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![W.B. SAUNDERS COMPANY
A Division of Harcourt Brace & Company
The Curtis Center
Independence Square West
Philadelphia, Pennsylvania 19106
Library of Congress Cataloging-In-Publication Data
Assessment in occupational therapy and physical therapy I [edited by]
Julia Van Deusen and Denis Brunt.
p. cm.
ISBN 0-7216-4444-9
1. Occupational therapy. 2. Physical therapy. I. Van Deusen,
Julia. II. Brunt, Denis.
[DNLM: 1. Physical Examination-methods. 2. Physical Therapy
methods. 3. Occupational Therapy-methods. we 205 A847 1997]
RM735.65.A86 1997 616.0T54-<lc20
DNLM/DLC 96-6052
Assessment in Occupational Therapy and Physical Therapy 0-7216-4444-9
Copyright © 1997 by WB. Saunders Company
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without
permission in writing from the publisher.
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-6-2048.jpg)
![Thus, validation is viewed as an continual process (Messick,
1989; Nunnally, 1978). Even when a large body of
evidence seems to exist in support of the validity of a
particular scale (e.g., the Wechsler Intelligence Scales),
validity studies are continually needed, as social or cultural
conditions change over time and cause our interpretation
of the trait or behavior to change. Thus, for a scale to
remain valid over time, its validity must be reestablished
periodically. Later in this chapter, the social consequences
of testing (MeSSick, 1989) are discussed as a reminder of
the need to reevaluate the validity of measures used in
occupational and physical therapy as times change and the
nature of the professions change. Much more is said about
the methods used to validate test scores later in the chapter
in the context of the development and evaluation of
observational measurement tools.
Reliability Theory
Clinicians and researchers are well aware of the impor
tance of knowing and reporting the reliability of the scales
used in their practice. In understanding conceptually what
is meant by reliability, we need to introduce the concept of
true score. A true score is the person's actual ability or
status in the area being measured. If we were interested in
measuring the level of "functional independence" of an
individual, no matter what scale is used, we assume that
each individual has a "true" functional independence
score, which reflects what his or her functional abilities are,
if they could be perfectly measured. An individual's true
score could be obtained by testing the individual an infinite
number of times using the same measure of functional
independence and taking the average ofall of his or her test
scores. However, in reality it is not possible to test an
individual an infinite number of times for obvious reasons.
Instead, we estimate how well the observed score (often
from one observation) reflects the person's true score. This
estimate is called a reliability coefficient.
While a true score for an individual is a theoretical
concept, it nonetheless is central to interpreting what is
meant by a reliability coefficient. A reliability coefficient is
an expression of how accurately a given measurement tool
has been able to assess an individual's true score. Notice
that this definition adds one additional element to the more
commonly referred to definition of reliability, usually
described as the accuracy or consistency of the measure
ment tool. By understanding the concept of true score, one
can better appreciate what is meant by the numeric value
of a reliability coefficient. In the next few paragraphs, the
mathematic logic behind a reliability coefficient is de
scribed.
In an actual assessment situation, if we needed to obtain
a measure of a person's functional independence, we likely
would take only one measurement. This one measurement
is referred to as an individual's observed score. The
discrepancy between an individual's true score and his or
her observed score is referred to as the error score. This
simple relationship forms the basis of what is referred to as
"classical test theory" and is shown by Equation 1-1:
observed score (0) = true score ( T ) + error score (E)
[1]
Since the concept of reliability is a statistic that is based on
the notion of individual differences that produce variability
in observed scores, we need to rewrite Equation 1-1 to
represent a group of individuals who have been measured
for functional independence. The relationship between
observed, true, and error scores for a group is given by
Equation 1-2:
[2]
where 0'
2
0 is the "observed score" variance, O'
2
T is the
"true score" variance, and O'
2
E is the "error score vari
ance." The variance is a group statistic that provides an
index of how spread out the observed scores are around
the mean "on the average." Given that the assumptions
of classical test theory hold, the error score drops out of
Equation 1-2, and the reliability coefficient (p"J is de
fined as
2 / 2 [3]pxx = 0' TO'O
Therefore, the proper interpretation of Equation 1-3 is
that a reliability coefficient is the proportion of observed
score variance that is attributed to true score variance. For
example, if a reliabilitycoefficient of 0.85 were reported for
our measure of functional independence, it would mean
that 85% of the observed variance can be attributed to true
score variance, or 85% of the measurement is assessing the
individual's true level of functional independence, and the
remaining 15% is attributed to measurement error.
The observed score variance is the actual variance
obtained from the sample data at hand. The true and error
score variance cannot be calculated in classical test theory
because they are theoretical concepts. As it is impossible to
testan individualan infinite number oftimes to compute his
or her true score, all calculations of reliability are consid
ered estimates. What is being estimated is a person's true
score. The more accurate the measurement tool is, the
closer the person's observed score is to his or her true
score. With only one measurement, we assume that 0 = T.
How much confidence we can place in whether the as
sumption of 0 = T is correct is expressed by the reliability
coefficient. (For the interested reader, the derivation of the
reliability coefficient, given that the numerator of Equation
1-3 is theoretical, is provided in many psychometric theory
texts, e.g., Crocker & Algina, 1986, pp. 117-122. Also,](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-27-2048.jpg)
![ASSESSING THE VALIDITY OF
OBSERVATIONAL MEASURES
Validi tells us what the test score measures. However,
5ina; anyone test can be use or qUlfeaifre-r~nt'purposes,
we need to know not just "is the test score valid" but also
is the test score valid for the purpose for which I wish to
J5e it?" Each form of validity calls for a different procedure
llat permits one type of inference to be drawn. Therefore,
the purpose for testing an individual should be clear, since
being able to make predictions or discuss a construct leads
to very different measurement research designs.
Several different procedures for validating scores are
derived from an instrument, and each depends on the
purpose for which the test scores will be used. An overview
of these procedures is presented in Table 1-3. As shown in
the table, each validation procedure is associated with a
given purpose for testing (column 1). For each purpose, an
illustrative question regarding the interpretation of the
score is provided under column 2. Column 3 shows the
form of validity that is called for by the question, and
::olumn 4, the relevant form(s) of reliability given the
purpose of testing.
Law (1987) has organized the forms of validation around
three general reasons for testing in occupational therapy:
descriptive, predictive, and evaluative. She indicates that
an individual in the clinic might need to be tested for several
different reasons. If the patient has had a stroke, then the
therapist might want "to compa!'e [him or her] to other
stroke patients (descriptive), determine the probability of
full recovery (prediction) or assess the effect of treatment
(evaluative)" (p. 134). For a tool used descriptively, Law
suggests that evidence of both content and construct
validation of the scores should exist. For prediction, she
advises that content and criterion-related data be available.
Finally, for evaluative, she recommends that content and
construct evidence be reported. Thus, no matter what the
purpose of testing is, Law feels that all instruments used in
JiBI l. 1<I
the clinic should possess content validity, as she includes it
in each reason for testing.
Given that validity is the most important aspect of a test
score, we shall discuss the procedures to establish each
form of validity noted in Table 1-3 for any measurement
tool. However, we focus our illustrations on observational
measures. In addition, we point out the issues inherent in
each form of validation so that the practitioner and
researcher can evaluate whether sufficient evidence has
been established to ensure a correct interpretation of the
test's scores.
Construct Validation
Construct validation is reguired when the interpretation
to be made of the scores implies an explanation of the
benailior or trait. A construct is a theoretical conceptual
ization ottnebe havior developed from observation. For
example, functional independence is a construct that is
operationalized by the Functional Independence Measure
(FIM). However, or a cons truCt'io be useful;--Lord and
Novick (1968) advise that the construct must be defined on
two levels: operationally and in terms of how the construct
of interest relates to other constructs. This latter point is the
heart of what Cronbach and Meehl (1955) meant when
they introduced the term nomological network in their
classical article that defined construct validity. A nomologi
cal network for a given construct, functionalindependence,
stipulates how functional independence is influenced by
other constructs, such as motivation, and in turn influences
such constructs as self-esteem. To specify the nomological
network for functional independence or any construct, a
strong theory regarding the construct must be available.
The stronger the substantive theory regarding a construct,
the easier it is to design a validation study that has the
potential for providing strong empirical evidence. The
weaker or more tenuous the substantive theory, the greater
the likelihood that equally weak empirical evidence will be
OVERVIEW OF VAUDD'Y AND REUABDlTY PROCEDtJRES
Purpose of the Test Validity Question Kind of Validity ReliabiUty Procedures
Assess current status Do items represent the domain? Content
Predict behavior or How accurate is the prediction? Criterion-related: concurrent
performance or predictive
Infer degree of trait How do we know a specific Construct
or behavior behavior is being measured?
a) Internal consistency within each subarena
b) Equivalency (for multiple forms)
c) Variance components for observers
a) Stability
b) Equivalency (for multiple forms)
c) Variance components for observers
a) Internal consistency
b) Equivalency (for multiple forms)
c) Stability (if measuring over time)
d) Variance components for observers
~_ _-=::::::::::i::::](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-33-2048.jpg)
![14 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
Criterion-Related Validity
There are two forms of criterion-related validation:
concurrent and predictive. Each form is assessed in the
same manner. The only difference between these two
forms is when the criterion is obtained. Concurrent
validation refers to the fact that the criterion is obtained at
approximately the same time as the predictor data,
whereas predictive validation implies that the criterion was
obtained some time after the predictor data. An example of
concurrent validation would be if the predictor is the score
on the FIM taken in the clinic and the criterion is the
observation made by the therapist on visiting the patient at
home the next day, then the correlation between these two
"scores" (for a group of patients) would be referred to as
the concurrent validity coefficient. However, if the criterion
observation made in the home is obtained 1 or 2 months
later, the correlation between these scores (for a group of
patients) is referred to as the predictive validity coefficient.
Thus, the only difference between concurrent and predic
tive validation is the time interval between when the
predictor and criterion scores are obtained.
The most important consideration in evaluating
criterion-related validity results is "what ,is the criterion?" In
a criterion-related validity study, what we are actually
validating is the predictor score (the FIM in the two
illustrations just given) based on the criterion score. Thus,
a good criterion must have several characteristics. First, the
criterion must be "unquestioned" in terms of its validity,
i.e., the criterion must be considered the "accepted
standard" for the behavior that is being measured. In the
illustrations just given, we might then question the validity
of the therapist's observation made at the patient's home.
In addition to the criterion being valid, it must also be
reliable. In fact, the upper bound of the validity coefficient
can be estimated using the following equation:
ry/ = VCrxx) . Cryy) [6]
where ryX' is the upper bound of the validity coefficient, rxx
is the reliability of the predictor, and ryy is the reliability of
the criterion. If the reliability of the predictor is 0.75 and the
reliability of the criterion is 0.85, then the maximum
validity coefficient is estimated to be 0.80, but if the
reliability of the predictor is 0.60 and criterion is 0.70, then
maximum validity coefficient is estimated to be 0.42. Being
able to estimate the maximum value of the validity coeffi
cient prior to conducting the validity study is critical. If the
estimated value is too low, then the reliability of the
predictor or criterion should be improved prior to initiating
the validity study, or another predictor or criterion measure
can be used.
The value of the validity coefficient is extremely impor
tant. It is what is used to evaluate the accuracy of the
prediction, which is obtained by squaring the validity
coefficient (rx/)' In the illustration just given, the accuracy
of the prediction is 36% when the validity coefficient
0.60 and 18% when the validity coefficient is 0.42. Th
accuracy of the prediction tells us how much variance th
predictor is able to explain of the criterion out of 100%
Given the results just presented, it is obvious that the choic
of the predictor and criterion should be made very carefully
Furthermore, multiple predictors often improve the accu
racy of the prediction. To estimate the validity coefficien
with multiple predictors requires knowledge of multipl
regression, which we do not go into in this chapter. A
readable reference is Pedhazur (1982).
Since criterion-related validation is based on using
correlation coefficient (usually the pearson produc
moment correlation coefficient if the predictor and crite
rion are both continuous variables), then the issues t
consider with this form of validity are those that impact th
correlation coefficient. For example, the range of individua
scores on the predictor or criterion can be limited, th
relationship between the predictor and criterion may not b
linear, or the sample size may be too small. These thre
factors singly or in combination lower the validity coeff
cient. The magnitude of the validity coefficient also
reduced, influenced by the degree of measureme,nt error i
the predictor and criterion. This situation is referred to a
the validity coefficient being attenuated. If a researche
wants to see how high the validity coefficient would be if th
predictor and criterion were perfectly measured, th
follOwing equation can be used:
ryx' = rx/VCrxx) . Cryy) [7
where rxy' is the corrected or disattenuated validit
coefficient, and the other terms have been previousl
defined. The importance of considering the disattenuate
validity coefficient is that it tells us whether it is worth it t
try and improve the reliability of the predictor or criterion
If the disattenuated validity coefficient is only 0.50, then
might be a better strategy to select another predictor o
criterion.
One final issue to consider in evaluating criterion-relate
validity coefficients is that since they are correlations, the
can be influenced by other variables. Therefore, correlate
of the predictor should be considered to determine if som
other variable is influencing the relationship of interest. Fo
instance, let us assume that motivation was correlated wit
the FIM. 1f we chose to use the FIM to predict employability
the magnitude of the relationship between the FIM an
employability would be influenced by motivation. We ca
control the influence of motivation on the relationshi
between the FIM and employability by using partial corre
lations. This allows us to evaluate the magnitude of th
actual relationship free of the influence of motivation
Crocker and Algina (1986) provide a discussion of the nee
to consider partial correlations in evaluating the results o
a criterion-related validity study.
Now that the procedures for assessing reliability an
validity have been presented, it would be useful to appl](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-36-2048.jpg)
![ability score can be estimated from any set of items that
have been Rasch scaled. Thus, not every individual has to
take the same set of items or the same number of items.
This really frees up the examiner to select the set of items
[hat is most appropriate for the individual and not frustrate
him or her with a set of items that is either too difficult or
too easy. Once the items have been Rasch scaled, the
observer or examiner does not need to be concerned with
administering all the items to each examinee; a subset can
just as efficiently measure his or her "true" score as the full
set of items. In fact, it could be argued that administering a
subset of items targeted to the individual's ability is more
',vhat assessment should be like, compared with the tradi
tional format of everyone receiving the same set of items.
Thus, Rasch scaling permits sample-free and test-free
measurement.
The Rasch model is a model from a larger class of models
:-eferred to as item response theory models. Item response
theory models form the basis of modern test theory, as
opposed to the classical procedures referred to earlier in
this chapter. One feature that distinguishes modern test
[heory from classical test theory is that the assumptions of
[he model are directly testable, whereas the assumptions
for classkal test theory are not. (The assumptions for
classical test theory involve the error term shown in
equations 1-1 and 1-2. The assumptions consider that an
individual is tested an infinite number of times on a given
instrument and that: 1) the mean of their error score is zero
llle = 0], 2) the correlation between the error scores is zero
IPee = 0], and 3) the correlation between an individual's
[rue score and his or her error scores is zero [Pte = 0].)
The assumptions made in using the Rasch procedures
are that the trait being measured is unidimensional, the
items used have equal discrimination power, and the items
are locally independent. Local independence refers to the
fact that responses to one item do not influence the
responses to another item. If these assumptions can be
verified, then a person's score on a scale is only a function
of his or her ability and the difficulty level of the item.
As pointed out earlier in the chapter, in observational
data, other sources of variation are introduced into the
measurement, such as observer effects. The many-faceted
Rasch model allows other sources of test score variation to
be accounted for, as did the variance component proce
dures described in the section on reliability of observational
measures. Fischer (1993) illustrates the use of the many
faceted Rasch model, in which rater severity and the
challenge of the task performed were considered in
addition to item difficulty and person ability.
Training Observers
The research on observer training has shown that
serious attention to this step in the process helps to ensure
reliable data (Spool, 1978). In fact, once the observers are
sufficiently trained, we can begin to collect reliability data to
determine how accurate the tool is in assessing true score.
In the initial process of training observers, it is very
important that the theoretical and operational definition of
the behavior to be observed is made clear. We do not want
the observers rating the behavior they "think" should be
rated but the behaviors on which the observational form
was developed. Usually, brief, concise definitions are
provided and discussed for clarity. Borg and Gall (1983)
have suggested that testing the observers at this point on
their understanding of the behavior may be helpful. We
certainly agree with their suggestion, especially if the
observation is part of a research study. This should also be
considered more often with instruments used in practice.
It is highly desirable to have available videotapes of the
behavior to be observed for the therapist to study and
replay. The training session then can run segments of the
videotape, have the therapist use the observational form,
then stop the tape for discussion of what behavior was
noted and whether it matches with the criterion. In the
training of observers, it is critical that a criterion be
established. Usually, the criterion is the ratings made by the
trainer, and the objective is for the therapists in training to
produce the ratings that the trainer made. In this way, the
reliability of the raters can be assessed. If therapists in
training do not match the criterion, then the videotape can
be stopped, and the behavior that was missed or mis
marked can be discussed and corrected. Being able to show
the persons being trained exactly what behavior is repre
sented by the item on the observational form improves
their understanding of the behavior and hence the reliability
of their observations. Thus, the point of providing training
for observers is to ensure the reliability of the data.
Once the training using videotapes has reached a
satisfactory level, then the training should be moved to an
actual site in which the behavior can be observed. This
enables a more realistic training arena in which to try out
the observational form and the accuracy of the observers.
The observers should not be practicing on patients for
whom actual data are required. It may be possible for the
criterion rater to make the rating that is required for the
patient and the observers being trained to likewise rate
the behavior and then compare the results after the fact. If
possible, videotaping these actual settings benefit those
currently being trained and could be used in later training
efforts as well.
When the observers are trained to an adequate level to
use the instrument in the setting in which it was designed,
then the process of gathering reliability data should be
started. One final point on the training of observers: If
rating takes place over time, such as when treatment is
needed over a long period or in a longitudinal research
study, it is critical to reevaluate the reliability of the
observers periodically. This can be done by either having
the criterion rater jointly rate the individual along with the
rater(s) being studied or videotape the rater(s) being studied
so that the criterion rater can also rate the same behavior.
These types of checks on the reliability of the observers](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-43-2048.jpg)
![24 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
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World Health Organization (1980). Interna tional classification of
impairments, disabilities, and handicaps. Geneva: World Health
Organization.](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-46-2048.jpg)
![50 UNIT TWO-COMPONENT ASSESSMENTS OFTHE ADULT
return to work status (Waddell et aL, 1992). Despite the
difficulties with which therapists are confronted, it is clear
that they will continue to use assessment of ROM as a part
of the evaluative process. When assessing joint ROM,
therapists want to link the act with a measurement,
converting their observations into quantitative information
(Michels, 1982). This information in turn allows therapists
to make decisions regarding the necessity of specific
treatment for the patient, as well as approach and modifi
cation of treatment. It also gives some indication of
progress, as well as anticipated functional status or disabil
ity (American Medical Association, 1969; Miller, 1985).
Assessment of joint ROM is based on what are termed
objective measurements, as distinguished from subjective
measurements, e.g., visual estimation. Objective measure
ments are characterized by the relative independence of
the examiner, providing reliability estimates that demon
strate the apparent subjective error (Bohannon, 1989;
Rothstein, 1989). Realizing that clinical measurements are
probably never completely objective, relying always to
some extent on the examiner's judgment (Rothstein,
1989), it should be noted that objective measures can
provide evidence of improvement (increases in ROM) often
earlier than subjective measurements or measurements of
function (Bohannon, 1989).
An ongoing goal should be to constantly make efforts
toward reducing the amount of error of variance in
measurement procedures and to provide an accurate
representation of the changes displayed by the patient.
Bohannon (1989) lists four basic purposes for objective
measures: 1) to describe status, 2) to document change, 3)
to explain performance, and 4) to predict outcome. A fifth
reason should be to encourage the patient's interest and
motivation in the treatment program (Palmer and Epler,
1990).
In assessing ROM, the therapist can determine the
patient's status by comparing measurements with those of
the uninvolved joint or with "normal" values. The ability to
document change is made by the therapist's remeasure
ments made over time. By knowing a patient's measure
ments in relation to measurements necessary for functional
ROM (e.g., climbing steps or combing hair), the therapist
can determine the patient's ability to perform a speCific
task. By measuring the ROM of various joints acting along
a kinetic chain, functional activities can be predicted to
some extent (Bohannon, 1982).
The purpose of this chapter is to provide the clinician
with a quick reference to reliability and validity of ROM
measurements for various upper and lower extremity
joints. Another goal isto introduce alternative methods that
depict novel and insightful proceduresand instrumentation
designed to acquire information regarding changes in
musculoskeletal joint position. The majority of the sections
on specific joint ROM provide both a table of "normal"
joint ROM measurements and information regarding func
tional ROM, with particular emphasis on the upper ex
tremities. In addition, by the year 2000 it is estimated
15 percent of the Gross National Product may be spe
the low back problem (Cats-Baril & Frymoyer, 1
Therefore, a special section on ROM for the lumbar s
which offers an in-depth review of commonly used
niques, has been included.
HISTORICAL PERSPECTIVE
The early beginnings of ROM measurements date
to the first decade of this century, when two Fr
physiologists, Camus and Amar (Smith, 1982), des
and began to use protractor goniometers to measur
relationship between mensuration and disablemen
deed, much of the earlier literature appears to
consequence of the postwar era and the necessi
relating ROM to disability (Smith, 1982).
The nomenclature and much of the standardized m
ods for measuring range of motion have been establ
by the American Academy of Orthopedic Surgeons
basis for this system was established by research perfo
by Cave and Roberts (1936) and has been widely acc
throughout the medical world (Smith, 1982). The pro
sion of these standards to improve objectivity by lo
both at inter- and intraobserver reliability and va
(Hellebrandt et aL, 1949; Leighton, 1955) added co
erably to the progression toward increased objectiv
measurements. Although a variety of instruments
methods have been used for measuring ROM, the univ
goniometer has been recognized as an accurate
convenient instrument for measurements (Defib
1964; Moore, 1949a; Salter, 1955).
Even though the methods indicated by the Ame
Academy of Orthopedic Surgeons have been widely
both the reliability of these methods and the certain
what has been cited as "normal range" values are h
questionable given the paucity of research that w
confirm these methodologies. However, ongoing res
has continued to substantiate the reliability and valid
certain methods and instrumentation, as well as docu
normal ROM values (Boone & Azen, 1979; Elveru e
1988; GogiaetaL, 1987; Riddleetal., 1987; Rothst
aI., 1983). Although goniometry has long been use
assessment in physical therapy, it was not until the
1940s that formal studies were performed to d
mine the reliability of these measurement techn
(Hellebrandt et aI., 1949; Moore, 1949b). Moore
earlier researchers in recognizing the necessity of loc
the "axis of motion," as well as appropriate place
of the two arms of the goniometer along definitive
landmarks. (For a more in-depth historical accou
methodology and instrumentation, see Moore's two
work [1949a, 1949b], which was followed by th
Hellebrandt et aI., 1949.) The determination tha](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-72-2048.jpg)
!["NORMAL" ROM MEASUREMENTS IN DEGREES FOR THE ElBOW, REPORTED BY SEVERAL
AUTHORS
Boone & Dorinson & Escb & Gerhardt & Petherick Solgaard Wiecbec &
MOS Azen- Wagner Lepley Russe AMA et al.t et a1.:f: Krusen
Joint (1965) (1979) ( 1948) (1974) (1975) (1958) (1988) (1986) (1939)
Elbow
Flexion 150 143 145 150 150 150 149 135
Radioulnar
Pronation 80 76 80 90 80 80 S6 90
Supination 80 82 70 90 90 SO 93 90
• N = 109, IS54 y. male.
t N = 30, x =24 y, male and female.
'' N = 31 , 24-65 y. male and female.
AAOS = American Academy of Orthopedic Surgeons; AMA = American Medical Association.
supination and pronation has been cited (Macrae 1983),
offering the examiner some assistance with regard to a
point of reference for alignment of the goniometer.
Another method for measuring forearm pronation and
supination utilizes an axial rotation gravity goniometer
(Fig. 3-7). This method demonstrated a high level of
intertester reliability (r = 0.94) for measuring supination
and pronation (n = 50) (Laupattarakasem et al., 1990).
When looking at normal values for elbow flexion and
extension, Boone and Azen (1979) provided values of 0 to
145 degrees and 0 to 140.5 degrees when comparing a
population younger than 19 years with one older than 19
years, respectively. Additional normative values are listed
in Table 3-3.
Studies to determine functional ROM (Safaee-Rad et al.,
1990) found that the required ranges for performance of
three feeding tasks (eating with a spoon, eating with a fork,
and drinking from a handled cup) required 70 degrees to
130 degrees elbow flexion and from 40 degrees forearm
pronation to 60 degrees forearm supination.
SHOULDER
It is well recognized that the shoulder is one of the more
complex functional units within the body. Earlier studies
(Hellebrandt et aI., 1949) indicated reliable repetitive
measurements involving shoulder joint movements, with
the exception of medial rotation and shoulder abduction.
Shoulder external rotation was examined by Boone and
Azen (1978), who demonstrated both intratester and
intertester reliability when measuring the shoulder at
r = 0.96 and 0.97, respectively. Because of the combined
contributions of both the glenohumeral and the scapu
lothoracic movements, resulting in total shoulder ROM,
delineation of the two needs to be identified when per
forming ROM measurements of the shoulder (Friedman &
Monroe, 1966). An early study (Doody et a!., 1970) was
designed to determine relative contributions of the scapu
lothoracic and glenohumeral movements to scapular plane
abduction. Using a double goniometer, the authors cleverly
isolated the contributions of the scapula at 58.62 degrees
and the glenohumeral at 112.52 degrees to give the total
scapulohumeral "rhythm" (Fig. 3-8). The reliability of this
technique has been challenged in recent years in a study by
Youdas and associates (1994). The results of this study
indicated that the margin of error for intratester measure
ments (variance of > 3 degrees 50 percent of the time and
> 8 degrees 10 percent of the time between first and
second measurements) was dinica:]]y unacceptable.
A method utilized by DeVita and colleagues (1990) in
measuring scapular motion used the spine (third thoracic
vertebrae) and the inferior angle of the acromion process of
FIGURE 3-8. A method for measuring both glenohumeral and
scapulothoracic ROM using a double goniometer. Scapular angle is the
angle of the spine of the scapula to the vertical: glenohumeral angle is the
angle between the spine of the scapula and the humerus. Summation of
the two angles is the arm angle. (From Doody, S. G. , et al. [1970J.
Shoulder movements during abduction in the scapular plane. Archives of
Physical Medicine and Rehabilitation, 51, 595-604.)](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-79-2048.jpg)
![58 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 3-9. It is important to note the amount of shoulder abduction
when measuring shoulder external and internal rotation.
the scapula as the "moveable" reference point Another
method (Kibler, 1991)used a linear measurement from the
nearest spinous process to the inferior angle of the scapula.
When investigating various techniques used in previous
studies, Gibson and coworkers (1995) demonstrated a high
level of intra- and intertester reliability (intraclass correla
tion coefficient [ICC] = 0.95, 0.92) for the method of
DeVita and coworkers (1990); however, they found low
,intertester reliability for the Kibler (1991) method. It has
been suggested that these methods may provide results that
prove to be somewhat difficult to interpret by the clinician,
particularly the Kibler (1991) method.
When measuring shoulder ROM, the clinician needs to
be aware of the contributions not only of shoulder flexion
and abduction but also of accompanying motions, e.g.,
external and internal rotation. Accompanying motion that
occurs during active shoulder flexion was ingeniously
determined in a study by Blakely and Palmer (1984). In this
study, a universal goniometer and a gravity-activated angle
finder were utilized to determine that medial rotation of the
humerus accompanied active and passive shoulder flexion
movements. During measurements of shoulder internal
and external rotation , the amount of shoulder abduction
needs to be noted, as this may limit ROM measurements
(Fig. 3-9). Also, the plane in which shoulder elevation is
made should be recorded, as this too may limit the available
ROM (Fig. 3-10). The plane of the scapula (30 degrees-45
degrees to the frontal plane) has been described as the most
functional position for elevation because the capsule is not
twisted on itself and the deltoid and supraspinatus are best
aligned for shoulder elevation (Zuckerman & Matsen,
1989) (Fig. 3-11).
Riddle and colleagues (1987) examined both intertester
and intratester reliability of shoulder passive range of
motion (PROM), utilizing two different-sized universal
goniometers. They demonstrated intratester reliability for
FIGURE 3-10. Measurement of shoulder abduction in the s
plane. This position is the most functional position for elevation.
all motions ranging from ICC = 0.87 to 0.99, wh
intertester reliability for measurements of flexion, a
tion, and lateral rotation ranged from ICC = 0.84 to
Intertester reliability for horizontal abduction and a
tion, extension, and medial rotation was poor. The g
metric measurements of shoulder PROM appeared
unaffected with different-sized goniometers in this
however. reliability between testers appears to be sp
to movements measured.
"Normal" ROM within the shoulder appears to b
specific, decreasing in aU ranges slightly with increase
(Boone & Azen, 1979). A list of normal ROM mea
ments from several authors is provided in Table 3-4
Functional ROM for the shoulder during three fe
tasks (eating with a spoon, eating with a fork, and dri
from a handled cup) required 5 degrees to 45 de
FIGURE 3-11. The plane of the scapula measures approxima
degrees to 45 degrees to the frontal plane.](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-80-2048.jpg)
![60 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 3-1 2. The use of the CRaM instrument in measuring cervi
cal ROM.
Table 3-5 lists normal ROM measurements provided by
various contributors.
LUMBAR SPINE
Simple backache is the most disabling condition of
peopre younger than 45 years of age and costs society an
estimated 25 to 100 billion dollars a year (Frymoyer &
Cats-Baril, 1991). The demand for scientific evidence in
the management of this industrialized epidemic is becom
ing increasingly important (Helms, 1994). Objective mea-
TABLE :~-~J
surement of spinal ROM is thought to be of cr
scientific importance in determining disability (Amer
Medical Association, 1990), selecting appropriate th
peutic intervention (Maitland, 1986; McKenzie, 19
and monitoring the patient's progress (Mayer
Gatchel, 1988). For example, disability ratings are la
based on the lumbar spine ROM measurements; i.e.,
are based on lost ROM versus a mean value. Interestin
many orthopedic surgeons (Davis, 1994) consider
much ROM, i.e., hypermobility leading to "instabil
to be pathologic (Froning & Frohman, 1968; Frym
et aL, 1979; Howes & Isdale, 1971). Thus, it is of cr
importance that thorough, accurate documentatio
mobillity is undertaken to determine hypermobility (Bu
et al., 1989), as well as hypomobility, through a ch
plane of motion.
In the appendicular skeleton, normal ROM can
determined by comparing ROM measurements both
normative data and with the uninvolved limb (Amer
Academy of Orthopedic Surgeons, 1965; American M
cal Association, 1990). In the axial skeleton, sagittal p
ROM is determined solely by comparison with norma
data (Gilbert, 1993). Unfortunately, normative data,
as the mean value recommended by the American Me
Association, are inadequate (Sullivan et aI., 1994), a
paucity of good, reliable, and valid data exists. No
spinal ROM measurements are influenced to diffe
degrees by many factors . These variables are thoug
include age (Moll & Wright, 1971; Sullivan et al., 1
Tanz, ] 953), gender (Batti'e et aL, 1987; Burto
Tillotson, 1991; Moll & Wright, 1971), time of day (Ru
et al. , 1992), occupation (Russell et al., 1993), le
activities (Burton & Tillotson, 1991), previous histor
low back pain (Burton et ill., 1989), sitting-to-stan
height ratios (Batti'e et aI., 1987), warming up (Keel
aI., 1986), obesity (Batti'e et aI., 1987), and the techni
with which normative data are collected (Pearcy & T
wal, 1984).
SEVERAL REPORTED VALUES FOR "NORMAL" ROM OF DIE CERVICAL SPINE
Capuano-Pucci Mayer et al.§
AMA Buck' Defibaugbt et al.~ (CROM) (Electronic IncUnomet
Motion (1988) (1959) (1964) (199 1) (1993)
Flexion 60 67 59 50 49
Extension 75 77 80 70 67
Rotation
Right 80 73 85 70 87
Left 80 74 89 69 84
Lateral flexion
Right 45 51 43 44
Left 45 49 44 39
• N = 100, 18-23 y, male and female.
t N = 30, 20-40 y, male.
r N = 20, x = 23.5 y, male and female .
§ N =58, 17-62 y, maJe and female.](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-82-2048.jpg)
![62 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
the use of such methods (Nelson et aI., 1979; Wolf et aI.,
1979). Consequently, therapists should be hesitant in
reaching important conclusions about facts such as pro
gression based on these inadequate measures. Originally,
the addendum to this procedure as advocated by the
American Medical Association was the use of the goniom
eter (American Medica'iAssociation, 1971). The use of the
uniaxial goniometer to measure multiaxial spinal move
ment is obviously problematic (Mayer & Gatchel, 1988).
Fitzgerald and associates (1983) confirm these problems
when they reported coefficients of variance (CVs) of up to
53 percent using the goniometer. (The use of CVs in
determining reliability of measures is of questionable value
[Williams et aI. , 1993], although they were commonly used
in earlier research.)
Another method once described as promising (Merritt et
a!., 1986) and still prevailing is the finger-to-floor method.
Interesting to note is that it has been long known that
patients with multilevel stabilization involVing more motion
segments than merely the lumbar spine are able to touch
their toes (Mayer et aI., 1984). Advocates of this method
are deceived not only by large amounts of accompanying
hip movement but also by movements in the thoracic spine
and, to a lesser degree, the amount of movement at the
knee, anIJe, and upper extremities. Merritt and colleagues
(1986), in comparing three simple noninvasive methods,
found the finger-to-floor method to be least reproducible.
Two methods that they found to be more promising and
worthy of attention are the modified Schober technique
and the double inclinometer method. Both methods have
the advantage of isolating the lumbar spine ROM. In 1937,
Schober used a simple tape measure to estimate lumbar
ROM. This technique has been modified (Macrae & Wright,
1969) and remodified (Williams et aI., 1993), and distrac
tion techniques can be used to measure movement in the
coronal plane as well. Fitzgerald and coworkers (1983),
using the Schober method, reported an interobserver
reliability using the Pearson correlation coefficient of
r = 1.0 for flexion and r = 0.88 for lumbar extension but
had the disadvantage of using healthy, young subjects.
Beattie and associates (1987) used both healthy subjects
and subjects with low back pain and reported high reliability
with the modified Schober attraction method for measur
ing extension. Macrae and Wright (1969) attempted to
validate both the modified Schober and the Schober
techniques, comparing them with radiographic techniques.
Pearson product-moment correlation coefficients of
r =0.97 for the modified Schober and r =0.90 for the
Schober technique were reported compared with radiog
raphy. Portek and colleagues (1983), however, demon
strated little collaboration between any of the commonly
used clinical methods, including the modified Schober
technique and radiographs. Miller and associates (1992)
have questioned the modified Schober technique on both
scientific merit due to the potential error (Table 3-7) and on
clinical grounds. Clinically, these authors offer the double
inclinometer (01) as a validated technique that eliminates
'IABLE :3-7
POTENTIAL ERRORS AFFECTING
REUABIUTV OF 1HE MODIFIED SCHOBE
ME11IOD EVALUATED IN ntiS STUDY
1. Presence or absence of "dimples of Venus. "
2. Anatomic location of dimples of Venus.
3. Anatomic variability of location of 10-cm line (correlation
among a skin mark 10 cm above the interdimple line. spinous
process at that level, and the number of levels from T-12 to S
measured with the technique).
4. Problems introduced by skin distraction occurring in the absen
of movement of underlying bony structures (e.g., the sacrum).
5. Problems engendered by expression of results of an essentially
angular movement in linear terms (in centimeters, not degrees
6. Problems in developing a normative database created by popu
lation variation in human height superimposed on a fixed-leng
test.
From Miller, S . A., Mayer, T, Cox, R. , & Gatchel, R. J. (1992). Relia
problems associated with the modi.fied Schober technique for true lu
flexion measurement. Spine, 17, 345-348.
many or all of the problems associated with the Scho
technique.
The 01 is generally attributed to Loebl (1967). Reliab
studies by Keeley and coworkers (1986) reported interr
reliability values of ICC =0.92 for 9 subjects with chro
low back and 0.90 for 11 subjects without low back p
Waddell and associates (1991), using the spinal inclin
eter, showed an ICC of 0.91 for interobserver reprod
ibility of lumbar flexion. The landmarks used for measu
ment for both the Schober and the 01 methods
described in Table 3-8 and in the succeeding instructio
on measurement of spinal ROM in the sagittal plane.
Today, electrogoniometers using these prinCiples
offered. A more recent study concluded both the 01
the Cybex EOI (Cybex, Ronkonkoma, Ny) to be s
stantially more reliable than observation (Chiarello
Savidge, 1993). Mayer and colleagues (1984), in a v
dation study, concluded that no significant differe
existed between Dl measures and radiographic measu
TABLl~ 3 S
REFERENCE POINTS ADVOCATED BY
'IFFERENT AunlORS WHEN MEASURING
LUMBAR ROM
Inferior Superior
Technique Landmark Landmark
Schober Lumbosacral junction A point 10 cm
above lumbosac
junction
Modified Schober 5 cm below lumbosa- A point 10 cm
cral junction above lumbosac
junction
Modified-modified Midline intersection A point 15 cm
Schober of posterosuperior above midline in
iliac spine tersection](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-84-2048.jpg)
![68 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 3-23. The use of an inclinometer utilizing finger braces,
allowing for direct palpation of the ASIS and PSIS during inclinometer
placement. (From Crowell, R. D., Cummings, G. S., Walker, J. R., &
Tillman, L. J. [19941. Intratester and intertester reliability and validity of
measures of innominate bone inclination. Journal of Orthopedic and
Sports Physical Therapy, 20[2], 88-97)
interrater reliability (ICC = 0.95) and validity (r = 0.93),
(Fig. 3-23). This device should prove beneficial for mea
suring pelvic inclination in the sagittal plane.
