conditions of the system. Thus, as long as the flow of events inside the clinic is replicated accurately, the impact of changes in specific variables may be evaluated without the need for real-life system changes. Brief descriptions of the main terms pertaining to discrete-event computer simulation are given in Appendix 1. In addition to the stochastic characteristics of a system, other necessary components for its representation are the model parameters or constraints, i.e. the fixed values that unambiguously define the physical layout of a system. Table 1 shows the parameters used for the clinic model. As typi-

cal in the literature [13], the average speed of a patient was defined as 1 m/second. The simulation consisted of 30 replications of a typical working day. The full model consisted of 36 locations, 20 model processes, 10 treatment modalities, 15 students and five physiotherapists (Table 1). As is the case in the actual clinic, patient mix according to modalities was fixed. The clinic was assumed to receive 80 patients/day, and the patients arrived with a mean interval of 8.8 minutes [standard deviation (SD) 5.5]. MedModel version 6.0 (ProModel Corporation, Allentown, PA, USA) was used for model development [17–19]. For the construction of the model, the first step involved defining the statistical behaviour and the actual attendance capacity of the treatment modalities at the clinic. The modelling process followed the steps suggested by Law and Kelton [20], and can be summarised as problem formulation and study planning, data collection and model definition, design validation, computational development, pilot test, model validation, design and execution experiments, result analysis, and model documentation and implementation. As mentioned above, locations are the places where entities and resources can operate, such as the cardiotherapy or kinesiotherapy rooms; entities are the patients who use the resources (students and physiotherapists); routes and nodes are the pathways through which resources and entities can move; and processes are the possible actions (admission, preparation, treatment and discharge) performed on the entities. The data probability distributions under which these processes are assumed to happen (e.g. normal and log-normal) were assessed by Kolmogorov–Smirnov tests [21,22]. Simulation strategies and statistical analysis The basic simulation strategy consisted of developing an initial model, and introducing changes in selected variables

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Table 2 Simulation strategies for the computer simulation of a physiotherapy clinic: variation in number of patients, human resources and number of rooms (according to treatment modality). Simulated variable

Patients not attended (monthly)

Length of stay (minutes)

Waiting time (minutes)

Service time (hours)

Patient arrivals (n subjects) – 87 88 89 –

– 0 0 0 2

– 118.9 118.1 118.4 –

– 3.1 3.0 3.0 –

– 14.9 14.9 14.9 >15.0

– 126.8 127.5 126.8 – –

– 17.2 17.2 17.3 – –

– 14.9 14.9 15.0 >15.0 >15.0

Patient scheduling (n subjects) – – 112 0 113 0 114 0 – 1 – 2 Simulated variable Physiotherapists (n)

Students (n)

3 3 3 3 3 4 4 4

11 12 13 14 15 13 14 15

Simulated variable

Patients not attended (monthly)

Length of stay (minutes)

Waiting time (minutes)

Service time (hours)

2 0 0 1 3 2 2 1

– 115.8 119.6 – – – – –

– 3.0 7.5 – – – – –

>15.0 14.9 14.5 >15.0 >15.0 >15.0 >15.0 >15.0

Patients not attended (monthly)

Length of stay (minutes)

Waiting time (minutes)

Service time (hours)

0 0 0 1

115.8 115.8 115.8 –

11.7 11.7 11.7 –

14.5 14.5 14.5 >15.0

Decrease in number of rooms by modality KT

CA

GPR

7 6 5 4

4 3 2 1

5 4 3 2

KT, kinesiotherapy; CA, cardiotherapy; GPR, global postural reeducation; –, values were not necessary for the analysis and therefore are not shown.

to maximise the use of resources (i.e. decreasing the waiting times and increasing the number of patients attended). Thus, after the initial model was developed and validated, the following input variables were altered (ranges inside brackets): a, patient arrivals (80–90); b, patient scheduling (80–114); c, available human resources (with the best configuration from Strategy a) (physiotherapists: 3–5); d, available human resources (with the best configuration from Strategy b) (students: 10–20); and e, number of patient beds in the three treatment rooms with the largest percentage of use: kinesiotherapy (12%), cardiotherapy (30%) and GPR (25%). The output variables were: number of patients not attended monthly, length of stay (total time a patient spent inside the clinic in minutes), waiting time (time the patient spent waiting to be taken to a service in minutes), walking time (time spent by the patient walking between locations in minutes) and service time (total time taken by the clinic to treat a patient in hours). The numbers for the patient scheduling variable correspond to changes in patient arrival intervals between 8.8 and 6.5 minutes.

Model validation For validation purposes, the differences between the initially constructed model and the actual clinic were assessed by Student’s t-tests with α = 0.05. Thus, at first, simulations were performed using a model that tried to reproduce the actual clinic configuration. The mean waiting time and number of patients obtained from the model were compared with the actual clinic values using these tests. The modelling process was considered to be valid if it was able to reproduce the actual clinic performance in terms of the number of patients attended and patient waiting times.

Results For each specific procedure, the identified probability distribution functions for treatment times (average, SD; in minutes) were: acupuncture, normal (54.3, 13.3); mechanical therapy, exponential (18.0, 4.0); kinesiotherapy, log-normal

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(51.3, 29.3); cardiotherapy and cryotherapy, normal (21.0, 2.0); GPR, log-normal (116.3, 33.1); hydrotherapy, normal (21.0, 2.0); electrotherapy, log-normal (40.3, 24.9); neurotherapy, log-normal (115.9, 40.9); and pilates, log-normal (78.5, 22.2). For the initial model, length of stay and patient number according to treatment modality were accepted as normally distributed with Kolmogorov–Smirnov P-values of 0.69 and 0.98, respectively. The null hypothesis of no difference between the initial model and the actual clinic could not be rejected, since no statistical difference could be detected in waiting time and number of patients according to modality (P = 0.76, P = 0.91). The simulation of the initial model resulted in average length of stay of 119.91 minutes, average waiting time of 3.35 minutes, average walking time of 13.95 minutes, average treatment time of 100.60 minutes, and average service time of 13.45 hours. The best characterisation of patient arrival was a log-normal distribution with a mean interval of 8.8 minutes between patient arrivals. Simulation results can be seen in Table 2. The column ‘patients not attended’ indicates the number of patients who could not complete treatment during the clinic’s working hours. With the initial configuration, the maximum number of patients that could be attended per day was 89, with average length of stay of 118.4 minutes and average waiting time of 3.0 minutes, and a total of 14.9 clinic working hours/day. By modifying the scheduling of patient arrivals, it was possible to attend a maximum of 114 patients/day. Table 2 also shows the results of the simulation of human resource changes, with an optimum (i.e. minimum number of non-attended patients, shortest waiting time and shortest length of stay) of three physiotherapists and 12 students. Strategy d (variation in the number of students while keeping fixed the number of physiotherapists and the optimum scheduling from Strategy b) yielded a maximum of 120 patients/day, with average length of stay of 113.5 minutes, average walking time of 14.3 minutes, average waiting time of 5.1 minutes and total service time of 14.88 hours. When the number of students was increased to 20, waiting times were reduced but there was no change in the number of patients attended (Fig. 2). Finally, Table 2 presents the simulation results for decreasing the number of beds in the treatment rooms for kinesiotherapy, cardiotherapy and GPR (starting with the actual clinic values). The simulation results indicated an optimum configuration of five, two and three rooms for kinesiotherapy, cardiotherapy and GPR, attending 89 patients/day.