KNEE
Few joints are exposed to measurements of ROM more
than the knee. The movements of the knee joint are not
those of a simple hinge joint but involve spinning, rolling,
and gliding, often simultaneously (Nordin and Frankel,
1989; Smidt, 1973). Certainly in the medical age when
total knee replacements and anterior cruciate ligament
(ACL) repairs are common occurrences, associated gonio
metric readings of knee ROM during the rehabilitation
process have added to the increased interest in the ROM of
this joint.
An early study (Boone et aI., 1978) using the universal
goniometer demonstrated a high level of intratester reli
ability r = 0.87 while shoWing a significantly lower inter
tester reliability of r = 0.50 when measuring the knee. This
study used standardized measurements described by the
American Academy of Orthopedic Surgeons (1965) for
knee AROM on 12 healthy volunteers. Investigations were
later made into the reliability of various goniometers within
a clinical setting in examining PROM at the knee (Rothstein
et aI. , 1983). In this study, each individual was allowed to
utilize his or her own technique in measuring the knee. The
results showed high intertester and intratester ICC values of
0.99 and 0.97, respectively, but showed moderately low
intertester ICC for knee extension (0.70), which was
statistically shown to be related to the patient's test
position. The use of various-sized goniometers did not
appear to affect the reliability of measurements, as in
cated in this study (Rothstein et a!., 1983). Universal a
fluid-based goniometers have demonstrated good in
tester reliability r = 0.87 and r = 0.83, whereas the flu
based goniometer showed a concurrent validity
r =0.82. However, statistical test differences between
instruments in this study suggest that the two instrume
should not be used interchangeably (Rheault et a!., 198
Goniometric measurements purport to give us an ac
rate account of the actual angle at the knee made by
universal goniometer; however, this is unsupportecl unt
validity study can substantiate this claim. A radiograp
study to verify the knee goniometry (Enwemeka, 19
used the universal goniometer to measure six positions
the knee, 0 degrees to 90 degrees, comparing goniome
measurements with radiographic bone angle measu
ments. All goniometric measurements were comparabl
the bone angle measurements, with the exception of
first 15 degrees, which were significantly different.
another study of goniometric measurements of the kn
both intertester reliability (ICC = 0.99) and vali
(ICC = 0.98-0.99) were high when compared with roe
genograms (Gogia et al., 1987).
Many times, clinical situations lend themselves to vis
estimations of ROM measurements at the knee. It has b
suggested that visual estimation is more accurate th
goniometric measurement when bony landmarks are
easily palpated (American Academy of Orthopedic S
geons, 1965; Rowe, 1964). However, other sources h
suggested that goniometry has proven to be more relia
than visual estimates of joint ROM (Moore, 1949a; Sal
1955). An early study using a small subject size (
demonstrated good intertester and intratester reliabi
when using visual estimates to determine ROM of kn
affected by rheumatoid arthritis (Marks et a!., 1978)
clinical study taken with a larger sample size (43) de
mined that PROM measurements were better determin
goniometrically over visual estimation to minimize
error of measurement (Watkins et a!., 1991). It has b
traditionally suggested that a knee ROM of 290 degree
necessary to negotiate elevated terrain, e.g., stairs,
clines.
Generally, normal ROM measurements for the knee
oto 135 or 140 degrees, decreasing with age. Studies
younger populations have shown that knee extension of
measures less than 0 degrees. Normative measurement
the knee are presented in Table 3-10.
Measurement of anterior-posterior (A-P) translation (
ity) has been commonplace in knees suspected of be
ACL deficient. As surgical procedures have progres
with ever-newer reconstructive techniques, the interes
evaluating the results of these techniques following ope
tions has led to instruments specifically designed to m
sure the A-P motion. Understanding that the knee not o
flexes and extends in the sagittal plane but also allows
A-P translation in the sagittal plane, as well as tibial rotat
in the transverse plane (Nordin and Frankel, 1989)](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-90-2048.jpg)
![72 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
1993) of three methods for measuring STJN position
(open kinetic chain, closed kinetic chain, and navicular
drop test) demonstrated poor intra- and intertester reliabil
ity when measuring (n = 30 ft) with a goniometer (for the
first two methods) and when measw-ing the distance
change from the floor to the navicular mark on a marked
index card (for the third method). However, a later study
measuring STI N (Sellet al., 1994)using two measurement
techniques (calcaneal position with an inclinometer [Fig.
3-27] and navicular drop test) in a weight-bearing position
(n =60) demonstrated moderate to high reliability.
Studies of normal ankle dorsiflexion demonstrated a
reduction in mean values with increasing age (middle age to
old age), decreasing from 20.0 degrees to 13.5 degrees in
males, whereas in females these values decreased from
20.7 degrees to 10. 1 degrees (Vandervorrt et aI., 1992).
Normal ROM for inversion and eversion of the subtalar
joint using a method described by the American Academy
of Orthopedic Surgeons (1965) was 35 degrees and 15
degrees, respectively. It has been suggested that 4 degrees
to 6 degrees of inversion and eversion, for a minimal tota,1
range of 8 degrees to 12 degrees, is normal for locomotion
(Root et aI. , 1977). Although norms have been cited for
subtalar inversion and eversion and STIN (3 degrees varus)
positions (Mjlgrom et al. . 1985), the baSis for "normal"
STIN with regard to the stance phase of gait has been
largely conjecture, without proven reliable or valid methods
performed on any substantial-sized group during gait
activities (Root et aI. , 1977; McPoU & Cornwall, 1994;
Wright et a1., 1964). Table 3-11 lists norms for ankle and
foot ROM.
A measurement quite possibly offering the therapist
increased information with regard to the biomechanical
alignment and forces acting on the ankle and foot is
FIGURE 3-28. Measw'ement of tibiil vara: an angle formed from a line
parallel to the lower leg bisecting the horizontal (ground).
measurement of tibia vara, which is the angle formed by
distal third of the leg to a horizontal line to the suppor
stance surface (ground). Lohmann and associates (19
demonstrated a mean absolute difference between m
surements of tibia vara of 2 to 3 degrees (Fig. 3-28).
Attraction methods-Measuring procedure usin
tape measure to record a decrease in distance between
points marked on the skin over the spine as it extend
Coefficient of variation-Measure of variability in
measurements relative to the mean value. Depicts
variability of measurements within the subjects as wel
the variability of the actual measurement. A ratio of
standard deviation and the mean in terms of a percenta
Distraction methods-Measuring procedure usin
tape measure to record an increase in distance betw
two points marked on the skin as the spine flexes.
Flexicurve techniques-Measuring procedures
which a tester manually molds a flexible curve to the mid
contour of the subject's lumbar spine. The flexible curv
then traced onto paper, and either a tangential o
trigonometric method is used to ca'iculate ROM.
Intraclass correlation coefficient (ICC)-Asses
common variance. Examines two or more sets of score
the same variable.
Modified Schober technique-Skin distract
attraction method using a midline point 5 CM below
lumbosacral junction and a point 10 CM above it.
Pearson product-moment correlation coe
dent-Generalized measure of linear association. Use
determining association concerning a bivariate distr
tion.
Pelvic incUnometer-Designed with calipers wit
mounted gravity protractor. Able to measure the chang
position of two separate points by the placement of ei
ends of the calipers over an identifable area used a
landmark.
Pendulum goniometer-Goniometer usually mad
metal with two movement arms. One arm is allowed
move freely in accordance with. the line of gravity an
used as a vertical reference.
Spinal incUnometer-A circular fluid-filled disk wi
weighted needle indicator, which is maintained in
vertical, that is placed over the spine and used to meas
ROM in degrees as the spine moves.
Subtalarjoint neutral-The position in which the
is neither pronated nor supinated. The position of in
sion or eversion that the calcaneus assumes when the t
is congruent in relation to the tibia.
3·Space lsotrak-Electomagnetic device for the m
surement of three-dimensional movements.](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-94-2048.jpg)
![the construct validity of the POI. Initially, Pollard (1984)
showed that this scale discriminated between nine persons
with lower back pain with a current work history from nine
who had just received surgery. The Tait research group
(1987, 1990) showed that the POI discretionary and
obligatory factors discriminated outpatients with pain from
inpatients with pain, the former, as expected, being less
disabled by their pain. In a major study, 197 POI high
scorers (greater disability) were compared with 204 low
scorers. The high scorers reported more psychological
distress, pain, and disability, stopped activity more, were in
bed more during the day, and spent more total time in bed
than did low scorers. Two other studies also supported the
construct validity of this instrument. Multiple regression
procedure showed that time in bed, stopping of activity,
psychological distress, and work status predicted POI
scores. Patients who were employed had lower POI scores
than did those unemployed. Finally, it was found that high
POI scorers had higher rates of pain behaviors such as
verbal complaints and grimaces than did low scorers.
Gronblad and collaborators (1993, 1994) provided still
further support for the construct validity of the POI, since
the POI total values correlated r = 0.83 with those from
the extensively used and researched Oswestry Oisability
Questionnaire. The coefficient for the discretionary factor
was r = 0.84 but only r = 0.41 for the obligatory factor,
showing less support for the validity of this part of the POI.
The POI was also related to a measure of pain intensity at
r = 0.69. Further work showed the POI to discriminate
persons with chronic pain who were working from those
on sick leave. Since the POI is a self-report measure,
Gronblad and associates (1994) studied its relation to
objective physical therapist observations of activities requir
ing back and leg muscle use. Subjects were 45 outpatients
with chronic back pain. Activities included a sit-up test
emphasizing abdominal muscles, an arch-up test for back
muscles, and a squatting test for lower extremity muscles.
Although correlation coefficients were low (0.30s and
0.40s), these researchers did find significant relationships
between POI results and observed activity scores, even after
adjustment for age and gender. Jerome and Gross (1991)
were concerned that the POI scores might not provide any
useful information beyond that of a pain intensity scale. For
74 subjects from a university pain clinic, they correlated
POI results to several variables used to assess functional
status in chronic pain. Although pain intensity was highly
related to POI, when intensity was partialled out, discre
tionary POI scores were still related to level of depression,
lack of employment, and use of pain medication. Thus, the
POI does provide information on disability beyond that
provided by a pain intensity scale.
In summary, an impressive bodyof research supports the
construct validity of the POI with chronic pain patients. I
concur with the researchers who consider the POI a feasible
clinical instrument if used as part of a battery to assess the
relation of chronic pain and activity level. The POI should
pain, but specific research in this area would be valuab
The POI would be an instrument of choice for assessm
in longitudinal studies of rehabilitation in which chro
pain is a factor.
Computerized Tests. In this information age, compu
aided testing is a given. However, because of time and c
constraints, use of a well-developed paper and pencil t
often may be of more practical value in the clinic than
use of elaborate electronic measuring devices. Comput
ized tests that are useful to the clinician are obviou
desirable. Anton and colleagues (1988) reported such a t
designed to assess visual neglect and extinction. In this t
situation, the subject, with gaze fixed centrally, respond
to randomly appearing lights (Fig. 8-2). Lights appeared
the subject's right side, to the left, or simultaneouslyto ri
and left sides. Testing with 30 "normal" volunteers show
that, although errors were made, no difference was ma
in the number on the right and left sides. When used w
patients after right cerebrovascular accident (CVA), grea
response to right than to left lights would indicate negle
Response only to right with simultaneous lights would sh
extinction. Relative to clinical evaluation by a physician a
identification by occupational therapists from paper a
pencil testing, the computerized test was found to be hig
sensitive, identifying visual neglect in 16 and extinction
13 of 24 subjects with right CVA. In every instance, wh
neglect and extinction were identified by the physician
occupational therapist, they were also identified by
computerized testing, but the computerized test identif
five more cases of extinction than did the physician and
more cases of neglect than did the occupational therap
FIGURE 8-2. Computerized test for visual neglect and extinction. (F
Anton, H., Hershler, c., Lloyd, P., & Murray, D. [1988]. Visual neg
and extinction: A new test. Archives of Physical Medicine and Re
bilitation, 69, 1013-1O16.)](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-189-2048.jpg)
![sizes, a self/ideal discrepancy index can also be computed.
Data from college students, 20 with bulimia and 20 with
out, in the Ruff and Barrios study (1986) showed internal
consistency coefficients (Cronbach's alpha) of 0.79 to
0.93. Interrater reliability coefficients were r = 0.98 or bet
ter. A1I3-week test-retest reliability coefficients were in the
O.70sand 0.80s for bulimic and control subjects, exceptfor
the waist estimate of bulimic subjects (0.44). The authors'
second study (Cited by Thompson, 1990) showed much
lower coefficients among college women. Keeton and as
sociates (1990) in their use of the BIDD found a coefficient
(alpha = 0.93) indicating high interrater reliability of the
measurement of the actual body site sizes.
Considerable evidence exists for the construct validity of
the data obtained from the BIDD. The estimated/actual
index discriminated between three weight groups, 12 each
of normal, over-, and underweight nonclinical subjects
(Cash & Green, 1986), between 20 each of bulimic
subjects and controls (Ruff & Barrios, 1986), and between
47 male and 78 female college students (Keeton et al.,
1990). The self-estimate scores and self/ideal discrepancy
index showed moderate correlations (0.42 to 0.67) with
those from a silhouette tool. For women, the self/ideal
discrepancy index was also significantly related to scores on
a test for bulimia, but the coefficient was low at r 0.38.
Evidence indicated that BIDD results were independent
from those of attitudinal measures (Keeton et al., 1990).
A modification of the BIDD, the Adjustable Light Beam
Apparatus, allows the projected light to be Simultaneously
adjusted for the three body sites (waist, hips, and thighs)
after practice with the face (Thompson & Spana, 1988).
The authors provideddetaileddirections for construction of
this device. It has also received research attention showing
acceptable reliability coefficients and evidence that size
estimation data are independent from those of attitudinal
measures (Altabe & Thompson, 1992; Coovert et al.,
1988; Thompson & Spana, 1988).
used figures or silhouettes graded from very thin to v
obese as stimuli for response by subjects in their b
image studies (Bell et al., 1986; Fallon & Rozin, 1985)
computer program version has also been evalua
(Dickson-Parnell et al., 1987).
One such silhouette assessment procedure for b
image was designed and researched by Williamson a
colleagues (Williamson, 1990; Williamson et al., 19
Williamson et al., 1993). Nine silhouettes (Fig. 8-3) grad
from thin to obese are presented to subjects on car
Cards are presented in a fixed order since no difference w
found from the random display originally used. Stand
instructions are used to request first accurate and th
preferred body size choices from the cards. Administrat
time is less than 1 minute. Normative data of subje
height and weight were established by cluster analy
(Williamson et al., 1989). These data may be used
determine if testees show body images outside of norm
limits.
Data estimating the reliability and validity of the B
Image Assessment were obtained (Keeton et al., 19
Williamson, 1990; Williamson et al., 1989; Williams
et al., 1993). Test-retest reliability data were gathe
from I-week, 2-week, and 3- to 8-week intervals betw
administrations. All reliability estimates were in the 0.7
0.80s, or 0.90s.
Williamson and colleagues provided evidence for
construct validity of the Body Image Assessment (Willi
son, 1990; Williamson et al., 1989; Williamson et
1993). In two separate studies, as hypothesized, itdiscri
nated between persons with bulimia nervosa and con
subjects and between persons with anorexia nervosa a
control subjects. No score differences were found betw
eating-disordered subjects. As hypothesized, relationsh
were found between scores on tests of eating attitudes a
bulimia and those of the Body Image Assessment. Furth
more, another research team, Keeton and cowork
FIGURE 8-3. Silhouettes for the Body Image Assessment by Williamson. (From Williamson, D. A. [1990]. Assessment ofeating disorders: Obe
anorexia, and bulimia nervosa. Needham Hights, MA: Allyn & Bacon.)
-
, '
. --~
- ""
. " ;:~~=](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-191-2048.jpg)
![182 UNIT 2-GOMPONENT ASSESSMENTS OF THE ADULT
Most diseases of the motor unit cause weakness and
atrophy of skeletal muscles. Various types of motor unit
diseases were characterized by pathologists in the 19th
century. Some patients showed pronounced pathologic
changes in the cell bodies of the motor neuron but no or
minor changes in the muscle (motor neuron diseases).
Other patients had a degeneration of muscle with little or
no change in motor neurons (myopathies). Other patients
had pathologic changes that affected only the axons of
peripheral nerves (peripheral neuropathy). Diseases of the
motor unit can be divided into two classes: 1) neurogenic
diseases, which affect the cell body or peripheral axon; and
2) myopathic diseases, which affect the muscle (Figs.
9-8 and 9-9;.
FIGURE 9-8. Diagram of motor unit in motor neuron disease. The
motor neuron on the left is degenerating. Its muscle fibers have become
atrophic (symbolized by dotted lines), and units innervated by the
degenerated nerve no longer produce motor unit potentials. This is
apparent on the oscillograph screen by decreased rate ofaction potentials
(compared with Fig. 9-7), However, the neuron on the right has sprouted
additional axonal branches that reinnervate some of the denervated
muscle fibers, These muscle fibers produce a larger than normal motor
unit potential (compared with Fig, 9-7), and they also fire spontaneously
at rest (fascicuiations), (Adapted, with permission, from Kandel, E., &
Schwarz, J, H. [1981]. Principles of Neural Science. Stamford, CT:
Appleton & Lange.)
Spinal cord
Motor neuro
Reinnervated
muscle fiber
~,f
Motor neuron
,
V
Regenerating
axon
,Q
(l
Action potentials seen on
oscilloscope screen recorded
from needle electrode
I I I I I I I I I I I inserted into muscle
Atrophied muscl
JLAction potentials seen on
oscilloscope screen reco
from needle electrode
inserted into muscle
FIGURE 9-9. Diagram of motor unit in muscle disease (myopa
Some muscles innervated by the motor neuron have become dise
The motor unit potential is reduced in amplitude. (Adapted,
permission, from Kandel, E., & Schwarz, J. H. 11981]. Principl
Neural Science. Stamford, CT: Appleton & Lange.)
Technique and Waveform
Nomenclature
The clinical utility of EMG lies in its ability to de
abnormalities in muscle activity resultant to injury to
nerve innervating that muscle. The EMG examina
includes four phases: the evaluation of spontaneous (
ing) muscle activity, insertional activity, activity du
minimal muscle contraction, and activity during max
muscle contraction. During these four phases, the e
tromyographer looks for abnormal electric activity of
muscle. The activity from the needle electrode is led
powerful amplifiers, and the activity is displayed on
oscilloscope screen. The electromyographer often l
the output of the amplifier to a loudspeaker; var
abnormal patterns produce distinctive sounds, which
often facilitate recognition. These needle EMG changes
discussed under "Abnormal EMG Activity."
The waveforms of various types of normal EMG act
are shown in Figure 9-10.
Spontaneous Activity. A very important point is
normal muscle fibers, with normal nerve supply, show
spontaneous (Le., at rest) electric activity.](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-204-2048.jpg)
![202 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
TABLE 10-3
OF AMBUJATION
Rate of Oxygen Uptake Net Oxygen Cost Heart Rate
Author Type (mVkg/min I±]) (ml/kg/m I±]) (beats/min I±])
Waters et al. (1976) 0 11.7 (16)
Waters et al. (1976) T 15.5 (2.9)
Pagliarulo et al. (1979) T 15.5 (28)
Huang et al. (1979) T 10.0
Waters et al. (1988) N 12.1
o = Dysvascular; N =nonamputee; T =traumatic.
Waters et al., 1976). In an attempt to reduce
oxygen uptake and heart rate, amputees may adopt
a slower walking speed (Table 10-3).
Other influencing factors such as age, self-selected walking
speed, prosthetic weight (Gailey et a1., 1994), and the type
of prosthetic foot, such as the "energy storing" prosthetic
feet or dynamic feet versus the use of conventional
prosthetic feet such as the SACH foot, do not reduce the
metabolic cost of amputee walking (Lehmann et a1. , 1993;
Perry & Shanfield, 1993). The length of the residual limb
(Gailey et aI. , 1994; Gonzalez et aI., 1974) and the cause
of amputation (Waters et al., 1976) appear to have the
most Significant effect on the metabolic energy cost of
walking for transtibial amputees.
TRANSFEMORAL AMPUTEES
VARIATIONS FROM NORMAL GAIT
Transfemoral amputees have been described
as having an increase in stride width during ambula
tion, increasing the displacement of the COM lat
erally (James & Oberg, 1973; Murray et aI. , 1964;
Zuniga et aI., 1972). One suggested reason for
the increase in walking width is prosthetic side hip
abductor weakness, which would require greater lat
eral stability (Jaegers et al., 1995; James & Oberg,
1973). Another possible explanation expands on
the lateral stability concept. As with transtibial am
putees, the COM of the transfemoral amputees
may have a tendency to shift over the nonpros
thetic limb, providing greater stability; therefore,
the sound limb adducts. If the prosthetic limb were
to follow the natural forward progression, the width
of walking base would be more narrow, resulting
in the prosthetic limb's having to exert greater mus
cular stability as the COM moves laterally during
prosthetic stance. If the prosthetic limb is slightly
more abducted, a strut effect occurs during stance,
requiring less muscular effort and greater lateral sta
bility.
Increased lateral bending of the trunk over the
0.26 (0.05) 105 (17)
0.20 (0.05) 106 (11)
0.22 (0.4) 106 (10)
0.20
0.15 99
prosthetic limb is a common gait deviation (Jae
gers et al., 1995; James, 1973c; Klopsteg et al.,
1968). James (1973c) noted that with a decrease i
the width of the walking base, there is decreased
lateral trunk bending. The assumption is that
decreasing step width decreases the lateral displace
ment in COM; consequently, less contractile effort
would be necessary to control trunk movement. An
other reason for lateral trunk bending over the
prosthetic side is that the amputee is attempting to
reduce weight-bearing directly over the prosthetic
limb because of pain, instability, poor balance, or
lack of trust in the prosthesis.
• The inability of the prosthetic knee to flex during
early stance results in an upward acceleration of
the trunk as the body progresses over the prostheti
limb toward mid-stance (Klopsteg et aI., 1968).
The most Significant consequence is the loss of
smooth progression of the vertical displacement of
COM and, as a result, an increase in the metabolic
cost of walking (Peizer et al., 1969).
Because of the loss of musculoskeletal tissue, there
is a loss of muscle strength and a greater difficulty
in balanCing over the prosthesis. Balance problems
and loss of strength are directly related to the
length of the residual limb: amputees with shorter
limbs experience greater difficulties than those with
longer limbs (Jaegers et al., 1995; James, 1973a;
James, 1973c; Ryser et aI., 1988). Consequently,
transfemoral amputees compensate for the
decreased ability to maintain Single-limb balance
over the prosthesis by taking a shorter stride length
with the sound limb, a faster prosthetiC step, or a
lateral lean of the trunk over the prosthetic limb
in an attempt to reduce weight bearing and main
tain balance.
• Lack of ankle plantar flexion in the prosthetic limb
results in the amputee relying on the hip flexors to
flex the hip and prosthetic knee during terminal
stance. To flex the knee, a contraction of the hip
greater than normal is required, and in addition,
flexion must be initiated conSiderably earlier than
normal (Hale, 1991; Klopsteg et al., 1968). How
ever, most transfemoral amputees tend to flex the](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-224-2048.jpg)
![- - -
THERMOPLASTIC
The low-temperature thermoplastics currently available
fall generally into one of four categories of material
depending on their chemical formulas .
The materials said to be plastic/ike generally have
excellent conformity and drape. When warm they stretch
with only the force of gravity, which allows them to
conform intimately over body parts with minimal effort on
the clinician's part. When cold, plasticlike materials are
very rigid and withstand the forces applied by outriggers
and resilient components.
The rubberlike materials tend to resist stretch and have
a low degree of conformability and drape. The resistance to
stretch of the rubberlike materials allows them to be
like materials generally are flexible and give when pr
is applied.
Combination plastic and rubberlike materials are
able that have midrange characteristics. They d
stretch as readily as do the plasticlike materials, bu
offer greater ease of conformability than do the rubb
materials. Their resistance to deformation when cold
than that of the plasticlike and greater than that
rubberlike materials.
The fourth category of materials is the elastics,
have unique handling characteristics because of
memory. These materials can be handled and stre
aggressively to form circumferential orthoses, and the
be readily re-formed by reheating. When cold,
materials may be quite rigid if full thickness (l/s in [3.2
or flexible if thin (1/16 in [1 .6 mm]) and highly perfo
---~
t _ - - - ](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-265-2048.jpg)
![250 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
of persons with stroke. This descriptive, longitudinal study
of individuals with occlusive cerebrovascular accidents
observed motor recovery of both upper and lower limbs but
focused on function in the arm and hand. Twitchell noted
that the patients studied progressed uniformly through a
series of recovery stages. All patients began with total,
flaccid paralysis of limb muscles. This was followed by the
demonstration of positive stretch reflexes in selected
muscles, and the influence of tonic neck reflexes on active
movement and muscle tone in the arm and leg.
Patients whose recovery was not arrested at one of these
early stages progressed to demonstrate active perfor
mance of gross, stereotypic movement patterns. Twitchell
termed these gross patterns the flexor and extensor limb
synergies. Patients who continued to progress eventually
performed voluntary hand movements, as well as active
arm and leg movements that deviated from the limb
synergies. Of the 121 patients in Twitchell's study, 25 were
observed until a comparatively stable condition had been
reached. After 3 months, five patients demonstrated full
recovery. The remaining participants varied in the levels of
recovery they achieved.
The Brunnstrom Approach
Signe Brunnstrom (1970) applied Twitchell's findings
and her own clinical experience to develop a program that
would gUide persons with hemiplegia through the following
six stages toward motor recovery:
Stage 1: flaccidity
Stage 2: associated reactions/developing spasticity
'lAI3LI' ] ] - ]
SYNERGIES OF DIE UPPER AND LOWER
UMBS
Flexor Synergy: Extensor Synergy:
Uppel'Umb Uppel'Umb
Elbow flexion Elbow extension
Forearm supination Forearm pronation
Shoulder abduction (to 90 Shoulder adduction (front of
degrees) body)
Shoulder external rotation Shoulder internal rotation
Shoulder girdle retraction Shoulder girdle protraction
Shoulder girdle elevation
Flexor Synergy: Extensor Synergy:
Lower Limb Lower Limb
Toe dorsiflexion Toe plantarflexion
Ankle dorsinexion and Ankle plantarflexion and
inversion inversion
Knee flexion Knee extension
Hip flexion, abduction, and ex Hip extension, adduction, and
ternal rotation internal rotation
Data from Brunnstrom, S. (1970). Movement therapy in hemiplegia:
A neurophysiological approach. New York: Harper & Row.
TABLE ]] -2
HANDFUNCTION-SEQUENCE
OF RECOVERY
Mass grasp
Hook grasp
Lateral prehension
Palmar prehension
CylindriC grasp
Sphericgrasp
Release of grasp
Individual finger movements
Manipulative tasks
Affected hand as an assist
Affected hand as dominant
Data from Brunnstrom, S. (1970). Movement therapy in hemiplegia:
A neurophysiological approach. New York: Harper & Row.
Stage 3: severe spastiCity/active movement in synergy
patterns
Stage 4: some movements deviating from synergy
patterns
Stage 5: active movements isolated from synergy pat
terns
Stage 6: isolated active movement with near normal
speed and coordination
Brunnstrom clearly categorized the flexor and extensor
synergies of the hemiparetic arm and leg (Table 11-1).
Other contributions included a postulated sequence of
recovery in hand function (Table 11-2) and a clearly
defined sequence of movement patterns hemiparetic indi
viduals are expected to achieve as they recover the ability
to perform movements that deviate from the gross limb
synergies.
In addition, Brunnstrom (1970) superficially introduced
the concept that balance and postural abnormalities are
common motor residuals of stroke. Brunnstrom proposed
that therapists evaluate balance impairments by (1) assess
ing patients' tendencies to list toward the affected side
when sitting unsupported, and (2) observing patients'
responses to forceful manual disturbance of their unsup
ported sitting posture.
Neurodevelopmental Treatment
While Brunnstrom's program sought to facilitate motor
recovery by encouraging the development of primitive
reflexes and active movement in synergy patterns, Berta
Bobath's (1970, 1978) approach followed an opposite
course. Neurodevelopmental treatment (NOT) for adults
with hemiplegia was designed to minimize the develop
ment of spasticity and to prevent the learning of stereotypic
patterns of movement.
Neurodevelopmental treatment viewed the motor im
pairments of stroke survivors from a broader perspective
than Brunnstrom and Twitchell. In addition to limb paraly
sis, descriptions of hemiplegia were expanded to include](https://image.slidesharecdn.com/assessmentinoccupationaltherapyandphysicaltherapy-140621131113-phpapp01/75/Assessment-in-occupational-therapy-and-physical-therapy-272-2048.jpg)
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Assessment in occupational therapy and physical therapy
- 4.