Discussion Worldwide, simulation studies have indicated the possibility of clear positive results when studying the optimisation of hospital resources [9,11,23]. For instance, Groothius et al. [11] achieved a large increase in the use of catheter rooms

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Fig. 2. Patient waiting times according to variation in the number of students in a discrete-event model of a physiotherapy clinic. This figure shows that, under the simulated conditions, a reduction in patient waiting times would be obtained by increasing the number of students to a maximum of 20, after which no further changes are apparent. By means of analysis of this type, optimum functioning levels can be found for parameters of interest in a hospital/clinic context.

by means of discrete-event models in the Netherlands, and similar utilisation increases have also been obtained with the simulation of patient flow in an emergency service in California [9]. In the present study, computer simulation appeared to be a useful tool for planners and decision-makers, enabling the analysis of multiple alternatives at an extremely low cost. However, despite the potential of the technique, no computer simulation studies could be identified that dealt specifically with physiotherapy planning and design applications. From the point of view of simulation, a hospital or a clinic is a dynamic system in which events such as patient arrival, waiting time and treatment time are discrete (i.e. an event can only occur after the preceding event is over, and events take a finite and measurable time to occur), with a defined probability distribution, such as normal, log-normal or exponential. In addition, events take place inside well defined locations (rooms), and these events determine the state (occupied, idle, standing by) of the clinics (physical and human) resources. As mentioned, the main concern of the clinic administration was that the clinic was nearing its maximum operating capacity. Therefore, the variables chosen for the analysis were those concerning the number of patients attended and their waiting times, and their ranges of change were defined taking into account the need to identify the clinic’s operational upper limits. However, the simulation of an increase in the demand for services that was presented in Table 2 indicated that a maximum attendance of 89 patients/day would still be possible within the clinic’s current resource constraints. Strategy b (variation in patient scheduling) allowed for maximising the number of patients attended at the clinic without changes in room capacity or the number of available resources. This strategy also showed that the clinic would be able to increase the number of patients attended by 28% if patients were scheduled with an interval of 6.5 minutes. Although it is not conceivable that such precise scheduling could actually be implemented, this value can be thought of as a target which would move the clinic closer to its maximum capacity.

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Strategy c (variation in the number of physiotherapists) shows that the number of patients attended could be increased by 20% by increasing the number of physiotherapists. In the current system, this extra time is used for teaching/studying; although, of course, it is not advisable to completely eliminate protected study time, careful planning could be attempted in order to increase the number of patients attended at the clinic. Also, it should be noted that, in Strategy c, the number of patients attended decreases after a certain increase in the number of physiotherapists. This is an advantage of discreteevent models, which incorporate stochastic and non-linear components in the representation of sequential events. Therefore, this result indicates that, after a certain level of increase, resource competition decreases the efficiency of the system. This type of non-linearity would not have been detected if a traditional linear statistical model had been used [13]. Strategy d (variation in the number of students) showed that an increase from 15 to 17 students, together with implementation of the optimum patient scheduling strategy developed from Strategy b, would increase the number of patients attended at the clinic by 34% without affecting patient waiting times. This would increase the clinic’s capacity considerably without altering service quality. When the number of students was increased to 20, patient waiting time was reduced from approximately 5 minutes to 1 minute, but the number of patients attended by the clinic did not exceed 120 patients/day, a limit already reached with the use of 17 students (two above the actual clinic number). Strategy e (reducing the number of available beds) showed that reducing the number of patients by one who could be attended in the kinesiotherapy, cardiotherapy and GPR rooms would not introduce any sensible changes in the system. In fact, this shows another advantage of the simulation approach, as it also indicates which changes should not be attempted. Simulation models allow for the possibility of representing the characteristics of such dynamic systems with very few limitations. In the present case, the most important of these concerned the impossibility of taking into account the specific pathologies and therapies that patients received. For instance, no distinction was made between the treatment of a benign condition compared with a more serious condition, and patient outcomes were not analysed. However, information on these issues was included in the model indirectly as the duration of treatment. Thus, treatment assessment at patient level was not attempted in this paper, and its only concern was the simulation of alternatives for resource allocation. Similarly, costs were not included in the analysis. Another limitation was that the impacts of the studied variables were analysed independently. Thus, a variable was considered fixed while another was altered. Although recognising that a comprehensive model should entail the analysis of simultaneous effects, it should be noted that the developed model is capable of providing relevant information for decisionmakers concerning the best use of the available resources. In conclusion, the present study suggests that the best strategy for the clinic would be to modify its scheduling

of patient arrivals, and, contingent on this, to re-assess the distribution of physiotherapists and students. Scheduling patient arrivals with an interval of approximately 6.5 minutes would increase the clinic’s capacity and optimise the human resources. Further research could investigate how the model would change if fixed variables were also changed. Funding: CNPq (Brazilian National Research Council). Conﬂict of interest: None declared.

Appendix A. Main computer simulation terms used in the study

Term

Explanation

Discrete-event simulation

Computer model for a system where changes in the state of the system occur at discrete points in time An orderly collection of logically related principles, facts or objects An object of interest in the system (e.g. patients) An object that perform activities with entities (e.g. physiotherapists) Places where the resources operate (e.g. rooms) Routines, procedures or other actions that connect locations The possible states of the resources and entities Variables that are changed under the control of the experimenter Response variables that change according to changes in inputs and represent the performance of the system The repetition of simulation experiment Time that a patient waits inside the system Time spent by resources and entities moving inside the system Time during which activities are performed on patients Waiting time + walking time + service time

System Entity Resources Location Process Attributes Input Output

Replication Waiting time Walking time Service time Length of stay

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J.R. Villamizar et al. / Physiotherapy 97 (2011) 71–77 [6] van Oostrum JM, Van Houdenhoven M, Vrielink MM, Klein J, Hans EW, Klimek M, et al. A simulation model for determining the optimal size of emergency teams on call in the operating room at night. Anesth Analg 2008;107:1655–62. [7] Edward GM, Das SF, Elkhuizen SG, Bakker PJ, Hontelez JA, Hollmann MW, et al. Simulation to analyzing planning difficulties at the preoperative assessment clinic. Br J Anaesth 2008;100:195–202. [8] Glick DN, Blackmore CC, Zelman WN. Extending simulation modeling to activity-based costing for clinical procedures. J Med Syst 2000;24:77–89. [9] Connelly LG, Bair AE. Discrete event simulation of emergency department activity: a platform for system-level operations research. Acad Emerg Med 2004;11:1177–85. [10] Elkhuizen SG, Das SF, Bakker PJ, Hontelez JA. Using computer simulation to reduce access time for outpatient departments. Qual Saf Health Care 2007;16:382–6. [11] Groothius S, Van Merode G, Hasman A. Simulation as a decision tool for capacity planning. Comp Meth Prog Biomed 2001;66:139–51. [12] Baldwin LP, Eldabi T, Paul RJ. Simulation in healthcare management: a soft approach (MAPIU). Simulat Model Pract Theor 2004;12:541–57. [13] Coelli FC, Ferreira RB, Almeida RMVR, Pereira WCA. Computer simulation and discrete-event models in the analysis of a mammography clinic patient flow. Comp Meth Prog Biomed 2007;87:201–7.

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[14] Harper PR, Gamlin HM. Reduced outpatient waiting times with improved appointment scheduling: a simulation modelling approach. OR Spectrum 2003;25:207–22. [15] Fishman GS. Discrete-event simulation: modeling, programming and analysis. New York: Springer-Verlag; 2001. [16] Kennedy MH. Simulation modeling for the health care manager. Health Care Manage 2009;28:246–52. [17] Cassandras CG, Lafortune S. Introduction to discrete event systems. 2nd edn New York: Springer; 2008. [18] Pidd M. Computer simulation in management science. 5th edn New York: John Wiley & Sons; 2004. [19] Ross SM. Simulation (statistical modeling and decision science). 4th edn San Diego: Elsevier Academic Press; 2006. [20] Law AM, Kelton D. Simulation modeling and analysis. 4th edn New York: McGraw-Hill; 2007. [21] Wilcox RR. Introduction to robust estimation and hypothesis testing. 2nd edn San Diego: Academic Press; 2004. [22] Krzanowski WJ. An introduction to statistical modeling. London: Arnold; 2001. [23] Ferreira RB, Coelli FC, Almeida RMVR, Pereira WCA. Optimizing patient flow in a large hospital surgical center by means of discrete-event computer simulation models. J Eval Clin Pract 2008;14:1031–7.

Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 78–82

Discussion

The evidence for and against ‘PhysioDirect’ telephone assessment and advice services Nadine E. Foster a,∗ , Bronwen Williams b , Sean Grove c , Jill Gamlin d , Chris Salisbury e a

e

Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele ST5 5BG, UK b Riverside GP Training Programme, London Deanery, UK c Bristol Community Health, UK d Physiotherapy Department, Hinchingbrooke Hospital, Huntingdon, UK Academic Unit of Primary Health Care, Department of Community Based Medicine, Bristol University, UK

Abstract Patients have experienced inadequate access to physiotherapy since the inception of the National Health Service (NHS). Over the last 50 years, many initiatives have been introduced to address this problem, the most recent being a new patient management pathway known as ‘PhysioDirect’. Within these services, physiotherapists offer initial assessment and advice by telephone, sometimes supported by computerised algorithms, and patients are sent written self-management and exercise advice by post. For some patients, face-to-face physiotherapy care will be offered where this is considered to be more appropriate. Although several such services have been developed across the UK, there is no robust evidence about clinical and cost-effectiveness, nor the acceptability of PhysioDirect to patients, physiotherapists or primary care organisations. This debate article summarises models of PhysioDirect, the links to other healthcare developments and relevant evidence to date about this type of service. By providing a summary of the arguments for, and key concerns about, PhysioDirect, this article stresses the need for more definitive evidence from high-quality randomised controlled trials before widespread roll-out across the NHS. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Telemedicine; Accessibility of health services; Physiotherapy; Musculoskeletal

Introduction Musculoskeletal problems are common and disabling [1]. Given projected increases in the number and proportion of older people in the population, the impact of these problems is set to rise [1]. Patients with musculoskeletal problems require access to effective and timely advice, assessment and treatment services that enable them to fulfil their optimum health potential and remain independent. Many such patients are referred to physiotherapists, comprising up to 94% of all referred patients [2] and contributing to 4.4 million new referrals to physiotherapy in England per year [3]. Patients with back, neck or shoulder complaints are most commonly referred, and contribute to significant disability and societal costs [4]. For example, each year in the ∗

Corresponding author. Tel.: +44 01782 734705; fax: +44 01782 733991. E-mail address: [email protected] (N.E. Foster).

UK, approximately 7 million general practitioner (GP) consultations relate to back pain, of which 1.6 million require onward referral [5] and 1.3 million are treated by physiotherapists [6]. The total direct costs of back pain were estimated at £1.6 billion in 1998, of which physiotherapy accounted for £251 million [7]. The most recent UK estimates are that these costs have risen by approximately 30% [8].

The problem of access to physiotherapy Ensuring timely access to physiotherapy has long been an issue within the National Health Service (NHS), with waiting times of several months in some areas. Many physiotherapy outpatient services battle with long waiting lists and patient delays, and struggle to meet the challenge of providing sufficiently responsive services. GPs and patients can be disappointed by these delays, choosing not to refer patients

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.05.003

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to the service at all in favour of other treatment options, such as orthopaedics [1]. Although many patients may only require advice and reassurance about self-management or a small number of treatment sessions, they join long waiting lists. When patients are finally offered an appointment, some fail to attend; other patients that gain little or no benefit might have gained more benefit if they had been seen more quickly [9,10]. It can be argued, therefore, that much of the current NHS physiotherapy resource is used inefficiently and ineffectively. There is a need for innovative ways to offer timely physiotherapy services for musculoskeletal patients, made ever more urgent by rising public expectations, an ageing population, technological advances, and the calls for further expansion of the primary care sector [1] coupled with waiting time targets [11].

PhysioDirect as a potential solution In response to the problem of access and in an attempt to improve the quality of care by reducing the waiting time to first physiotherapy contact, several areas in the UK have introduced a new service known as ‘PhysioDirect’. Two areas, Huntingdon and Cheltenham, developed the concept and coined the term ‘PhysioDirect’ at the same time. The Huntingdon system was devised with the primary care lead for the primary care trust and two local GP practices in 2001. The algorithms were developed by the physiotherapy service lead and converted into a computerised screening tool by an information technology specialist. A physiotherapist was employed for the initial trial to assess patients over the telephone using the computer software. The team entered the project for the Health and Social Care awards in 2003 and were runners up. In 2004, all of Huntingdonshire Primary Care Trust had access, covering the local population of 155,000. Further details of the current service in Huntingdonshire are summarised in Box 1 . A number of other primary care trusts have since developed PhysioDirect services (e.g. Hull, North East Essex). Some of these services have been used as case studies for the Musculoskeletal Services Framework [1] and the NHS white paper ‘Our Health, Our Care, Our Say’ [12]. Although there are several variations of PhysioDirect services, they tend to involve patients being invited to telephone a physiotherapist for initial assessment and advice, following which many patients are posted information on self-management and exercise. Physiotherapists determine the priority of need, or ‘triage’, and provide rapid advice to the patient so that recommended self-management activities, such as postural improvements and exercise, can commence. Patients are advised to telephone if their condition does not improve, and a timeframe for the repeat call may be recommended. Some patients are invited for a face-to-face consultation if the initial telephone triage establishes that this is necessary. Alternatively, they may be referred back to the

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Box 1: Summary of the Huntingdon PhysioDirect service. • A computer program with algorithms containing drop-down boxes and free text designed for each region of the body records clinical data to assist the physiotherapist in making a diagnosis. • In conjunction with colleagues from pharmacy, there is a specially designed section for advice about overthe-counter medication if applicable. • The patient receives verbal and written advice on selfmanagement, and is given a timeframe for expected improvement and clear instructions to telephone after a set period of time if their condition has not resolved as anticipated. • The GP receives a report on the outcome of the assessment. • The physiotherapist may also request a prescription or sickness certificate from the GP. • Clear pathways exist to move patients to tier II (or interface services) or on to secondary care.

GP or another health professional if appropriate. Within integrated services, patients may be referred to a tier II or interface service (where these exist in England, for example) or on to secondary care following agreed local pathways. Thus, PhysioDirect can form part of a streamlined patient management system which aims to ensure that a patient’s needs are met by the most appropriate clinician in a timely fashion. In some services, telephone assessments are prebooked into physiotherapists’ diaries, and they make the telephone call at a time that is convenient for the patient. Additionally, patient assessments within PhysioDirect may be supported by computerised algorithms or paper-based templates. Some services offer PhysioDirect in conjunction with self-referral to physiotherapy as a way of managing direct contacts from patients. Increasingly, the boundaries between telephone triage and advice and self-referral services are blurring, given the impetus from recent Department of Health reports on musculoskeletal services [1], community services [12] and the evidence about self-referral [13,14].