- 5. Assessment in Occupational Therapyand Physical Therapy JuliaVan Deusen, PliO, OTR/L, FAOTA Professor Department of Occupational Therapy College of Health Professions Health Science Center University of Florida Gainesville, Florida Denis Brunt, PT, EdD Associate Professor Department of Physical Therapy College of Health Professions Health Science Center University of Florida Gainesville, Florida W.B. SAUNDERS COMPANY ADillision ofHarcourt Brace &Company Philadelphia London Toronto Montreal Sydney Tokyo
- 6. W.B. SAUNDERS COMPANY ADivision of Harcourt Brace & Company The Curtis Center Independence Square West Philadelphia, Pennsylvania 19106 Library of Congress Cataloging-In-Publication Data Assessment in occupational therapy and physical therapy I [edited by] Julia Van Deusen and Denis Brunt. p. cm. ISBN 0-7216-4444-9 1. Occupational therapy. 2. Physical therapy. I. Van Deusen, Julia. II. Brunt, Denis. [DNLM: 1. Physical Examination-methods. 2. Physical Therapy methods. 3. Occupational Therapy-methods. we 205 A847 1997] RM735.65.A86 1997 616.0T54-<lc20 DNLM/DLC 96-6052 Assessment in Occupational Therapy and Physical Therapy 0-7216-4444-9 Copyright © 1997 by WB. Saunders Company All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1
- 7. To those graduatestudents everywhere who are furthering their careers in the rehabilitation professions
- 9. J'Oontributors ELLEN D. ADAMS,MA, CRC, CCM Executive Director, Physical Restora tion Center, Gainesville, Ronda Work Activities JAMES AGOSTINUCCI, SeD, OTR Associate Professor of Physical Therapy, Anatomy & Neuroscience, Physical Therapy Program, University of Rhode Island, Kingston, Rhode Island Motor Control: Upper Motor Neuron Syndrome MELBA J. ARNOLD, MS, OTR/L Lecturer, Department of Occupational Therapy, Uriiversityof Ronda, College of Health Professions, Gainesville, Ronda Psychosocial Function FELECIA MOORE BANKS, MEd, OTR/L Assistant Professor, Howard Univer sity, Washington, DC Home Management IAN KAHLER BARSTOW, PT Department of Physical Therapy, Uni versity of Ronda, GaineSville, Ronda Joint Range of Motion JUUE BELKIN, OTR, CO Director of Marketing and Product De velopment, North Coast Medical, Inc., San Jose, California Prosthetic and Orthotic Assess ments: Upper Extremity Orthotics and Prosthetics JERI BENSON, PhD Professor of Educational Psychology Measurement Specialization, The Uni versity of Georgia, College of Educa tion, Athens, Georgia Measurement Theory: Application ,.0 Occupational and Physical Therapy STEVEN R. BERNSTEIN, MS, PT Assistant Professor, Department of Physical Therapy, Ronda Interna tional University, Miami, Ronda Assessment ofElders and Caregivers DENIS BRUNT, PT, EdD Associate Professor, Department of Physical Therapy, College of Health Professions, Health Science Center, University of Ronda, Gainesville, Ronda Editor; Gait Analysis PATRICIA M. BYRON, MA Director of Hand Therapy, Philadel phia Hand Center, P.C., Philadelphia, Pennsylvania Prosthetic and Orthotic Assess ments: Upper Extremity Orthotics and Prosthetics SHARON A. CERMAK, EdD, OTR/L, FAOTA Professor, Boston University, Sargent College, Boston, Massachusetts Sensory Processing: Assessment of Perceptual Dysfunction in the Adult vii
- 10. vIII CONTRIBUTORS BONNIE R.DECKER, MHS, OTR Assistant Professor of Occupational Therapy, University of Central Arkan sas, Conway, Arkansas; Adjunct Fac ulty, Department of PediatriCS, Univer sity of Arkansas for Medical Sciences, Uttle Rock, Arkansas Pediatrics: Developmental and Neo natalAssessment; Pediatrics: Assess ment of Specific Functions EUZABETH B. DEVEREAUX, MSW, ACSWIL, OTRIL, FAOTA Former Associate Professor, Director of the Division of Occupational Therapy (Retired), Department of Psy chiatry, Marshall University School of Medicine; Health Care and Academic Consultant, Huntington, West Virginia Psychosocial Function JOANNE JACKSON FOSS, MS, OTR Instructor of Occupational Therapy, University of florida, GaineSville, florida Sensory Processing: Sensory Defi cits; Pediatrics: Developmental and Neonatal Assessment; Pediatrics: Assessment of Specific Functions ROBERT S. GAILEY, MSEd, PT Instructor, Department of Ortho paedics, Division of PhYSical Therapy, University of Miami School of Medi cine, Coral Gables, florida Prosthetic and Orthotic Assess ments: Lower Extremity Prosthetics JEFFERY GILUAM, MHS, PT, OCS Department of Physical Therapy, Uni versity of florida, Gainesville, florida Joint Range of Motion BARBARA HAASE, MHS, OTRIL Adjunct Assistant Professor, Occupa tional Therapy Program, Medical Col lege of Ohio, Toledo; Neuro Clinical Specialist, Occupational Therapy, St. Francis Health Care Centre, Green Springs, Ohio Sensory Processing: Cognition EDWARD J. HAMMOND, PhD Rehabilitation Medicine Associates P.A., Gainesville, florida Electrodiagnosis of the Neuromuscu lar System CAROLYN SCHMIDT HANSON, PhD,OTR Assistant Professor, Department of Occupational Therapy, College of Health ProfeSSions, University of flor ida, GaineSville, florida Community Activities GAIL ANN HILLS, PhD, OTR, FAOTA Professor, Occupational Therapy De partment, College of Health, flor ida International University, Miami, florida Assessment ofElders and Caregivers CAROL A. ISAAC, PT, BS Director of Rehabilitation Services, Columbia North florida Regional Medical Center, Gainesville, florida Work Activities SHIRLEY J. JACKSON, MS, OTRIL Associate Professor, Howard Univer sity, Washington, DC Home Management PAUL C. LaSTAYO, MPT, CHT Clinical Faculty, Northern Arizona University; Certified Hand Therapist, DeRosa Physical Therapy P.c., flag staff, Arizona Clinical Assessment of Pain MARY LAW, PhD, OT(C) Associate Professor, School of Reha bilitation Science; Director, Neurode velopmental Clinical Research Unit, McMaster University, Hamilton, On tario, Canada Self-Care KEH-CHUNG UN, ScD, OTR National Taiwan University, Taipei, Taiwan Sensory Processing: Assessment of Perceptual Dysfunction in the Adult
- 11. BRUCE A. MUELLER,OTR/L, CHT Clinical Coordinator, Physical Restora tion Center, Gainesville, Rorida Work Activities KENNETH J. OTTENBACHER, PhD Vice Dean, School of Allied Health Sciences, University of Texas Medical Branch at Galveston, Galveston, Texas Foreword ELIZABETH T. PROTAS, PT, PhD, FACSM Assistant Dean and Professor, School of Physical Therapy, Texas Woman's University; Clinical Assistant Profes sor, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas Cardiovascular and Pulmonary Function A. MONEIM RAMADAN, MD, FRCS Senior Hand Surgeon, Ramadan Hand Institute, Alachua, Rorida Hand Analysis ROBERT G. ROSS, MPT, CHT Adjunct Faculty of PhYSical Therapy and Occupational Therapy, Quin nipiac College, Hamden, Connecticut; Clinical Director, Certified Hand Therapist, The Physical Therapy Cen ter, Torrington, Connecticut Clinical Assessment of Pain JOYCE SHAPERO SABARI, PhD, OTR Associate Professor, Occupational Ther apy Department, New York, New York Motor Control: Motor Recovery Af ter Stroke BARBARA A. SCHELL, PhD, OTR, FAOTA Associate Professor and Chair, Occu pational Therapy Department, Brenau University, Gainesville, Georgia Measurement Theory: Application to Occupational and PhYSical Therapy MAUREEN J. SIMMONDS, MCSP, PT,PhD Assistant Professor, Texas Woman's University, Houston, Texas Muscle Strength JUUA VAN DEUSEN, PhD, OTR/L, FAOTA Professor, Department of Occupa tionalTherapy, College of Health Pro fessions, Health Science Center, Uni versity of Rorida, Gainesville, Rorida Editor; Body Image; Sensory Pro cessing: Introduction to Sensory Pro cessing; Sensory Processing: Sensory Defects; An Assessment Summary JAMES C. WALL, PhD Professor, Physical Therapy Depart ment; Adjunct Professor, Behavioral Studies and Educational Technology, University of South Alabama, Mobile, Alabama Gait Analysis
- 13. word In describingthe importance of interdisciplinary assessment in rehabilitation, Johnston, Keith, and Hinderer (1992, p. 5-5) note that "We must improve our measures to keep pace with the development in general health care. If we move rapidly and continue our efforts, we can move rehabilitation to a position of leadership in health care." The ability to develop new assessment instruments to keep pace with the rapidly changing health care environ ment will be absolutely critical to the future expansion of occupational therapy and physical therapy. Without assessmentexpertise, rehabilitation practitionerswill be unable to meet the demands for efficiency, accountability, and effectiveness that are certain to increase in the future. An indication of the importance of developing assessment expertise is reflected in recent publications by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). In 1993 the JCAHO published The measurement mandate: On the road to performance improvement in health care. This book begins by stating that "One of the greatest challenges confronting health care organizations in the 1990's is learning to apply the concepts and methods of performance measurement." The following year, the JCAHO published a related text titled A guide to establishing programs and assessing outcomes in clinical settings (JCAHO, 1994). In discussing the importance of assessment in health care, the authors present the following consensus statement (p. 25): "Among the most important reasons for establishing an outcome assessment initiative in a health care setting are: • to deSCribe, in quantitative terms, the impact of routinely delivered care on patients' lives; • to establish a more accurate and reliable basis for clinical decision making by clini cians and patients; and • to evaluate the effectiveness of care and identify opportunities for improvement." This text, Assessment in Occupational Therapy and PhYSical Therapy, is designed to help rehabilitation practitioners achieve these objectives. The text begins with a compre hensive chapter on measurement theory that provides an excellent foundation for understanding the complexities of asseSSing impairment, disability, and handicap as defined by the World Health Organization (WHO, 1980). The complexity ofdefining and assessing rehabilitation outcome is frequently identified as one of the reasons for the slow progress in developing instruments and conducting outcome research in occupational and physical therapy. Part ofthe difficulty indeveloping assessment procedures and outcome measures relevantto the practice of rehabilitation is directly related to the unit of analysis in research investigations (Dejong, 1987). The unit of analysis in rehabilitation is the individual and the individual's relationship with his or her environment. In contrast, the unit of analysis in many medical specialties is an organ, a body system, or a pathology. In fact, Dejong has argued that traditional medical research and practice is organized around these pathologies and organ systems; for example, cardiology and neurology. One consequence of this organizational structure is a focus on assessment xl
- 14. xii FOREWORD procedures andoutcome measures that emphasize an absence of pathology or the performance of a specific organ or body system; for instance, the use of an electrocardio gram to evaluate the function of the heart. In contrast to these narrowly focused medical specialties, the goal of rehabilitation is to improve an individual's ability to function as independently as possible in his or her natural environment. Achieving this goal requires measurement instruments and assessment skills that cover a wide spectrum of activities and environments. Julia Van Deusen and Denis Brunt have done an admirable job of compiling current information on areas relevant to interdisciplinary assessment conducted by occupational and physical therapists. The chapters cover a wide range of assessment topics from the examination of muscle strength (Chapter 2) to the evaluation of work activities (Chapter 20). Each chapter provides detailed information concerning evaluation and measurement protocols along with research implications and their clinical applications. Assessment in Occupational Therapy and Physical Therapy will help rehabilitation practitioners to achieve the three objectives of outcome assessment identified by the JCAHO. In particular, the comprehensive coverage of assessment and measurement procedures will allow occupational and physical therapists to achieve the final JCAHO outcome assessment objective; that is, to evaluate the effectiveness of care and identify opportunities for improvement (JCAHO, 1994, p. 25). In today's rapidly changing health care environment, there are many variables related to service delivery and cost containment that rehabilitation therapists cannot control. The interpretation of assessment procedures and the development of treatment programs, however, are still the direct responsibility of occupational and physical therapists. Informa tion in this text will help therapists meet this professional responsibility. In the current bottom-line health care environment, Assessment in Occupational Therapy and Physical Therapy will help ensure that the consumers of rehabilitation services receive the best possible treatment planning and evaluation. REFERENCES DeJong, G. (1987). Medical rehabilitation outcome measurement in a changing health care market. In M. J. Furher (Ed.), Rehabilitation outcomes: Analysis and measurement (pp. 261-272). Baltimore: Paul H. Brookes. Johnston, M. v., Keith, R. A., & Hinderer, S. R. (1992). Measurement standards of interdisciplinary medical rehabilitation. Archilles of Physical Medicine and Rehabllitation, 73, 12-5. Joint Commission on Accreditation of Healthcare Organizations (1994). A guide to establishing programs for assessing outcomes in clinical settings. Oakbrook Terrace, IL: JCAHO. Joint Commission on Accreditation of Healthcare Organizations (1993). The measurement mandate: On the road to performance improvement in health care. Oakbrook Terrace, IL: JCAHO. World Health Organization. (1980). International classification of impairment, disability. and handicap. Geneva, Switzerland: World Health Organization. KENNETH OrrENBACHER
- 15. ce Our professions ofoccupational therapy and physical therapy are closely linked by our mutual interest in rehabilitation. We interact through direct patient service activities, and students in these fields frequently have courses together in the educational setting. Because of their common core and the fact that joint coursework is cost effective, it is probable that in the future more, rather than fewer, university courses wi)) be shared by occupational and physical therapy students. One type of content that lends itself we)) to such joint study is that of assessment. Assessment in Occupational Therapy and Physical Therapy is well suited as a text for graduate students in these joint courses. Although designed as a text for graduate students in occupational therapy, physical therapy, and related fields, this book will also meet the needs of advanced clinicians. Assessment in Occupational Therapy and Physical Therapy is intended as a major resource. When appropriate, certain content may be found in more than one chapter. This arrangement minimizes the need to search throughout the entire volume when a specialist is seeking a limited content area. It is assumed that the therapiSts using this text will have a basic knowledge of the use of clinical assessment tools. Our book provides the more extensive coverage and research needed by health professionals who are, or expect to be, administrators, teachers, and master practitioners. Assessment in Occupational Therapy and Physical Therapy is not intended as a procedures manual for the laboratory work required for the entry-level student who is learning assessment skills. Rather, this book provides the conceptual basis essential for the advanced practice roles. It also provides a comprehensive coverage of assessment in physical therapy and in occupational therapy. After a general overview of measurement theory in Unit One, Unit Two covers component assessments such as those for muscle strength or chronic pain. Unit Three thoroughly addresses the assessment of motor and of sensory processing dysfunction. In Unit Four, age-related assessment is covered. Finally, in Unit Five, activities ofdaily living are addressed. The contributing authors for this book have been drawn from both educational and service settings covering a widegeographic area. Although the majority ofauthorsappropriatelyare licensed occupational therapists or physical therapists, contributors from other health professions have also shared their expertise. Such diversity of input has helped us reach our goal of providing a truly comprehensive work on assessment for occupational therapists and for physical therapists. JuUA VAN DEUSEN DENIS BRUNT
- 17. nowledgments We wish toexpress our sincere thanks to all those who have helped contribute to the success of this project, especially The many contributors who have shared their expertise The staff in the Departments of Occupational Therapy and Physical Therapy, University of Florida, for their cooperation The professionals at W. B. Saunders Company who have been so consistently helpful, particularly Helaine Barron and Blair Davis-Doerre The specialreviewers for the chapter on hand assessment, especially Kristin Froelich, who viewed it through the eyes of an occupational therapy graduate student, JoAnne Wright, and Orit Shechtman, PhD, OTR And the many, many others. JULIA VAN DEUSEN DENIS BRUNT
- 19. ents UNIT ONE Overview ofMeasurement Theory 1 CHAPTER 1 Measurement Theory: Application to Occupational and Physical Therapy ........................................................................................3 Jeri Benson, PhD, and Barbara A. Schell, PhD, OTR, FAOTA UNIT1WO Component Assessments of the Adult 25 CHAPTER 2 Muscle Strength ............................................................................27 Maureen J. Simmonds, MCSP, PT, PhD CHAPTER 3 Joint Range of Motion ....................................................................49 Jeffery Gilliam, MHS, PT, OCS, and Ian Kahler Barstow, PT CHAPTER 4 Hand Analysis...............................................................................78 A. Moneim Ramadan, MD, FRCS CHAPTERS Clinical Assessment of Pain............................................................123 Robert G. Ross, MPT, CHT, and Paul C. LaStayo, MPT, CHT CHAPTER 6 Cardiovascular and Pulmonary Function ...........................................134 Elizabeth T. Protas, PT, PhD, FACSM CHAPTER 7 Psychosocial Function...................................................................147 Melba J. Arnold, MS, OTR/L, and Elizabeth B. Devereaux, MSW. ACSW/L, OTR/L, FAOTA CHAPTER 8 Body Image ................................................................................159 Julia Van Deusen, PhD, OTR/L, FAOTA xvii
- 20. xviii CONTENTS CHAPTER 9 Electrodiagnosisof the Neuromuscular System...................................175 Edward J. Hammond, PhD CHAPTER 10 Prosthetic and Orthotic Assessments................................................199 LOWER EXTREMITY PROSTHETICS, 199 Robert S. Gailey, MSEd, PT UPPER EXTREMITY ORTHOTICS AND PROSTHETICS, 216 Julie Belkin, OTR, CO, and Patricia M. Byron, MA UNIT THREE Assessment of Central NelVous System Function of the Adult 247 CHAPTER 11 Motor ControL ............................................................................249 MOTOR RECOVERY AFrER STROKE, 249 Joyce Shapero Sabari, PhD, OTR UPPER MOTOR NEURON SYNDROME, 271 James Agostinucci, SeD, OTR CHAPTER 12 Sensory Processing ......................................................................295 INTRODUCTION TO SENSORY PROCESSING, 295 Julia Van Deusen, PhD, OTR/L, FAOTA SENSORY DEACITS, 296 Julia Van Deusen, PhD, OTR/L, FAOTA, with Joanne Jackson Foss, MS, OTR ASSESSMENT OF PERCEPTUAL DYSFUNCTION IN THE ADULT, 302 Sharon A. Cermak, EdD, OTR/L, FAOTA, and Keh-Chung Un, SeD, OTR COGNITION, 333 Barbara Haase, MHS, OTR/L, MHS, BS UNIT FOUR Age-Related Assessment 357 CHAPTER 13 Pediatrics: Developmental and Neonatal Assessment...........................359 Joanne Jackson Foss, MS, OTR, and Bonnie R. Decker, MHS, OTR CHAPTER 14 Pediatrics: Assessment of Specific Functions......................................375 Bonnie R. Decker, MHS, OTR, and Joanne Jackson Foss, MS, OTR CHAPTER 15 Assessment of Elders and Caregivers ...............................................401 Gail Ann Hills, PhD, OTR, FAOTA, with Steven R. Bernstein, MS, PT
- 21. Assessment of Activitiesof Daily Living 419 CHAPTER 16 Self-Care....................................................................................421 Mary Law, PhD, OT(C) CHAPTER 17 Clinical Gait Analysis: Temporal and Distance Parameters....................435 James C. Wall, PhD, and Denis Brunt, PT, EdD CHAPTER 18 Home Management .....................................................................449 Shirley J. Jackson, MS, OTR/L, and Felecia Moore Banks, MEd, OTR/L CHAPTER 19 Community Activities....................................................................471 Carolyn Schmidt Hanson, PhD, OTR CHAPTER 20 Work Activities ............................................................................477 Bruce A. Mueller, OTR/L, CHT, BIen D. Adams, MA, CRC, CCM, and Carol A. Isaac, PT, BS An Assessment Summary ...................................................................521 Index..............................................................................................523
- 23. UNIT ONE Overviewof Measurement Theory
- 25. CHAPTER 1 Measurement Theory: Applicationto Occupational and Physical Therapy Jeri Benson, PhD Barbara A. Schell, PhD, OTR, FAOTA SUMMARY This chapter begins with a conceptual overview of the two primary is sues in measurement theory, validity and reliability. Since many of the measure ment tools described in this book are observationally based measurements, the re mainder of the chapter focuses on several issues with which therapists need to be familiar in making observational measurements. First, the unique types of errors in troduced by the observer are addressed. In the second and third sections, meth ods for determining the reliability and validity of the scores from observational measurements are presented. Since many observational tools already exist, in the fourth section we cover basic gUidelines to consider in evaluating an instrument for a specific purpose. In the fifth section, we summarize the steps necessary for de veloping an observational tool, and, finally, a discussion of norms and the need for local norms is presented. The chapter concludes with a brief discussion of the need to consider the social consequences of testing. The use of measurement tools in both occupational and physical therapy has increased dramatically since the early 1900s. This is due primarily to interest in using scientific approaches to improve practice and to justify each profes sion's contributions to health care. Properly developed measures can be useful at several levels. For clinicians, valid measurement approaches provide important information to support effective clinical reasoning. Such measures help define the nature and scope of clinical problems, provide benchmarks against which to monitor progress, and serve to summarize important changes that occur as a result of the therapy process (Law, 1987). Within departments or practice groups, aggregated data from various measures allow peers and managers to both critically evaluate the effectiveness of current interventions and develop direc tions for ongoing quality improvement. ~~--" - . 3
- 26. 4 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY Measurement is at the heart of many research endeavors designed to test the efficacy of therapy approaches (Short DeGraff & Fisher, 1993; Sim & Arnell, 1993). In addition to professional concerns with improving practice, meas urement is taking on increased importance in aiding decision-making about the allocation of health care re sources. At the health policy level, measurement tools are being investigated for their usefulness in classifying differ ent kinds of patient groups, as well as justifying the need for ongoing service provision (Wilkerson et aI., 1992). Of particular concern in the United States is the need to determine the functional outcomes patients and clients experience as a result of therapy efforts. Most of the measures discussed in the remaining chap ters of this book can be thought of as being directed at quantifying either impairments ordisabilities (World Health Organization, 1980). Impairments are problemsthat occur at the organ system level (e.g., nervous system, musculo skeletal system). Impairments typically result from illness, injury, or developmental delays. Impairments mayor may not result in disabilities. In contrastto impairment, disability implies problems in adequately performing usual func tional tasks consistent with one's age, culture, and life situation. Different psychometric concerns are likely to surface when considering the measurement of impair ments versus functional abilities. For instance, when rating impairments, expectations are likely to vary as a function of age or gender. For example, normative data are needed for males and females of different ages for use in evaluating the results of grip strength testing. Alternatively, a major concern in using functional assessments to assess disability is how well one can predict performance in different contexts. For example, how well does being able to walk in the gym or prepare a light meal in the clinic predict performance in the home? Therefore, before evaluating a given tool's validity, one must first considerthe purpose for testing. Thus, whether a therapist is assessing an impair ment or the degree of disability, the purpose for testing should be clear. The objective of this chapter is to provide occupational and physical therapy professionals with sufficient theo retical and practical information with which to betterunder stand the measurements used in each field. The follOWing topics are addressed: the conceptual baSis of validity and reliability; issues involved in making observational meas urements, such as recent thinking in assessing the reliabil ity and validity of observational measures; guidelines for evaluating and developing observational measurement tools (or any other type of tool); and, finally, the need for local norms. Clinicians should be able to use this infor mation to assess the quality of a measurement tool and its appropriate uses. Such understanding should promote valid interpretation of findings, allowing for practice deci sions that are both effective and ethical. Educators will find this chapter useful in orienting students to important measurement issues. Finally, researchers who develop and refine measures will be interested in the more recent procedures for stUdying reliability and validity. CONCEPTUAL BASIS OF VALIDITY AND RELIABILITY Psychometric theory is concerned with quantifying ob servations of behavior. To quantify the behaviors we are interested in studying, we must understand two essential elements of psychometric theory: reliability and validity. Therefore, a better understanding of the conceptual basis for these two terms seems a relevant place to start. Validity Validity is the single most important psychometric concept, as it is the process by which scores from measurements take on meaning. That is, one does not validate a scale or measuring tool; what is validated is an interpretation about the scores derived from the scale (Cronbach, 1971; Nunnally, 1978). This subtle yet impor tant distinction in terms of what is being validated is sometimes overlooked, as we often hear one say that a given measurement tool is "valid." What is validated is the score obtained from the measurement and not the tool itself. This distinction makes sense if one considers that a given tool can be used for different purposes. For example, repeated measures of grip strength could be used by one . therapist to assess a patient's consistency of effort to test his or her apparent willingness to demonstrate full physical capacity and to suggest his or her motivation to return to work. Another therapist might want to use the same measure of grip strength to describe the current level of strength and endurance for a hand-injured individual. In the former situation, the grip strength measurement tool would need to show predictive validity for maximum effort exertion, whereas in the latter situation, the too) would need to show content validity for the score interpretation. It is obvious then that two separate validity studies are required for each purpose, as each purpose has a different objective. Therefore, the score in each of the two above situations takes on a different meaning depending on the supporting validity evidence. Thus, validity is an attribute of a measurement and not an attribute of an instrument (Sim & Arnell, 1993). A second aspect of validity is that test score validation is a matter of degree and not an all-or-nothing property. What this means is that one study does not validate or fail to validate a scale. Numerous studies are needed, using different approaches, different samples, and different populations to build a body of evidence that supports or fails to support the validity of the score interpretation.
- 27. Thus, validation isviewed as an continual process (Messick, 1989; Nunnally, 1978). Even when a large body of evidence seems to exist in support of the validity of a particular scale (e.g., the Wechsler Intelligence Scales), validity studies are continually needed, as social or cultural conditions change over time and cause our interpretation of the trait or behavior to change. Thus, for a scale to remain valid over time, its validity must be reestablished periodically. Later in this chapter, the social consequences of testing (MeSSick, 1989) are discussed as a reminder of the need to reevaluate the validity of measures used in occupational and physical therapy as times change and the nature of the professions change. Much more is said about the methods used to validate test scores later in the chapter in the context of the development and evaluation of observational measurement tools. Reliability Theory Clinicians and researchers are well aware of the impor tance of knowing and reporting the reliability of the scales used in their practice. In understanding conceptually what is meant by reliability, we need to introduce the concept of true score. A true score is the person's actual ability or status in the area being measured. If we were interested in measuring the level of "functional independence" of an individual, no matter what scale is used, we assume that each individual has a "true" functional independence score, which reflects what his or her functional abilities are, if they could be perfectly measured. An individual's true score could be obtained by testing the individual an infinite number of times using the same measure of functional independence and taking the average ofall of his or her test scores. However, in reality it is not possible to test an individual an infinite number of times for obvious reasons. Instead, we estimate how well the observed score (often from one observation) reflects the person's true score. This estimate is called a reliability coefficient. While a true score for an individual is a theoretical concept, it nonetheless is central to interpreting what is meant by a reliability coefficient. A reliability coefficient is an expression of how accurately a given measurement tool has been able to assess an individual's true score. Notice that this definition adds one additional element to the more commonly referred to definition of reliability, usually described as the accuracy or consistency of the measure ment tool. By understanding the concept of true score, one can better appreciate what is meant by the numeric value of a reliability coefficient. In the next few paragraphs, the mathematic logic behind a reliability coefficient is de scribed. In an actual assessment situation, if we needed to obtain a measure of a person's functional independence, we likely would take only one measurement. This one measurement is referred to as an individual's observed score. The discrepancy between an individual's true score and his or her observed score is referred to as the error score. This simple relationship forms the basis of what is referred to as "classical test theory" and is shown by Equation 1-1: observed score (0) = true score ( T ) + error score (E) [1] Since the concept of reliability is a statistic that is based on the notion of individual differences that produce variability in observed scores, we need to rewrite Equation 1-1 to represent a group of individuals who have been measured for functional independence. The relationship between observed, true, and error scores for a group is given by Equation 1-2: [2] where 0' 2 0 is the "observed score" variance, O' 2 T is the "true score" variance, and O' 2 E is the "error score vari ance." The variance is a group statistic that provides an index of how spread out the observed scores are around the mean "on the average." Given that the assumptions of classical test theory hold, the error score drops out of Equation 1-2, and the reliability coefficient (p"J is de fined as 2 / 2 [3]pxx = 0' TO'O Therefore, the proper interpretation of Equation 1-3 is that a reliability coefficient is the proportion of observed score variance that is attributed to true score variance. For example, if a reliabilitycoefficient of 0.85 were reported for our measure of functional independence, it would mean that 85% of the observed variance can be attributed to true score variance, or 85% of the measurement is assessing the individual's true level of functional independence, and the remaining 15% is attributed to measurement error. The observed score variance is the actual variance obtained from the sample data at hand. The true and error score variance cannot be calculated in classical test theory because they are theoretical concepts. As it is impossible to testan individualan infinite number oftimes to compute his or her true score, all calculations of reliability are consid ered estimates. What is being estimated is a person's true score. The more accurate the measurement tool is, the closer the person's observed score is to his or her true score. With only one measurement, we assume that 0 = T. How much confidence we can place in whether the as sumption of 0 = T is correct is expressed by the reliability coefficient. (For the interested reader, the derivation of the reliability coefficient, given that the numerator of Equation 1-3 is theoretical, is provided in many psychometric theory texts, e.g., Crocker & Algina, 1986, pp. 117-122. Also,
- 28. 6 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY Equation 1-3 is sometimes expressed in terms of the error score as 1 - (a2E/a20)') In summary, the conceptual basis of reliability rests on the notion of how well a given measurement tool is able to assess an individual's tme score on the behavior of interest. This interpretation holds whether one is estimating a stability, equivalency, or internal consistency reliability coefficient. Finally, as discussed earlier with regard to validity, reliability is not a property of the measurement tool itself but of the score derived from the tool. Furthermore, as pointed out by Sim and Arnell (1993) the reliability of a score should not be mistaken for evidence of the validity of the score. Measurement Error The study of reliability is integrally related to the study of how measurement error operates in given clinical or research situations. In fact, the choice of which reliability coefficient to compute depends on the type of measure ment error that is conceptually relevant in a given meas urement situation, as shown in Table 1-1 . The three general forms of reliability shown in Table 1-1 can be referred to as classical reliabil,ity procedures because they are derived from classical test theory, as shown by Equation 1-1. Each form of reliability is sensitive to differ ent forms of measurement error. For example, when con sidering the measurement of edema it is easy to recognize that edema has both trait (dispositional) and state (situ ational) aspects. For instance, let us say we developed an edema battery, in which we used a tape measure to meas ure the circumference of someone's wrist and fingers, fol- TABLE 1- 1 lowed by a volumetric reading obtained by water displace ment and a clinical rating based on therapist observation. Because an unimpaired person's hand naturally swells slightly at different times or after some activities, we would expect some differences if measurements were taken at different times of day. Because these inconsistencies are expected, they would not be attributed to measurement error, as we expect all the ratings to increase or decrease together. However, inconsistencies among the items within the edema battery would suggest measurement error. For example, what if the tape measure indicated an increase in swelling, and the volumeter showed a decrease? This would suggest some measurement error in the battery of items. ~ The internal consistency coefficient reflects the amount of measurement error due to internal differences in scores measuring the same constmct. To claim that an instrument is a measure of a trait that is assumed to remain stable over time for noninjured indi viduals (excluding children), such as coordination, high reliability in terms of consistency across time as well as within time points across items or observations is required. Potential inconsistency over measurement time is measured by the stability coefficient and reflects the degree of measurement error due to instability. Thu's, a high stability coefficient and a high internal consistency coeffi cient are required of tools that are attempting to measure traits. It is important to know how stable and internally consistent a given measurement tool is before it is used to measure the coordination of an injured person. If the measurement is unstable and the behavior is also likely to be changing due to the injury,then it will be difficult to know if changes in scores are due to real change or to measure ment error. OVERVIEW OF C ,ICAL APPROACHES FOR ESTIMATING REUABIUIY ReUabiHty Type Sources of Error Procedure StabiHty (test-retest) For tools monitoring change over time (e.g.. Functional Independence Measure) Equivalency (parallel forms) For multiple forms of same tool (e.g. , professional certification examinations) Internal consistency (how will items in tool measure the same construct) For tools identifying traits (e.g., Sensory Integration and Praxis Test) Change in subject situation over time (e.g., memory, testing conditions, compliance) Any change treated as error, as trait ex pected to be stable Changes in test forms due to sampling of items. item quality Any change treated as error, as items thought to be from same content domain Changes due to item sampling or item quality Any change treated as error, because items thought to be from same content domain Test, wait, retest with the same tool and same subjects Use PPM; results will range from -1 to 1, with negatives treated as O. Time inter vals should be reported. Should be > 0.60 for long intervals, higher for shorter in tervals Prepare parallel forms, give forms to same subjects with no time interval Use PPM; results will range from -1 to 1, with negatives treated as O. Should be > 0.80 A. SpUt half: Test, split test in half. Use PPM, correct with Spearman Brown Should be > 0.80 B. Covariance procedures: Average of all split halves. KR20, KR 21 (di chotomous scoring: right/wrong, mul tiple choice), Alpha (rating scale). Should be > 0.80
- 29. Issue of SampleDependency The classical approaches to assess scale reliability shown in Table 1-1 are sample-dependent procedures. The term sample dependent has two different meanings in meas urement, and these different meanings should be consid ered when interpreting reliability and validity data. Sample dependency usually refers to the fact that the estimate of reliability will likely change (increase or decrease) when the same scale is administered to a different sample from the same population. This change in the reliability estimate is primarily due to changes in the amount of variability from one sample to another. For example, the reliability coeffi cient is likely to change when subjects of different ages are measured with the same scale. This type of sample dependency may be classified within the realm of "statis tical inference," in which the instrument is the same but the sample of individuals differs either within the same popu lation or between populations. Thus, reliability evidence should be routinely reported as an integral part of each study. Interms ofinterpreting validitydata, sample dependency plays a role in criterion-related and construct validity studies. In these two methods, correlational-based data are frequently reported, and correlational data are highly influenced by the amount or degree of variability in the sample data. Thus, a description of the sample used in the validity study is necessary. When looking across validity studies for a given instrument, we would like to see the results converging for the different samples from the same population. Furthermore, when the results converge for the same instrument over different populations, even stronger validity claims can be made, with one caution: Validity and reliability studies may produce results that fail to converge due to differences in samples. Thus, in interpreting correctly a testscore for patients who have had cerebrovascular accidents (CVAs), the validity evidence must be based on CVA patients of a similar age. Promising validity evidence based on young patients with traumatic brain injury will not necessarily generalize. The other type of sample dependency concerns "psy chometric inference" (Mulaik, 1972), where the items constituting an instrument are a "sample" from a domain or universe of all potential items. This implies that the reliability estimates are specific to the subdomain consti tuting the test. This type of sample dependency has important consequences for interpreting the specific value of the reliability coefficient. For example, a reliability coeffiCient of 0.97 may not be very useful if the measure ment domain is narrowly defined. This situation can occur when the scale (or subscale) consists of only two or three items thatare slight variations ofthe same item. In this case, the reliability coefficient is inflated since the items differ only in a trivial sense. For example, if we wanted to assess mobility and used as our measure the ability of an individual to ambulate in a 10-foot corridor, the mobility task would be quite narrowly defined. In this case, a very high reliability coefficient would be expected. However, if mobility were more broadly defined, such as an individual's ability to move freely throughout the home and community, then a reliability coeffiCient of 0.70 may be promising. To increase the 0.70 reliability, we might increase the number of items used to measure mobility in the home and community. Psychometric sample dependency has obvious implica tions for validity. The more narrowly defined the domain of behaviors, the more limited is the validity generalization. Using the illustration just described, being able to walk a 10-foot corridor tells us very little about how well the individual will be able to function at home or in the community. Later in the chapter, we introduce procedures for determining the reliability and validity of a score that are not sample dependent. Numerous texts on measurement (Crocker & Algina, 1986; Nunnally, 1978) or research methods (Borg & Gall, 1983; Kerlinger, 1986) and measurement-oriented re search articles (Benson & Clark, 1982; Fischer, 1993; Law, 1987) have been written; these sources provide an extensive discussion of validity and the three classical reliability procedures shown in Table 1-1. Given that the objective of this chapter is to provide applications of measurement theory to the practice of occupational and physical therapy, and that most of the measurement in the clinic or in research situations involves therapists' observations of individual performance or be havior, we focus the remaining sections of the chapter on the use of observational measurement. Observational measurements have a decided advantage over self-report measurements. While self-report measurements are more efficient and less costly than observational measurements, self-report measures are prone to faking on the part of the individual making the self-report. Even when faking may not be an issue, some types of behaviors or injuries cannot be accurately reported by the individual. Observational measures are favored by occupational and physical thera pists because they permit a direct measurement of the behavior of the individual or nature and extent of his or her injury. However, observational measurements are not without their own sources of error. Thus, it becomes important for occupational and physical therapiSts to be aware of the unique effects introduced into the measure ment process when observers are used to collect data. In the sections that follow, we present six issues that focus on observational measurement. First, the unique types of errors introduced by the observer are addressed. In the second and third sections, methods for determining the reliability and validity of the scores from observational measurements are presented. Since many observational tools already exist, in the fourth section we cover basic guidelines one needs to consider in evaluating an instru ment for a specific purpose. However, sometimes it may be necessary to develop an observational tool for a specific situation or facility. Therefore, in the fifth section, we summarize the steps necessary for developing an observa tional tool along with the need for utilizing standardized
- 30. 8 UNIT O~IE-OVERVIEWOF MEASUREMENTTHEORY procedures. Finally, the procedures for developing local norms to gUide decisions of therapists and health care managers in evaluating treatment programs are covered. ERRORS INTRODUCED BY OBSERVERS Observer effects have an impact on the reliability and the validity of observational data. Two distinct forms of ob server effects are found: 1) the observer may fail to rate the behavior objectively (observer bias) and 2) the presence of the observer can alter the behavior of the individual being rated (observer presence). These two general effects are summarized in Table 1-2 and are discussed in the following sections. Observer Bias Observer bias occurs when characteristics of the ob server or the situation being observed influence the ratings made by the observer. These are referred to as systematic errors, as opposed to random errors. SystematiC errors usually produce either a positive or negative bias in the observed score, whereas random errors fluctuate in a random manner around the observed score. Recall that the observed score is used to represent the ''true score," so any bias in the observed score has consequences for how reliably we can measure the true score (see Equation 1-3). Examples of rater characteristics that can influence obser vations range from race, gender, age, or social class biases to differences in theoretical training or preferences for different procedures. In addition to the background characteristics of observ ers that may bias their observations, several other forms of TABLE }· 2 systematic observer biases can occur. First, an observer may tend to be too lenient or too strict. This form of bias has been referred to as either error of severity or error of leniency, depending on the direction of the bias. Quite often we find that human beings are more lenient than they are strict in their observations of others. A second form of bias is the error of central tendency. Here the observer tends to rate all individuals in the middle or average category. This can occur if some of the behaviors on the observational form were not actually seen but the observer feels that he or she must put a mark down. A third type of systematic bias is called the halo effect. The halo effect is when the observer forms an initial impression (either positive or negative) of the individual to be observed and then lets this impression guide his or her subsequent ratings. In general, observer biases are more likely to occur when observers are asked to rate high-inference or evaluation-type variables (e.g., the confidence with which the individual buttons his or her shirt) compared with very specific behaviors (e.g., the person's ability to button his or her shirt). To control for these forms of systematic observer bias, one must first be aware of them. Next, to remove their potential impact on the observational data, 'adequate training in using the observational tool must be provided. Often, during training some of these biases come up and can be dealt with then. Another method is to have more than one observer present so that differences in rating may reveal observer biases. Observer Presence While the "effect" of the presence of the observer has more implications for a research study than in clinical practice, it may be that in a clinical situation, doing OBSERVER EfFECTS AND STRATEGIES TO MANAGE THEM JofIueuces Definition Strategies to Control Observer biases Background of observer Error of severity or leniency Error of central tendency Halo effect Observer presence Observer expectation Bias due to own experiences (e.g., race, gender, class, theoretical orientation, practice preferences) Tendency to rate too strictly or too leniently Tendency to rate everyone toward the middle Initial impression affects all subsequent ratings Changes in behavior as a result of being measured Inflation or deflation of ratings due to observer's per sonal investment in measurement results Increase observer awareness of the influence of his or her background Provide initial and refresher observer training Provide systematic feedback about individual rater tendencies Do coratings periodically to detect biases Minimize use of high-inference items where possible Spend time with individual before evaluating to de sensitize him or her to observer Discuss observation purpose after doing observation Do routine quality monitoring to assure accuracy (e.g., peer review, coobservations)
- 31. something out ofthe ordinary with the patient can alter his or her behavior. The simple act of using an observational form to check off behavior that has been routinely per formed previously may cause a change in the behavior to be observed. To reduce the effects of the presence of the observer, data should not be gathered for the first few minutes when the observer enters the area or room where the observation is to take place. In some situations, it might take several visits by the obseiver before the behavior of the individual or group resumes to its "normal" level. If this precaution is not taken, the behavior being recorded is likely to be atypical and not at all representative of normal behavior for the individual or group. A more serious problem can occur if the individual being rated knows that high ratings will allow him or her to be discharged from the clinic or hospital, or if in evaluating the effect of a treatment program, low ratings are initially given and higher ratings are given at the end. This latter situation describes the concept of observer expectation. However, either of these situations can lead to a form of systematic bias that results in contamination of the observational data, which affects the validity of the scores. To as much an extent as possible, it is advisable not to discuss the purpose of the observations until after they have been made. Alternatively,. one can do quality monitoring to assure accuracy of ratings. ASSESSING THE RELIABILITY OF OBSERVATIONAL MEASURES The topic of reliability was discussed earlier from a conceptual perspective. In Table 1-1, the various methods for estimating what we have referred to as the classical forms of reliability of scores were presented. However, procedures for estimating the reliability of observational measures deserve special attention due to their unique nature. As we noted in the previous section, observational measures, compared with typical paper-and-pencil meas ures of ability or personality, introduce additional sources of error into the measurement from the observer. For example, if only one observer is used, he or she may be inconsistent from one observation to the next, and there fore we would want some information on the intrarater agreement. However, if more than one observer is used, then not only do we have intrarater issues but also we have added inconsistencies over raters, or interrater agreement problems. Notice that we have been careful not to equate intrarater and interrater agreement with the concept of reliability. Observer disagreement is important only in that it reduces the reliability of an observational measure, which in turn reduces its validity. From a measurement perspective, percentage of ob server agreement is not a form of reliability (Crocker & Algina, 1986; Herbert & Attridge, 1975). Furthermore, research in this area has indicated the inadequacy of reporting observer agreement alone, as it can be highly misleading (McGaw et aI., 1972; Medley & Mitzel, 1963). The main reason for not using percentage of observer agreement as an indicator of reliability is that it does not address the central issue of reliability, which is how much of the measurement represents the individual's true score. The general lack of conceptual understanding of what the reliability coefficient represents has led practitioners and researchers in many fields (not just occupational and physical therapy) to equate percentage of agreement methods with reliability. Thus, while these two concepts are not the same, the percentage of observer agreement can provide useful information in studying observer bias or ambiguity in observed events, as suggested by Herbert and Attridge (1975). Frick and Semmel (1978) provide an overview of various observer agreement indices and when these indices should be used prior to conducting a reliability study. Variance Components Approach To consider the accuracy of the true score being measured via observational methods, the single best pro cedure is the variance components approach (Ebel, 1951; Frick & Semmel, 1978; Hoyt, 1941). The variance components approach is superior to the classical ap proaches for conducting a reliability study for an observa tion tool because the variance components approach allows for the estimation of multiple sources of error in the measurement (e.g., same observer over time, different observers, context effects, training effects) to be partitioned (controlled) and studied. However, as Rowley (1976) has pOinted out, the variance components approach is not well known in the diSciplines that use observational measure ment the most (e.g., clinical practice and research). With so much of the assessment work in occupational and physical therapy being based on observations, it seems highly appropriate to introduce the concepts of the variance components approach and to illustrate its use. The variance component approach is based on an analysis of variance (ANOVA) framework, where the variance components refer to the mean squares that are routinely computed in ANOVA. In an example adapted from Rowley (1976), let us assume we have n;;:: 1 obser vations on each of p patients, where hand dexterity is the behavior to be observed. We regard the observations as equivalent to one another, and no distinction is intended between observations (observation five on one patient is no different than observation five on another patient). This "design" sets up a typical one-way repeated-measures ANOVA, with P as the independent factor and the n observations as replications. From the ANOVA summary table, we obtain MSp (mean squares for patient) and MSw (mean squares within patients, or the error term). The reliability of a score from a single observation of p patients would be estimated as:
- 32. 10 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY MSp MSw [4) ric = MSp + (n - I)MSw Equation 1-4 is the intraclass correlation (Haggard, 1958). However, what we are most interested in is the mean score observed for the p patients over the n> 1 observations, which is estimated by the following expres sion for reliability: -MSw rxx = [5) MSp Generalizability Theory Equations 1-4 and 1-5 are specific illustrations of a more generalized procedure that permits the "generaliz ability" of observational scores to a universe of observa tions (Cronbach et al., 1972). The concept of the universe of observational scores for an individual is not unlike that of true score for an individual introduced earlier. Here youcan see the link that is central to reliability theory, which is how accurate is the tool in measuring true score, or, in the case of observational data, in producing a score that has high generalizability over infinite observations. To improve the estimation of the "true observational score," we need to isolate as many sources of error as may be operating in a given situation to obtain as true a measurement as is possible. The variance components for a single observer making multiple observations over time would be similar to the illustration above and expressed byequations 1-4and 1-5, where we corrected for the observer's inconsistency from each time point (the mean squares within variance com ponent). If we introduce two or more observers, then we can study several different sources of error to correct for differences in background, training, and experience (in addition to inconsistencies within an observer) that might adversely influence the observation. All these sources of variation plus their interactions now can be fit into an ANOVA framework as separate variance components to adjust the mean observed score and produce a reliability estimate that takes into account the background, level of training, and years of experience of the observer. Roebroeck and colleagues (1993) provide an introduc tion to using generalizability theory to estimate the reliabil ity of assessments made in physical therapy. They point out that classical test theory estimates of reliability (see Table 1-1) are limited in that they cannot account for different sourceS of measurement error. In addition, the classical reliability methods are sample dependent, as mentioned earlier, and as such cannot be generalized to other therapists, situations, or patient samples. Thus, Roebroeck and associates (1993) suggest that generaliz ability theory (which is designed to account for multiple sources of measurement error) is a more suitable method for assessing reliability of measurement tools used in clinical practice. For example, we might be interested in how the reliability ofclinical observations is influenced if the number of therapists making the observations were in creased or if more observations were taken by a single therapist. In these situations, the statistical procedures associated with generalizability theory help the clinical researcher to obtain reliable ratings or observations of behavior that can be generalized beyond the specific situation or therapist. A final point regarding the reliability of observational data is that classic reliability procedures are group-based statistics, where the between-patient variance is being studied. These methods are less useful to the practicing therapist than the variance components procedures of generalizability theory, which account for variance within individual patients being treated over time. Roebroeck and coworkers (1993) illustrate the use of generalizability theory in assessing reliably the change in patient progress over time. They show that in treating a patient over time, what a practicing therapist needs to know is the "smallest detectible difference" to determine that a real change has occurred rather than a change that is influenced by measurement error. The reliability of change or difference scores is not discussed here, but the reliability of difference scores is known to be quite low when the pre- and postmeasure scores are highly correlated (Crocker & AJgina, 1986; Thorndike & Hagen, 1977). Thus, gener alizability theory procedures account for multiple sources of measurement error in determining what change in scores over time is reliable. For researchers wanting to use generalizabilitytheory proceduresto assess the reliability of observational data (or measurement data in which multiple sources of error are possible), many standard "designs" can be analyzed using existing statistical software (e.g., SPSS or SAS). Standard designs are one-way or factorial ANOVA designs that are crossed, and the sample size is equal in all cells. Other nonstandard designs (unbalanced in terms of sample size, or not all levels are crossed) would required specialized programs. Crick and Brennan (1982) have developed the program GENOVA, and a version for IBM-compatible computers is available (free of charge), which will facilitate the analysis of standard and nonstan dard ANOVA-based designs. It is not possible within a chapter devoted to "psycho metric methods in general" to be able to provide the details needed to implementa generalizability study. Our objective was to acquaint researchers and practitioners in occupa tional and physical therapy with more recent thinking on determining the reliability of observers or raters that maintains the conceptual notion of reliability, i.e., the measurement of true score. The following sources can be consulted to acquire the details for implementing variance components procedures (Brennan, 1983; Crocker & Algina, 1986; Evans, Cayten & Green, 1981; Shavelson & Webb, 1991).
- 33. ASSESSING THE VALIDITYOF OBSERVATIONAL MEASURES Validi tells us what the test score measures. However, 5ina; anyone test can be use or qUlfeaifre-r~nt'purposes, we need to know not just "is the test score valid" but also is the test score valid for the purpose for which I wish to J5e it?" Each form of validity calls for a different procedure llat permits one type of inference to be drawn. Therefore, the purpose for testing an individual should be clear, since being able to make predictions or discuss a construct leads to very different measurement research designs. Several different procedures for validating scores are derived from an instrument, and each depends on the purpose for which the test scores will be used. An overview of these procedures is presented in Table 1-3. As shown in the table, each validation procedure is associated with a given purpose for testing (column 1). For each purpose, an illustrative question regarding the interpretation of the score is provided under column 2. Column 3 shows the form of validity that is called for by the question, and ::olumn 4, the relevant form(s) of reliability given the purpose of testing. Law (1987) has organized the forms of validation around three general reasons for testing in occupational therapy: descriptive, predictive, and evaluative. She indicates that an individual in the clinic might need to be tested for several different reasons. If the patient has had a stroke, then the therapist might want "to compa!'e [him or her] to other stroke patients (descriptive), determine the probability of full recovery (prediction) or assess the effect of treatment (evaluative)" (p. 134). For a tool used descriptively, Law suggests that evidence of both content and construct validation of the scores should exist. For prediction, she advises that content and criterion-related data be available. Finally, for evaluative, she recommends that content and construct evidence be reported. Thus, no matter what the purpose of testing is, Law feels that all instruments used in JiBI l. 1<I the clinic should possess content validity, as she includes it in each reason for testing. Given that validity is the most important aspect of a test score, we shall discuss the procedures to establish each form of validity noted in Table 1-3 for any measurement tool. However, we focus our illustrations on observational measures. In addition, we point out the issues inherent in each form of validation so that the practitioner and researcher can evaluate whether sufficient evidence has been established to ensure a correct interpretation of the test's scores. Construct Validation Construct validation is reguired when the interpretation to be made of the scores implies an explanation of the benailior or trait. A construct is a theoretical conceptual ization ottnebe havior developed from observation. For example, functional independence is a construct that is operationalized by the Functional Independence Measure (FIM). However, or a cons truCt'io be useful;--Lord and Novick (1968) advise that the construct must be defined on two levels: operationally and in terms of how the construct of interest relates to other constructs. This latter point is the heart of what Cronbach and Meehl (1955) meant when they introduced the term nomological network in their classical article that defined construct validity. A nomologi cal network for a given construct, functionalindependence, stipulates how functional independence is influenced by other constructs, such as motivation, and in turn influences such constructs as self-esteem. To specify the nomological network for functional independence or any construct, a strong theory regarding the construct must be available. The stronger the substantive theory regarding a construct, the easier it is to design a validation study that has the potential for providing strong empirical evidence. The weaker or more tenuous the substantive theory, the greater the likelihood that equally weak empirical evidence will be OVERVIEW OF VAUDD'Y AND REUABDlTY PROCEDtJRES Purpose of the Test Validity Question Kind of Validity ReliabiUty Procedures Assess current status Do items represent the domain? Content Predict behavior or How accurate is the prediction? Criterion-related: concurrent performance or predictive Infer degree of trait How do we know a specific Construct or behavior behavior is being measured? a) Internal consistency within each subarena b) Equivalency (for multiple forms) c) Variance components for observers a) Stability b) Equivalency (for multiple forms) c) Variance components for observers a) Internal consistency b) Equivalency (for multiple forms) c) Stability (if measuring over time) d) Variance components for observers ~_ _-=::::::::::i::::
- 34. 12 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY gathered, and very little advancement is made in under standing the construct. Benson and Hagtvet (1996) recently wrote a chapter on the theory of construct validation in which they describe the process of construct validation as involving three steps, as suggested earlier by Nunnally (1978): 1) specify the domain of observables for the construct, 2) determine to what ex tent the observables are correlated with each other, and 3) determine whether the measures of a given construct cor relate in expected ways with measures of other constructs. The first step essentially defines both theoretically and op erationally the trait of interest. The second step can be thought of as internal domain studies, which would include such statistical procedures as item analysis, traditional fac tor analysis, confirmatory factor analysis (Jreskog, 1969), variance component procedures (such as those described under reliability of observational measures), and multitrait multimethod procedures (Campbe'll & Fiske, 1959). A rela tively new procedure to the occupational and physical therapy literature, Rasch modeling techniques (Fischer, 1993) could also be used to analyze the internal domain of a scale. More is said about Rasch procedures later in this chapter. The third step in construct validation can be viewed as external domain studies and includes such statis tical procedures as multiple correlations of the trait of inter est with other traits, differentiation between groups that do and do not possess the trait, and structural equation model ing (Joreskog, 1973). Many researchers rely on factor anal ysis procedures almost exclusively to confirm the presence of a construct. However, as Benson and Hagtvet (1996) pOinted out, factor analysis focuses primarily on the inter nal structure of the scale only by demonstrating the conver gence of items or similar traits. In contrast, the essence of construct validity is to be able to discriminate among differ ent traits as well as demonstrate the convergence of similar traits. The framework proVided by Benson and Hagtvet for conducting construct validity studies indicates the true meaning of validity being a process. That is, no one study can confirm or disconfirm the presence of a construct, but a series of studies that clearly articulates the domain of the construct, how the items for a scale that purports to meas ure the construct fit together, and how the construct can be separated from other constructs begins to form the basis of the evidence needed for construct validation. To illustrate how this three-step process would work, we briefly sketch out how a construct validity study would be designed for a measure of functional independence, the FIM. First, we need to ask, "How should the theoreticaland empirical domains of functional independence be concep tualized?" To answer this question, we would start by drawing on the research literature and our own informal observations. This information is then summarized to form a "theory" of what the term functional independence means, which becomes the basis of the construct,as shown in Figure 1-1 above the dashed line. A construct is an abstraction that is inferred from behavior. To assess functional independence, the construct must be operationalized. This is done by moving from the Theoretical: Constructs Empirical: Measurements FIGURE 1-1. Relationship between a theoretical construct empirical measurement. theoretical, abstract level to the empirical level, as sho Figure 1-1 below the dashed line, where the sp aspects of function are shown. Each construct is ass to have its own empirical domain. The empirical d contains all the possible item types and ways to me the construct (e.g. , nominal or rating items, self-r observation, performance assessment). Finally, s within the empirical domain in Figure 1- 1 is. our s measure of functional independence, the FIM. Th operationalizes the concept of functional independe terms of an individual's need for assistance in the ar self-care, sphincter management, mobility, locom communication, and social cognition (Center for tional Assessment Research, 1990). A number of possible aspects of function are not included in th (such as homemaking, ability to supervise attendan driving) because of the desire to keep the assessme as short as possible and still effectively reflect the deg functional disability demonstrated by individuals. Figure 1-2 illustrates how others have operation the theoretical construct of functional independen rehabilitation patients, such as the Level of Rehabil Scale (LORS) (Carey & Posavac, 1978) and the B (Mahoney & Barthel, 1965). It is expected that the and Barthel would correlate with the FIM becaus operationalize the same construct and their items subset of the aspects of function domain (see large s circle in Figure 1-2). However, the correlations wou be perfect because they do not operationalize the con of functional independence in exactly the same way they include some different aspects of functional ind dence). In our hypothetical construct validity study, we now selected a specific measurement tool, so we can mo to step 2. In the second step, the internal domain of th is evaluated. An internal domain study is one in whi items on the scale are evaluated. Here we might use analysis to determine how well the items on th measure a single construct or whether the two dime recently suggested by Linacre and colleagues (1994) empirically verified. Since the developers of the (Granger et al., 1986) suggest that the items be summ total score, which implies one dimenSion, we can te
- 35. Theoretical Theoretical trait: ::mpirical R GURE1-2. Several empirical measures of the same theoretical :'.)OStruct. competing conceptualizations of what the FIM items seem '0 measure. For the third step in the process of providing construct ',<alidity evidence for the RM scores, we might select other variables that are assumed to influence one's level of functional independence (e.g. , motivation, degree of family support) and variables that functional independence is thought to influence (e.g., self-esteem, employability). In this third step, we are gathering data that will confirm or fail to confirm our hypotheses about how functional indepen dence as a construct operates in the presence of other constructs. To analyze our data, we could use multiple regression (Pedhazur, 1982) to study the relation of motivation and degree of family support to functional independence. A second regression analysis might explore whether functional independence is related to self-esteem and employability in expected ways. More advanced statistical procedures combine the above two regression analyses in one analysis. One such procedure is structural equation modeling (Joreskog, 1973). Benson and Hagtvet (1996) provide an illustration of using structural equation modeling to assess construct validation in a study similar to what was just described. The point of the third step is that we expect to obtain results that confirm our hypotheses of how functional independence as a construct operates. If we do happen to confirm our hypotheses regarding the behavior of functional independence, this then becomes one more piece of evidence for the validity of the FIM scores. However, the generalization of the construct be yond the sample data at hand would not be warranted (see earlier section on sample dependency). Thus, for appro priate use of the FIM scores with individuals other than those used in the hypothetical study described here, a separate study would need to be conducted. Content Validation To determine the content validity of the scores from a scale, o~wo.!..!lcLneed to sp~cify an explicit definition of the· behavioral domain and how that domain is to be opera tionally defined. This step is critical, since the task in content validation is to ensure that the items adequately assess the behavioral domain of interest. For example, consider Figure 1-1 in thinking about how the FIM would be evaluated for content validity. The behavioral domain is the construct of functional independence, which needs to be defined in its broadest sense, taking into account the various perspectives found in the research literature. Then functional independence is operationally defined as that set of behaviors assessed by the FIM items (e.g., cognitive and motor activities necessary for independent living). Once these definitions are decided on, an independent panel of experts in functional independence would rate whether the 5 cognitive items and the 13 motor items of the FIM adequately assess the domain of functional independence. Having available a table of specifications (see section on developing an observational form and Table 1-5) for the experts to classify the items into the cells of the table facilitates the process. The panel of experts should be: 1) independent of the scale being evaluated (in this case, they were not involved in the development of the FIM) and 2) undisputed experts in the subject area. Finally, the panel of experts should consist of more than one person. Crocker and Algina (1986) provide a nice framework for conducting a content validity study along with practical considerations and issues to consider. For example, an important issue in assessing the content validity of items is what exactly the expert rates. Does the expert evaluate only the content of the items matching the domain, the difficulty of the task for the intended examinee that is implied in the item plus the content, the content of the item and the response options, or the degree of inference the observer has to make to rate the behavior? These questions point out that the "task" given to the experts must be explicitly defined in terms of exactly what they are to evaluate so that "other item characteristics" do not influ ence the rating made by the experts. A second issue pertains to how the results should be reported. Crocker and Algina (1986) point out that different procedures can lead to different conclusions regarding the match between the items and the content domain. The technical manual for an assessment tool is important for evaluating whether the tool has adequate content validity. In the technical manual, the authors need to provide answers to the following questions: "Who were the panel of experts?" "How were they sampled?" "What was their task?" Finally. the authors should indicate the degree to which the items on the test matched the definition of the domain. The results are often reported in terms of per centage of agreement among the experts regarding the classification of the items to the domain definition. Content validation is particularly important for test scores used to evaluate the effects of a treatment program. For example, a therapist or facility manager might be interested in determining how effective the self-care retraining program is for the patients in the spinal cord injury unit. To draw the conclusion that the self-care treatment program was effec tive in working with rehabilitation patients with spinal cord injuries, the FIM scores must be content valid for measuring changes in self-care skills.
- 36. 14 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY Criterion-Related Validity There are two forms of criterion-related validation: concurrent and predictive. Each form is assessed in the same manner. The only difference between these two forms is when the criterion is obtained. Concurrent validation refers to the fact that the criterion is obtained at approximately the same time as the predictor data, whereas predictive validation implies that the criterion was obtained some time after the predictor data. An example of concurrent validation would be if the predictor is the score on the FIM taken in the clinic and the criterion is the observation made by the therapist on visiting the patient at home the next day, then the correlation between these two "scores" (for a group of patients) would be referred to as the concurrent validity coefficient. However, if the criterion observation made in the home is obtained 1 or 2 months later, the correlation between these scores (for a group of patients) is referred to as the predictive validity coefficient. Thus, the only difference between concurrent and predic tive validation is the time interval between when the predictor and criterion scores are obtained. The most important consideration in evaluating criterion-related validity results is "what ,is the criterion?" In a criterion-related validity study, what we are actually validating is the predictor score (the FIM in the two illustrations just given) based on the criterion score. Thus, a good criterion must have several characteristics. First, the criterion must be "unquestioned" in terms of its validity, i.e., the criterion must be considered the "accepted standard" for the behavior that is being measured. In the illustrations just given, we might then question the validity of the therapist's observation made at the patient's home. In addition to the criterion being valid, it must also be reliable. In fact, the upper bound of the validity coefficient can be estimated using the following equation: ry/ = VCrxx) . Cryy) [6] where ryX' is the upper bound of the validity coefficient, rxx is the reliability of the predictor, and ryy is the reliability of the criterion. If the reliability of the predictor is 0.75 and the reliability of the criterion is 0.85, then the maximum validity coefficient is estimated to be 0.80, but if the reliability of the predictor is 0.60 and criterion is 0.70, then maximum validity coefficient is estimated to be 0.42. Being able to estimate the maximum value of the validity coeffi cient prior to conducting the validity study is critical. If the estimated value is too low, then the reliability of the predictor or criterion should be improved prior to initiating the validity study, or another predictor or criterion measure can be used. The value of the validity coefficient is extremely impor tant. It is what is used to evaluate the accuracy of the prediction, which is obtained by squaring the validity coefficient (rx/)' In the illustration just given, the accuracy of the prediction is 36% when the validity coefficient 0.60 and 18% when the validity coefficient is 0.42. Th accuracy of the prediction tells us how much variance th predictor is able to explain of the criterion out of 100% Given the results just presented, it is obvious that the choic of the predictor and criterion should be made very carefully Furthermore, multiple predictors often improve the accu racy of the prediction. To estimate the validity coefficien with multiple predictors requires knowledge of multipl regression, which we do not go into in this chapter. A readable reference is Pedhazur (1982). Since criterion-related validation is based on using correlation coefficient (usually the pearson produc moment correlation coefficient if the predictor and crite rion are both continuous variables), then the issues t consider with this form of validity are those that impact th correlation coefficient. For example, the range of individua scores on the predictor or criterion can be limited, th relationship between the predictor and criterion may not b linear, or the sample size may be too small. These thre factors singly or in combination lower the validity coeff cient. The magnitude of the validity coefficient also reduced, influenced by the degree of measureme,nt error i the predictor and criterion. This situation is referred to a the validity coefficient being attenuated. If a researche wants to see how high the validity coefficient would be if th predictor and criterion were perfectly measured, th follOwing equation can be used: ryx' = rx/VCrxx) . Cryy) [7 where rxy' is the corrected or disattenuated validit coefficient, and the other terms have been previousl defined. The importance of considering the disattenuate validity coefficient is that it tells us whether it is worth it t try and improve the reliability of the predictor or criterion If the disattenuated validity coefficient is only 0.50, then might be a better strategy to select another predictor o criterion. One final issue to consider in evaluating criterion-relate validity coefficients is that since they are correlations, the can be influenced by other variables. Therefore, correlate of the predictor should be considered to determine if som other variable is influencing the relationship of interest. Fo instance, let us assume that motivation was correlated wit the FIM. 1f we chose to use the FIM to predict employability the magnitude of the relationship between the FIM an employability would be influenced by motivation. We ca control the influence of motivation on the relationshi between the FIM and employability by using partial corre lations. This allows us to evaluate the magnitude of th actual relationship free of the influence of motivation Crocker and Algina (1986) provide a discussion of the nee to consider partial correlations in evaluating the results o a criterion-related validity study. Now that the procedures for assessing reliability an validity have been presented, it would be useful to appl
- 37. them by seeinghow a therapist would go about evaluating a measurement tool. EVALUATION OF OBSERVATIONAL MEASURES Numerous observational tools can be used in occupa tional and physical therapy. To assist the therapist in selecting which observational tool best meets his or her needs, a set of gUidelines is proVided in Table 1-4. These gUidelines are designed to be helpful in evaluating any instrument, not just observational tools. We have organized 'I,BI [ 1-·1 the guidelines into five sections (descriptive information, scale development, psychometric properties, norms and scoring, and reviews by professionals in the field). To respond to the points raised in the guidelines, multiple sources of information often need to be consulted. To illustrate the use of the gUidelines, we again use the FIM as a case example because of the current emphasis on outcome measures. Due to the FIM being relatively new, we need to consult multiple sources of information to evaluate its psychometric adequacy. We would like to point out that a thorough evaluation of the FIM is beyond the scope of this chapter and, as such, we do not comment on either the strengths or the weaknesses of the tool. Rather, we wanted to sensitize the therapist to the fact that a given GlJIDEUNES FOR EVALUATING A MEASUREMENT TOOL Manual Grant Reports Book Chapter Articles Descriptive Infonnation Title, author, publisher, date X X X Intended age groups X Cost X Time (train, score, use) X Scale Development Need for instrument X X X X Theoretical support X X Purpose X X X X Table of specifications described? Item development process X Rationale for number of items Rationale for item format X X X Clear definition of behavior X Items cover domain X Pilot' testing X X X Item analysis X X X Psychometric Properties Observer agreement X X Reliability Stability Equivalency NA Internal-consistency X X Standard error of measurement Generalizability approaches X X Validity Content Criterion related Construct X Sample size and description X X X Nonns and Scoring Description of norm group NA Description of scoring X Recording of procedures X Rules for borderline X Computer scoring available Standard scores available Independent Reviews NA NA NA = nonapplicable; X = information needed was found in this source. X
- 38. 16 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY tool can be reliable and valid for many different purposes; therefore, each practitioner or researcher needs to be able to evaluate a given tool for the purpose for which he or she intends to use it. Numerous sources may need to be consulted to decide if a given tool is appropriate for a specific use. Some of the information needed to evaluate a measurement tool may be found in the test manual. It is important to recognize that different kinds of test manuals, such as administration and scoring guides and technical manuals, exist. In a technical manual, you should expect to find the following points addressed by the author of the instrument (at a minimum): Need for the instrument Purpose of the instrument Intended groups or ages Description of the instrument development proce dures Field or pilot testing results Administration and scoring procedures Initial reliability and validity results, given the in tended purpose Normative data (if relevant) Sometimes the administration and scoring procedures and the normative data are a separate document from the technical manual. Book chapters are another source of information and are likely to report on the theoretical underpinnings of the scale and more extensive reliability, validity, and normative results that might include larger samples or more diverse samples. The most recent infor mation on a scale can be found in journal articles, which are likely to provide information on specific uses of the tool for specific samples or situations. Journal articles and book chapters written by persons who were not involved in the development of the instrument offer independent sources of information in terms of how useful the scale is to the research community and to practicing therapists. Finally, depending on the popularity of a given scale, independent evaluations by experts in the field may be located in test review compendiums such as Buros' Mental Measure ment Yearbooks or Test Critiques found in the reference section of the library. As shown in Table 1-4, we consulted four general types of sources (test manual, grant reports, book chapters, and journal articles) to obtain the information necessary to evaluate the FIM as a functional outcome measure. The FIM, as part of the Uniform Data System, was originally designed to meet a variety of objectives (Granger & Hamilton, 1988), including the ability to characterize disability and change in disability over time, provide the basis for cost-benefit analyses of rehabilitation programs, and be used for prediction of rehabilitation outcomes. To evaluate the usefulness of the FIM requires that the therapist decide for what specific purpose the FIM will be used. A clear understanding of your intended use of a measurement tool is critical to determining what form(s) of reliability and validity you would be looking to find ad dressed in the manual or other sources. In our example assume the reason for using the FIM is to determin usefulness as an outcome measure of "program effec ness of an inpatient rehabilitation program." Such comes would be useful in monitoring quality, mee program evaluation gUidelines of accrediting bodies, helping to identify program strengths useful for marke services. In deciding whether the FIM is an appropriate for our purposes, the following questions emerge: Does it measure functional status? Should single or multiple disciplines perform the rati How sensitive is the FIM in measuring change admission to discharge of inpatients? How.weLl does it capture the level of human assist required for individuals with disabilities in a varie functional performance arenas? Does it work equally well for patients with a rang conditions, such as orthopedic problems, spinal injury, head injury, and stroke? Most of these questions are aimed at the reliability validity of the scores from the FIM. In short, we nee know how the FIM measures functional status and for w groups, as well as how sensitive the measurement is. According to Law (1987, p. 134), the form of va called for in our example is evaluative. Law desc evaluative instruments as ones that use "criteria or item measure change in an individual over time." Under ev ative instruments, Law suggests that the items shoul responsive (sensitive), test-retest and observer reliab should be established, and content and construct va should be demonstrated. Given our intended use of FIM, we now need to see if evidence of these form reliability and validity exists for the FIM. In terms of manuals, the only one available is the G for the Use of the Uniform Data Set for Med Rehabilitation Including the Functional Independe Measure (FlM) Version 3.1, which includes the (Center for Functional Assessment Research, 19 Stated in the Guide is that the FIM was found to "face validity and to be reliable" (p. 1), with no suppor documentation of empiric evidence within the Gu Since the FIM was developed from research funding needed to consult an additional source, the final re of the grant (Granger & Hamilton, 1988). In the report is a brief description of interrater reliability an validity. Interrater reliability was demonstrated thro intraclass correlations of 0.86 on admission and 0.8 discharge, based on the observations of physicians, cupational and physical therapists, and nurses. The terrater reliability study was conducted by Hamilton colleagues (1987). In a later grant report, Heinemann colleagues (1992) used the Rasch scaling techniqu evaluate the dimensionality of the FIM. They found the 18 items do not cluster into one total score but sh be reported separately as motor (13 items) and cogn (5 items) activities. Using this formulation, the aut reported internal consistency estimates of 0.92 for m
- 39. ~ique also indicatedwhere specific items are in need of ~evision and that others could be eliminated due to redundancy. The Rasch analysis indicated that the FIM "tems generally do not vary much across different patient subgroups, with the exception of pain and burn patients on the motor activities and patients with right and bilateral m oke, brain dysfunction, and congenital impairments on :he cognitive activities (Heinemann et aI., 1992). This m plies that the FIM items do not fit well for these disability groups and should be interpreted cautiously. The authors 'ndicate that further study of the FIM in terms of item revision and item misfit across impairment groups was needed. In sum, the reliability data reported in the sources we reviewed seem to indicate that the FIM does produce reliable interrater data, and that the FIM is composed of :wo internally consistent subscales: motor and cognitive activities. The information provided in the grant under the heading of validity related primarily to scale development and refinement (e.g. , items were rated by clinicians as to ease of e and apparent adequacy), to which the authors refer as face validity. In the face validity study conducted by Hamilton and associates (1987), clinical rehabilitation therapists (with an average of 5.8 to 6.8 years of experi ence) rated the FIM items on ease of use, redundancy, and other factors. However, the results from the face validity study do not address whether the scale possesses content validity. In fact, psychometricians such as Crocker and Algina (1986), Nunnally (1978), and the authors of the Standards for Educational and Psychological Testing (1 985) do not recognize face validity as a form of scale validation. Therefore, if face "validity" is to be used, it would. be more appropriately placed under instrument development procedures. (The procedures for determining the content validity of scores from an instrument were described previously under the section on validity of observational measures.) In terms of construct validity of the FIM for our in tended purpose, we wanted to see whether the FIM scores can discriminate those with low levels of functional independence from those with high levels of indepen dence. It was necessary to consult journal articles for this information. Several researchers reported the ability of the FIM to discriminate levels of functional independence of rehabilitation patients (Dodds et aI., 1993, Granger et aI., 1990). From a partial review of the literature, we can say that the FIM was able to detect change over time and across patients (Dodds et aI., 1993; Granger et aI., 1986). While the interrater agreement appears adequate from reports by the test authors, some researchers report that when ratings are done by those from different disciplines or by untrained raters, reliability decreases (Adamovich, 1992; Chau et aI. , 1994; Fricke et aI. , 1993). From a validity perspective, recent literature strongly suggests that the FIM may be measuring several different dimensions of functional ability evidence, questions have been raised about the appropri ateness of using a total FIM score, as opposed to reporting the separate subscale scores. As was already mentioned, more literature about the FIM exists than has been referenced here, and a thorough review of all the relevant literature would be necessary to fully assess the FIM. The intent here is to begin to demonstrate that effective evaluation of measurement tools requires a sustained effort, using a variety of sources beyond the information provided by the test developer in the test manual. However, even this cursory review sug gests that observer agreement studies should be under taken by the local facility to check the consistency among therapists responsible for rating patient performance (see section on reliability of observation measures). This is but one example of the kinds of responsible actions a user of measurement tools might take to assure appropriate use of measurement scores. DEVELOPMENT OF OBSERVATIONAL MEASURES Quite often an observational tool does not exist for the required assessment, or a locally developed "checklist" is used (e.g., prosthetiC checkouts or homemaking assess ments, predriving assessments). In these situations, thera pists need to be aware of the processes involved in developing observational tools that are reliable and valid. The general procedures to follow in instrument construc tion have been discussed previously in the occupational therapy literature by Benson and Clark (1982), although their focus was on a self-report instrument. We shall adjust the procedures to consider the development of observa tional instruments that baSically involve avoiding or mini mizing the problems inherent in observational data. To illustrate this process, we have selected the evaluation of homemaking skills. The purpose of this assessment would be to predict the person's ability to safely live alone. There are two major problem areas to be aware of in using observational data: 1) attempting to study overly complex behavior and 2) the fact that the observer can change the behavior being observed. The second point is not directly related to the development of an observational measure but relates more to the reliability of the measure. The first point is highly relevant to the development of an observational measure and is addressed next. Often when a therapist is interested in making an observation of an individual's ability to perform a certain task, the set of behaviors involved in the task can be overly complex, which creates problems in being able to accu rately observe the behavior. One way to avoid this problem is to break down the behavior into its component parts. This is directly analogous to being able to define the behavior, both conceptually and empirically. This relation
- 40. 18 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY ship was iHustrated in Figures 1-1 and 1-2, in which a conceptual definition of the trait fu nctionaJ independence was given above the dashed line. It should be recognized that several conceptual definitions based on different theoretical positions regarding our understanding of what functional independence means could exist. Each concep tual definition of a trait could in turn lead to different ways to operationalize the trait at the empirical level (see the area below the dashed line in Figure 1-2). First, let us consider how conceptual and operational definitions are developed for the behavior to be observed. A conceptual or theoretical definition begins most often with unsystematic observa tions or hunches about a particular behavior from working in the clinic. For instance, therapists may be aware that meal p'lanning and preparation, cleaning, and washing clothes are typical behaviors that people must do to live alone. Therapists often have to make predictions about how well a person would do at home, based on patient performances observed in the clinic. For instance, a therapist may feel that by observing a patient in the simple act of making a cup of instant coffee, a prediction could be made about that person's safety in preparing meals at home. These thoughts are then abstracted up to a more theoretical level where they are fit into a complex of behavior patterns, and a theory regarding the behavior of interest begins to be formed. Theories are used to explain behavior and in this case are only useful if they can be empirically verified. Therefore, it is important to be able to test a theory, which is where the operational definition comes in. To test a theory we must move from the conceptual level to the empirical 'level, at which the actual data are collected. To collect data regarding a particular theory of behaVior, we must operationally define the behavior to be studied. An operational definition then makes concrete what is implied in the conceptual defini tion. For example, the concept of kitchen safety might be operationalized as the person's ability to verbalize kitchen safety concerns; demonstrate safe use of the stove; and safely obtain supplies, prepare food, and clean up after ward. The conceptual definition of the behavior is important because it attempts to define the boundary of the domain covered by the behavior. For instance, a narrow definition of kitchen safety might be operationalized as the ability to safely heat meals in a microwave. A broader definition would include obtaining groceries, preparing three meals a day, and cleaning up after meal preparation. Also, the domain may consist of one or more dimensions. For each dimension, each act or task must be explicitly and sequen tially described. That is, within each dimension are poten tially several''behavior units" that comprise the behavior to be observed, and each must be detailed. For instance, the concept of' 'kitchen safety" can include cognitive as well as motor aspects. A person can verbalize safe procedures but act unsafely, or a person may not even be aware of safety concerns. Further, the scope of safety issues can vary. For instance, a person may be safe in routine situations but unable to respond to emergency situations, such as a fire on the stove. This lack of safety can be due to cogni problems (e.g. , lack of immediate recognition of prob and timely response), motor problems (e.g., moves slowly to respond to the emergency), or affective probl (e.g., does not care about safety). In thinking about the behavior units and dimension the behavior to be observed, Borg and Gall (1983) h suggested that to be able to observe the behavior relia one should use descriptive or low-inference variable items. In general, "observer inference refers to the deg of observer judgement intervening between the actual d observed and the subsequent coding of that data on ob vational instruments." (Herbert & Attridge, 1975, p. A descriptive or low-inference variable is one that can clearly defined and easily observed (e.g., turns on stove). While many behaviors in occupational or phys therapy are of the low-inference variety, on some o sions a therapist may be called on to observe high-infere behaviors. A high-inference variable is one that involv series of events, where the behaviors are more globa where the therapist must draw a conclusion about the havior being observed. Examples of high-inference v ables might be items such as "how well will t)1e per respond to kitchen emergencies?" or more globally, "H well does the individual respond to household emerg cies?" Being able to respond to emergencies represen series of behaviors. How should the therapist rate the havior if all behaviors related to emergency responses not successful, such as when the person can dial 911 cannot describe what to do next for a fire? Even m difficult to reliably observe are evaluative variables. evaluative variable requires an inference regarding the havior, plus the therapist must make a judgment about behavior as welL For example, an evaluative item might "Rate how safe the person is likely to be living alone." only does this type of item or variable require an inferen but the therapist must make a qualitative judgment to spond to the item. Borg and Gall (1983) have warned that high-infere and evaluative variables often lead to less-reliable obse tions. To counter this reliability problem, Medley and M (1963, p. 252) have espoused a very strong posit stating that the observer should use the least amoun judgment possible, only a judgment "needed to perc whether the behavior has occurred or not." Herbert Attridge's (1975) position on the level of inference is m balanced, calling for the level of inference that is deman by the complexity of the behavior studied. If it is essen to the behavior being observed that high-inference evaluative variables are necessary, then to produce reli observational data, a great deal of attention must be g to training observers to be able to "see" and then rate high-inference and evaluative types of variables con tently. This point is addressed more in the section training observers. To organize the behavior units and dimensions of behavior as speCified in the conceptual and operatio definitions, a table of specifications is often used. A tabl