The arguments for PhysioDirect Prompt access to advice and treatment is the most compelling argument for the PhysioDirect philosophy. There is evidence that, for some conditions, prompt access to conventional (face-to-face) physiotherapy brings about an improvement in symptoms [15] and a reduction in the risk of chronicity [10]. Early intervention has advantages beyond that of patient convenience: it promotes less absenteeism, results in fewer physician consultations and has economic benefits [16–18].

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The triage process within PhysioDirect offers a way of providing early access to physiotherapy advice for patients that might benefit, and reserving more intensive (and expensive) treatments for patients who do not improve with self-management advice. This is analogous to the steppedcare approach advocated increasingly in a range of conditions (e.g. mental health) where there is a high level of demand and a need to target resources. PhysioDirect fits with other models of care that emphasise the importance of patient self-management, and matches the supported self-care approach advocated by the Department of Health’s policy on supporting people with long-term conditions [19]. There is evidence, for example, that appropriate patient information, education and encouragement can reduce work absenteeism related to back pain and increase patient satisfaction [20], and that a single session with a physiotherapist including advice is equally effective as routine physiotherapy for mild-to-moderate back symptoms [21].

Concerns expressed about PhysioDirect Anecdotally, the main initial concern about PhysioDirect expressed by GPs was a potential ‘flooding’ of physiotherapy services, thus ultimately increasing waiting times. However, this was mainly in relation to the ‘direct access’ component of the first initiative in Huntingdonshire, and local audits showed that this anxiety was unfounded. It is notable that even in the most established PhysioDirect services, the majority of referrals still come from GPs rather than patient self-referral. Other concerns include a potential inequity of service, with only those patients with access to a telephone and who are able to communicate clearly over the telephone being able to access the service. Physiotherapists have expressed concerns in unpublished data from interviews of a pilot trial of PhysioDirect by one of the authors (BW). These included worries about professional identity and competence, the difficulty of assessing patients over the telephone, the fear of missing important diagnoses, potential deskilling of manual assessment approaches, and the fear that physiotherapy might turn into a office-based profession with minimal patient contact; these concerns have been mirrored elsewhere [22,23]. Concerns about safety seem to be particularly important, and any PhysioDirect service needs careful clinical risk management training and arrangements. The ability to diagnose safely and bring patients in for face-to-face assessment where appropriate is a key underpinning principle of this type of service. For that reason, some services only have experienced band 6 and 7 physiotherapists providing telephone-based care. A further concern is that if an insufficient proportion of patients can be managed over the telephone alone, this type of service may not be cost-effective in the long term. Experienced physiotherapists can manage three straightforward calls per hour compared with one or, at most, two face-toface assessments with new patients. Audits suggest that up

to 60% of patients can be managed on the telephone alone, but other studies are beginning to question these figures. In Turner’s study [24], physiotherapists thought that 71% of patients assessed over the telephone required further assessment or manual ‘hands-on’ treatment. If replicated elsewhere, this appears to undermine some of the arguments about the cost-savings of PhysioDirect services.

Evidence for PhysioDirect To date, a small number of audits and research studies on the use of telephone consultation services in physiotherapy have been undertaken. These show that approximately 60% of callers are managed by telephone assessment alone, with advice posted to them on the same day, and 40% receive face-to-face contact with a physiotherapist. In addition, nonattendance rates reduce from 15% to <1%, GPs have fewer musculoskeletal consultations, and patients have faster access to secondary care consultants when required [22]. Patient [25,26] and GP [26] satisfaction appears to be good, and a recent study showed that physiotherapists reach the same decisions when using telephone-based assessment as they do with face-to-face approaches [24].

Evidence from related services Overall, PhysioDirect initiatives contribute towards the NHS modernisation agenda, which looks to develop new and more convenient ways of providing access to care. They also reflect a wider trend to explore the use of technology in health care, exemplified by NHS Direct within the UK. There is a growing body of evidence about telephone consultations [27,28], much of it relating to the provision of out-of-hours primary care. Telephone consultations have been widely used in the USA, Canada and Sweden, and in most cases, nurses or GPs are the primary healthcare providers. Nurse-led telephone triage initiatives have been found to be clinically accurate, cost-effective and reduce overall GP workload with no increase in adverse events [29–31]. Review of asthma patients over the telephone has been shown to enable more patients to be reviewed, without clinical disadvantage or reduction in satisfaction [27]. A Cochrane review assessed the effects of telephone consultation on safety, service usage and patient satisfaction, and compared telephone consultation by different healthcare professionals [32]. Findings were that at least 50% of calls were handled by telephone advice alone, and telephone triage reduced the number of surgery contacts for patients and out-of-hours visits by GPs. Although telephone consultations in primary care are generally seen to provide improved access, clinicians have expressed concerns about safety, and some have recommended that this type of service should be used for managing follow-up appointments after diagnostic assessment has been undertaken [33].

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The need for research These services have been shown to be popular with patients [25], and the diagnoses reached by physiotherapists over the telephone have been found to be similar to those they would reach in traditional face-to-face consultations [24]. However, this is not sufficient to prompt widespread changes in NHS service delivery. Even in areas where there are relatively short waiting lists for physiotherapy, the question of whether services can be made more accessible and cost-effective by the use of telephone assessment and advice systems needs to be answered urgently in order to inform future commissioning decisions. A randomised trial has been funded by the Medical Research Council (MRC) in the UK to address the clinical and cost-effectiveness of PhysioDirect services in comparison with the usual model of delivering physiotherapy for adults with musculoskeletal problems [34]. This will report in 2011 and will provide evidence about the effectiveness, cost-effectiveness and acceptability of PhysioDirect. Other valuable research questions include questions about patients (Is PhysioDirect more effective for some groups of patients than others? How can these services be provided to meet the challenges of the equality agenda in terms of age, communication difficulties and language barriers?) and physiotherapists (What are the education and training needs of physiotherapists working in PhysioDirect services? What are the levels of experience and skill needed to be effective? How can technological advances facilitate patient assessment and treatment using telephone systems?). The results of the MRC PhysioDirect trial will help to provide guidance for physiotherapists, GPs, patients and service commissioners about the role of this type of service innovation for the NHS. This type of large, multicentre study with longer-term patient follow-up and detailed cost analyses is needed to provide sufficient evidence to guide future service design for physiotherapy. Prior to the results, there is insufficient information to advocate widespread roll-out of PhysioDirect services. Ethical approval: Not applicable. Conﬂict of interest: None declared.

References [1] Department of Health. The Musculoskeletal Services Framework—a joint responsibility: doing it differently. London: Department of Health; 2006. [2] Jorgensen CK, Olesen F. Predictors for referral to physiotherapy from general practice. Scand J Prim Health Care 2001;19:48–53. [3] NHS Physiotherapy Services Summary Information for 2004–2005, Health and Social Care Information Centre, 2005, Government Statistical Service, England. Available at: http://www.ic.nhs.uk/webfiles/publications/physioservices05/NHSPhysiotherapyServices160905 PDF.pdf (last accessed 26.04.10). [4] Clinical Standards Advisory Group. Epidemiology review: the epidemiology and cost of back pain. London: HSMO; 1994.

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[5] Chartered Society of Physiotherapy. 2006. Improving Services for people with back pain, London, accessed 26/4/10, Available at: www.csp.org.uk/ uploads/documents/csp sep is4pwbp.pdf. [6] Rivero-Arias O, Gray A, Frost H, Lamb SE, Stewart-Brown S. Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain. Spine 2006;31:1381– 7. [7] Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95–103. [8] Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G, Cotterell M, et al. Low back pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2009. [9] Gatchel RJ, Polatin PB, Noe C, Gardea M, Pulliam C, Thompson J. Treatment and cost-effectiveness of early intervention for acute lowback pain patients: a one-year prospective study. J Occup Rehabil 2003;13:1–9. [10] Wand BMB, Bird CM, McAuley JHB, Dore CJB, MacDowell MM, De Souza LH. Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy and exercise. Spine 2004;29: 2350–6. [11] Department of Health. The NHS Improvement Plan: putting people at the heart of public services. London: The Stationary Office, Department of Health; 2004. [12] Department of Health. Our health, our care, our say: a new direction for community services. London: The Stationary Office, Department of Health; 2007. [13] Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. Leeds: Department of Health; 2008. Electronic version only. Accessed 26/4/10, Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 089516. [14] Holdsworth L, Webster V, McFadyen A. What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial. Physiotherapy 2007;93:3–11. [15] Lau PMY, Chow DHK, Pope MH. Early physiotherapy intervention in an accident and emergency department reduces pain and improves satisfaction for patients with acute low back pain: a randomised trial. Aust J Physiother 2008;54:243–9. [16] Zigenfus GC, Yin J, Giang GM, Fogarty WT. Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders. J Occup Environ Med 2000;42:35–9. [17] Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000;25:1973–6. [18] Pinnington MA, Miller J, Stanley I. An evaluation of prompt access to physiotherapy in the management of low back pain in primary care. Fam Pract 2004;21:372–80. [19] Department of Health. Supporting people with long-term conditions: an NHS and social care model to support local innovation and integration. London: Department of Health; 2005. [20] Niemisto L, Rissanen P, Sarna S, Lahtinen-Suopanki T, Lindgren KA, Hurri H. Cost-effectiveness of combined manipulation, stabilizing exercises and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2 year follow-up. Spine 2005;39:1109–15. [21] Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004;329:708. [22] Gamlin J, Duffield K. PhysioDirect. Cambridgeshire, UK: Huntingdonshire NHS Primary Care Trust; 2001. [23] Lyall J. Physiotherapy direct worries. Physiother Frontline 2007;13(6):6–7, 21 March. [24] Turner D. An exploratory study of physiotherapy telephone assessment. Int J Ther Rehabil 2009;16:97–105.

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[25] Taylor S, Ellis I, Gallagher M. Patient satisfaction with a new physiotherapy telephone service for back pain patients. Physiotherapy 2002;88:645–57. [26] Clayson M, Woolvine M. Back pain direct clinic: a collaboration between general practitioners and physiotherapists. Work Based Learn Prim Care 2004;2:38–43. [27] Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D, et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ 2003;326:477. [28] Charles-Jones H, May C, Latimer J, Roland M. Telephone triage by nurses in primary care: what is it for and what are the consequences likely to be? J Health Serv Res Policy 2003;8:154– 9. [29] Marklund B, Koritz P, Bjorkander E, Bengtsson C. How well do nurse-run telephone consultations and consultations in the surgery agree: experience in Swedish primary health care. Br J Gen Pract 1991;41:462–5.

[30] Gallagher M, Huddart T, Henderson B. Telephone triage of acute illness by a practice nurse in general practice: outcomes of care. Br J Gen Pract 1998;48:1141–5. [31] Lattimer V, Sassi F, George S, Moore M, Turnbull J, Mullee M, et al. Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial. BMJ 2000;320:1053–7. [32] Bunn F, Byrne G, Kendall S. The effects of telephone consultation and triage on healthcare use and patient satisfaction: a systematic review. Br J Gen Pract 2005;55:956–61. [33] McKinstry B, Watson P, Pinnock H, Heaney D, Sheikh A. Telephone consulting in primary care: a triangulated qualitative study of patients and providers. Br J Gen Pract 2009;59:e209– 18. [34] Salisbury C, Foster NE, Bishop A, Calnan M, Coast J, Hall J, et al. ‘PhysioDirect’ telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial. BMC Health Serv Res 2009;9:136.

Available online at www.sciencedirect.com

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Discussion

Measuring quality of life in Parkinson’s disease: selection of-an-appropriate health-related quality of life instrument Sze-Ee Soh a,∗ , Jennifer McGinley a,b , Meg E. Morris a a

Melbourne School of Health Sciences, University of Melbourne, 200 Berkeley Street, Victoria, 3010, Australia b Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Victoria, 3052, Australia

Abstract There is growing awareness of the need to measure quality of life (QOL) in people with Parkinson’s disease during routine physiotherapy assessment. This paper highlights why it is important for clinicians to focus particularly on health-related QOL (HRQOL) when assessing people with this disabling and progressive neurological condition, and provides a guide for selection of the most appropriate instruments for measuring HRQOL. Using measures of health utility, health status and wellbeing, physiotherapists can better understand the social, physical and emotional consequences of Parkinson’s disease. Crown Copyright © 2010 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved. Keywords: Quality of life; Parkinson’s disease; Physiotherapy; HRQOL; QOL

Introduction

Deﬁning quality of life

This article will demonstrate the importance of measuring health-related quality of life (HRQOL) when assessing people with Parkinson’s disease, and provides a clinical decision matrix to assist therapists to select the most appropriate instrument for measuring HRQOL. Movement disorders such as hypokinesia, tremor, dyskinesia and postural instability are common characteristics of Parkinson’s disease [1]. Individuals with Parkinson’s disease may also experience a variety of non-motor symptoms, including depression, sleep disturbance, sensory symptoms and autonomic dysfunction [2,3]. As well as contributing to disability, the motor and non-motor consequences of Parkinson’s disease can compromise quality of life (QOL) in some individuals [2]. Although physiotherapists are accustomed to measuring movement disorders and disability, it can be argued that they have only recently started to incorporate measures of QOL into routine clinical assessment.

QOL can be defined as ‘an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ (p.1405) [4]. Although debate persists regarding what constitutes QOL [5], there are some key concepts common to most definitions. Firstly, QOL can only be validly judged by the individual themselves [5]. This is because the way in which an individual evaluates their QOL often differs from the way in which others judge it [6,7]. For example, Pearlman and Uhlmann [6] reported that some physicians underestimate the QOL of community-dwelling elderly patients with chronic diseases, including arthritis, ischaemic heart disease, diabetes, chronic pulmonary disease and cancer. McKinlay et al. [7] also found low levels of agreement between reports from individuals with Parkinson’s disease and their caregivers with respect to QOL. It is important for physiotherapists to gain the perspective of the individual living with Parkinson’s disease to accurately assess how the disease impacts on QOL. This can be achieved using self-completed questionnaires or patient-reported outcome measures. Cultural norms and value systems can have a major influence on QOL [8]. People from different cultures place different values on activities, social relationships and mate-

∗

Corresponding author. Tel.: +61 3 8344 4171; fax: +61 3 8344 4188. E-mail address: [email protected] (S.-E. Soh).