- 41. specifications guides instrumentconstruction to ensure that 1) all dimensions and behavior units are considered and 2) a sufficient number of items is written to cover each dimension. Later, if content validation is required for the TYpe of test score interpretation, the table of specifications again is used in classifying the instrument's items by a panel of experts. An example of a table of specifications is shown in Table 1-5 for measuring the behavior of kitchen safety. In the ble, the column headings indicate important components of the construct of kitchen safety. The rows reflect different dimensions of each of these behavior units. At each intersection of the rows and columns, we would make a iudgment about the relative importance of this cell and the number of items to be included. It is common to use experts 35 resources in identifying the degree of importance of each art of the assessment. Assuming we wanted to keep the :001 brief, we might start by limiting ourselves to 20 items :otal, and then apportion them, based on our predeter mined percentages. For example, the first row-by-column ::ell, "verbalize safety and cognitive," we show as being somewhat less important (10%, or wo items) then the second row-by-column cell, "obtain supplies and sen sorimotor" (20%, or four items). The number of items depends on many factors, such as the level of complexity of :he behavior to be measured, the number of dimensions and behavior units that were operationally defined, and the amount of time available to observe the behavior. The Observational Form Once the behavior to be observed has been fully defined both theoretically and operationally) and the number of irems has been decided on, the next step is to produce the observational form. The observational form is used to record or score the behavior. If each behavior unit under each dimension has been described, then it is just a matter .)f transferring those descriptions, which then become the items, to the observational form. If each behavior is well defined and involves low-inference behaviors, the form can ' e quite easy to use, as shown in Table 1-6. It may be important to have several high-inference or evaluation items, such as those shown in the lower part of Table 1-6. It should be obvious that these items require a higher level of observation skill and are much more difficult to measure objectively. To increase the level of reliability for the high.·inference and evaluative items, one can opt to have fewer categories to record the behavior. That is, a three-point scale is easier to use and produces more reliable ratings than a seven-point scale. Borg and Gall (1983) suggest that most human observations cannot be reliably rated on a continuum with more than five points. While it is a well-known fact that if you increase the observation pOints (aU other factors held constant), the amount of variance increases, which in turn increases the reliability of a scale. However, the increase in variance and, hence, reliability may be spuriously inflated and represent more TABLE I 5 EXAMPLE OF TABLE OF SPECIFICATIONS FOR KITCHEN SAFElY* Verbalize Obtain Prepare Clean Safety Supplies Food Up CognitiCJe 10%/2 10%/2 15%/3 5%/1 Sensorimotor 20%/4 20%/4 10%/2 Ajject;CJe 10%/2 Percentage indicates percent of items allocated per cell, followed by actual number of items. A blank cell indicates that the component/dimension represented by that cell is not relevant. error variance than systematic variance. Therefore, we agree with Borg and Gall that using three to five observa tion points per item should be sufficient to rate most behaviors and improves the reliability of the observations of high-inference and evaluative items. Finally, when the observational form is developed, it is important to field test the instrument. Field testing (or pilot testing) allows one to be sure all aspects of the behavior have been included, determine whether each behavior unit is suffiCiently described to be able to rate it, and assess how easy the form is to use. In addition, instructions on how to use the form should be developed and field tested. Any revisions to the form or instructions should be made and field tested again to see how the revisions work. Once the form has been suffiCiently field tested, we then turn to the training of observers to use the form. Rasch Scaling Procedures Often the items on the observational form are arranged hierarchically. That is, some behaviors are presumed to be easier than others, or some behaviors precede others. For instance, many therapists would suggest that getting on and off a chair is easier than gettting in and out of a bathtub. From a theoretical perspective, it is important to be able to validate this hierarchy. The Rasch measurement models (Fischer, 1993) are procedures that are currently being used in the development of assessment tools in occupa tional therapy that have the potential to validate hierarchi cally based assessments. Rasch measurement models are, in part, scaling procedures that permit a test developer to rank order the items on a scale from easiest to hardest. This ordering of items in turn allows the ordering of individuals in terms of their ability on the trait being measured . For example, the FIM motor and cognitive items could be hierarchically ordered such that an individual can be placed on a continuum from less independent to more indepen dent. More importantly, Rasch scaling converts the ordinal response that the observer marks on the FIM (7 = com plete independence to 1 = total assistance) to an interval scale of measurement. Interval measurements have more desirable properties than ordinal measurements, e.g., the
- 42. 20 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY TABLE 1 (, EXAMPLE OF LOW· AND mGH·INFERENCE ITEMS FROM KITCHEN SAFElY ASSESSMENT Requires Some Cuing or Completes Physical Unable to Low-Inference Items Independently Assistance Perform Patient writes out a menu for the day Patient obtains supplies for sandwich Patient puts meat on bread High-Inference Items Patient plans nutritious meals Patient routinely uses safe practices Patient can locate supplies for meals High-Inference and Evaluation Items Patient plans nutritious meals of high quality Patient has adequate endurance to perform daily cooking tasks Patient is well motivated to use safety practices separate item scores are now additive. While it is possible to add up the rankings from ordinal measurements, it should be pointed out that an assumption is being made that the distance between each scale point is equal. Typically, these distances are not equal but reflect different distances for each observer. This distinction might be made clear by the following, more typical, situation. Consider your response to a self-report attitude measure with a 1 to 5 likert-type response format. For item 1 you might select a 5 (strongly agree) and then for item 2 select response 4 (agree). The assumption of interval measurement we are making when these two responses are summed is that we move one unit's distance in intensity when going from a response of 4 to 5. The validity of this assumption becomes even more tenuous when we consider that the assumption is assumed to hold not just for an individual's responses but across individuals as well. The Rasch procedures, on the other hand, convert the ordinal data into interval data through a logistic transformation based on the proportion of persons with a given item score (Andrich, 1988; Fischer, 1993). The result is item difficulty values and person ability scores expressed in terms of interval measurements. Typically, item difficulties are expressed as the proportion of individuals passing an item, where a proportion is an ordinal measurement. In addition to the interval properties of the Rasch scaling technique, the items subjected to a Rasch analysis are no longer sample dependent. That is, the level of difficulty for an item, once scaled, is independent from the group used for the scaling. Recall that sample dependency was one of the problems with the classically based procedures. For example, using traditional items analysis, the difficulty of an item is dependent on the group tested. If the same item is given to a more able group, the item appears easy; on the otber hand, if the item is given to a less able group, the item appears difficult. Clearly it is not a very desirable property for an item's difficulty value to "bounce" around. Fischer (1993) provides a nice illustration of this issue in her development of a motor scale. Another deSirable property of Rasch scaling is that the individual's scores obtained from the measurement are also independent in terms of the set of items used. What is meant here is that a person's
- 43. ability score canbe estimated from any set of items that have been Rasch scaled. Thus, not every individual has to take the same set of items or the same number of items. This really frees up the examiner to select the set of items [hat is most appropriate for the individual and not frustrate him or her with a set of items that is either too difficult or too easy. Once the items have been Rasch scaled, the observer or examiner does not need to be concerned with administering all the items to each examinee; a subset can just as efficiently measure his or her "true" score as the full set of items. In fact, it could be argued that administering a subset of items targeted to the individual's ability is more ',vhat assessment should be like, compared with the tradi tional format of everyone receiving the same set of items. Thus, Rasch scaling permits sample-free and test-free measurement. The Rasch model is a model from a larger class of models :-eferred to as item response theory models. Item response theory models form the basis of modern test theory, as opposed to the classical procedures referred to earlier in this chapter. One feature that distinguishes modern test [heory from classical test theory is that the assumptions of [he model are directly testable, whereas the assumptions for classkal test theory are not. (The assumptions for classical test theory involve the error term shown in equations 1-1 and 1-2. The assumptions consider that an individual is tested an infinite number of times on a given instrument and that: 1) the mean of their error score is zero llle = 0], 2) the correlation between the error scores is zero IPee = 0], and 3) the correlation between an individual's [rue score and his or her error scores is zero [Pte = 0].) The assumptions made in using the Rasch procedures are that the trait being measured is unidimensional, the items used have equal discrimination power, and the items are locally independent. Local independence refers to the fact that responses to one item do not influence the responses to another item. If these assumptions can be verified, then a person's score on a scale is only a function of his or her ability and the difficulty level of the item. As pointed out earlier in the chapter, in observational data, other sources of variation are introduced into the measurement, such as observer effects. The many-faceted Rasch model allows other sources of test score variation to be accounted for, as did the variance component proce dures described in the section on reliability of observational measures. Fischer (1993) illustrates the use of the many faceted Rasch model, in which rater severity and the challenge of the task performed were considered in addition to item difficulty and person ability. Training Observers The research on observer training has shown that serious attention to this step in the process helps to ensure reliable data (Spool, 1978). In fact, once the observers are sufficiently trained, we can begin to collect reliability data to determine how accurate the tool is in assessing true score. In the initial process of training observers, it is very important that the theoretical and operational definition of the behavior to be observed is made clear. We do not want the observers rating the behavior they "think" should be rated but the behaviors on which the observational form was developed. Usually, brief, concise definitions are provided and discussed for clarity. Borg and Gall (1983) have suggested that testing the observers at this point on their understanding of the behavior may be helpful. We certainly agree with their suggestion, especially if the observation is part of a research study. This should also be considered more often with instruments used in practice. It is highly desirable to have available videotapes of the behavior to be observed for the therapist to study and replay. The training session then can run segments of the videotape, have the therapist use the observational form, then stop the tape for discussion of what behavior was noted and whether it matches with the criterion. In the training of observers, it is critical that a criterion be established. Usually, the criterion is the ratings made by the trainer, and the objective is for the therapists in training to produce the ratings that the trainer made. In this way, the reliability of the raters can be assessed. If therapists in training do not match the criterion, then the videotape can be stopped, and the behavior that was missed or mis marked can be discussed and corrected. Being able to show the persons being trained exactly what behavior is repre sented by the item on the observational form improves their understanding of the behavior and hence the reliability of their observations. Thus, the point of providing training for observers is to ensure the reliability of the data. Once the training using videotapes has reached a satisfactory level, then the training should be moved to an actual site in which the behavior can be observed. This enables a more realistic training arena in which to try out the observational form and the accuracy of the observers. The observers should not be practicing on patients for whom actual data are required. It may be possible for the criterion rater to make the rating that is required for the patient and the observers being trained to likewise rate the behavior and then compare the results after the fact. If possible, videotaping these actual settings benefit those currently being trained and could be used in later training efforts as well. When the observers are trained to an adequate level to use the instrument in the setting in which it was designed, then the process of gathering reliability data should be started. One final point on the training of observers: If rating takes place over time, such as when treatment is needed over a long period or in a longitudinal research study, it is critical to reevaluate the reliability of the observers periodically. This can be done by either having the criterion rater jointly rate the individual along with the rater(s) being studied or videotape the rater(s) being studied so that the criterion rater can also rate the same behavior. These types of checks on the reliability of the observers
- 44. 22 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY TABLL 1 7 OVERVIEW OF STEPS IN DEVELOPING OBSERVATIONAL MEAS Develop conceptual definition of behavior to be observed Develop operational definitions of behaviors to be obselved Develop table of specifications Percentage weights of relative behaviors within domain Number of items Develop observation form Pilot Define and repilot as needed Finalize form Train observers to use form Assess rater agreement Intrarater Interrater Assess reliability appropriate to purpose Classical procedures Variance components procedures Rasch-based procedures Assess validity appropriate to purpose Content Criterion referenced Construct Assess any ethical issues Unintended effects of measurement Social consequences help to prevent "rater drift" (Borg & Gall, 1983) and ensure the reliability of the observationaj data. An overview of the steps we have presented in developing an observa tional measure is given in Table 1-7. DEVELOPING LOCAL NORMS FOR OBSERVATIONALMEASURES Before addressing the need for local norms and how to gather them, it might be useful to consider the topic of norms in general. Norms refer to the scores obtained from the individuals who were tested during standardization of the scale. For many commercially available measurement tools, normative data have already been collected and summarized in the test manual for use in evaluating an individual's score. These types of tools are more commonly referred to as standardized measurements. Standardized means that the measurement has been taken under a specific set of gUidelines for administration and scoring. When data are collected in a systematic standardized fashion, the scores for all the individuals tested can be combined and summarized. The data are typically summa rized by reporting means, standard deviations, percentiles, and various forms of standard scores. The summarized data then are reported as norms in the manual accompanying the test. Norms should not be confused with standards, which are predetermined levels used to make decisions. Rather, norms are just the summarized data for the sample tested. If a different sample is tested, the norms can change. Given that norms are sample dependent, a thorough description of the individuals in the norm group is essential for score interpretation. In describing the norm group, attention should be paid to how relevant, representative, and recent the norm group is. Relevant refers to whether the norm group has similar characteristics to those of individuals to be evaluated. For example, if your practice involves mostly children and you see that in the norm group, the youngest age represented is 16, the norms will not be relevant. Representative refers to whether the population was sampled in a way that adequately reflects your patients or clients. For example, were appropriate percentages of ages, genders, and ethnic groups included? Finally, recency of norms refers to when the normative data were gathered. If the normative data are a few years old and no changes have occurred in our understanding of the trait or behavior being tested , then recency of norms is not an issue. However, if our under standing of the trait changes, like the FIM comprising three dimensions (and therefore three scores) and not one, then normative data on the FIM would have to be recollected to ensure adequate interpretation of the three new scores. Normative data are very useful for therapists to compare an individual's level of functioning with the typical expec tations for an unimpaired person. In some' cases, a treatment facility might want to develop local norms. For instance, if a commercially developed tool is used fre quently by the facility for which normative data are already available, collection of local norms would enable a com parison of the type of individuals seen at the facility to the commercial norms. One might find differences in the characteristics of individuals served by your own facility and the sample that was used to develop the norms in the test manual. Additionally, many tools used in practice do not have normative data; therefore, compiling local norms would help in clinical decision-making. To develop local normative data, one must be sure that the measurement tool is used in a standardized manner; that is, all therapists are trained in using the tool, admin istering it in the same time frame, and scoring it in the same manner. Under these conditions, the data collected on the tool at the facility can be combined and basic descriptive statistics computed (e.g., means, standard deviations, percentiles). From the descriptive statistics, standard scores can be computed to use in comparing individual scores (e.g., T-scores, where the mean is set at 50 and the standard deviation is 10). In this way, a person's raw score can be converted to a percentile and to a T-score for comparison. While percentiles are useful in that most people can understand them, they are not appropriate for statistical analyses. For example, a manager at the treat ment facility might want to see what the "average" intake score is on the patients who have a diagnosis of head injury and their "average" exit scores. Percentiles should not be averaged; therefore, some form of standard score could be used. By compiling data on the tool over time, the manager could look at cost-to-benefit relationships, such as the differences in outcomes associated with different lengths of
- 45. ---- stay, and differentkinds of therapy services. In fact, the need for such information has been an important motivator for the development of tools such as the FIM and the Uniform Data System (Center for Functional Assessment Research, 1990). SUMMARYAND CONCLUSIONS This chapter began with a conceptual overview of the two primary issues in measurement theory, validity and reliability. Since many of the measurement tools described i this book are observationally based measurements, we focused much of the chapter around the issues therapists need to be familiar with in making observational measure ments. This overview should set the stage for a better understanding of observational measurement encountered i:1later chapters in this book. Finally, the chapter ends with the use of local norms to enable therapists and faCility managers to make comparisons of individuals or groups of individuals at their facility. A chapter on measurement theory would not be com plete without attention to the ethics involved in testing human beings. We are reminded of the seminal work of Messick (1989), in which he asserts that one should not interpret the meaning ofany score without consideration of the social consequences of that test score. Because it is common to use tools to assess individuals, we must be careful that the label of the tool does not take on more meaning than the validity evidence can support. That is, many traits such as competence, self-esteem, and functional independence have value implications that may not Qe a part of their validity evidence. Thus, careful test score interpretation is called for. Finally, we must con stantly be aware of the potential and actual social conse quences of testing, e.g., the risks of a sel'f-fulfill'ing prophecy operating when the assumption is that identified impair ments necessarily result in disability. Since no "statistically based approaches" exist to evaluate the value implications of test use or the social consequences of test interpretation, it becomes important to raise and openly discuss these concerns in a variety of forums. In summary, responsible testing requires that the measurement community under stand that "validity and values are one imperative, not two, and test validation implicates both science and the ethics of assessment" (MeSSick, 1994, p.8). R Attenuated-Measurement error has influenced the result. Disattenuated-Measurement error removed. Local norms-Normative data collected at a specific facility or site. Nomological network-A representation of how dif ferent constructs are interrelated. Norms-Summarized scores from group tested during standardization of a scale. Observer bias-When characteristics of the observer or the situation being observed influence the ratings made by the observer. Observer presence-When the presence of the ob server alters the behavior of the individual being tested. Reliability coefficient-An expression of how accu rately a given measurement tool has been able to assess an individual's true score. - -_.Sample dependency-Has two forms: a) inferential, when the statistic of interest fluctuates from sample to sample and b) psychometriC, when the items constituting an instrument are a "sample" from a universe of all potential items. Standardized-Measurement taken under a speCific set of guidelines for administration and scoring. Table of specifications-Grid used to layout the dimensions of a scale. Validity-The rocess by- which scores frgm ~~r,? ments take a c-ID.eaning. VaHdity coefficient-Correlation between a predictor and the criterion. REFERENCES ' Adamovich, B, L B. (1992). Pitfalls in functional assessment: A comparison of FIM ratings by speech-language pathologists and nurses. Neurorehabilitation, 2(4). 42-51. Andrich, D. (1988). 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- 46. 24 UNIT ONE-OVERVIEWOF MEASUREMENT THEORY Crick, G. , & Brennan, R. (1982). GENOVA: A generalized analysis of variance system (Fortran IV computer program and manual.) Dorchester, MA: University of Massachussets at Boston, Computer Facilities. Crocker, L. J., & Algina, J. (1986). Introduction to classical and modern test theory. New York: Holt. Cronbach, L. J. (1971). Test validation. In R. L. Thorndike (Eel.), Educational measurement (2nd ed.) (pp. 443-507). Washington DC: American Council on Education. Cronbach, L. J. , Gieser, R, Nanda, H, & Rajaratnam, N. (1972). The dependability of behavioral measurements: Generalizability of scores and profiles. New York: Wiley. Cronbach, L. J.,& Meehl, P. E. (1955). Construct validity of psychological tests. Psychological Bulletin , 52, 281-302. "Dodds, A., Martin, D. P., Stolov, we, & Deyo, R A. (1993). Validation of the Functional Independence Measurement and its performance among rehabilitation inpatients. 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Archives of Physical Medicine and Rehabilitation, 71 . 870-875 'Granger, C v., & Hamilton, B. B. (1988). Development of a uniform national data system for medical rehabilitation 1984-1987. (Grant Number G008435062). Washington DC: National Institute on Disabil ity and Rehabilitation Research, Office of Special Education and Rehabilitation Services, Department of Education. ' Granger, C v., Hamilton, B. B., Keith, R A., Zielezny, M., & Sherwin, F. S. (1986). Advances in functional assessment for medical rehabili tation. Topics in Geriatric Rehabilitation, 1(3) 59-74. Haggard. E. (1958). Introclass correlation and the analysis of variance. New York: Dryden Press. ' Hamilton, B. B., Granger, C v., Sherwin, S. S., Zielezny, M., & Tash man, J. S. (1987). A uniform national data system for medical rehabili tation. In M. J. Fuhrer (Ed.), Reha.bilitation outcomes: Analysis and measurement (pp. 137-146) Baltimore, MD: Paul H. Brookes Pub lishing Co. "Heinemann, A., Hamilton, B., Granger, C , linacre, M., & Wright, B. (1992). Rehabilitation efficacy for brain and spinal injured: Final report. (Grant Number R49/CCR503609). Atlanta, GA: Center for Disease Control. Herbert, J. , & Attridge, C (1975). A guide for developers and users of observation systems and manuals. American Educational Research Journal . 12, 1-20. Hoyt, C (1941). Test reliability estimated by the analysis of variance. Psychometrika, 6, 153-160. Joreskog, K. G. (1969). A general approach to maximum likelihood factor analysis. Psychometrika, 34, 183-202. Joreskog, K. G. (1973). A general method for estimating a linear structural equation system. In A. Goldberger & D. Duncan (Eds.). Structural equation models in the social sciences (pp. 85-112). New York: Academic Press. Kerlinger, F. (1986) Foundations of behavioral research (3rd ed.). New York: Holt. Law, M. (1987). Measurement in occupational therapy: Scientific criteria for evaluation. Canadian Journal of Occupational Therapy, 54(3), 133-138. *linacre, J. M., Heinemann, A. W, Wright, B. D., Granger, C v., & Hamilton, B. B. (1994). The structure and stability of the Functional Independence Measure. Archives of Physical Medicine, 75, 127-132. Lord, F., & Novick, M. (1968). Statistical theories of mental test scores. Reading, MA: Addison-Wesley. Mahoney, F. I., & Barthel, D. W (1965). Functional evaluation: The Barthel index. Maryland State Medical Journal, 14, 61-65. McGaw, B. , Wardrop, J., & Bunda, M. (1972). Classroom observation schemes-Where are the errors? American Journal of Educational Research, 9, 13-27. Medley, D, & Mitzel, H. (1963). Measuring classroom behavior by systematic observation. In N. Gage (Ed .). Handbook of research on teaching. Skokie, IL Rand McNally. Messick, S. (1994). Foundations of validity: Meaning and consequences in psychological assessment. European Journal of Psychological Assessment, 10, 1-9. Messick, S. (1989). Validity. In R linn (Ed.)., Educational measurement (3rd ed.). Washington DC: American Council on Education. Mulaik, S. (1972). The foundations of factor analysis. New York: McGraw Hill. Nunnally, J. (1978). Psychometric theory (2nd ed.). New York: McGraw Hill Pedhazur, E. (1982). Multiple regression in behavioral research (2nd ed.). New York: Holt. Roebroeck, M., Harlaar, J., & Lankhorst, G. (1993). The application of generalizability theory reliability assessment: An illustration using isometric force measurements. PhYSical Therapy , 73,386-395. Rowley, G. (1976). The reliability of observational measures. American Journal of EdlKational Research, 13, 51-60. Shavelson, R, & Webb, N. (1991). Generalizability theory: A primer. Newbury Park: Sage. Short-DeGraff, M., & Fisher, A. G. (1993). Nationally speaking-A pro posal for diverse research methods and a common research language. American Journal of Occupational Therapy, 47, 295-297. Sim, J. , & Arnell, P. (1993). Measurement validity in physical therapy research. PhYSical Therapy, 73, 102-115. Spool, M. (1978). Training programs for observers of behavior: A review. Personnel Psychology, 31, 853-888. Standards for Educational and Psychological Testing. (1985). Wash ington DC: American Psychological Association. Thorndike, R , & Hagen, E. (1977). Measurement and evaluation in psychology and education (4th ed.). New York: Wiley & Sons. Wilkerson, D. L. , Batavia, J.D., & DeJong, G. (1992). The use of functional status measures for payment of medical rehabilitation services. Archives of Physical MediCine, 74, 111-120. World Health Organization (1980). Interna tional classification of impairments, disabilities, and handicaps. Geneva: World Health Organization.
- 47. UNI T TWO Compo ent Assessments of the A ult .-.. --=-- - -..-..
- 49. 2 Maureen J'.Simmonds, MCSP, PT, PhD SUMMARY One of the most frequent physical assessment tests used in rehabilita tion is the testing of muscle strength. Strength measurements are used for diagnos tic and prognostic purposes. Changes in strength are also used to assess changes in a patient's condition and to determine the effectiveness of exercise programs. Although strength is a frequently used term, it is not universally used for the same measurement. Strength may be used when muscle torque, force, power; or work would be a more appropriate term. A myriad of anatomic, physiologic, biomechanical, psychological, pathologic and other factors contribute to muscle performance. Knowledge of these factors is important if tests of muscle strength are to be carried out and interpreted in a meaningful manner. Clinical assessment of muscle strength involves measuring the force exerted against an external force or resistance. This force may include the effect of gravity and that exerted by a therapist or a muscle testing device. Manual muscle tests (MMTs) without instrumentation have a long history of clinical use but have been subjected to little scientific scrutiny. MMTs are limited by the strength of the examiner and are of limited value because of their unproven reliability and lack of responsiveness. Instrumented MMTs with hand-held dynamometry improve the reliability and responsiveness of testing muscle strength but are also limited by the strength of the examiner. Isokinetic and isoinertial devices are now frequently used to assess muscle performance in static and dynamic modes. The devices are mechanically re liable and are reasonably reliable in measuring the forces exerted by muscles, al though this depends on the conditions of testing. Most reliability studies have been conducted on normal, healthy individuals. The validity of muscle strength tests has not been tested. They appear to have face validity for measuring the force exerted by a muscle. The validity of muscle strength tests as diagnostic or prognostic tools has not been established. Muscle strength tests are in frequent use despite the paucity of information about the reliability of strength tests in populations for whom the test is deSigned, rather than in healthy individuals. It is essential that the relationship between the patient's problems with function and clinical tests of muscle strength is established. . - --- -~-~ 27
- 50. I 28 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT ""~;r~~,,,,,,t~_~_;_IWM?*~.....~ _~__,__~ __~~,~ OVERVIEW OF MUSCLE STRENGTH The measurement of muscle strength is a fundamental component of a physical assessment. Strength measure ments are used in clinical practice for diagnostic purposes, to examine the improvement or deterioration of a patient's status over time, and as a predictive or prognostic tooL Strength tests are also used to determine the extent of strength loss by comparing the results of strength tests between opposite limbs or against normative data. In addition, strength tests are used in clinical research as outcome measures. The results of strength tests can be used to describe a population and examine the effects of exercise programs or some other therapy. Measurements of static and dynamic muscle performance (torque output, fatigue, work, or power) can be related to the histochem istry, biochemistry, and electromyographic activity of muscle to better understand the physiologic bases of muscle function and to determine the relationship between static and dynamic strength tests and functional activities. The major function of the muscular system is to stabilize and support the body and allow movement to occur. Muscle function is the product of a myriad of contributing sub systems. The biologic subsystems include sensory, motor, and cognitive systems. In addition, muscle function is influenced by the environment, the task, and the time and effort required to complete the task. Many different techniques purport to measure strength. Some are very simple, such as manual muscle tests (MMTs), and others use complex equipment and computerized technology and provide a plethora of information. Is one method of testing better or more reliable than the other? What do these tests tell us? Do either of these methods of testing have anything to do with function? Clinicians and researchers test muscle strength regularly, but what do we really know about the psychometric characteristics of the tests in common clinical use? Are the tests reliable, valid, sensitive, and specific? Have the tests been tested? If so, under what conditions? Finally, what is known about the factors that influence the test? To address these and other questions, it is necessary to discuss strength testing in a comprehensive manner. Thus, the purpose of this chapter is to critically review the theoretical and practical bases of muscle strength and the clinicalmethodsof muscle strength testing. Historical Perspective of Strength Tests MANUAL MUSCLE TESTS Early clinical tests of muscle strength involved the use of manual resistance by the therapist. The tests were, and still are, considered useful diagnostic and prognostic tests (Lamb, 1985), although they have been subjected t scientific scrutiny. The initial development and doc tation of MMTs occurred about 80 years ago an attributed to Lovett, an orthopedic surgeon (Danie Worthingham, 1986; Kendall et aL, 1993). The prin of MMT have changed little since that time, although modifications have been made, especially in regard grading system used. The bases of MMTs are simple and essentially anatomic and· biomechanical principles. Thus, the measures of impairment rather than function, and their use is most common for persons with disord the muscle or peripheral neural systems (Daniel Worthingham, 1986), these tests have been use patients with central nervous system problems, inc those with brain injury (Riddle et aI., 1989). Fundamental to MMT is the notion that muscles, individually or as a group, have a specific action on a Based on this premise and utilizing the effectsofgravi manual resistance provided by the therapist as ex forces, a patient is positioned in such a way that one m or group of muscles is primarily responsible for mo joint through a specific range of motion. Grading of m strength is then based on the arc of movement produ the muscle and the amount of external resistance motion. The muscle or tendon is palpated by the the to ensure that the muscle of interest is contracting a substitution of muscle activity is responsible for the sp movement tested. INSTRUMEMTED TESTS OF MUSCLE STRENGTH Although the criteria for grading muscle streng quite specific, manual grading does not provide qu tive data about the force ortorque generated bythe m Thus, instrumented strength testing (1ST) was deve Instrumented strength testing allows one to quantify precisely the force generated by a muscle or a gro muscles. Early 1ST devices consisted of cable tensiom strain gauges, or hand-held load cells that measure metric strength at some point in the range. Han dynamometers (HHDs) are in regular clinical use a discussed later in this chapter. The second generation of 1ST devices were thos measured dynamic muscle strength. Such devices c categorized as isokinetic, i.e., constant velocity, or ertial, i.e., constant resistance. The Cybex II (Lume Bay Shore, NY), Kin-Com (Chattecx Corp., Chattan TN), and Udo (Loredan Biomedical Inc., DaviS, C examples of isokinetic devices that can be used to m muscle strength in the limbs or the trunk. The (Isotechnologies, Inc., Hillsborough, NC) back t device is an example of an isoinertial device that me trunk strength. These devices provide quantitative mation about muscle function. They can provide inf tion about muscle strength, endurance, power, and
- 51. has advanced andmoved ahead of the scientific evaluation of the technology, due, in part, to successful marketing. Terms and Issues Related to Strength Testing and Measurement Mayhew and Rothstein (1985) have noted that strength is a vague, nonscientific term that needs to be operationally defined if it is to be of value. They base their argument on the fact that reported tests of muscle strength have utilized many different ways of determining strength, a fact that is indicative of the imprecise use of the word. A dictionary definition of strength highlights the problem. Muscular strength is defined as muscular force or power. Yet these are different terms with different meanings. It is therefore imperative that operational definitions are used. Strength is defined as the force or torque produced by a muscle during a maximal voluntary contraction. It is a measure of the maximal force or torque required to resist an isometric or isotonic contraction. Torque is a more precise term. Itis the degree to which a force tends to rotate an object about a specified fulcrum. Torque is not a commonly used term in lay usage, which may explain why it is a less ambiguous term than strength. Quantified strength values may be reported in absolute terms orin relative values. For example, the strength of one muscle group may be expressed as a ratio with the torque of another muscle group. The agonist-to-antagonist ratio is most frequently used, but strength may also be expressed in terms of body weight. .Another measurement term is power. Power is work per unit time. The temporal factor indicates that the muscle is working over a period of time. This time period may be long or short. One example of such a period is the time taken by the muscle to move a limb through a range of motion. Alternatively, the time may be the total duration of a purposefully fatigue-inducing endurance activity. Endur ance is the ability to maintain torque over a period of time or a set number of contractions. Conversely, fatigue is the inability to maintain torque over a period of time or a set number of contractions. Fatigue is described as either the amount of power that is lost or that which is maintained. Thus, a 30% loss of power is eqUivalent to the maintenance of 70% of power. These terms apply to all types of muscle contractions. An isometric contraction is when the muscle generates an internal force or tenSion, but no movement of a joint occurs. The term isometric is a misnomer. It means constant length, but clearly the muscle does change shape and the protein filaments within the muscle certainly shorten (Gordon et aI., 1966). An isotonic contraction is when the internal force generated by a muscle results in movement of a joint. Again, the term isotonic is a the motion, yet this is clearly not the case. Isotonic contractions are further described as concentr and eccentric. A concentric contraction is a shortenin contraction. It occurs when the internal force produced b the muscle exceeds the external force of resistance. A eccentric contraction is one in which the muscle lengthen while it continues to maintain tension. Cogent discussion of the measurement of muscle pe formance requires consideration of the principles of mea urement as well as the principles of muscle activity Measurement principles are discussed in depth elsewhe in this book. Some fundamental prinCiples are now brief presented. Reliability is the degree to which repeated measur ments of a stable phenomenon fall closely together. Thes measurements can betaken bythe same person(intratest or within-tester reliability) or by different testers (intertest or between-tester reliability). Devices that measure th same phenomenon may also be compared (concurren parallel-forms reliability). The notion of reliability is illu trated in Figure 2-1. Reliability of measures is importan but it is not the only criterion to be considered. A reliab measure is not useful if it does not measure what it supposed to measure. If the measure misses the target, it not a true or valid measure. Validity is the accuracy of the measurement. It is th degree to which the measurement corresponds to the tru state of affairs. It is the most important consideration whe selecting a test. A measure is validated by accumulatin evidence that supports logical inferences made from th measure (Johnston et aI., 1992). The types of validity in most frequent use include fac construct, and criterion validity. Face validity is the lowe b b b b b b bb b b b cc c c c c qs;c Graphic representation of the concepts of reliability and validity a Scores are both reliable and valid b Scores are neither reliable nor valid c Scores are reliable but not valid d Scores are valid but not reliable FIGURE 2-1. Graphic representation of reliability and validity.