0031-9406/$ – see front matter. Crown Copyright © 2010 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved. doi:10.1016/j.physio.2010.05.006

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rial possessions. They also vary in their expectations of what it means to feel good and how to communicate their feelings to others [8,9]. For instance, harmonious family relationships are an integral part of some cultures, and a breakdown in the family unit is viewed unfavourably [9]. In other cultures, the public expression of socio-emotional distress is considered to be undesirable and may not be reported to health professionals [8]. It can be informative to consider cultural variations in perceptions of QOL when assessing and measuring it in people with Parkinson’s disease. QOL has both subjective and objective elements [9,10]. Subjective QOL refers to how satisfied an individual is with their life [10], and includes aspects such as wellbeing, life satisfaction and happiness [9]. The objective component relates to how an individual evaluates their actual life circumstances, and the extent to which they are satisfied with or bothered by their accomplishments [10]. Objective QOL includes aspects such as general health, functional performance and socioeconomic status [9,10]. When measuring QOL in people with Parkinson’s disease, physiotherapists need to consider which of these components to assess. For example, if the aim is to assess subjective QOL, the Personal Wellbeing Index (PWI) [11] could be used to measure life satisfaction. Alternatively, if the aim is to measure the impact of Parkinson’s disease on QOL, the Medical Outcomes Study Short Form-36 (SF-36) [12] could be a suitable tool. QOL is a multi-dimensional construct and the number of possible dimensions is large. It can be argued that the key dimensions relevant to clinical practice can be classified into five categories (Fig. 1) [9,13–15]. These are health, global issues, social relationships, personal characteristics and socio-economic status. Inter-relationships exist between these dimensions, and the overall QOL of a person with Parkinson’s disease can be determined by their interactions [9]. The health dimension of QOL, which is known as HRQOL, takes into account aspects of physical health, emotional status and cognitive ability [16]. Previous literature has shown that people with Parkinson’s disease have poorer QOL compared with healthy older people [2]. The global dimension of QOL refers to worldwide issues that may play a role in determining QOL [14]. Political and ecological factors such as human rights or global warming have been shown to account for variations in QOL in people who live in different regions of the world [14]. The social dimension is concerned with interpersonal relationships and community involvement [14]. Elderly individuals without adequate social support often report poor QOL [9]. The personal characteristics dimension incorporates factors such as selfesteem, coping styles and a sense of personal control, which have been shown to correlate strongly with psychological wellbeing and improved QOL [13]. Socio-economic status includes factors such as income, occupation and education [13,14]. Poor financial circumstances are often negatively associated with QOL because the individual may have

fewer resources to cope with increasing costs of health care, housing conditions and education [9].

Health-related quality of life When assessing an individual with Parkinson’s disease, HRQOL is the dimension of life quality that is of particular interest to physiotherapists. This narrows the focus of QOL to the effects of health, and is closely related to the activity and participation domains of the International Classification of Functioning, Disability and Health [15–17]. For example, a person with Parkinson’s disease can have a good HRQOL despite having movement impairments such as tremor or dyskinesia if they do not perceive them as a problem [15]. If an individual is unable to walk independently or to continue working due to the disease, they may be more likely to report poor HRQOL. This is because HRQOL is influenced by the ability of an individual to complete daily activities and participate in life situations [15]. Measuring HRQOL in clinical practice can be useful because it provides an insight into how individuals in the early, middle and late phases of Parkinson’s disease perceive the disease to impact on their QOL [18]. This might guide the assessment and clinical decision making of physiotherapists in their efforts to minimise the burden of disease. Routine use of HRQOL tools within specialised Parkinson’s disease services can also be used to evaluate the effectiveness of care and guide service delivery. For instance, if numerous people in a given service report that pain impacts on their HRQOL, it may be beneficial to implement a pain management programme. Examples of suitable tools for measuring HRQOL in people with Parkinson’s disease are provided in Table 1.

Measuring health-related quality of life Instruments available for measuring HRQOL in people with Parkinson’s disease can be classified into three categories: (i) health status, (ii) health utility and (iii) wellbeing (Fig. 2).

Measures of health status Measures of health status quantify the degree of health and how a person perceives their health to affect their ability to perform functional tasks and daily activities [19]. Health status measures can be categorised as generic or disease specific. Generic measures can be used for all people [3], whereas disease-specific instruments contain questions that are only applicable to a specific condition, such as Parkinson’s disease [19].

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Fig. 1. Dimensions of quality of life and examples of factors influencing each dimension.

Fig. 2. Measures of health-related quality of life (HRQOL) and examples of instruments. PD, Parkinson’s disease; EQ-5D, EuroQoL; AQoL, Assessment of Quality of Life; SF-36, Medical Outcomes Study Short Form-36; NHP, Nottingham Health Profile; SIP, Sickness Impact Profile; PDQ-39, Parkinson’s Disease Questionnaire; PDQL, Parkinson’s Disease Quality of Life Questionnaire; PIMS, Parkinson’s Impact Scale; PDQUALIF, Parkinson’s Disease Quality of Life Scale; PWI, Personal Wellbeing Index; WHOQOL-100, World Health Organization Quality of Life Assessment Instrument-100.

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Table 1 Summary of instruments that can be used to quantify health-related quality of life (HRQOL) in people with Parkinson’s disease. Type of measure

Instrument

Dimensions of health-related quality of life

Comments for use

Generic health status

SF-36 [12]

Physical function, social function, role limitation (physical), role limitation (emotional), mental health, energy/vitality, pain, general health Pain, physical mobility, emotional reactions, energy, social isolation, sleep Ambulation, body care, movement and mobility, eating, emotional behaviour, social interaction, alertness behaviour, communication, sleep and rest, home management, work, recreation, pastimes Mobility, activities of daily living, emotional, stigma, social support, cognition, communication, bodily discomfort Parkinsonian symptoms, systemic symptoms, social symptoms, emotional symptoms Self, family, relationships, community relationships, work, leisure, travel safety, financial security, sexuality Social/role function, self-image/sexuality, sleep, outlook, physical function, independence, urinary function Mobility, self-care, usual activities, psychological status, pain Illness, independent living, social relationships, physical senses, psychological wellbeing

Physical and mental summary scores may not be valid in people with Parkinson’s disease [22]

Standard of living, personal health, achieving in life, personal relationships, personal safety, community connectedness, future security, spirituality/religion Physical, psychological, level of independence, social relationships, environment, personal beliefs

Detects changes in health-related quality of life under chronic stressful situations

NHP [20] SIP [21]

Disease-specific health status

PDQ-39 [24]

PDQL [25] PIMS [27]

PDQUALIF [28]

Health utility

EQ-5D [29] AQoL [30]

Well being

PWI [11]

WHOQOL-100 [32]

Has a bias towards people with more advanced disease [23] Contains 136 items and may be a lengthy questionnaire to complete [3]

May not be able to detect clinically important effects in people with less severe disease [23] Lacks items related to self-care [26] Does not include items related to physical functioning which is important in people with Parkinson’s disease Further psychometric testing required

Utility weights have been published for selected countries Requires further psychometric testing in people with Parkinson’s disease

Contains 100 items and may be a lengthy questionnaire to complete

EQ-5D, EuroQoL; AQoL, Assessment of Quality of Life; SF-36, Medical Outcomes Study Short Form-36; NHP, Nottingham Health Profile; SIP, Sickness Impact Profile; PDQ-39, Parkinson’s Disease Questionnaire; PDQL, Parkinson’s Disease Quality of Life Questionnaire; PIMS, Parkinson’s Impact Scale; PDQUALIF, Parkinson’s Disease Quality of Life Scale; PWI, Personal Wellbeing Index; WHOQOL-100, World Health Organization-Quality of Life Assessment Instrument-100.