- 52. 30 UNIT TWQ-COMPONENTASSESSMENTS OF THE ADULT level of validity. A measure has face validity if it simply appears to measure what it is supposed to measure. Con struct validity is the degree to which the scores obtained are in agreement with the theoretical construct of that which is measured. Criterion validity concerns the extent to which the measur;Is related to other measures that are regarded as a "gold standard" of measurement. Another property that any clinical measurement tool needs is re sponsiveness or sensitivity to change. Responsiveness is the ability of a test to measure clinically important change. Variability and error are factors in all measurements. A number of sources contribute to the variability of test measurements. Knowledge of the sources of variability is necessary for appropriate interpretation of test results. The measurement device may be a source of variability. The device may be reliable, in that under the same conditions it always provides a similar reading. However, the device may systematically over- or underestimate the measurement. This is one reason why devices such as an HHD are not necessarily interchangeable. The observer is another source of variability in a test measurement. Generally, less variability occurs within than between observers. The variability may be more systematic within than between observers but maydiffer depending on the test; therefore, it needs to be measured. The subject can be a source of variability. Strength measurements may change within a testing session due to fatigue or discomfort. They may change between sessions depending on the stability of the condition, intervening activities, and other stresses. Psychometric factors obViously influence the measure ment of muscle strength. In addition, a myriad of biologic and motivational characteristics contribute to the muscle tension, muscle strength, and muscle performance that is being measured. These factors are now discussed. Biologic Factors Influencing Muscle Strength At the most basic level, movement and force are produced by the contraction of the sarcomeres (Ghez, 1991). The amount of contractile force that a muscle can produce depends on its absolute size, i.e., its length and cross-sectional area, the cytoarchitecture, the phenotype, and the vascularity of the muscle. These factors influence not only the magnitude of force that the muscle can generate but also how quickly that force can be generated and the duration for which it can be maintained. The amount of force generated by a muscle is controlled through the recruitment order and the firing rate of the motor neuron. Motor units are recruited in a fixed order from weakest to strongest. The weakest input controls the SF (slow fatigable) fibers, which are resistant to fatigue but generate the least force. The FFR (fast fatigue-resistant) units are recruited next and, finally, the FF (fast fatigable) units which can exert the most force, but which are to fatigue. In humans, muscles are composed o different types of motor fibers; however, the fibers s by each motor neuron are homogenous. Some pat or injury conditions, e.g., low back problems, re selective atrophy of FF (Mattila et al., 1986; Rissane 1995; Zhu et ai, 1989). However, this loss can be r with training at maximal or submaximal effort (Riss aI., 1995). The endurance performance of a muscle is influe a numberoffactors. The morphologic characteristic muscle, muscle mass, capilliary density, and percen SF fibers are all related to efficiency of activity 1995). The recruitment of a larger muscle mass a spread of power output over a large area, includ recruitment of different muscles, all potentially e endurance or limit fatigue. Biomechanical factors are also important in function. These factors are linked to anatomic st and playa role in the muscles' ability to generate fo cause movement. Cytoarchitectural factors that in muscle performance include the arrangement of fibers and the angle of pull of the muscle. At the macro muscle level, aponeuroses and tend both store energy and redirect force, thus improv efficiency of muscle action. Passive tension of a contributes to the total tension that a muscle gen Shorter muscles have relatively high levels of tension earlier in the range than longer muscles. T contributes to the differences in length-tension r ships between muscles. Another factor that influences muscle perform elastic energy. Elastic energy can be stored and formed into kinetic energy (Soderberg, 1992). tension and elastic energy are important becau influence measurements of muscle strength. Applic a stretch prior to a measurement can increase the a of force generated by the muscle. At the micro level, the generation of force is inf by the arrangement of muscle fibers (Trotter et ai., If the fibers of the motor unit are in series rath parallel, then the capacity of the motor unit to d force is hindered. This is because the total force that developed by a motor unit is related to the sum of generated by fibers lying in parallel, not in series, other. Thus, forces would be smaller in a series- muscle, such as sartorious, compared with a musc parallel fibers, such as soleus (Edgerton et ai., 198 Based on the work of several researchers, Sod (1992) has illustrated how muscles with the same angle of pull, and fiber type, but with different sectional areas and length differ in the magnitude o that they can generate and the velocity with which th generate this force. All other factors being equal, th the muscle's cross-sectional area, the larger is the m force-generation capacity. Within this same muscl
- 53. greater the velocitywith which the peak force can be achieved (Soderberg, 1992). The force-velocity relationships of a muscle are also important considerations. Essentially, lower forces are associated with faster velocities. Conversely, higher forces are associated with slower velocities. However, this rela tionship holds true only for concentric contractions. Ec centric contractions are associated with higher forces at higher velocities. The magnitude of force generated iso metrically is lower than that generated eccentrically but higher than that generated concentrically (Komi, 1973). It is clear that many factors influence the force that a muscle can exert and the duration for which it can do so. The physical factors discussed above are doubtless related to function. Some of the functional implications, such as the preponderance of SO (slow oxidative) muscle fibers in endurant muscles, are obvious. It also seems obvious that the method of testing muscles should provide information about their functional ability. This is not always the case. For instance, is an isometric test of muscle strength the best way to test a muscle whose primary function is one that involves rapid motion? Also, isolated tests of individual muscles may not give much indication of their ability to function in a coordinated pattern of activity. PAIN AND MUSCLE PERFORMANCE Perhaps one of the most important but least studied factors that influences muscle performance is the presence of pain. Pain and the fear of pain and injury influence the measure of muscle strength. This invalidates the measure as one of true strength. The presence of pain during an MMT is cause to discontinue the test (Daniels and Worthingham, 1986). But testing of muscle strength is done and needs to be done in patients with chronic pain. In such cases, the influence of pain on the measure of muscle strength has to recognized. Pain has been oversimplified, which is why it has remained enigmatic, problematiC, and a frequent cause of frustration for patient and clinician alike. A few erroneous beliefs about pain exist: 1) in the acute pain state, tissue injury and pain are related; and 2) in the chronic pain state, the tissue has healed and no physiologic reason exists for the pain to persist. The assumption, then, is that the pain is psychological or at least exaggerated. In truth, pain and injury are not always well correlated. Nociceptive activity contributes to the physiologic dimen sion of pain, but pain is multidimensional and has cognitive and affective dimensions as well as physiologic compo nents. Even the physiologic component of pain has been oversimplified. Unfortunately, a review of pain mecha nisms is beyond the scope of this chapter. However, in measuring the muscle strength of patients that have had, or do have pain, clinicians and researchers should be aware that: 2. Tissue injury leads to the release of a cascade o biochemical mediators that are both neurogenic an nonneurogenic in origin 3. These biochemical mediators sensitize nociceptiv nerve endings directly and indirectly (Coderre et a 1993) The presence of pain, the anticipation of pain, and th fear of injury can influence the performance of the perso being tested. This influence can be at both a conscious an an unconscious level. Research is needed to examine th effect of pain on measures of muscle strength, both durin testsessions and overtime. Simplistic interpretations abou a patient's "real pain" or lack of effort during muscl strength testing should be recognized as a reflection of th personal biases of the clinician. Although some worker have suggested that strength testing can provide evidenc of pain and malingering, this is not true. No empirica evidence supports this biased opinion. Furthermore, th notion is flawed from a theoretical perspective because assumes that pain mechanisms are stable and that a simpl relationship exists between pain and motion or pain an muscle contraction. None of these assumptions are cor rect. DEMOGRAPHIC FACTORS INFLUENCING MUSCLE STRENGTH Conventional wisdom suggests that females are weake than males and older individuals are weaker than younge individuals. This notion is reasonable and true for grou comparisons of young versus old or male versus female bu only as long as confounding variables such as heigh weight, health status, and usual activity level are controlled Several authors have reported that the strength of female is about 60 to 70 percent that of males (Backman et aI 1995; Kumar et aI., 1995a; Kumar et aI., 1995b; Newto et ai, 1993a). This appears to be true across differen muscle groups and for both isometric and dynamic meth ods of testing. However, Backman and collegues (1995 reported that differences in measures of muscle strengt between genders almost disappeared when the subjects weight was considered. One fact that is evident from th literature is that a large range of individual variability exist in measures of muscle strength. Endurance measures ar characterized by even greater variability. It is possible tha psychosocial factors, including motivational factors, con tribute to the high variability in endurance performance which is a test of tolerance. Certainly, measures of pai tolerance are strongly influenced by psychOSOcial rathe than physiologic factors (Harris and Rollman, 1983) Endurance is associated with the ability to tolerate discom fort and pain. Significant lossesin maximal force production occurwit aging, although substantial variability can be seen in th
- 54. 32 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT rate of loss, both between individuals and between muscles (Rogers and Evans, 1993). The decline in muscle can be attributed to loss of muscle mass or an altered capacity of the muscle to generate force. Recent research has shown that dynamic strength declines earlier and more rapidly than isometric strength (Pentland, et al., 1995). Thus, the method of testing influences the results between different age groups. Although a decline of muscle mass occurs in the elderly, this loss of strength is greater than that accounted for by cross~sectional area alone (Vandervoort and McComas, 1986). The loss of muscle mass is due to a decline in both the number and the size of muscle fibers and in the degree of vascularization (Rogers and Evans, 1993). Differential loss of fiber type may account for the differential decline in isokinetic, compared with isometric, strength (Pentland et ai., 1995). All of the previously discussed factors are influenced by inactivity and by cardiovascular fitness, as well as by aging. Thus, it is difficult to tease out causes and consequences of aging, inactivity, and cardiovascular fitness on measures of muscle strength. Furthermore, these changes can be reversed through training of sufficient intensity and dura tion. Thus, although normative data must account for gender and age, individual variability is paramount. Indi~ vidual variability in muscle strength testing is even more crucial when tests of muscle strength are conducted clinically. In a clinical population, the physiologic and psychosocial impact of an injury or disease enhances this individual variability. Cognitive Factors Influencing Muscle Strength The capability for intentional and purposeful human action is rooted in cognitive activity (Bandura and Cervone, 1983). Tests of muscle strength are learned psychomotor skills for the tester and the testee. The contributory role of learning must be considered when strength tests are administered and interpreted. More practice over a longer time is necessary to learn a complex motor skill. If the test movement for strength testing is an unfamiliar movement or skill, then optimal performance cannot occur before the movement is learned. This results in a series of strength tests that show an increase in the magnitude of measured force over a period of time. This increase in force is the result of a learning effect, as well as an increase in muscle strength capability. (See section on trunk testing for more discussion on learning}. A distinction must be made between an increase in muscle torque due to a true change in muscle strength and an increase in muscle torque due to learning the motor skill of the test. Motivation and self-perception of abilities influence the measurement of strength. Self-efficacy is one's belief in personal capabilitiesto perform a specific action. Estlander and colleagues (1994} found that the patients' beliefin their ability to endure physical activities was the most pow predictor of isokinetic performance. Perhaps more i tantly, these authors showed that a patient'sfear of re was also a pertinent factor in strength testing. The patient's ability to focus on the strength test a screen out distractions influences the measurement can be facilitated through instructions by the tester tractions have been shown to have a negative influen test results. They influence the planning of the activ well as the activity itself (Pratt and Abrams, 1994). strength testing conditions should be focused on the a consistent manner so that the truest measure of m strength is obtained. Summary Figure 2-2 summarizes the preceding information clear from this overview section that many factors co ute to what would appear to be a simple muscle co tion. Clinicians must be aware that a myriad of f contribute to muscle strength and that assessme muscle strength is more than a mere test of the m Although it is necessary to know how to test m strength, it is also necessary to know what the results test mean. The interpretation of the test results mu made in the context of all relevant factors. CLINICAL STRENGTH TESTING Muscle strength tests are indicated in the major patients who have pathology or injury that resu movement impairment. Tests of muscle strength ar most frequently used tests in physical rehabilitation (C ai., 1994). This is not surprising. The modus opera therapists involved in physical rehabilitation is to patients in attaining their optimum level of physica occupational function. Muscles playa fundamental r function, and loss of function is the primary reason patients are referred to therapy. It is clear from the previous section that many f along the neuromuscular pathway, as well as cognitiv motivational factors, influence muscle performance also clear that muscles contract and work in different depending on their usual function. It seems ob therefore, that if muscles are to be assessed, they sho assessed using tests that provide useful information re ing the muscle's ability to function. Secondly, the should provide objective, reliable information in the c population for which the tests are designed. Thirdl tests should be simple to use and simple to inte otherwise the tests will not be used, or if they are, the are subject to misinterpretation. The following se discusses specific tests and the instruments used to a
- 55. Healthy Patients Injury Pathology Comorbidity Pain Gender Age Height Weight Usual activity level Active Sedentary Generalhealth status Muscle factors Fiber type Fast fatigable Fast fatigue resistant Slow fatigable Cytoarchitecture Angle of pull Length of lever Parallel vs. series fibers Size of muscle Length FIGURE 2-2. Summary of factors Cross-sectional area influencing the measure of muscle Vascularity strength. Innervation ratio muscle strength and endurance. Issues of validity, reliabil ity, and utility are addressed within this section. Strength Test Protocol Documentation No matter what the type or the purpose of the strength test, the testing protocol must be well described. Strength tests, as with any other measurement test, must be reproduced as exactly as possible so that measurement errors and artifacts are minimized. Thus, test protocol descriptions should include the following: 1. Warm-up procedure. The length of time or number of contractions prior to the test, as well as whether the warm-up contractions were maximal or sub maximal. 2. Previous practice sessions. Motorskills are learned and improve with practice. Does the test measure a change in strength or an improvement in skill? 3. The method of stabilization. Can the subject stabilize himself or herselfby holding on with hands? Are stabilization straps used? If so, where are the straps placed, and how many are there? The better the stabilization, the higher the torque. 4. Rest periods. What is the length of the rest period between contractions and set of contractions? 5. Position of the subject. Include the relation of the muscle to gravity. Is the position easily reproduc ible? Does the subject have back support? What are Motivation Manual Learning Instrumented Level of skill Individual vs. group muscles Self-efficacy Position of subject Fear of injury Joint position 01 test Distress Stabilization Depression Warm-up Perceived effort Prestretch Expectation Previous practice Rest periods Encouragement Order of testing 1 J Static vs. dynamic STRENGTH ...C f - - - - - - Concentric vs. eccentric Velocity of testing lsokinetic Isoinertial Criterion values Average Measurement factors Peak Operational definition Absolute or relative values Reliability Position in range Intratester Force/torque Intertester Work Test-retest Power Validity Device Face Device settings Construct Gravity correction Discriminative Tester skill Predictive Tester expectation Responsiveness Tester strength the angles of the hip or knee? What is the effect o gravity? 6. Order of testing. Include the type of contraction (isometric, concentric, or eccentric), the muscle groups, and the velocity of testing. 7. Commands and vocal encouragement. Standard ized commands should be used. Vocal encourage ment should be standardized as much as possible 8. Test range of motion. At what point in the range was the strength test conducted? 9. Criterion measure. Are peak or average values o torque or force used? Is work or power used? Wha was the number of repetitions, and were absolute o relative values used? For example, with absolute values, are the torques expressed as angle speCific or the angles at peak torque? If relative values are used, relative to what? 10. Instrument and settings. What instrument wa used, and how was it used? What were the settings on the machine, e.g., damping, leverarm, pause, o minimum force? Isome'tric Tests MANUAL MUSCLE TESTS Probably the most common tests in general use are MMTs. These tests have a long history of use, require no equipment, and are generally regarded as basic clinica skills. These facts no doubt contribute to the frequency with ~~-~ " - - ~:;~::-- :/ ~-~" ":E" . :"--t~~~~"':-
- 56. 34 UNIT TWO-COfvlPONENTASSESSMENTS OF THE ADULT which MMTs are used. Manua'i muscle tests are weH described by Kendall and colleagues (1993) and by Daniels and Worthingham (1986). Both groups of authors stress the importance of attention to detail when using MMTs. Kendall and coworkers suggest that precision in MMT is necessary to preserve the "science" of muscle testing (p. 4). In fact, MMT has been subjected to little scientific scrutiny. That is not to suggest that the techniques are not sound, but merely that they have not been systematically tested. Proponents of techniques have the responsibility to test the techniques that they describe so well. Nevertheless, some important points must be kept in mind regarding the use of MMT. Both Kendall and associ ates (1 993)and Daniels and Worthingham (1986) describe standardized positions that attempt to isolate muscle func tion. Resistance to the motion is applied throughout the range of motion (Daniels and Worthingham, 1986) or at a specific point in the range (Kendall et aL , 1993). In addition to applying resistance through the range of motion (the "make test"), Daniels and Worthingham also use a "break tes1" ' at the end of range. In the break test, the patient is instructed to "hold" the limb as the therapist applies a gradual increasing resistance. Pain or discomfort should not occur, and if it does then the test should be discontinued (Daniels and WortJ1ingham, 1986, p. 3). Make and break tests are not equivalent and should not be used interchange ably. Using dynamometry, Bohannon (1988, 1990) has shown that significantly greater strength values occur with the break test compared with the make test in both healthy subjects and in patients. Grading systems for MMT have included letter grades, numeric grades, percentage grades, and descriptive cri teria. Pluses and minuses have also been utilized (Table 2-1). The methods of Kendall and colleagues and of Daniels and Worthingham have obvious similarities and some differences (e.g., grading system). Neither method has a proven advantage. Neither method has been sub jected to much critical scrutiny. Based on the weight of the limited evidence available, the reliability of MMT is low (Beasley, 1961; Frese et aL, 1987; Wadsworth et aL, 1987). It is obvious that the reliability of the test would depend on which muscle was being tested , the strength of that muscle, and whether other confounding factors such as, but not limited to, the presence of spasticity, were present. The confounding impact of spasticity on the results of muscle strength tests is not surprising. It is surprising that the examiners' designation of "normal" is somewhat idiosyncratic. In a study by Bohannon (1986), one third of the normal subjects were graded as "normal minus." Bohannon examined muscle strength of the knee extensors in a controlled trial. He compared knee extension "make" forces in 60 healthy adults and 50 patients with a variety of neuromuscular diagnoses. The MMT grades were con tJ'asted with forces measured with an HHD. The author calculated dynamometer percentage scores for the pa tients, based on the dynamometer scores measured on the TABLl2 I GRADING SYSTEMS USED IN MANUAL MUSCLE TESTING Criteria for M Grading Symbols Grading Normal 10 5 5.0 100% Can move or hold gravity and max resistance Good + 9 4+ 4.5 80% Can raise part aga Good 8 4 4.0 gravity and an e Good 7 4 3.66 resistance Fair + 6 3+ 3.33 50% Can raise part aga Fair 5 3 3.0 gravity Fair 4 3 2.66 Poor + 3 2+ 2.33 20% Produces moveme Poor 2 2 2.0 gravity eliminate Poor 1 2 1.5 Trace T 1 1.0 5% A flicker or feeble traction Zero 0 0 0.0 0% No contraction healthy subjects. These calculated scores were the pared with the measured scores. Essentially, the revealed that the MMT and HHD scores were co but significantly different. Bohannon also reported MMT percentage scores overestimated the extent to the patient was "normal." However, Bohannon se have trouble with the designation normal, since a his normal subjects were designated as "normal m Problems with this study are evident. One of th pertinent concerns relates to the different starting p used in testing muscle strength with HHD compar MMT. All HHD testing was conducted in sitting po whereas MMT tests were conducted in Side-lying po The author did not correct for effect of gravity even it would have had a significant impact. Finally, Bo did not report reliability in this study. Reliability differs depending on the strength muscle and its anatomic characteristics. It seems that it is easier to palpate a contraction in a large sup muscle like the quadriceps than in a small deep musc as the piriformis. Thus, reliability would be higher MMT in the quadriceps. Conversely, it would be dif determine whether the contraction of the quadrice good (80%) or normal (100%) in a large athletic in because the therapist would have difficulty challeng muscle with manual resistance. This problem of relatively weak therapist streng reported by Deones and colleagues (1994). These gators measured quadriceps strength in a healthy tion using the Kin-Com and HHD. They reporte correlations in strength measured with each device they attributed to the examiner not being able to re force of the quadriceps. In a review of MMT, Lamb (1985) noted that in M patient responds to the amount of force applied examiner. Different examiners no doubt apply a d
- 57. different amount offorce at different times. Force applica tion by therapists has been reviewed and tested and is a significant source of variability (Simmonds and Kumar, 1993a; Simmonds et at, 1994). Although the application of the testing technique can be standardized in terms of patient position and the point at which the examiner applies resistance to the muscle, the amount of applied resistance is still variable. The examiner also has to compare the muscle with "normal," but the concept of normal and the expectation of how a muscle should perform is somewhat idiosyncratic. In addition to problems with reliability, MMT grading scales are not responsive to change (Griffen et aL, 1986). A large change in muscle strength is necessary before such variation is reflected in a change of grade on an MMT scale. For example, a muscle may be conferred a grade of "good" because it can move a joint through a full range of movement against gravityand an external force applied by the examiner. Although repeated testing over time would reveal an increase in the muscle's functional ability, this improvement could not be measured using the zero-normal grading system. The use of "pluses" and "minuses" to the grading system may have been instituted in an effort to improve the responsiveness of the test but probably only leads to lower levels of reliability. The lack of reliability and responsiveness of MMT is problematic because the test is supposed to measure change in a patient's muscle strength. This may not be a problem clinically if other more responsive tests are used to measure change in the patient's function. The other tests may provide more useful information in regard to how the muscle is functioning; they could also help to validate MMTs. But one must ask, if MMTs are not useful, why use them? The main value of the MMTs is in their apparent ability (which needs to be tested) to isolate and to test the contractability and "strength" of individual muscles and groups of muscles that are weak. The use of MMTs is less useful in stronger muscles because it is limited by the ability and strength of the therapist to provide resistance to the muscle while adequately stabilizing the patient. MMTs have limited usefulness in recording improvement or deteriora tion in a patient's condition because they have poor reliability and lack responsiveness. It could be argued that, if the reliability and responsiveness of MMTs is poor, then validity is moot. However, different types of validity exisi. The lowest level of validity is face validity. Face validity asks, does the test appear to measure what it is supposed to measure? So, is an MMTsupposed to measure the ability of a muscle to contract, to move a limb through a range of motion, or to function normally? Manual muscle tests measure the ability of a muscle to contract and to move a limb through a range of motion. They do not measure the ability of a muscle to function. Function is much more complex than an isolated muscle contraction. Although one can infer that function will be impaired if a muscle or muscles in a functional manner, and the relationshi between muscle impairment and functional deficit is ce tainly not clear. The patient's motivation, determination ability to problem-solve and substitute alternative moto patterns has far more to do with function than with th isolated ability of a muscle to contract. Although the MMT has a long history and is entrenche in clinical education and practice, it is a technique tha needs to be systematically and scientifically scrutinized. It necessary to determine which specific MMT tests ar reliable, under what conditions, and in what patient group It is also necessary to determine which MMTs are no useful, and they should be discarded. Finally, it is necessar to determine the diagnostic and prognostic and discrim native validity of MMTs and to determine what can b reasonably inferred from the results of specific MMTs. INSTRUMENTED MUSCLE TESTING The problems of poor reliability and responsiveness ar alleviated somewhat with the use of instrumented MMT (Bohannon, 1986; Currier, 1972; Riddle et aI., 1989 Stratford and Balsor, 1994; Trudelle-Jackson et aI., 1994 However, instrumented hand-held MMTs are still limited b the therapist's ability to adequately resist muscle strength Instrumented muscle testing has increased the level o accuracy and the reliability of strength testing and ha contributed significantly to the body of knowledge abou muscle performance. One of the first devices to be used measuring muscle strength was the cable tensiometer. A the name implies, cable tensiometers measure tension in cable. To use this device to test muscle performance, on end ofthe cable is attached to a limb segment and the othe to a fixed object. The tensiometer is then placed on th cable, and a gauge on the meter measures the amount o tension. Calibration is necessary to convert the gaug reading into a measure of force. This is usually done b suspending known weights from the cable, reading an recording the measurement from the gauge, and conver ing these units into units of force. A key procedural facto for using the cable tensiometer is that the cable must b positioned along the line of muscle action. A secon procedural point to consider (because it facilitates compu tation) is that the cable should make a 90-degree angle wit the point of attachment to the body. Cable tensiometers have been used in research (Beasley 1961; Currier, 1972), are fairly reliable, and provide th quantitative data needed for research and clinical applica tions. However, they have never been widely used in th clinic. The same is true for strain gauges. A strain gauge a device that has electroconductive material incorporate in it. The application of a load to this device results deformation of the electroconductive material, whic changes the electrical resistance and thus the electric outputto a display device. Again, calibration is necessaryt convert the electrical output into force. These devices ar
- 58. 36 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT not discussed further here because they have not been utilized by clinicians in the past and are unlikely to be so in the future. In contrast, HHD has been widely adopted in clinical practice. A few reasons probably account for the adoption of these instruments. 1. The need to document the results of clinical tests in a quantitative manner. Th~s is a prerequisite so that treatment efficacy can be established and optimal treatment regimens can be defined. 2. The technique of HHD is the same as that used during the MMT, and therapists are very familiar with MMT techniques. 3. The devices are inexpensive, simple to understand , and simple to use. Two devices are described and discussed in this sec tion: the modified sphygmomanometer (Fig. 2-3) and the HHD (Fig. 2-4). A modified sphygmomanometer (SM) can be used to quantify the resistance offered during a manually resisted isometric contraction (Giles, 1984; Helewa et al. , 1981; Helewa et aI. , 1990). Sphygmomanometers are usually available in the clinic and are easily modified to measure muscle strength. Essentially, the MS is a regular sphygmo manometer from which the bladder has been removed from the cuff. The bladder is folded into three sections and placed in a cotton bag. Alternatively, the cuff may simply be rolled up. A baseline pressure is set within the MS, and the device is then placed between the body part and the therapist's hand , as if an MMT was being carried out. The patient then performs a resisted contraction against the MS cuff, and the pressure is noted. Conversion from units of pressure to units of force necessitates calibration. The MS has one advantage over the HHD, and thus is related to its softness and compressibility of the material. FIGURE 2-3. Use of modified sphygmomanometer to measure grip strength. Thus, the MS can be applied against bony surfaces w causing discomfort (the experience of pain or disc during a test would confound the results of the test The HHD is a hand-held device that incorporates scales or strain gauges to measure applied force . The measures the applied force in kilograms or pounds no conversion of measurement units is required. The is used in the same way as the MMT and the MS. T is subject to some of the same limitations of especially that regarding the strength of the exa Bohannon (1986) suggests that this limitation may as the examiner becomes more experienced. B (1956) showed that examiners were able to hold a higher forces with practice. A learning effect exists examiner as well as for the patient. The learning results in a greater amount of force being recorded, force difference is obviously not reflective of a cha muscle strength. The HHD has been tested for intrarater, interrat interdevice reliability for different muscles and in di population groups (Bohannon, 1990; Riddle et aI., Trudelle-Jackson et aI., 1994) and for quantitative parisons between make and break tests (Stratfor Balsor, 1994). This device has also been compare other, more technically sophisticated, devices such Kin-Com isokinetic testing unit (Deones et ai, Stratford and Balsor, 1994; Trudelle-Jackson et ai, In a nonblinded trial, Bohannon (1988) used an H measure intratester and intrasession reliability of me of force in the elbow flexors of 31 healthy subjec reported good reliability (ICC = 0.995). Trudelle-Ja and colleagues (1994) tested interdevice reliability a not demonstrate such high levels of reliability. authors also tested a healthy population. They com two different HHDs and mea.sured hamstring force class correlatie n coefficients between the two devic low (ICC = 0.58). These results suggest that di devices cannot be used interchangeably to mea patient's progress. These authors also compared th measured with the HHDs to that measured wi Kin-Com (parallel forms of concurrent reliability). Th calculated between the Kin-Com and each HHD reasonable (ICCs =0.83 and 0.85), but an analy variance between the Kin-Com and the HHDs reve significant difference between the Kin-Com and one HHDs. The mean force measured with each HH 7.5 kg and 12.5 kg; the mean force measured w Kin-Com was 13 kg. This suggests that the differe values is clinically significant as well as statistically cant. It also shows that calibration should be checke odically, and that HHD devices are not interchang Riddle and colleagues (1989) tested the stren several muscle groups within and between session sample of patients with brain damage. They measur muscle forces on the paretic and nonparetic lim their surprise, they obtained higher levels of reliabi the nonparetic limb compared with the pareti
- 59. FIGURE 2-4. A,Hand-heJd dynamometer. B, Use of hand-held dynamometer to measure quadriceps force. (A and B, Courtesy of Lafayette Instrument. Lafayette, IN.) (ICC =0.90-0.98 and 0.31-0.93, respectively). This was a repeated measures design with strength measures taken more than 2 days apart. The lower level of reliability obtained on the nonparetic side may be due to the difficulty associated with applying adequate resistance to strong muscles. The HHD dynamometer can be used to assess isometric strength in many muscle groups relatively easily. Its reli ability is lower when it is used to test relatively large and relatively strong muscles. Although isometric measure ment of force has face validity, it is not clear how much force is necessary to perform specific functional tasks. Also, HHD is not useful for testing trunk strength or hand strength. For hand strength testing, two devices are in common clinical use: grip strength dynamometers (Fig. 2-5) and pinch meters (Fig. 2-6). Both of these devices measur force , which is recorded in pounds or kilograms on a gauge Computerized versions of these devices are available bu are not always necessary or advantageous, depending o the mathematic algorithms used in the software. Stan dardized testing protocols are included with the device Both intra- and interrater reliability of the grip strengt dynamometer is good in normals (Neibuhr et ai, 1994 Stratford et ai, 1987: Stratford, 1989) and patien (Stegnick Jansen, 1995). The influence of the position of the elbow joint durin testing of normal subjects is not clear. Mathiowetz an associates (1985) showed that elbow joint position influ enced the magnitude of grip force, but the results were no replicated by Balogun and colleagues (1991). Stegnic Jansen (1995) contrasted grip force in a patient and contro FIGURE 2-5. A, Grip dynamometer. (Sammons Preston, Burr Ridge. IL.) B, Use of grip dynamometer to measure grip force. - _0 --
- 60. 38 UNIT TWO-COI'vlPONENTASSESSMENTS OF THE ADULT FIGURE 2-6. A, Pinch meter. B, Use of pinch meter to measure pinch force. group with the elbow in flexed compared with extended position. Twenty-two subjects with lateral epicondylitis and 15 normal subjects participated. Excellent reliability coef ficients were reported (ICCs ::::: 0 .95). Noteworthy was the fact that elbow position did not influence grip strength in the normal group but did influence grip strength in the patient group. In the patient group, grip strength was greater with the elbow flexed on both the involved and the uninvolved sides. The magnitude of difference was much greater on the involved side. This work highlights the problems inherent in testing normal subjects and general izing those findings to patient populations. Patients and nonpatients are different. To summarize, it can be stated that reliability of instru mented MMT is reasonable and appears to be primarily limited by the strength of the examiner, standardization of technique is important, and instruments are not inter changeable. The validity of instrumented MMT is subject to the same issues and questions posed for noninstrumented MMT. The validity needs to be assessed. Dynamic Tests Isometric measurements provide some information about muscle strength that is important to clinicians. But because muscles usually fundion in a dynamic manner, it makes sense to measure muscle performance in a dynamic manner (Fig. 2-7). Although dynamic testing appears to be more functional , the relationship between function and dynamic testing has not been established (Rothstein et a!. . 1987). One of the first papers to appear in the physical therapy literature about isokinetic exercise was by Hislop and Perrine (1967). These authors differentiated between isotonic (constant load) and isokinetic (constant speed) exercise. They suggested that isotonic exercise involves muscular contractions against a mechanical system provides a constant load,such as when lifting a free w In fact, the load of a ~ree weight is not constant be changes in the angulation of the limb lever influenc effect of gravity on the load. A consequence of this the muscle could be working at its greatest mech advantage when the resistance of the load has its effect (Hislop and Perrine, 1967), and the muscle not be challenged throughout its range. Theoreti isokinetic exercise challenges the muscle througho range. Isokinetic testing uses an electromechanical devic prevents a moving body segment from exceeding a p angular speed. The axis of the device is aligned wi anatomic axis of the joint that will be moving. The leve of the device is attached to the subject's limb, an subject is instructed to move as fast as possible. The d does not initiate motion, nor does it provide any resis to motion until the preset speed is reached. Howev soon as the subject's limb moves as fast as the preset s the device exerts an opposing force against the m body. As the subject tries to accelerate, the machine r the movement. The harder the subject pushes again device, the greater is the resistance provided by the d This resistance is measured by the machine througho range of motion and torque curves are plotted using of motion and torque (Fig. 2-8).The earliest machine a strip chart recorder, but most machines are now puterized. Algorithms within the software compute sures such as average and peak values of torque, p and work in addition to the position within the ran which peak torque was generated. The output is u presented in tabular and graphic form (Fig. 2-8). Much of the research in isokinetic testing has conducted on the knees of normal subjects, but resear have examined the machines, muscle groups other
- 61. ent attachments thatallow an examiner to test different mance in a dynamic quantitative manner has contributed muscle groups, including those of the trunk. Trunk testing the body of knowledge about muscle performance. Isome machines are discussed separately. ric tests provide information about the ability of a muscle FIGURE 2-7. A, lido isokinetic device. B, Calibration of the lido isokinetic device using weights. C, Subject in position for the measurement of ankle dorsi- and plantarflex ion. (A-C, Courtesy of Loredan Biomedical, Inc., Davis, CA.)
- 62. UNIT TWO-COMPONENT ASSESSMENTSOF THE ADULT40 INITIAL REPORT PATIENT NAME: Edward REPORT DATE: Mon Jan 10 20: 56: 06 TEF TRUNK EXTENSION/FLEXION CYBEX TEST DATE(S) 1nt1994 SPEED (deglsee) R 60 120 150 REPETITIONS 3 5 5 BODY WEIGHT (Ibs) (180) EXTENSION PEAK TORQ (ftlbs) 209 67 27 PEAK TORQ % BW 116% 37% 15% ANGLE OF PEAK TORQ 32 6 7 TORQ@ DEGREES TORQ@ DEGREES ACCEL. TIME (sees) .06 .13 .21 TOTAL WORK (BWR, ftlbs) 195 47 17 TOTAL WORK (BWR) %BW 108% 26% 9% AVG. POWER (BWR, 226 110 52 WADS) AVG. POWER (BWR) %BW 125% 61% 28% AVG. POINTS VARIANCE 29% 39% 32% TAE (ftlbs) 27.6 26.2 17.6 TOTAL WORK SET 1 (ftlbs) 1st SAMPLE 1 (TW) 2nd SAMPLE 1 (TW) ENDURANCE RATIO 1 TOTAL WORK SET 2 (ftlbs) 1st SAMPLE 2 (TW) 2nd SAMPLE 2 (TW) RECOVERY RATIO FLEXION PEAK TORQ (ftlbs) 151 118 84 PEAK TORQ % BW 83% 65% 46% ANGLE OF PEAK TORQ 52 45 47 TORQ@ DEGREES TORQ@ DEGREES ACEL. TIME (sees) .07 .09 .21 TOTAL WORK (BWR. ftlbs) 144 93 56 TOTAL WORK (BWR) %BW 80% 51% 31% AVG. POWER (BWR. 169 216 162 WADS) AVG. POWER (BWR) %BW 93% 120% 90% AVG. POINTS VARIANCE 21% 18% 28% TAE (ftlbs) 26.1 49.5 52.2 TOTAL WORK SET 1 (ftlbs) 1st SAMPLE 1 (TW) 2nd SAMPLE 1 (TW) ENDURANCE RATIO 1 TOTAL WORK SET 2 (ftlbs) 1st SAMPLE 2 (TW) 2nd SAMPLE 2 (TW) RECOVERY RATIO FLEXION/EXTENSION RATIO AND ROM PEAK TORQ 72% 176% 311% TOTAL WORK (SWR) 73% 197% 329% AVERAGE POWER (BWR) 74% 196% 311% TOTAL WORK SET 1 TOTAL WORK SET 2 AVERAGE ROM (DEGREES) 70 70 70 MAX ROM (72) (e) COPYRIGHT LUMEX 1987.1988.1989.1990 FIGURE 2-8. Output from isokinetic device. (Courtesy of Isotechnologies, Inc., Hillsborough. NC.)
- 63. TRUNK EXTENSION/FLEXION TORQUE VS.POSITION-INITIAL REPORT LEGEND: - maximum points, - average points, - bestwork FLEXION 440 I 400 T 0 360 R 320 Q U 280 E 200 F 160 T 120 * 80 L B 40 _/ .".. I S 20 0 I 440 400 360 320 280 200 160 120 80 40 20 0 Mon Jan 1020:56:131994 test date-11711994 14:20 test speed-60 deg/sec test reps-3 EXTENSION 95° -15° 0° 40° ANGLE (degrees) ANGLE COMMENTS: ________________________________________________________________________ FIGURE 2-8 Continued exert a force or torque against an external resistance. Dynamic tests also provide information about muscle work, muscle power, the speed of muscle contraction, and the ability of a muscle to maintain a force through a range of motion (Moffroid et al., 1969; Moffroid and Kusiak, 1975; Rothstein etal, 1987). As notedearlier, although the testing appears to be more functional than isometric testing, the validity of isokinetic testing has not been established. The construct of movement occurring .at constant speed is artificial (Kannus, 1994), as are the positions and movement constraints under which isoki netic testing is done. Isokinetic tests measure the follOwing characteristics of muscle performance. Torque is the force that acts about an axis of rotation. It is the product of this force and its point of application from the axis of rotation. Work is force exerted through some distance. lsokinetic testing measures force and the angular distance through which the limb moves. Thus, the work of the muscle can be computed easily (work> = torque or force x distance). In the clinical context, work is a term that may be reserved for that done by the therapist. Power is a more frequently used term, but it is also used inappropriately at times. Moffroid and Kusiak (1975) define five separate measurements of power: power, peak power, average power, instantaneous power and contractile power. Power is the rate orspeed ofdoing work and is expressed in watts. Computation of power is relatively straightfor ward in isokinetic testing because the speed is constan (power = work/time). According to Moffroid and Kusiak (1975), other types of power are calculated by substituting some specific value into an equation. For example, peak power is defined as peak torque divided by the duration o the isokinetic contraction (peak power = peak torque contraction duration). Thus, in the peak power equation peaktorque is substituted for work, and distance is dropped from the equation. Operational definitions of terms are obviously necessary. Butdefinition of a term does not make it a useful or meaningful term. Rothstein and coworker (1987) decry the erroneous use of measurement terms and caution clinicians about uncritical acceptance of the jargon associated with isokinetic testing. In support of thei position, they describe how "power" has been erroneously used to describe the torque values measured during high velocity testing. This consideration of terminology is not simply a pedan tic diSCUSSion of semantics. Words are powerful tools Loosely used pseudoscientific terms have a tendency to
- 64. 42 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT persist because they have an aura of credibility and techno logic sophistication that does not invite questioning critical or otherwise. This facilitates the adoption of errone ous terms into accepted dogma. Appropriate terms or measures obtained with dynamic strength testing devices usually include such measurements as isometric torque or force and isokinetic force or torque throughout the range of joint motion and at different velocities. Power and work can be computed from torque and velocity data using the equations noted previously. Test factors that can influence these measures are as follows. Velocity. The velocity at which the isokinetic test is conducted makes a significant difference to the torque output and the position in range at which peak torque output occurs (Chen et al., 1987; Gehlsen et aI., 1984; Hsieh et aI., 1987; Osternig et aI., 1977; Rothstein et aI., 1983; Tredinnick and Duncan, 1988; Watkins et aI., 1984). It is well known that a force velocity relationship exists in dynamic muscle contractions. This relationship is essentially linear (Rothstein etaI., 1983). An increase in the load on a dynamically contracting muscle causes the velocity of the contracting muscle to decrease. Similarly, as the velocity of the muscle contraction increases, the torque generated by the muscledecreases, and peaktorque occurs later in the range. These findings are robust between different muscle groups and between normal subjects and patient groups. Experience and Repetitions. Isokinetic tests are not only a test of strength but also a test of motor skill. Learning is involved in this skill, which is reflected in torque increases, and of course influences the reliability of the test. Based on their study of knee extensor torque in 40 healthy women, Johnson and Seigel (1978) recommended that a mean of three repetitions provides the highest level of reliability (0.93-0.99). Their protocol included a warm-up of three submaximal and three maximal contractions, and strength tests conducted at 180 degrees per second. In another study, Mawdsley and Knapik (1982) tested 16 subjectswith no warm-up, in three sessions across 6 weeks, at 30 degrees per second. They reported no Significant differ ence in torque values across the 6-week time period. The results from the within-session testing were interesting. In the first trial, the first test produced the highest torque, whereas in the second and third sessions, the first trial produced the lowest torque. It is difficult to explain why torque values increased with each repetition within the first test session but decreased with each repetition in the sec ond and third sessions. Based on the information reported, any interpretation would be entirely speculative. However, the fact that no significant difference was seen between the averaged values across the 6-week period suggests that under the conditions of testing used in the study, a reason able level of reliability can be expected over a relatively long time period (6 weeks). Calibration and Equipment. The manufacturers of isoki netic devices usually supply the calibration protocol for use with their machine. For the Lido isokinetic device, weights of known value are applied to the load arm at a kno distance from the point of rotation. Because the wei values and arm length are known, the torque applied to shaft is also known. This torque value is then compa with that torque value recorded by the machine. This c bration procedure tests in the isometric mode. lsokin calibration is not speCifically tested, which is problem when strength testing is conducted in the isokinetic mo The manufacturers claim that their device has long-te stability and accuracy, but whether this has been tested w the machine in clinical use is not clear. Cybex II calibrat protocol uses known weights applied at a single speed. based on extensive testing of the device, Olds and asso ates (1981) have suggested that the Cybex should be tes daily and at every test speed. Essentially, the calibrat protocol needs to simulate the clinical testing situation much as possible. This includes testing the machine w the settings that are used during clinical testing, eg, damp setting on the Cybex II. Damp is a means of redUcing signal artifacts in electr systems. An undamped eletric signal results in "oversho or an erroneously high torque reading. Sapega and leagues (1982) showed that the overshoot was due inertial forces rather than muscular torque. The Cybe has five damp settings (0-4). Increasing the value of damp setting results in a decrease in the peak torque an shift of the curve to the right, which implies that p torque occurred later in the range (Sinacore et aI., 198 The important point is that all the machine settings mus documented, and clinical evaluations must be retes using the same settings. Another factor that affects torque output is gravity. T effect of gravity obviously varies with the position of limb. If gravity is not corrected for, then the torq generated, and thus the power and work calculated, wo be subjectto error (Winter et a!., 1981). The error would systematic and therefore would not affect the reliability the isokinetic tests, but the validity of the measureme would be compromised. Fillyaw and coworkers (19 tested peak torques of the quadriceps and hamstrings in soccer players. They computed the effect of gravity a added this value to the quadriceps torque and subtracte from the hamstring torque. Depending on the speed testing, the effect of gravity correction on mean p torques was approximately 6 ft-lb in the quadriceps a 8 ft-lb in the hamstrings. One other equipment consideration that affects iso netic muscle testing relates to the center of rotation of equipment and its alignment with the center of rotation the joint axis. This is an especially important issue measuring muscle strength in multijoint areas, such as trunk. Testing Protocol. Potentially many factors within specific testing protocols could influence the measurem of muscle strength. Factors such as length and type warm-up activity, the number and length of rest perio and the type and order of muscle contractions could
- 65. make it difficultto compare the results from different studies. But these factors have not been specifically tested, so the extent of the influence is really not known and these factors should be tested. The mechanical aspects of isokinetic machines appear to be reliable. But how reliable is the device for measuring muscle strength? And is the level of reliability different in patient populations compared with normals and at differ ent testing speeds? A reasonable level of reliability appears to exist in testing muscle strength, as long as standard protocols are adhered to. Standardization is crucial be cause so many factors can influence the test measurement. The validity of the tests and of the interpretation of the output has received less scrutiny. The reliability of specific isokinetic devices in measuring muscle strength has been examined to a limited extent testing different muscle groups. In a recent review of isokinetic testing of the ankle musculature, Cox (1995) concluded that isokinetic testing was generally reliable. However, he noted that reliability was higher for the plantar- and dorsiflexors than for the invertersand everters. It was apparent from the review that most studies were conducted on normals. Frisiello et al. (1994) examined the test-retest reliability of the Biodex isokinetic dynamometer (Biodex Medical Systems, Shirley, NY) on medial and lateral rotation of the shoulder. He tested eccentric peak torque of both shoulders in 18 healthyadults at 90 and 120 degrees per second. He reported ICC values between 0.75 and 0.86, with medial rotation being slightly less reliable than lateral rotation. It appears from the literature that isokinetic devices are mechanically reliable within themselves, but comparisons between devices have not been conducted. It also appears that isokinetic devices measure muscle torque reliably. Many reliability studies have been conducted measuring peripheral muscle strength in normal subjects. The "nor mal" subjects are frequently well educated, well motivated, and free from pain and dysfunction. Typical patients may also be well educated and well motivated, but they usually have some discomfort and dysfunction, which may influ ence their performance and thus the reliability of the strength measure. Therefore, the assumption of similar levels of reliability in patients is not appropriate. Reliability needs to be established in the specific populations that are to be tested under the conditions of testing that are used in that population. Trunk Testing Finally, an area of testing that has evolved rapidly in the last decade is the use of isokinetic and isoinertial devices to measure isometric and dynamic muscle strength in the trunk. Spinal problems are complex problems that are difficult to prevent, difficult to diagnose, and difficult to treat. The tendency for spinal problems to recur is a source and very costly in financial and personal terms. They can lead to a great deal of distress and demand on the health care system. Many patients in rehabilitation are patients with low back problems. The trunk is a complex multiseg mental system with multiple joints, multiple axes of motion and multiple complex musculature. It is more difficult to measure range of motion and muscle strength in the trunk than it is in peripheral joints because of the trunk's complexity. The perceived need to quantitatively measure trunk function coupled with the availability of new technol ogy has led to the development of trunk testing devices There is now a great deal of use, and unfortunately misuse of trunk testing devices. Functional strength tests of trunk musculature have been used as a preemployment screening tool, as a measure o progress in rehabilitation, and as a "malingerer detector." Use of functional muscle testing as a screening device is based on some epidemiologic data thatsuggestthat manua materials handling leads to back injuries. However, the supporting evidence for this notion is not strong. Mos studies are retrospective; do not distinguish between back injuries, reports of back injuries, and time lost from work; and do not account for confounding psychosocial variables (Pope, 1992). This knowledge has not stemmed the tide of technology or the inappropriate use of isodevices. Recent critica reviews on trunk strength testing with isodevices conclude that no evidence has been found to supportthe use ofthese devices for preemployment screening, medicolegal evalu ation, or even clinical evaluation (Andersson, 1992 Mooney et al., 1992; Newton and Waddell, 1993; Pope 1992). The strength of this criticism may be a reaction to overclaims by manufacturers and overinterpretation o results by those with a vested interest in the device or in the results of the test. Inappropriate interpretation of results may also be due to an incomplete understanding o biopsychosocial factors that contribute to a person's per formance on an isodevice. Medicolegal issues and clini cians' suspicions have complicated the use of trunk testing machines to a shameful degree. However, on the positive side, these machines do provide information that is no otherwise available. Systematic research is now necessary to determine the validity of the information that these devices do provide about trunk function. Trunk testing devices have contributed to the body o knowledge on trunk performance, including isometric and dynamic trunkstrength. Isomachines for trunktesting were introduced about 10 years ago. They now include the Cybex back testing system, the Udo, the Kin-Com, and the B-200. With the exception of the B-200 (Fig. 2-9), which is an isoinertial (constant resistance) device, most trunk testing machines are isokinetic. All the isokinetic devices operate on similar principles to each other and to the isokinetic devices that measure peripheral muscle strength. The main difference between the devices is in the tes positions (lying, sitting, semistanding, or standing) and'the
- 66. 44 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT degree of stabilization and constraints to motion. Some of the machines can measure strength in all directions of trunk motion simultaneously and with the person in the same device, eg, the B-200. Other devices have different ma chines for different motions. For example, the Cybex system has one device that measures trunk flexion and extension and another that measures axial rotation. All of the factors that need to be considered in isokinetic testing in peripheral muscles, such as warm-up protocol and standardization of instructions, need to be considered in trunk testing. There are, however, some factors that are unique to strength testing of the trunk because of its biomechanical complexity. The amount of torque generated by a muscle is the product of force and the length of the lever arm from the axis of motion. Determining the axis of motion in a multiaxial system is obviously problematic. The hip joint (Hasue et aI., 1980), the LS-S1 joint (Davies and Gould, FIGURE 2-9. A, 8-200 isoinertial back testing unit. B subject in the 8-200 isoinertial back testing device. (A Courtesy of Isotechnologies, Inc., Hillsborough, NC.) 1982), and the iliac crest (Suzuki and Endo, 1983) h been used as a designated axis of motion. It is no whether any axis has more validity than another. Ho regardless of which axis is intended for selection, a of plus or minus one spinal level exists betwe segment that is intended for selection and that w actually selected (Simmonds and Kumar, 1993b important points for testing are that the specific axis be documented and that the same axis should be u repeated testing. In peripheral joints, isometric strength was show greater than dynamic strength. Moreover, as the velo testing increased, the magnitude of torque decreased occurred later in the range. The same phenome present in trunk masculature, and this holds for al tions of movement (Kumar et a!., 1995a; Kumar 1995b). The position of testing trunk performance influen
- 67. the musculature andbecause of the differential effects of gravity on the trunk. Cartas and colleagues (1993) evalu ated the effect of subject position on isometric and isoinertial muscle performance. They tested 25 healthy male subjects with the 8-200 isoinertial dynamometer on two different occasions. The first test involved isometric measurements in three directions and in three positions; sitting (hip in 90 degrees fleXion), semistanding (hip at 135 degrees fleXion), and standing. The second session in volved dynamic testing in three directions against 50 percent resistance. Isometric flexion strength was highest in standing and lowest in semistanding, whereas isometric extension strength was not influenced by position. Dy namic muscle performance was highest in standing for all directions. These results give an indication of the impor tance of posture to muscle strength and suggest that one particular posture is not optimal for all muscle perfor mance. Unfortunately, these tests were conducted in normal, pain-free individuals. The results cannot be gen eralized to the patient population because patients have different pathophysiologic constraints on their posture and on their muscle performance. Several investigators have used isomachines to compare muscle performance between patients and pain-free sub jects (Cassisi et aI., 1993; Gomez, 1994; Newton et aI., 1993). Newton and colleagues (1993) tested 70 normal subjects and 120 patients using the Cybex II device. They considered the reliability of the device and the learning effect of the subjects. They evaluated whetherisokinetic measures could discriminate between patients and con trols. They also examined the relationship between clinical and isokinetic measures. Similar to other reports, the device was found to be reliable and a learning effect was noted. It was interesting to find that the magnitude of the learning effect was greater in the patients than in the controls. A couple of factors can account for this. First, the magnitude of difference was calculated as a percentage change in mean torque. The torque output was lower in the patient group compared with the control group; thus, patients are at a mathematical advantage. For example, it can be seen from Table 2-2 that the magnitude of change between the first and second test of trunk extension at 120 degrees per second was 14.6 ft-Ib in the normal group and 18.3 ft-lb in the patients, a negligible difference between groups, However, when this difference is presented as a percentage learning increase, the appar ent learning effect is much more significant in the patient group (28%, compared with 15% in the normal group), All data should be scrutinized, and this example shows why, Cooke and colleagues (1992) examined isokinetic per formance in 45 subjects with low back pain, They acknowl edged a learning effect between the first and second tests but found no Significant difference in strength measures between the second and third test. They conducted isoki netic tests at 2 and 4 weeks following therapy and measured an improvement in muscle strength beyond that isokinetic devices can be useful for measuring clinica change, Studies that have compared males and females and patients and controls are consistent in their findings Muscle strength is lower in a group of females compared with a group of males. Furthermore, muscle strength i lower in a group of patients compared with a group o healthy subjects. However, within all groups, a high level o variability is seen between individual subjects This variabil ity compromises the ability of the isokinetic test results to discriminate between indiuidual patients and indiuidua controls, In attempting to classify subjects as patients o controls, Newton and colleagues (1993) found that isoki netic scores were not useful. Using two standard deviations as the cut-off criteria, 80 percent of patients were deSig nated "normal. " This figure was reduced to 56 percen using one standard deviation as the cutoff criterion. The data from this study did not provide much support for the ability of isokinetic tests to discriminate between norma subjects and those with spinal problems. Mean torque scores are not useful in discriminating between patients and control subjects. Is it possible that evaluation of the ratio between flexor to extensor strength is more useful? Al though some authors have suggested that this is the case (Mayer et al., 1985; McNeill et aI. , 1980;Suzuki and Endo 1983), no consensus as to the normative ratio has been reached. This lack of consensus can be explained by recen work of Kumar and colleagues (1995a, 1995b). They showed that the ratio of flexion to extension strength varies as a function of trunk position and speed of testing, Other difficulties in attempting to use isokinetic scores to discriminate between patients and controls are reported by Gomez (1994), Gomez tested 168 normal subjects and 120 patients using the 8-200, speCifically to look a TiBI.L 2 2 SHOWS HOW USE Of PERCENTAGE CHANGE SCORES TO DEMONSTRATE A LEARNING EffECT IS BIASED IN fAVOR OF PATIENTS· Velocity of Test (degrees Test 1 Test 2 Magnitude Learning per sec) (ft-Ib) (ft-Ib) of Cbange % Increase Normal Group (n = 21) 60 122,6 142,9 20,3 16 90 116,9 132.4 15,5 13 120 98,8 113.4 14,6 15 Patient Group (n = 20) 60 93.5 122,0 28.5 30 90 88,3 100,9 12,6 14 120 63,4 81.7 18,3 28 : Based on data from Newton, [VI" Thow, M" Somerville, D" Henderson I. , & Waddell , G, (1993) Trunk strength testing with iso-machines Part 2: Experimental evaluation of the Cybex II back testing system in normal subjects and patients with chronic low back pain, Spine, 18(7) 812-824
- 68. 46 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT asymmetry of trunk strength and range of motion. He found that asymmetric motion and strength was present in the subjects with low back pain. However, the asymmetry did not discriminate between patients and normal subjects. This was because ALL subjects were asymmetric and moved asymmetrically. The magnitude of variability of isokinetic test data both within and between groups argues against the value of using normative isokinetic data. Comparing the magnitude of force exerted by a patient against a normative database is probably less useful than using the patient as his or her own control and measuring the change in performance. The tremendous variability in the magnitude of muscle strength is due to the myriad of factors that influence strength and that influence the measurement of muscle strength. It is difficult for normative databases to control for the considerable number of relevant factors. It is obvious from the previous discussion that many issues regarding trunk testing with isomachines are unre solved. These issues will only be resolved through system atic research. They will not be resolved through anecdotal evidence or patient orclinician testimonials. It can be stated that these machines are mechanically reliable and appear to measure muscular torque reliably. The validity of the devices in terms of measuring trunk function has not been established. CONCLUSIONS This chapter shows how complex the measurement of muscle strength is. The strength of a muscle is dependent on a variety of factors in different domains (see Fig. 2-2). Measures of muscle strength are dependent on the strength of the muscle but on many other factors too. The reliability of muscle strength varies with the methodology of testing. Reliability and responsiveness have not been adequately demonstrated with MMTs. The reliability of instrumented muscle testing is reasonable, at least in normal subjects, but devices are not interchangeable. The greatest shortcoming in tests of muscle strength lies in their lack of proven diagnostic and prognostic validity when they are used for this purpose. Systematic research is necessary. Priorities of research include 1. Establishing the reliability of strength tests in popu lations for whom the test is intended 2. Establishing whether and how isometric and dynamic tests of muscle strength can be used for diagnostic and prognostic purposes 3. Demonstrating the relationship of isometric and dynamic tests of muscle strength to function Finally, before using any measurement test, clinicians should ask themselves why they are using the test and what they hope to learn from the results ofthat test. What are the factors that influence the test? They should a whether the measurement has any relationship w patient's problem as the patient perceives it. I would like to leave the reader with the follOWin to ponder: We sometimes measure what we m because we can measure it, it is easy to measure, have been taught to measure it. We do not measu we should measure because it is more difficult an complex. We then use the easy measure to infe about the difficult measure. Isolated and constrained tests of muscle strength own do not provide an adequate indication of coor discomfort-free functional muscle activity. Concentric-A shortening muscle contraction. Eccentric-An eccentric muscle contraction is which the muscle lengthens as it continues to m tension. Endurance-The ability to maintain torque over of time or a set number of contractions. Fatigue-The inabilityto maintain torque overa p time or a set number ofcontractions. What you lose you maintain, ie, 30 percent loss of power equals nance of 70 percent power. lsoinertial-Constant resistance to a movemen Isokinetic-Constant velocity of the joint, not a c shortening or lengthening of the muscle. Isometric-An isometric contraction is when the generates an internal force or tension but no move a joint occurs. Isotonic-An isotonic contraction is when the force generated by a muscle results in movement o Moment arm-The perpendicular distance from of action of the force to the fulcrum. Power-Work per unit time. ReHabiHty-The degree to which repeated m ments of a stable phenomenon fall closely togethe Responsiveness-The ability of a test to measu cal change. Sensitivity-The ability of a test to correctly ide subjects with the condition of interest. Sped6dty-The ability of a test to identify only with the condition of interest. Strength-I) Force or torque produced by a during a maximal voluntary contraction; 2) measu of force output at the end of a lever; or 3) maximal torque required to resist an isometric or isotonic tion. 'The definitions given here are operational definitions.