Generic measures of health status Widely used generic health status measures for people with Parkinson’s disease include the SF-36 [12], the Nottingham Health Profile (NHP) [20] and the Sickness Impact Profile (SIP) [21]. The SF-36 [12] has 36 items in eight scales. It has been used extensively in people with Parkinson’s disease, and is reliable and valid for this condition [3]. A recent study has shown, however, that the physical and mental summary scores from the SF-36 are not always valid indicators of physical and mental health in people with Parkinson’s disease [22]. The NHP [20] is another generic health status measure commonly used for people with Parkinson’s disease, and is relatively easy to administer. The NHP has two sections. The first consists of 38 dichotomous items measuring perceptions of health in six scales. The second contains seven dichotomous yes/no statements. Recent reviews of the psychometric properties of the NHP in people with Parkinson’s disease found the instrument to be biased towards individuals with more advanced disease. This limits its ability to assess the QOL of people with less severe disease [23]. The SIP [21] is another measure of perceived health status. It has good con-

struct, convergent and discriminatory validity in people with Parkinson’s disease [3]. The SIP contains 136 items in 12 categories, and may not be suitable for use in all situations because it is a longer questionnaire to complete. Generic health status measures do not always fully address areas that are associated with a particular condition, such as Parkinson’s disease [24]. For example, none of the generic instruments address issues related to difficulties with concentration, communication or bodily discomfort as a result of dyskinesia or tremor which are common in people with Parkinson’s disease [24]. Disease-specific health status measures, such as the Parkinson’s Disease Questionnaire (PDQ-39) [24] or Parkinson’s Disease Quality of Life Questionnaire (PDQL) [25], may be more relevant to the individual with Parkinson’s disease, responsive to clinical changes and useful to clinicians monitoring progress [24]. Parkinson’s disease-speciﬁc measures of health status Disease-specific measures contain items that are specific to Parkinson’s disease [19]. These instruments focus on areas that are routinely examined by clinicians, such as difficulties with writing clearly or carrying bags of shopping [19]. The

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PDQ-39 [24] is the most widely used disease-specific instrument for Parkinson’s disease. It comprises of 39 items in eight discrete dimensions that indicate physical, emotional and social functioning due to the disease. The PDQ-39 has good evidence for construct validity, internal consistency, test–retest reliability and sensitivity [3,26]. Recent investigations of the psychometric properties of the PDQ-39 have found some limitations [23]. Ambiguity in the ‘occasionally’ and ‘sometimes’ response categories were found to result in a bias towards individuals with severe disease in a study by Hagell et al. [23]. This may limit the ability of the PDQ-39 to detect small yet clinically important effects in people with less severe disease [23]. The PDQL [25] is another Parkinson’s-disease-specific instrument, and has 37 items across four subscales. The PDQL has good internal consistency reliability in all four subscales, and correlates strongly with clinical measures of Parkinson’s disease [25]. It is also able to discriminate between people at different stages of disease severity [3]. The test–retest reliability and responsiveness of the PDQL still need verification. This is important to ensure that the scale can detect changes in HRQOL over time [3,26]. Two other Parkinson’s-disease-specific health status measures are the Parkinson’s Impact Scale (PIMS) [27] and the Parkinson’s Disease Quality of Life Scale (PDQUALIF) [28]. The PIMS is a 10-item questionnaire that is easy-to-complete. It has only been validated in Canada to date [26]. The PDQUALIF [28] is a 33-item instrument with seven domains. Preliminary results from a cross-sectional study by Welsh et al. [28] indicated that the PDQUALIF has adequate validity and reliability as a measure of HRQOL in people with Parkinson’s disease. Further research is still required to fully evaluate the responsiveness of this instrument, and its ability to discriminate between different disease stages [3]. Measures of health utility Measures of health utility assume that when offered a choice, a rational person prefers to have a shorter life with a more satisfactory state of health compared with a longer life with a considerable disability [5]. Health utility scales require individuals to assign a value to a particular state of health, which are known as ‘utilities’ [5,19]. Preferences of the individual are measured as a single number along a continuum where 0.00 is the equivalent to death and 1.00 is excellent HRQOL [5]. As all utilities for all health states fall on the life–death scale, measures of health utility are generic and can be used to assess HRQOL for any condition, including Parkinson’s disease, osteoarthritis, stroke and mental health [5]. The EuroQoL (EQ-5D) [29] is a health utility measure of HRQOL that has been found to be feasible and valid in people with Parkinson’s disease [3,26]. It consists of a fiveitem descriptive questionnaire and a visual analogue scale (VAS). Responses from the descriptive questionnaire can be converted into a utility value using preference weights estab-

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lished by the EuroQoL Group [29]. Both the utility value and VAS measurement allow different health states and conditions to be compared directly [29]. Utility weights have only been published for countries such as New Zealand, the UK and the USA to date. Consequently, health state values have to be interpreted with caution when using the EQ-5D in countries without published weights, such as Australia, France and Sweden. The Assessment of Quality of Life (AQoL) [30] instrument is another health utility questionnaire that is increasingly being used as a measure of HRQOL. Utility values can be computed to allow the comparison of health states of individuals with different conditions. Studies in elderly people have shown that the AQoL is a sensitive and internally consistent instrument with good construct validity [30,31]. A limitation of these measures is that utility values generated from one instrument may not be equivalent to those generated from another. For example, the utility values obtained from the EQ-5D and AQoL are not directly comparable because both instruments utilise a different approach in placing a value on a given health state. The EQ-5D values health states by asking an individual to rate a given health state, such as living with quadriplegia, on a VAS ranging from 0 (death equivalent) to 1 (full health equivalent) [5]. The AQoL asks the individual to imagine that they are living with quadriplegia, and to specify the number of years they are willing to trade to live in full health [5]. Measures of wellbeing Measures of wellbeing focus on how satisfied an individual with Parkinson’s disease is with their personal life and social situation [11]. Examples of these measures include the PWI [11] and the World Health Organization (WHO) Quality of Life Assessment Instrument-100 (WHOQOL-100) [32]. The PWI is a life satisfaction scale that contains eight life domains designed to assess subjective wellbeing [11]. The WHOQOL-100 is a cross-cultural measure of wellbeing developed by WHO. It categorises QOL into six dimensions, and is designed to be used as a multi-dimensional profile with a wide range of diseases and conditions [32]. Measures of wellbeing are generic and can be used to assess HRQOL for any condition. Using these measures, physiotherapists may be able to determine the satisfaction of a person with Parkinson’s disease with their life and compare their life quality with individuals with other chronic conditions.

Clinical implications Fig. 3 depicts a decision matrix that may assist clinicians and researchers to select the most appropriate tool for assessing HRQOL in people with Parkinson’s disease. The first step is to decide whether to measure HRQOL or another dimension of QOL. If the choice is to measure HRQOL, the next step is to choose a Parkinson’s disease-specific or generic instrument. The Parkinson’s disease-specific instruments are

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Fig. 3. Decision matrix to select an appropriate instrument to measure health-related quality of life (HRQOL) in people with Parkinson’s disease (PD). PDQ39, Parkinson’s Disease Questionnaire; PDQL, Parkinson’s Disease Quality of Life Questionnaire; PIMS, Parkinson’s Impact Scale; PDQUALIF, Parkinson’s Disease Quality of Life Scale; SF-36, Medical Outcomes Study Short Form-36; SIP, Sickness Impact Profile; NHP, Nottingham Health Profile; EQ-5D, EuroQoL; AQoL, Assessment of Quality of Life; PWI, Personal Wellbeing Index; WHOQOL-100, World Health Organization Quality of Life Assessment Instrument-100.

shown on the left side of the matrix and the generic tools are shown on the right. The generic tools allow the therapist to compare the HRQOL of people with Parkinson’s disease with healthy individuals or those with other medical conditions. Three different types of generic instruments are available. If the aim is to determine the ability of an individual to perform functional tasks, a generic health status measure such as the SF-36 is recommended. If the purpose is to undertake economic and cost-utility analysis, the EQ-5D or AQoL could be used. Wellbeing measures such as the PWI are appropriate if the goal is to assess the satisfaction of an individual with their life. These decisions may change over the course of Parkinson’s disease. Health status measures may be useful in the early and mid phase of the disease to monitor self-reported functional ability. In the later stages of the disease when individuals are confined to bed, wellbeing measures that assess global life satisfaction may be considered. If the decision is to use a Parkinson’s disease-specific instrument, there are also several choices. The PDQ-39 has items related to physical, social and emotional functions. It addresses experiences that are important to people with Parkinson’s disease, such as difficulties cutting food, difficulties performing usual activities of daily living, social embarrassment, feelings of isolation and bodily discomfort [24]. The PDQL assesses the impact of Parkinson-related symptoms such as stiffness, tremor, on/off periods and dyskinesias. It also has items relating to constipation, feeling embarrassed due to the disease and being unable to participate

in normal social activities [25]. Although the PIMS covers 10 dimensions of HRQOL, it only has general statements about mobility and transfers. It is therefore recommended for use as a tool to identify areas of potential problems in a person with Parkinson’s disease [26]. Many of the items in the PDQUALIF focus on the physical features of Parkinson’s disease. Nevertheless, it also addresses issues related to fatigue, driving ability and financial consequences which are important to people with Parkinson’s disease.

Summary QOL in people with Parkinson’s disease can be influenced by their health, socio-economic status, personal beliefs, environmental issues and social relationships. Physiotherapists can assess the HRQOL of people with Parkinson’s disease using measures of health utility, health status or wellbeing. Incorporating measures of HRQOL together with clinical measures of Parkinson’s disease can guide the assessment and clinical decision-making processes with the aim of optimising the effectiveness of physiotherapy. Ethical approval: None required. Funding: Sze-Ee Soh was provided with financial support to write this article by the Australian Postgraduate Award and a Faculty of Medicine, Dentistry and Health Sciences Scholarship, University of Melbourne. Conﬂict of interest: None declared.

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Available online at www.sciencedirect.com

Physiotherapy 97 (2011) 90

Erratum

Erratum to the Letter to the Editor ‘Cognitive determinants of pain and disability in patients with chronic whiplash-associated disorder: a cross-sectional observational study’ and ‘Response’ [Physiotherapy 96 (2010) 350–351] Chris Worsfold (Letter to the Editor), Dave P. Thompson (Response)

The Publisher regrets that the address for Chris Worsfold inadvertently appeared as the details for Dave P. Thompson. Please note that the address for Chris Worsfold is as follows: Kent Whiplash & Neck Pain Centre, The Tonbridge Clinic, 339 Shipbourne Road, Tonbridge, Kent, UK The address for Dave P. Thompson is as follows: The Pennine Acute Hospitals NHS Trust, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester, UK The addresses have been corrected in the on-line version. doi: 10.1016/j.physio.2010.11.004 DOIs of Original articles: 10.1016/j.physio.2010.07.001, 10.1016/j.physio.2010.07.002

Book review Orthopaedic Manual Therapy Diagnosis – Spine and Temporomandibular Joints, Aad van der El, Jones and Bartlett Publishers, 2010, 578 pages, ISBN-13: 978-0-7637-5594-2 Orthopaedic Manual Therapy Diagnosis is a textbook on neuromusculoskeletal diagnosis of dysfunction of the spine and temporomandibular joints. It evolved from a 1983 training manual for manual therapists, and the author is targeting entry level and postgraduate health professionals working in the field of orthopaedic manual therapy. The content is organised into two parts: Part 1 (Introduction) provides an overview of the structure and function of the spine, and Part 2

(Examination) describes the examination processes of the different parts of the spine and the temporomandibular joints. The material covered in Part 1 could be of clinical use, although it would benefit from a greater reliance on the evidence and more recent references. The discussions throughout the book dealing with pain need to acknowledge the advances in knowledge on pain mechanisms over the past decade. Similarly, the literature cited on the coupling of movements in the different regions of the spine would benefit from updating to include the results of more recent three-dimensional studies of spinal movement. In Part 2, the material is generally presented in a readable and comprehensible manner, although

some parts can be difficult to follow and would benefit from more recent references. The author makes use of a number of tables and figures to summarise the examination processes. More description of the test procedures would have been useful to support the numerous photographs. The concept of this endeavour is very good, and the author should be commended for his efforts in converting the manual into a textbook. With significant updating and some alterations in presentation, it could be a useful text for orthopaedic manual therapists in clinical practice. G. Zito E-mail address:[email protected] doi: 10.1016/j.physio.2010.02.002

Available online at www.sciencedirect.com

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.11.004

Physiotherapy 97 (2011) 90

Erratum

Erratum to the Letter to the Editor ‘Cognitive determinants of pain and disability in patients with chronic whiplash-associated disorder: a cross-sectional observational study’ and ‘Response’ [Physiotherapy 96 (2010) 350–351] Chris Worsfold (Letter to the Editor), Dave P. Thompson (Response)

The Publisher regrets that the address for Chris Worsfold inadvertently appeared as the details for Dave P. Thompson. Please note that the address for Chris Worsfold is as follows: Kent Whiplash & Neck Pain Centre, The Tonbridge Clinic, 339 Shipbourne Road, Tonbridge, Kent, UK The address for Dave P. Thompson is as follows: The Pennine Acute Hospitals NHS Trust, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester, UK The addresses have been corrected in the on-line version. doi: 10.1016/j.physio.2010.11.004 DOIs of Original articles: 10.1016/j.physio.2010.07.001, 10.1016/j.physio.2010.07.002

Book review Orthopaedic Manual Therapy Diagnosis – Spine and Temporomandibular Joints, Aad van der El, Jones and Bartlett Publishers, 2010, 578 pages, ISBN-13: 978-0-7637-5594-2 Orthopaedic Manual Therapy Diagnosis is a textbook on neuromusculoskeletal diagnosis of dysfunction of the spine and temporomandibular joints. It evolved from a 1983 training manual for manual therapists, and the author is targeting entry level and postgraduate health professionals working in the field of orthopaedic manual therapy. The content is organised into two parts: Part 1 (Introduction) provides an overview of the structure and function of the spine, and Part 2

(Examination) describes the examination processes of the different parts of the spine and the temporomandibular joints. The material covered in Part 1 could be of clinical use, although it would benefit from a greater reliance on the evidence and more recent references. The discussions throughout the book dealing with pain need to acknowledge the advances in knowledge on pain mechanisms over the past decade. Similarly, the literature cited on the coupling of movements in the different regions of the spine would benefit from updating to include the results of more recent three-dimensional studies of spinal movement. In Part 2, the material is generally presented in a readable and comprehensible manner, although

some parts can be difficult to follow and would benefit from more recent references. The author makes use of a number of tables and figures to summarise the examination processes. More description of the test procedures would have been useful to support the numerous photographs. The concept of this endeavour is very good, and the author should be commended for his efforts in converting the manual into a textbook. With significant updating and some alterations in presentation, it could be a useful text for orthopaedic manual therapists in clinical practice. G. Zito E-mail address:[email protected] doi: 10.1016/j.physio.2010.02.002

Available online at www.sciencedirect.com

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.11.004