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- 71. CHAPTER 3 Joint Rangeof Moron Jeffery Gilliam, MHS, PT, oes Ian Kahler Barstow, PT SUMMARY Early measurement of joint range of motion (ROM) was initiated by the necessity to assess disability from postwar injuries. Measurements of joint ROM provide information designed to describe status, document change, explain perfor mance, and predict outcome. It is critical to establish reliability in goniometric mea surements to substantiate consistency over time. Some level of validity should al ways be demonstrated with measurements of ROM, correlating the measurements taken with the actual angles involved. While it is difficult to compare reliability stud ies, those methods with established standardized procedures demonstrate a higher degree of repeatability. The universal goniometer has been established as one of the most accurate and efficient instruments used in measuring joint ROM. Because of the enormous financial burden related to low back pathology, methods of mea suring lumbar ROM for purposes of function and disability have come under scrutiny. To establish "normal" ROM measurements as a standard for reference, population differences such as age, sex, race and ethnic background, as well as vo cation, clearly need to be considered before standards can be enforced stringently. Measurements related to functional ROM continue to be the key to providing meaningful information about the patient's progress. Within this chapter, each section covers a specific joint, examining reliability and validity studies on ROM for that joint, describing the latest devices and methods for measuring joint ROM, as well as providing tables with "norms" for joint ROM and information regarding functional ROM. The measurement of joint range of motion (ROM) has been a part of clinical assessment since the early 1920s and continues to be one of the most commonly used techniques for evaluation used by physical and occupational therapists today (Cobe, 1928; Hewitt, 1928; Smith, 1982; Miller, 1985). The necessity of taking joint ROM measurements has been an accepted part of the evaluation procedure and is often performed clinically without the understanding of its purpose and usefulness in providing information for the clinician, as well as to the patient, regarding progress or lack thereof (Bohannon, 1989; Miller, 1985). Certainly the meaning of joint ROM and what it tells therapists, particu larly with regard to patient function, has been perSistently challenged, especially in the area of lumbar ROM (Waddell, 1992). Therapists have also witnessed that the term normal ROM assures neither normalcy nor that a patient will return to normal functional activity, particularly when related to 49
- 72. 50 UNIT TWO-COMPONENTASSESSMENTS OFTHE ADULT return to work status (Waddell et aL, 1992). Despite the difficulties with which therapists are confronted, it is clear that they will continue to use assessment of ROM as a part of the evaluative process. When assessing joint ROM, therapists want to link the act with a measurement, converting their observations into quantitative information (Michels, 1982). This information in turn allows therapists to make decisions regarding the necessity of specific treatment for the patient, as well as approach and modifi cation of treatment. It also gives some indication of progress, as well as anticipated functional status or disabil ity (American Medical Association, 1969; Miller, 1985). Assessment of joint ROM is based on what are termed objective measurements, as distinguished from subjective measurements, e.g., visual estimation. Objective measure ments are characterized by the relative independence of the examiner, providing reliability estimates that demon strate the apparent subjective error (Bohannon, 1989; Rothstein, 1989). Realizing that clinical measurements are probably never completely objective, relying always to some extent on the examiner's judgment (Rothstein, 1989), it should be noted that objective measures can provide evidence of improvement (increases in ROM) often earlier than subjective measurements or measurements of function (Bohannon, 1989). An ongoing goal should be to constantly make efforts toward reducing the amount of error of variance in measurement procedures and to provide an accurate representation of the changes displayed by the patient. Bohannon (1989) lists four basic purposes for objective measures: 1) to describe status, 2) to document change, 3) to explain performance, and 4) to predict outcome. A fifth reason should be to encourage the patient's interest and motivation in the treatment program (Palmer and Epler, 1990). In assessing ROM, the therapist can determine the patient's status by comparing measurements with those of the uninvolved joint or with "normal" values. The ability to document change is made by the therapist's remeasure ments made over time. By knowing a patient's measure ments in relation to measurements necessary for functional ROM (e.g., climbing steps or combing hair), the therapist can determine the patient's ability to perform a speCific task. By measuring the ROM of various joints acting along a kinetic chain, functional activities can be predicted to some extent (Bohannon, 1982). The purpose of this chapter is to provide the clinician with a quick reference to reliability and validity of ROM measurements for various upper and lower extremity joints. Another goal isto introduce alternative methods that depict novel and insightful proceduresand instrumentation designed to acquire information regarding changes in musculoskeletal joint position. The majority of the sections on specific joint ROM provide both a table of "normal" joint ROM measurements and information regarding func tional ROM, with particular emphasis on the upper ex tremities. In addition, by the year 2000 it is estimated 15 percent of the Gross National Product may be spe the low back problem (Cats-Baril & Frymoyer, 1 Therefore, a special section on ROM for the lumbar s which offers an in-depth review of commonly used niques, has been included. HISTORICAL PERSPECTIVE The early beginnings of ROM measurements date to the first decade of this century, when two Fr physiologists, Camus and Amar (Smith, 1982), des and began to use protractor goniometers to measur relationship between mensuration and disablemen deed, much of the earlier literature appears to consequence of the postwar era and the necessi relating ROM to disability (Smith, 1982). The nomenclature and much of the standardized m ods for measuring range of motion have been establ by the American Academy of Orthopedic Surgeons basis for this system was established by research perfo by Cave and Roberts (1936) and has been widely acc throughout the medical world (Smith, 1982). The pro sion of these standards to improve objectivity by lo both at inter- and intraobserver reliability and va (Hellebrandt et aL, 1949; Leighton, 1955) added co erably to the progression toward increased objectiv measurements. Although a variety of instruments methods have been used for measuring ROM, the univ goniometer has been recognized as an accurate convenient instrument for measurements (Defib 1964; Moore, 1949a; Salter, 1955). Even though the methods indicated by the Ame Academy of Orthopedic Surgeons have been widely both the reliability of these methods and the certain what has been cited as "normal range" values are h questionable given the paucity of research that w confirm these methodologies. However, ongoing res has continued to substantiate the reliability and valid certain methods and instrumentation, as well as docu normal ROM values (Boone & Azen, 1979; Elveru e 1988; GogiaetaL, 1987; Riddleetal., 1987; Rothst aI., 1983). Although goniometry has long been use assessment in physical therapy, it was not until the 1940s that formal studies were performed to d mine the reliability of these measurement techn (Hellebrandt et aI., 1949; Moore, 1949b). Moore earlier researchers in recognizing the necessity of loc the "axis of motion," as well as appropriate place of the two arms of the goniometer along definitive landmarks. (For a more in-depth historical accou methodology and instrumentation, see Moore's two work [1949a, 1949b], which was followed by th Hellebrandt et aI., 1949.) The determination tha
- 73. varied instrumentation wasconfirmed by these studies. RELIABILITY Clinicians agree that measurement of ROM is an impor tant part of the assessment process; it thus becomes paramount that these measurements are shown to be reliable, i.e., they can be reproduced over time. It can be said that objective measures are only as good as their repeatability, i.e., their ability to be reproduced accurately (Gajdosik & Bohannon, 1987; Low, 1976). Hellebrandt and associates (1949) defined good reliability for ROM as an agreement of measurements within 3 degrees of one another. To substantiate what determines a reliable mea surement procedure is difficult at best Because reliability of goniometric measurements have been demonstrated to vary between different joints of the body (Boone et al., 1978; Hellebrandt et al., 1949; Low, 1976; Rothstein et aI., 1983), measurement error may be attributed to factors such as length and mass of a body segment and ability to identify bony landmarks. Other factors influencing varia tion are changes occuring over time (Atha & Wheatley, 1976; Bohannon, 1984), differencesdue to the time ofday that measurements are taken (Russell et al., 1992), and levels of goniometric skills among raters (Fish & Wingate, 1985). These variations certainly leave the therapist with the sobering thought that any interpretation of the data on goniometric measurement must be performed with discre tion. Comparing two different forms of a test on the same subjects (parallel-forms reliability) indicates whether mea surements obtained can be used interchangeably (Roth stein & Echternach, 1993). Youdas et al., (1993) demon strate an example of this when comparing goniometric measurements with visual estimates of ankle joint ROM. A comparison of two methods of goniometry (Grohmann, 1983) demonstrated no difference between using the lateral and over-the-joint methods of goniometry for mea suring the elbow joint In examining methodology, Ek strand and coworkers (1982) determined that a standard ized method increased reliability in jOint motions of the lower extremity. The use of different instruments to make measurements of the same jointangle was demonstrated as reliable by Hamilton and Lachenbruch (1969), who used three different devices to measure finger joint angle. In comparing three different-sized goniometers to measure knee and elbow ROM, Rothstein and colleagues (1983) demonstrated a high level of interdevice reliability. Greene and Wolf (1989) demonstrated a strong relationship be tween the Ortho Ranger (electronic goniometer; Orthotronics, Inc., Daytona Beach, FL) and a universal goniometer for shoulder internal and external ROM but a poor relationship for elbow movements. A comparative goniometry (universal goniometer, fluid goniometer, an electrogoniometer) for measuring elbow ROM showed significant differences between the goniometers and sug gested that interchangeable use of the different types i inadvisable. The varied results of these studies suggest tha although a small amount of error may occur within th goniometer, the main source of variation is in the method ology, and that by standardizing procedures, improve reliability can be realized. VALIDITY It has been suggested that the goniometric error i negligible and that the source of errors is from poo methodology (Salter, 1955). Although some small amoun of error may occur within the instrument used for mea surement due to equipment fault, the accuracy of goniom eters can be ascertained. To validate a measurement o unknown validity, researchers compare it with anothe measurement of known validity (criterion-based validity (Rothstein & Echternach, 1993). An example of this would be to compare an instrument designed for measuring ROM with something that has a known angle (Crowell et al. 1994). Concurrent validity, a class of criterion-base validity, can be established by comparing two instrument of measurement, one of unknown validity and the othe having demonstrated validity during measurement of specific joint (Rheault et aI., 1988). When assessing the accuracy of goniometric measure ments, realizing the limitation of the information received is paramount The goniometric measurements give th examiner quantity in degrees concerning a joint being assessed (Michels, 1982). However, this does not give u information about a specific tissue or allow the examinerto make qualitative judgments concerning worth, usefulness or value of the joint being assessed (Bohannon, 1987 Rothstein, 1989). For example, when assessing lumba ROM, the therapist cannot interpret the results as infor mation about the vertebrae, disks, or muscles; nor can th therapist determine the level of function of the patient from the measurements alone. Until the results of the ROM measurements can be highly correlated with the status of specific tissue, functional movement, or activity, the thera pist is limited in the interpretation to a measurement o quantity in degrees only. While therapists have depended on their knowledge o anatomy and appropriate placement of the goniometer to ensure accurate measurements (content validity), difficult in finding bony landmarks or in identifying the axis o rotation may jeopardizethe results. Radiographic compari sons have long been referred to as the "gold standard" i terms of validity studies and have been used effectively i studies of ROM (Enwemeka, 1986). Other methods such
- 74. 52 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT as cinematography (Bohannon, 1982; Vander-Linden & Wilhelm, 1991), electrogoniometry (Chiarello & Savidge, 1993), as well as other motion analysis systems (Day et al., 1984; Pearcy et al., 1984; Petersen et al., 1994; Scholz, 1989), offer new directions in strengthening content validity by demonstrating criterion-based validity (Gadjosik & Bohannon, 1987). NORMALCY IN JOINT RANGE OF MOTION While it is imperative that reliability is demonstrated for an ROM measurement procedure and that some form of validity is indicated to confirm a "true" measurement, it is also recommended that normative data be available to which to compare the measures. A point of reference is helpful in giving information to the clinician about where the patient is in terms of "normal range." Standards that clinicians use to judge the progress of their patient may assist in determining the cause of functional deficits. Many medicolegal and disability evaluations use "norms" as a standard in determining the level of disability (American Medical ASSOCiation, 1969). Because many studies have demonstrated bilateral sym metry in ROM measurements (Boone & Azen, 1979; Mallon et al., 1991; Roaas & Andersson, 1982), it has been suggested that the uninvolved joint be used as a reference point to assess progress made in the involved joint. However, this rationale has been challenged (Miller, 1985) from the standpoint that compensatory mecha nisms alter biomechanics, causing changes in movement patterns and ROM. This may be particularly true in chronic diseases or injury. Although the message is clear that normal values of joint ROM are necessary as a standard to measure progress, the problem becomes specificity of standards. General stan dards for ROM can not be applied across the board for all populations. An early study by Clark (1920) that listed rough averages for various joint ROM measurements was followed by studies in which measurements of a more specified population (Cobe, 1928; Hewitt, 1928) demon strated that females had on the average greater wrist motion than males. More recent studies (Boone & Azen, 1979) examined age differences in a group of male subjects, noting an overall reduction in joint ROM with increased age, specifically indicating a progressive reduc tion in hip abduction and rotation during the first two decades of life. Bell and Hoshizaki (1981) demonstrated in eight different joints a general decline in ROM with age (not clearly indicated in upper extremity joints) and that females have greater ROM than males throughout life. When measuring ROM in the hip, knee, and ankle of males 30 to 40 years of age, Roaas and Andersson (1982) found Significant differences between measures found by previ ous studies (American Academy of Orthopedic Surgeons, 1965; Boone & Azen, 1979). In looking at normal of digital ROM in young adults, Mallon and colle (1991) found females had greater total active motion digits. While the above studies demonstrate some ge trends in regard to gender and age, fewer studie available with regard to ROM differences in race and e backgrounds (Ahlberg, et al., 1988; Allender et al., 1 Roach & Miles, 1991). These studies clearly point shortcomings of following a strict adherence to a giv of "normal" measurements of ROM rather than all specific patient characteristics to determine the op measurements for a given situation. Finally, while these studies of normal measurements improve our k edge base, the therapist should not lose sight of the important aspect, returning the patient to an ROM functional. Understanding the ROM that is necessa functional movement patterns is paramount when m ing joint ROM. Miller (1985) suggests three advanta using functional ROM over other methods: 1) go treatment are based on individual characteristics, su gender, age, and activity level; 2) therapists are assisted in understanding the problem and devel strategies for treatment; and 3) therapists are able to on relieving a problem rather than on achieving quantity that has been deemed "normal." WRIST AND HAND Many complicating factors must be considered measuring the joints of the wrist and hand, includin large number of joints and the intricacy in the variat joint surfaces, particularly within the wrist. The num joints and multiple muscle attachments may lead creased variations in measurements of the wrist compared with a more simple joint like the elbow 1976). The presence of scars, edema, large hypertr and deformed joints, as in rheumatoid arthritis, ma make the wrist difficult to measure in terms of gonio placement. It is important to stabilize the numerous segments, allowing for accurate alignment of the go eter during ROM measurements of the hand and (Hamilton & Lachenbruch, 1969). Because a subst number of variables can add to measurement error measuring the joints of the hand and wrist, the necess providing a reliable method of measurement and i mentation is foremost. An early study assessing the finger joint angle (Ham & Lachenbruch, 1969) demonstrated no significan ance when looking at three different goniomete determining joint angle: a dorsum goniometer, a uni goniometer, and a pendulum goniometer. When m ing ROM for the wrist and hands in flexion and exten the clinician is confronted with basically three techn for measurement: 1) measurement utilizing vola
- 75. & Moran, 1981);2) the use of the ulnar surface (Moore 1984; Norkin & White, 1985); and 3) the use of the radial surface (Hamilton & Lachenbruch, 1969) (Fig. 3-1). The use of these different methods in measuring wrist ROM has led to varied approaches with conflicting results (Horger, 1990; Solgaard et al., 1986). When comparing the three methods in measuring passive wrist ROM in a clinical setting, LaStayo and Wheeler (1994) found that the dorsal/volar alignment method had a higher reliability than either the radia'l or ulnar method. Under controlled conditions, Hamilton and Lachen bruch (1969) found the lateral (radial) method of measure- FIGURE 3-1. Measurement of wrist flexion and extension can be taken by using (A) the radial side of wrist and hand, (8) the ulnar side of hand, or (C) the suggested volar or dorsal side of hand. FIGURE 3-2. Measurement of finger flexion uses a method o measuring the distance between the pulp of the finger and the dista palmar crease. ment was as reliable as the dorsal method when measuring finger ROM. Problems with good joint alignment second ary to joint deviation, edema, and enlarged jOints make i apparent that appropriate selection of methods should be determined by the adaptability of the method to the speCific clinical situation. In estimating changes in ROM, the use of a standard error of measurement (SEM) in the wrist of ±4 to 6 degrees appears to be an acceptable figure for intratester reliability while generally a slightly higher SEM, ±6 to 8 degrees, is characteristic of intertester reliability (Bear-Lehman & Abreu, 1989; Boone & Azen, 1979; Hamilton & Lachen bruch, 1969; Low, 1976), although this has not always been found to be the case, as LaStayo and Wheeler (1994) found a lower SEM and slightly higher intertester reliability during passive wrist measurement. While the above studies present proven methods for measuring ROM in the wrist and hand, other methods have been presented in the literature that raise some interest, although with less substantial data confirming their reliabil ity. Methods using a ruler to measure the distance between the finger and the palm of the hand (often a speCific point e.g., pulp of finger to distal palmar crease) (Fig. 3-2) to determine functional flexion of the digits (American Medi cal Association, 1988) have been used follOWing tendon repair (Jansen & Watson, 1993). Dijkstra and associates (1994) present a method for measuring thumb appositon (distance between the thumb and wrist), demonstrating small intra- and interobserver variability (Fig. 3-3). The importance of the thumb and the functional loss in its absence is difficult to quantify. The American Medica Association (1988) quantifies the loss of the thumb as a 40 percent loss of the total hand. Because of the unique structure and biaxial movement of the carpometacarpa
- 76. 54 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 3-3. A method for measuring thumb apposition measures the distance between the pulp of the thumb and the ,I.Tist. joint and the thumb's ability to move through a 360-degree are, the ability to measure circumduction is of value to the therapist. Browne and coworkers (1979) present a method for measuring circumduction of the thumb by taking measurements of the axes of the ovoid-shaped design of circumduction (Fig. 3-4). An increased distance in mea surements of the long axis (X-Z) (Fig. 3-5) and short axis (Y-Y') (Fig. 3-6) give the therapist a quantifiable amount, indicating an increase in circumduction motion. As previously mentioned, the intricacies of the joints of the hand and the complexity of the movement patterns most assuredly match the complexity of its function. However, a paucity of research on the measurement of digital ROM and effects of contiguous joints on ROM exists (Mallon et aI., 1991). Digital ROM has often been left to a A x FIGURE 3- 4. Circumduction motion of the metacarpal head about a long axis (X-Zl, and a short axis (Y-Y') (Adapted from Browne. E. Z., Teague, M. A., Gruenwald, C [19791. Method for measurement of circumduction of the thumb to evaluate results of opponensplasty. Plastic and Reconstructive Surger}l, 64, 204-207) FIGURE 3-5. The range of the first metacarpal in the long axis. of movement. B, End of movement. general concensus that the metacarpophalangea (Mep) has 90 degrees of flexion and the proxima phalangeal joint (PIP) has 100 degrees, while the interphalangeal joint (DIP) has 70 to 90 degrees (Am Association Orthopedic Surgeons, 1965; American cal Association, 1958). However, little has been done way of differentiating the values among the digi quantifying these differences, as weH as assessin effects of adjacent joints in the finger and how the affect ROM. Tables 3-1 and 3-2 give reported provided by several researchers for "normal" ROM wrist and hand and for the digits of the hand. While returning a patient to what would be consid normal ROM is deemed important, a more critical m is functional ROM, particularly in a clinical setting 1985 study by Palmer and coworkers, 10 normal s performed 52 standardized tests, demonstrating a n
- 77. FIGURE 3-6. Therange of the first metacarpal in the short axis. A, Start of movement. B, End of movement. TABLE J l degrees extension, 10 degrees for radial deviation, and 1 degrees for ulnar deviation. In looking at ROM for joints o the hand (Hume et aI. , 1990), 11 activities of daily livin were evaluated for functional ROM of the Mep an interphalangeal (IP) joints. Only a small percentage of th active ROM (AROM) of the joints was actually required fo functional tasks. In this study, functional flexion average 61 degrees at the Mep joints, 60 degrees at the PIP joints and 39 degrees at the DIP joints. The thumb demonstrate functional flexion averaging 21 degrees at the Mep join and 18 degrees at the IP joint. This amount was 32 percen of the amount of flexion that was available. Ryu an colleagues (1991) demonstrated that a battery of activitie of daily living couId be performed with 70 percent of th maximal range of wrist motion, which was 40 degrees fo wrist flexion and extension and 40 degrees of combine radial and ulnar deviation. This is somewhat more than tha estimated previously by Palmer and associates (1985) Safaee-Rad and coworkers (1990), who looked at func tional ROM in regard to three feeding tasks (eating with spoon, eating with a fork, and drinking from a handle cup), found that 40 degrees forearm pronation to 6 degrees forearm supination, with 10 degrees wrist flexio to 25 degrees wrist extension and from 20 degrees wri ulnar deviation to 5 degrees wrist radial deviation wa required to perform tasks. Wrist rotation was found to b negligible. These estimates are more in line with earlie studies by Palmer and colleagues (1985). These measure ments indicate ranges that are required to perform basi functional activities; however, when our goal is to return patient to extracurricular activities, we clearly must asses the ROM necessary to realize a predetermined moto pattern. ELBOW like other musculoskeletal joints, the elbow has receive attention in the way of reliability studies. As a hingelik MEASUREMENTS WITIDN UMlTS OF " NORMAL" ROM IN DEGREES FOR THE HAND AND WRIST. REPORTED BY SEVERAL AUTHORS AND RESEARCHERS· Boone & Dorinson & Esch & Gerhardt & Solgaard Wiechec& AAOS Azent Wagner Lepley Russe AMA et al.=!, Kruseo doint (1965) (1979) (1 9 48) (1974) (1975) (1958) (1986) (1939) Wrist Flexion 80 76 80 90 60 70 77 60 Extension 70 75 55 70 50 60 73 55 Radial deviation 20 22 20 20 20 20 26 35 Ulnar deviation 30 36 40 30 30 30 40 75 • Studies not showing demographics in table did not include them in the original research. t N = 109, 18- 54 y, male. r N = 31,24--65 y, male and female. AAOS = American Academy of Orthopedic Surgeons; AMA = American Medical Association.
- 78. 56 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT TABl [:~-2 "NORMAL" DIGITAL ROM IN DEGREES, RECORDED BY MAllON AND COLLEAGUES· Joint Motion Male Female Index MP Extension -16 --26 Flexion 85 86 PIP Extension -5 -8 Flexion 103 101 DIP Extension -4 -11 Flexion 71 73 Long MP Extension -13 - 23 Flexion 90 91 PIP Extension -4 - 9 Flexion 105 105 DIP Extension -5 -12 Flexion 71 71 Ring MP Extension -15 -30 Flexion 99 98 PIP Extension -4 - 8 Flexion 107 109 DIP Extension -4 - 12 Flexion 65 61 Small MP Extension -15 -22 Flexion 103 106 PIP Extension -7 -11 Flexion 106 106 DIP Extension - 3 -12 Flexion 63 66 • N =120. 18-35 y, male and female. Negative numbers indicate hyperextension. MP =Metacarpophalangeal. Data from Mallon, W ,I., Brown, H. R , & Nunley, J. A. (1991). Digital ranges of motion: Normal values in young adults. The Journal of Hand Surgery, 16A, 882-887. joint, its axis of rotation is at approximately the center of the trochlea (Morrey & Chao, 1976). Earlier studies of the elbow have questioned the reliability of the universal goniometer when comparing it with visual estimation, indicating a wide range of errors for both the goniometer and visual estimation (Baldwin & Cunningham, 1976). Another study performed during that same period indi cated a moderately high level of reliability, with intraob selver error less than 3 degrees and interobserver error less than 5 degrees (low, 1976). The study of different methods of measurement, as well as the use of various measurement devices, has been an area of research to determine reliability. ~n a comparison of two methods using a half-circled goniometer for goniometric measurements of the elbow, Grohmann (1983) noted no difference between the lateral and the over-the-joint methods of goniometric measure ment of the elbow joint. A comparison of two measure ment devices (Greene & Wolf, 1989), the Ortho Ranger (electronic goniometer; Orthotronics, lnc., Daytona Beach, FL) and the universal goniometer, in measuring elbow ROM demonstrated good within-session relia but a poor relationship between the two device addition, a more recent study comparing a univ goniometer with a fluid-based goniometer indicated intertester reliability for standard goniometers (r = 0 compared with the fluid-filled goniometer (r = 0.92) (P erick et al., 1988). One of the better comparative stu with regard to methodology (Rothstein et al., 1 determined a high level of both intertester and intrat reliability (ICC = 0.89 and 0.96, respectively) when u three different-sized universal goniometers for measu the elbow position. The ability to measure pronation and supination been less exact, and studies to substantiate reliability been elusive. The recommendation that the patient a short stick, e.g., a pencil, while measuring fore FIGURE 3-7. A new method for measuring forearm supinatio pronation. Arrow indicates the position of upper arm against (Laupattarakasem, W, et al. 119901. Axial rotation gravity goniome simple design of instrument and a controlled reliability study. Cl Orthopaedics and Related Research, 251, 271-274.)
- 79. "NORMAL" ROM MEASUREMENTSIN DEGREES FOR THE ElBOW, REPORTED BY SEVERAL AUTHORS Boone & Dorinson & Escb & Gerhardt & Petherick Solgaard Wiecbec & MOS Azen- Wagner Lepley Russe AMA et al.t et a1.:f: Krusen Joint (1965) (1979) ( 1948) (1974) (1975) (1958) (1988) (1986) (1939) Elbow Flexion 150 143 145 150 150 150 149 135 Radioulnar Pronation 80 76 80 90 80 80 S6 90 Supination 80 82 70 90 90 SO 93 90 • N = 109, IS54 y. male. t N = 30, x =24 y, male and female. '' N = 31 , 24-65 y. male and female. AAOS = American Academy of Orthopedic Surgeons; AMA = American Medical Association. supination and pronation has been cited (Macrae 1983), offering the examiner some assistance with regard to a point of reference for alignment of the goniometer. Another method for measuring forearm pronation and supination utilizes an axial rotation gravity goniometer (Fig. 3-7). This method demonstrated a high level of intertester reliability (r = 0.94) for measuring supination and pronation (n = 50) (Laupattarakasem et al., 1990). When looking at normal values for elbow flexion and extension, Boone and Azen (1979) provided values of 0 to 145 degrees and 0 to 140.5 degrees when comparing a population younger than 19 years with one older than 19 years, respectively. Additional normative values are listed in Table 3-3. Studies to determine functional ROM (Safaee-Rad et al., 1990) found that the required ranges for performance of three feeding tasks (eating with a spoon, eating with a fork, and drinking from a handled cup) required 70 degrees to 130 degrees elbow flexion and from 40 degrees forearm pronation to 60 degrees forearm supination. SHOULDER It is well recognized that the shoulder is one of the more complex functional units within the body. Earlier studies (Hellebrandt et aI., 1949) indicated reliable repetitive measurements involving shoulder joint movements, with the exception of medial rotation and shoulder abduction. Shoulder external rotation was examined by Boone and Azen (1978), who demonstrated both intratester and intertester reliability when measuring the shoulder at r = 0.96 and 0.97, respectively. Because of the combined contributions of both the glenohumeral and the scapu lothoracic movements, resulting in total shoulder ROM, delineation of the two needs to be identified when per forming ROM measurements of the shoulder (Friedman & Monroe, 1966). An early study (Doody et a!., 1970) was designed to determine relative contributions of the scapu lothoracic and glenohumeral movements to scapular plane abduction. Using a double goniometer, the authors cleverly isolated the contributions of the scapula at 58.62 degrees and the glenohumeral at 112.52 degrees to give the total scapulohumeral "rhythm" (Fig. 3-8). The reliability of this technique has been challenged in recent years in a study by Youdas and associates (1994). The results of this study indicated that the margin of error for intratester measure ments (variance of > 3 degrees 50 percent of the time and > 8 degrees 10 percent of the time between first and second measurements) was dinica:]]y unacceptable. A method utilized by DeVita and colleagues (1990) in measuring scapular motion used the spine (third thoracic vertebrae) and the inferior angle of the acromion process of FIGURE 3-8. A method for measuring both glenohumeral and scapulothoracic ROM using a double goniometer. Scapular angle is the angle of the spine of the scapula to the vertical: glenohumeral angle is the angle between the spine of the scapula and the humerus. Summation of the two angles is the arm angle. (From Doody, S. G. , et al. [1970J. Shoulder movements during abduction in the scapular plane. Archives of Physical Medicine and Rehabilitation, 51, 595-604.)
- 80. 58 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 3-9. It is important to note the amount of shoulder abduction when measuring shoulder external and internal rotation. the scapula as the "moveable" reference point Another method (Kibler, 1991)used a linear measurement from the nearest spinous process to the inferior angle of the scapula. When investigating various techniques used in previous studies, Gibson and coworkers (1995) demonstrated a high level of intra- and intertester reliability (intraclass correla tion coefficient [ICC] = 0.95, 0.92) for the method of DeVita and coworkers (1990); however, they found low ,intertester reliability for the Kibler (1991) method. It has been suggested that these methods may provide results that prove to be somewhat difficult to interpret by the clinician, particularly the Kibler (1991) method. When measuring shoulder ROM, the clinician needs to be aware of the contributions not only of shoulder flexion and abduction but also of accompanying motions, e.g., external and internal rotation. Accompanying motion that occurs during active shoulder flexion was ingeniously determined in a study by Blakely and Palmer (1984). In this study, a universal goniometer and a gravity-activated angle finder were utilized to determine that medial rotation of the humerus accompanied active and passive shoulder flexion movements. During measurements of shoulder internal and external rotation , the amount of shoulder abduction needs to be noted, as this may limit ROM measurements (Fig. 3-9). Also, the plane in which shoulder elevation is made should be recorded, as this too may limit the available ROM (Fig. 3-10). The plane of the scapula (30 degrees-45 degrees to the frontal plane) has been described as the most functional position for elevation because the capsule is not twisted on itself and the deltoid and supraspinatus are best aligned for shoulder elevation (Zuckerman & Matsen, 1989) (Fig. 3-11). Riddle and colleagues (1987) examined both intertester and intratester reliability of shoulder passive range of motion (PROM), utilizing two different-sized universal goniometers. They demonstrated intratester reliability for FIGURE 3-10. Measurement of shoulder abduction in the s plane. This position is the most functional position for elevation. all motions ranging from ICC = 0.87 to 0.99, wh intertester reliability for measurements of flexion, a tion, and lateral rotation ranged from ICC = 0.84 to Intertester reliability for horizontal abduction and a tion, extension, and medial rotation was poor. The g metric measurements of shoulder PROM appeared unaffected with different-sized goniometers in this however. reliability between testers appears to be sp to movements measured. "Normal" ROM within the shoulder appears to b specific, decreasing in aU ranges slightly with increase (Boone & Azen, 1979). A list of normal ROM mea ments from several authors is provided in Table 3-4 Functional ROM for the shoulder during three fe tasks (eating with a spoon, eating with a fork, and dri from a handled cup) required 5 degrees to 45 de FIGURE 3-11. The plane of the scapula measures approxima degrees to 45 degrees to the frontal plane.
- 81. SEVERAL AU11IORS ANDRESEARCHERS Boone & Dorinson & Esch& Gerhardt & Wiechec & AAOS Azen* Wagner Lepley Russe AMA Krusen Joint (1965) (1979) (1948) (1974) (1975) (1958) (1939) Shoulder Flexion 180 167 180 170 170 150 180 Extension 60 62 45 60 50 40 45 Abduction 180 184 180 170 170 150 180 Internal rotation 70 69 90 80 80 40+ 90 External rotation 90 104 90 90 90 90+ 90 Horizontal abduction 45 30 Horizontal adduction 135 140 135 • N = 109, 18-54 y, male. MOS =American Academy of Orthopedic Surgeons; AMA =American Medical Association. shoulder flexion , 5 degrees to 35 degrees shoulder abduc tion, and 5 degrees to 25 degrees shoulder internal rotation (Safaee-Rad et al. , 1990). It has been demonstrated that restrictions in elbow joint ROM significantly increase the need for an increased arc of motion for both shoulder flexion and internal rotation during feeding tasks (Cooper et al. , 1993). CERVICAL SPINE While the spinal segment is one of the most frequently treated areas of the body, it continues to be one of the most elusive areas in determining reliable measurements for ROM. Because of the difficulty in aligning the goniometer with a definitive axis of rotation, as well as the inability to locate standardized landmarks to act as points of reference (Cole, 1982), the cervical spine remains one of the least accurately yet most highly measured of all musculoskeletal joints. Having 23 points of contact at which motion occurs from the occiput to the first thoracic vertebra, cervical motion combines sliding and rotation with flexion (Kottke & Mundale, 1959). Because flexion and extension occur at each of the cervical vertebrae, the axis of rotation for flexion and extension movements is segmental in the sagittal plane with multiple axis; consequently, a single instantaneous axis of rotation (IAR) for the entire cervical spine cannot be isolated. Measuring the total movement of the head in anyone plane approximates the change in the degrees occurring in the cervical spine. Anatomically, alignment of the goniometer's axis with the external auditory meatus has been used for measuring flexion and extension (Norkin and White, 1985). Due to the shift of the line of reference during flexion and extension, it becomes virtually impossible to maintain congruency with the refer ence point (Kottke & Mundale, 1959; Nordin & Frankel; 1989). Slight variations in alignment of the goniometer's arms or placement of the axis may cause large variations in angular measurements (Robson, 1966). Much literature exists on various techniques that have been used over the years to try to determine more accurate and efficient ways to measure cervical ROM (Defibaugh, 1964; Hand, 1938; Loebl, 1967; Moore, 1978; Schenker, 1956). The tape measure is used to determine the distance between bony landmarks (e.g., chin to sternal notch, chin to acromion tip) in many of the methods tried over the years (Storms, 1955; Moll & Wright, 1976), with varying degrees of accuracy. To avoid inaccuracies due to changing reference points, several early studies placed or attached a gravity-assisted device or an equivalent measurement device to the head and determined ROM by changes affected by gravity (Buck et al., 1959; Hand, 1938; Leighton, 1955; Schenker, 1956). This appears to have been one of the more accurate techniques for measurement described in the literature (Defibaugh, 1964b; Kadir, 1981; Tucci et al., 1986). An increased level of accuracy through increased standardiza tion can be achieved by attaching a gravity goniometer to the subject's head and taking measurements from changes in head position. With the universal goniometer, a moder ate to good level of accuracy was demonstrated w.ith intratester reliability. However, intertester reliability proved to have only a marginal level of accuracy with extension and rotation, proving to offer a higher level of reliability than side-bending and cervical flexion (Tucci et al., 1986; Youdas et aI., 1991). Improving on this method in terms of efficiency, accuracy, and ease of use, the cervical ROM instrument (CROM) has demonstrated a high level of intertester and intratester reliability (Capuano-Pucci et al., 1991) (Fig. 3-12). Cinefluorography and the electronic digital inclinometer have contributed greatly to our knowledge of normal cervical ROM, demonstrating a high level of reliability when compared with radiographic measurements (Field ing, 1957; Kottke & Mundale, 1959; Mayer et al. , 1993).
- 82. 60 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 3-1 2. The use of the CRaM instrument in measuring cervi cal ROM. Table 3-5 lists normal ROM measurements provided by various contributors. LUMBAR SPINE Simple backache is the most disabling condition of peopre younger than 45 years of age and costs society an estimated 25 to 100 billion dollars a year (Frymoyer & Cats-Baril, 1991). The demand for scientific evidence in the management of this industrialized epidemic is becom ing increasingly important (Helms, 1994). Objective mea- TABLE :~-~J surement of spinal ROM is thought to be of cr scientific importance in determining disability (Amer Medical Association, 1990), selecting appropriate th peutic intervention (Maitland, 1986; McKenzie, 19 and monitoring the patient's progress (Mayer Gatchel, 1988). For example, disability ratings are la based on the lumbar spine ROM measurements; i.e., are based on lost ROM versus a mean value. Interestin many orthopedic surgeons (Davis, 1994) consider much ROM, i.e., hypermobility leading to "instabil to be pathologic (Froning & Frohman, 1968; Frym et aL, 1979; Howes & Isdale, 1971). Thus, it is of cr importance that thorough, accurate documentatio mobillity is undertaken to determine hypermobility (Bu et al., 1989), as well as hypomobility, through a ch plane of motion. In the appendicular skeleton, normal ROM can determined by comparing ROM measurements both normative data and with the uninvolved limb (Amer Academy of Orthopedic Surgeons, 1965; American M cal Association, 1990). In the axial skeleton, sagittal p ROM is determined solely by comparison with norma data (Gilbert, 1993). Unfortunately, normative data, as the mean value recommended by the American Me Association, are inadequate (Sullivan et aI., 1994), a paucity of good, reliable, and valid data exists. No spinal ROM measurements are influenced to diffe degrees by many factors . These variables are thoug include age (Moll & Wright, 1971; Sullivan et al., 1 Tanz, ] 953), gender (Batti'e et aL, 1987; Burto Tillotson, 1991; Moll & Wright, 1971), time of day (Ru et al. , 1992), occupation (Russell et al., 1993), le activities (Burton & Tillotson, 1991), previous histor low back pain (Burton et ill., 1989), sitting-to-stan height ratios (Batti'e et aI., 1987), warming up (Keel aI., 1986), obesity (Batti'e et aI., 1987), and the techni with which normative data are collected (Pearcy & T wal, 1984). SEVERAL REPORTED VALUES FOR "NORMAL" ROM OF DIE CERVICAL SPINE Capuano-Pucci Mayer et al.§ AMA Buck' Defibaugbt et al.~ (CROM) (Electronic IncUnomet Motion (1988) (1959) (1964) (199 1) (1993) Flexion 60 67 59 50 49 Extension 75 77 80 70 67 Rotation Right 80 73 85 70 87 Left 80 74 89 69 84 Lateral flexion Right 45 51 43 44 Left 45 49 44 39 • N = 100, 18-23 y, male and female. t N = 30, 20-40 y, male. r N = 20, x = 23.5 y, male and female . § N =58, 17-62 y, maJe and female.
- 83. declines with age(Moll & Wright, 1971; Russell et al., 1993; Sullivan et aI., 1994; Tanz, 1953). With regard to gender, Moll and Wright (1971), using the mexlified Schober technique, observed males to have greater ROM in the sagittal plane, but females were observed to have greater frontal plane motion. Russell and colleagues (1993), using the 3-Space Isotrak (Polhemus Navigation SCiences, UK), concurred that lateral bending was gener ally greater in females. Leisure activities have been pro posed to influence lumbar mobility, and an increased exposure to adult sports has been shown to produce a reduction in spinal mobility when flexicurve techniques are used (Burton & Tillotson, 1991). Although it is generally accepted that a history of low back pain affects subsequent mobility (Burton et aI., 1989; Russell et aI., 1993), sobering is the work by Waddell and associates (1992); using a spinal inclinometer, they have shown that lumbar flexion in chronic low back pain patients was not restricted, as commonly believed. Batti'e and coworkers (1987) found ROM with distraction methods not only to be influenced by age and gender but also by obesity, height, and sitting-to standing height ratio. With respect to height, Burton and colleagues (1989) could not find any clear correlation between sagittal mobility and trunk height. Russell and associates (1992) have demonstrated circadian variations and have further complicated the reliabilities of studies that did not control for time of day. For example, taking measurements at different times throughout the day can cause discrepancies of greater than 5 degrees. Of further consideration in obtaining reliable, normal values is the need for warm-up, as demonstrated by Keeley and cowork ers (1986). Finally, both the reliability and validity of the methods used to gain normative values (e.g., distraction methods, inclinometry, flexicurve, and motion analysis techniques) must be scrutinized. The most accurate spinal measurements rely on radio graphic measures (Pearcy et aI., 1985). Radiographic measures are thought to be the gold standard for validating methods and gaining normal ROM values. Due to ethical concerns regarding exposure, a large normative base using this gold standard is not available. Table 3-6 describes 'I/BLL 3- () insight considering age and gender (Bogduk, 1992). Newer knowledge on lumbar spine motion reveals th importance of three-dimensional movement (Pearcy Tibrewal, 1984; Pearcy et aI., 1985; Pearcy et aI., 1984 Normal-plane radiographs are limited to two-dimension interpretations of three-dimensional information. "Thes two-dimensional measurements may be erroneous due movements in the third dimension; and measurements movements out of the planes of the radiographs are liab to large errors." (Pearcy, 1985). An exciting developme is the 3-Space Isotrak, which gives three-dimension motion analysis (Russell et aI., 1993). It has been shown be valuable not only in measuring the extremes of spin motion but also, very importantly, in measuring the patter of movement. It is of particular importance to note th large variations occur in normal ROM that have le researchers to question the usefulness of ascertainin normalcy (Hayes et aI., 1989; Penning et aI., 1984 Normal data are influenced by many variables besides ag and gender, as has been illustrated. A very importa consideration since the gold standard is of limited use is th objectivity of the methods to gain normal information. The objective measurement of 15 joints encased in 1 cm of spine, inaccessib'le to the naked eye and moving ,in coupled fashion, is a difficult task. In research, sophist cated, expensive equipment such as biplanar radiograph vector stereography, and photographic methods hav been used (Mayer & Gatchel, 1988). Clinically, the cha lenge of making objective measurements has been met b visual estimation (Nelson et aI., 1979; Wolfet at., 1979 the goniometer (American Medical Association, 1971 Fitzgerald et aI., 1983), flexible curves (Burton, 1986 Youdas et aI., 1995), skin distraction methods (Macrae Wright, 1969; Schober, 1937; Williams et aI., 1993), an the inclinometer (Loebl, 1967; Mayer et aI., 1984). The practice of estimating ROM by visual observatio perseveres probably because it is time efficient and simpl It must be realized that all clinical examinations, even thos thought to be irrefutably objective, are subject to observ bias and error (Deyo et aI., 1994). Not surprising is th discrepancy of up to 30 percent that has been noted wi RANGES OF SEGMENTAL MOnON IN MALES AGED 25 TO 36 YEARS. Lateral Flexion Axial Rotation Flexion and Level Left Right Left Right Flexion Extension Extension U-2 S 6 1 1 8±S S±2 13 ± S L2-3 S 6 1 1 10 ± 2 3±2 13 ± 2 L3-4 S 6 1 2 12 ± 1 1 ± 1 13 ± 2 L4-S 3 S 1 2 13 ± 4 2 ± 1 16 ± 4 LS-Sl 0 2 1 0 9±6 S±4 14 ± S • Mean range (measured in degrees, with standard deviation). From Bogduk, N., & Twomey, L. I. (1991). Clinical anatomy of the lumbar spine (2nd ed.). New York: Churchilllivingstone. - --- ~
- 84. 62 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT the use of such methods (Nelson et aI., 1979; Wolf et aI., 1979). Consequently, therapists should be hesitant in reaching important conclusions about facts such as pro gression based on these inadequate measures. Originally, the addendum to this procedure as advocated by the American Medical Association was the use of the goniom eter (American Medica'iAssociation, 1971). The use of the uniaxial goniometer to measure multiaxial spinal move ment is obviously problematic (Mayer & Gatchel, 1988). Fitzgerald and associates (1983) confirm these problems when they reported coefficients of variance (CVs) of up to 53 percent using the goniometer. (The use of CVs in determining reliability of measures is of questionable value [Williams et aI. , 1993], although they were commonly used in earlier research.) Another method once described as promising (Merritt et a!., 1986) and still prevailing is the finger-to-floor method. Interesting to note is that it has been long known that patients with multilevel stabilization involVing more motion segments than merely the lumbar spine are able to touch their toes (Mayer et aI., 1984). Advocates of this method are deceived not only by large amounts of accompanying hip movement but also by movements in the thoracic spine and, to a lesser degree, the amount of movement at the knee, anIJe, and upper extremities. Merritt and colleagues (1986), in comparing three simple noninvasive methods, found the finger-to-floor method to be least reproducible. Two methods that they found to be more promising and worthy of attention are the modified Schober technique and the double inclinometer method. Both methods have the advantage of isolating the lumbar spine ROM. In 1937, Schober used a simple tape measure to estimate lumbar ROM. This technique has been modified (Macrae & Wright, 1969) and remodified (Williams et aI., 1993), and distrac tion techniques can be used to measure movement in the coronal plane as well. Fitzgerald and coworkers (1983), using the Schober method, reported an interobserver reliability using the Pearson correlation coefficient of r = 1.0 for flexion and r = 0.88 for lumbar extension but had the disadvantage of using healthy, young subjects. Beattie and associates (1987) used both healthy subjects and subjects with low back pain and reported high reliability with the modified Schober attraction method for measur ing extension. Macrae and Wright (1969) attempted to validate both the modified Schober and the Schober techniques, comparing them with radiographic techniques. Pearson product-moment correlation coefficients of r =0.97 for the modified Schober and r =0.90 for the Schober technique were reported compared with radiog raphy. Portek and colleagues (1983), however, demon strated little collaboration between any of the commonly used clinical methods, including the modified Schober technique and radiographs. Miller and associates (1992) have questioned the modified Schober technique on both scientific merit due to the potential error (Table 3-7) and on clinical grounds. Clinically, these authors offer the double inclinometer (01) as a validated technique that eliminates 'IABLE :3-7 POTENTIAL ERRORS AFFECTING REUABIUTV OF 1HE MODIFIED SCHOBE ME11IOD EVALUATED IN ntiS STUDY 1. Presence or absence of "dimples of Venus. " 2. Anatomic location of dimples of Venus. 3. Anatomic variability of location of 10-cm line (correlation among a skin mark 10 cm above the interdimple line. spinous process at that level, and the number of levels from T-12 to S measured with the technique). 4. Problems introduced by skin distraction occurring in the absen of movement of underlying bony structures (e.g., the sacrum). 5. Problems engendered by expression of results of an essentially angular movement in linear terms (in centimeters, not degrees 6. Problems in developing a normative database created by popu lation variation in human height superimposed on a fixed-leng test. From Miller, S . A., Mayer, T, Cox, R. , & Gatchel, R. J. (1992). Relia problems associated with the modi.fied Schober technique for true lu flexion measurement. Spine, 17, 345-348. many or all of the problems associated with the Scho technique. The 01 is generally attributed to Loebl (1967). Reliab studies by Keeley and coworkers (1986) reported interr reliability values of ICC =0.92 for 9 subjects with chro low back and 0.90 for 11 subjects without low back p Waddell and associates (1991), using the spinal inclin eter, showed an ICC of 0.91 for interobserver reprod ibility of lumbar flexion. The landmarks used for measu ment for both the Schober and the 01 methods described in Table 3-8 and in the succeeding instructio on measurement of spinal ROM in the sagittal plane. Today, electrogoniometers using these prinCiples offered. A more recent study concluded both the 01 the Cybex EOI (Cybex, Ronkonkoma, Ny) to be s stantially more reliable than observation (Chiarello Savidge, 1993). Mayer and colleagues (1984), in a v dation study, concluded that no significant differe existed between Dl measures and radiographic measu TABLl~ 3 S REFERENCE POINTS ADVOCATED BY 'IFFERENT AunlORS WHEN MEASURING LUMBAR ROM Inferior Superior Technique Landmark Landmark Schober Lumbosacral junction A point 10 cm above lumbosac junction Modified Schober 5 cm below lumbosa- A point 10 cm cral junction above lumbosac junction Modified-modified Midline intersection A point 15 cm Schober of posterosuperior above midline in iliac spine tersection
- 85. technique is controversial(Portek et aI. , 1983). More recently, reliability studies have compared these two very 'promising methods. Merritt and associates (1986) sug gested that to increase objectivity of spinal ROM mea surements, the Schober test should be used in routine clinical examinations. They showed that the modified Schober method demonstrated high reproducibility (in flexion , CV = 6.3 percent for interexaminer reproduc ibility and 6.6 percent for intraexaminer reproducibUity), whereas the inclinometer showed poorer reproducibility (in extension, CV = 65.4 percent for interexaminer re producibility and 50.7 percent for intraexaminer repro ducibility). Gill et aI., (1988) compared the repeatability of the modified Schober, double inclinometer, finger-to-floor, and photographic methods. They concluded that the modified Schober method was the most repeatable (CV = 0.9 percent for modified Schober flexion and 2.8 percent for modified Schober extension). An additional study (Williams et aI., 1993) compared the modified-modified Schober with the DI method. The authors found that the modified modified Schober method of measuring the lumbar ROM (ICC = flexion 0.72 and extension 0.76) was more reliable than the DI technique (lumbar flexion 0.60 and lumbar extension 0 .68). No validation was given for this new method in the study. Problems with the DI technique may be attributed to palpation of bony landmarks, use of the flat surface of the inclinometer over the curvature of the flexing spine (i.e., offering many tangents), and technical skills. Both techniques have both disadvantages and advan tages. Either method is offered as a more reliable method than goniometric, eyeballing, or finger-to-floor measures. However, a problem common to both methods that should be considered is the starting position when stand ing (Keeley et aI., 1986; Sullivan et al., 1994). To a large degree, the initial lordosis (not apparent lordosis) deter mines the amount of flexion or extension available. An obese person with increased lordosis has potentially less extension and a potential for an inflated flexion value. The American Academy of Orthopedic Surgeons (1965) ad vocates the use of tape measures when measuring lumbar spine flexion. The American Medical Association has revised its guidelines and now supports the use of the spinal inclinometer (Engelberg, 1988). The American Medical Association firmly states that an evaluation uti lizing the spinal inclinometer takes precedence over an evaluation using an alternative measuring technique. Be fore 1988, the use of the goniometer was advocated by the American Medical Association, and it is questionable as to whether these measures, which have been shown to be notoriously unreliable, would have taken precedence over the Schober techniques, which have been proven to be more reliable. An area that is very controversial and of great impor tance to the manual therapist is the art of assessment of convinced of their reliability and validity (Grieve, 1987 Grimsby, 1990; Kaltenborn & Lindahlo, 1969; Maitland 1986; Paris, 1987). In fact, a whole profession is based on the ability to reliably palpate intervertebra.l motion. Inter esting to note is the discovery of the palpatory illusion (Lewit & Liebenson, 1993). Sobering is the scientific evidence that has proven these assessment techniques to be unreliable (Maher & Adams, 1994). ObViously, the opinion of many of these manual therapists must be scrutinized in light of the reliability studies. Finally, the measurement of lumbar spine ROM is a clinical conundrum, especially when considering move ment outside the sagittal plane. The measuring of norma values is inherently difficult and affected by many factors that are often overlooked. The usefulness of these mea sures to the clinician is not really clear. By using skin distraction, skin attraction, and double inclinometer meth ods, a therapist can improve the objectivity of lumbar spine ROM measurements in the sagittal plane. The low back problem threatens the health of the public, and it is only through becoming more scientific and thus more objective that clinicians move toward a solution. Sagittal Spinal Range of Motion Measurement To increase the reliability of lumbar flexion and exten sion, the double inclinometer method or versions of the Schober method are recommended. The following proce dure is suggested: 1. Accurate location of anatomic landmarks is critical Helpful tips are that the dimples of Venus usually correspond to S-2, the iliac crests are approximately at the L-4,5Ievel, counting up the spinous processe will find T-12 and L-1, and the average length of the male lumbar column is 18 em (Waddell et aI. , 1992 Williams et aI. , 1989) 2. A standardized starting position needs to be selected e.g. , bare feet, heels together, knees straight, equa weight-bearing. looking straight ahead, arms hang ing at the side, relaxed (Waddell et aI., 1992). 3. A " neutral" lumbopelvic position is required, e.g. midway between flexion and extension to eliminate troubles of differing lordosis (others have modified the standing starting position to eliminate this problem (Sullivan et aI. , 1994). 4. Warm-up is necessary for reliable measures, e.g., flex and extend twice, left and right rotation twice, left and right lateral flexion twice, and one more flexion and extension (Keeley et aI., 1986; Waddell et al. , 1992) 5. The inclinometers or tape measures should be placed on the selected points and held in place (Figs. 3-13 and 3-14). 6. Instruct the patient to bend forward as far as possible (Figs. 3-15 and 3-16).
- 86. 64 UNIT TWO-COMPONE~JTASSESSMENTS OF THE ADULT FIGURE 3-15. Schober's method using the attraction techniq trunk extension. FIGURE 3-13. Skin distraction and attraction techniques are based on the fact that the distance between two pOints marked on the skin over the spine increases with flexion and decreases with extension. Demonstrated here is the modified Schober's method. Initial measurement in neutral lumbar position. 7. If the modified Schober technique is being used, measure the length ofthe tape measure to the nearest millimeter. If the inclinometer method is being used, measuretQthe nearest degree. 8. Instruct the patient to return to neutral. 9, Ask the patient to bend backward as far as possible. FIGURE 3-14. Schober's method using the distraction technique with trunk flexion. FIGURE 3-16. Spinal inclinometer methods require placemen instruments over fixed points and taking tangential measuremen superior inclinometer is fixed over T12-Ll, and the inferior inclin is placed over the sacrum. Lumbar flexion and extension are derive these simple measurements: total flexion (TF) = Lj'-Lj, pelvic (PF) =S/-SI' lumbar flexion =TF-PF.
- 87. FIGURE 3-17. Spinalinclinometer method used to measure trunk flexion . If the modified Schober technique is being used, measure the length of the tape measure to the nearest millimeter (Fig. 3-17). If the inclinometer method is being used, measure to the nearest degree (Fig. 3-18). THORACIC SPINE As with the lumbar spine, similar difficulties exist in measuring ROM through the thoracic spine. Difficulties in isolating pure planar movements due to coupling motions, as well as maintaining accurate contact with bony land marks during measurement, are some of the problems clinicians are faced with. Although reliability studies for thoracic ROM have been elusive, recommendations from the literature indicate similar methods for measuring the thoracic spine as were incorporated with the lumbar spine, e.g. , Loebl (01). Placement of the inclinometer for sagittal flexion and extension should be on T-12/ L-1, as well as on C-7IT-1 , with the difference in the two beginning and end measurements giving the total thoracic ROM (American Medical Association, 1991). HIP During measurement of hip ROM , controlling for the movement of the pelvis is of paramount importance (Ashton et aI. , 1978; Gajdosik et aI., 1993). The lumbar curve is often used as a reference point to alert the therapist et aI. , 1984). The determination of degrees of true hi extension and flexion is probably one of the more comple measurements, as it is very difficult for the tester t delineate the obliteration of the normal lumbar curv during measurement, particularly in the presence of a hi flexion contracture (Gajdosik et at.. 1993). To determin the amount of hip flexion deformity present, Ekstrand an colleagues (1982) utilized a rigid standardized procedur for measurement with identification and marking of th anatomic landmarks. The results showed coefficients o variation of 1.2 percent, l.4-percent, and 2.5 percent fo hip extension, hip flexion, and hip abduction, respectively In this study, hip abduction was made with a double protractor goniometer, whereas hip flexion and extensio were determined by a gravity inclinometer attached to th patient's thigh. Table 3-9 lists norms for hip ROM according to individual researchers. Using the universal goniometer, Boone and coworker (1978) demonstrated a higher intratester reliability o r = 0.74 for hip abduction, as opposed to an interteste reliability of r = 0.55. Ashton and associates (1978) deter mined an overall relatively low level of reliability whe giving specific procedural instructions (described by th American Academy of Orthopedic Surgeons, 1965) to a experimental group of therapists versus a control group o therapists, while measuring passive hip ROM in childre with mild to moderate spastic cerebral palsy. With th exception of hip external rotation, which improve (r = 0.79 and 0.82)with specific instructions to the exper FIGURE 3-18. Spinal inclinometer method used to measure trun extension.
- 88. 66 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT TABLE ~'J VALUES FOR "NORMAL" ROM FOR 11IE HIP. USTED BY VARIOUS AUDIORS Roac:h & Boone & Dorinson & Esc:b & Gerbardt& Roa_& Miles Wiec:bec: & AAOS Azen· Wagner Lepley Russe AMA Andersont (NHANES 1) Krusen Joint (1965) (1979) (1948) (1974) (1975) (1958) (1982) (1991) (1939) Hip Flexion 120 122 Extension 30 10 Abduction 45 46 Adduction 30 27 Internal 45 47 rotation External 45 47 rotation • N =109, x =22.4, male. t N = 108, 30--40 y, male. r N =1683. 25-74 y. male and female. 125 50 45 20 30 130 45 45 15 33 125 15 45 15 45 100 30 40 20 40 120 9 39 30 33 121 19 42 32 120 45 45 50 36 45 50 34 32 AAOS =American Academy of Orthopedic Surgeons; AMA =American Medical Association. mental group, the other measurements were inconsistent and had poor reliability. Hip extension measurements in particularly were low, even when the examiners made efforts to control for compensatory pelvic movement by flexion of the opposing hip (Fig. 3-19). Straight-Leg Raise Certainly one of the most measured ROMs has been for the straight-leg raise (SLR) (Fig. 3-20). However, this measurement has not been without its difficulties in ascer taining a standardized method in which reliability can be assured (Bohannon, 1984; Cameron et aI., 1994; Gaj dosik et aI., 1985; Tanigawa et aI., 1972). An early study FIGURE 3-19. A method used to decrease the contribution of the lumbar spine to hip extension. Note that the lumbar spine is to stay in contact with the table during measurement. comparing three instruments (a standard plastic: goniom eter, a flexometer, and a tape measure)for measuring SL (Hsieh et aI., 1983) demonstrated a good level of interse sion reliability for both the goniometer and the flexomete (r = 0.88) and for the tape measure (r = 0.74). In the sam study, high intrasession reliability was found for all thre (r = 0.94). To isolate the contribution of the lumbar spin the pelvis was palpated during passive SLR to determin the point at which pelvic rotation began (Hsieh et aI 1983). A review of the methods that might improve reliabili has presented varied hip positions, active versus passiv and trial repetitions during SLR (Cameron et aI., 1994 Cameron and coworkers determined that all of thes factors made a difference in the amount of SLR exper enced and recommended consistency of method during th performance and interpretation of the SLR. Other meth ods to determine SLR have included the knee extensio method with the hips stabilized at 90 degrees of flexio FIGURE 3-20. The use of a blood pressure cuff as a feedback devi used to measure force placed against the posterior leg during SLR.
- 89. FIGURE 3-21. Apressurized biofeedback device. which indicates to the user changes in the position of the lumbar spine during SLR. (Gajdosik & Lusin, 1983). Comparing the position of the ankle dorsiflexion versus plantar flexion during active and passive SLR (Gajdosik et a!., 1985) showed significantly less ROM with dorsiflexion. The apparently critical aspect of SLR has been controlling pelvic rotation (Bohannon et al. , 1985). which has been addressed using a method in which the opposite thigh is stabilized with straps versus the opposite thigh, slightly flexed to allow for low back flat position (Gajdosik et a!., 1993). This particu'lar study indicated increased ROM with low back flat position versus thigh stabilized with straps. The use of a passive versus an active method of measuring SLR does appear to influence straight-leg ROM, with greater increases apparent with passive ROM (Cameron et a!., 1994: Gajdosik et aI., 1993). An early study analyzing passive straight-leg raise demonstrated that the clinician should take into consider ation the contribution of pelvic rotation to the angle of SLR when interpreting results. It should also be recognized that small increases in sequential multiple measurements of joint range may in fact be a normal occurrence of compliance of the viscoelastic tissues with repeated mea surements (Atha & Wheatley, 1976; Bohannon, 1984; Cameron et a!., 1994; McHugh et a!., 1992). It has also been demonstrated that the accommodation to "stretch tolerance" leve'! is a factor in measuring ROM during passive SLR (Halbertsma et al., 1994). In retation to measuring ROM of passive Sl R, the necessity for control .Hng for the amount of force applied has often been overlooked (Bandy & Irion, 1994). Conceivably, a method that might better control for force during SLR would be measuring force with a dynamometer (Bohannon & Lieber, 1986) or equivalent instrumentation (Helewa et aI., 1993) (see Fig. 3-20). Perhaps a method that would better control for the contribution of the lumbar spine through pelvic rotation during SLR would be to use a stabilization device placed at the low back position, which would indicate when the lumbar curve began to flex (Jull et a!. , 1993) (Fig. 3-21). PELVIC RANGE OF MOTION Physical therapists are often involved with treatments that are designed to affect the position of the lumbopelvic region (Sal & Sal. 1991). Measuring the pelvic indination allows therapists to monitor quantifiable changes in the position of the pelvis made during therapeutic intervention (Gilliam et a!. , 1994). A method (Alviso et a!., 1988; Gajdosik et a!. , 1985), originally suggested by Sanders and Stavrakas (198 1), uses trigonometric functions to measure pelvic ROM, achieving an overall intertester reliability of ICC = 0.87 and ICC = 0.90, respectively, when measur ing posterior and anterior pelviC inclination. An early study (Day et a!., 1984) measured both anterior and posterior pe:lvic tilt utilizing a computerized system with external markers over bony landmarks. A later technique intro duced by Walker and colleagues (1987) utilized an incli nometer placed on the anterior superior iliac spine and the posterior superior iliac spine to determine the angle formed with the horizontal from a line drawn between the anterior-superior illiac spine and the posterior-superior Wac spine (Fig. 3-22). This method was later used (Gilliam et al., 1994), demonstrating a high level of both inter- and intraobserver reliability (ICC = 0.96, 0.95, respectively). This method, however, demonstrated poor validity com pared with radiographic measurements. A modification to the inclinometer used by Gilliam and coworkers (1994) and Walker and colleagues (1987) provided two finger braces, allOWing for palpation of the anterior-superior iliac spine and posterior-superior iliac spine while measurements are read (Crowell et aI., 1994), demonstrating both good FIGURE 3-22. The inclinometer is used to measure changes in pelvic inclination, measured from an angle made by a line from the ASlS to the PSIS as it bisects the horizontal.
- 90. 68 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 3-23. The use of an inclinometer utilizing finger braces, allowing for direct palpation of the ASIS and PSIS during inclinometer placement. (From Crowell, R. D., Cummings, G. S., Walker, J. R., & Tillman, L. J. [19941. Intratester and intertester reliability and validity of measures of innominate bone inclination. Journal of Orthopedic and Sports Physical Therapy, 20[2], 88-97) interrater reliability (ICC = 0.95) and validity (r = 0.93), (Fig. 3-23). This device should prove beneficial for mea suring pelvic inclination in the sagittal plane. KNEE Few joints are exposed to measurements of ROM more than the knee. The movements of the knee joint are not those of a simple hinge joint but involve spinning, rolling, and gliding, often simultaneously (Nordin and Frankel, 1989; Smidt, 1973). Certainly in the medical age when total knee replacements and anterior cruciate ligament (ACL) repairs are common occurrences, associated gonio metric readings of knee ROM during the rehabilitation process have added to the increased interest in the ROM of this joint. An early study (Boone et aI., 1978) using the universal goniometer demonstrated a high level of intratester reli ability r = 0.87 while shoWing a significantly lower inter tester reliability of r = 0.50 when measuring the knee. This study used standardized measurements described by the American Academy of Orthopedic Surgeons (1965) for knee AROM on 12 healthy volunteers. Investigations were later made into the reliability of various goniometers within a clinical setting in examining PROM at the knee (Rothstein et aI. , 1983). In this study, each individual was allowed to utilize his or her own technique in measuring the knee. The results showed high intertester and intratester ICC values of 0.99 and 0.97, respectively, but showed moderately low intertester ICC for knee extension (0.70), which was statistically shown to be related to the patient's test position. The use of various-sized goniometers did not appear to affect the reliability of measurements, as in cated in this study (Rothstein et a!., 1983). Universal a fluid-based goniometers have demonstrated good in tester reliability r = 0.87 and r = 0.83, whereas the flu based goniometer showed a concurrent validity r =0.82. However, statistical test differences between instruments in this study suggest that the two instrume should not be used interchangeably (Rheault et a!., 198 Goniometric measurements purport to give us an ac rate account of the actual angle at the knee made by universal goniometer; however, this is unsupportecl unt validity study can substantiate this claim. A radiograp study to verify the knee goniometry (Enwemeka, 19 used the universal goniometer to measure six positions the knee, 0 degrees to 90 degrees, comparing goniome measurements with radiographic bone angle measu ments. All goniometric measurements were comparabl the bone angle measurements, with the exception of first 15 degrees, which were significantly different. another study of goniometric measurements of the kn both intertester reliability (ICC = 0.99) and vali (ICC = 0.98-0.99) were high when compared with roe genograms (Gogia et al., 1987). Many times, clinical situations lend themselves to vis estimations of ROM measurements at the knee. It has b suggested that visual estimation is more accurate th goniometric measurement when bony landmarks are easily palpated (American Academy of Orthopedic S geons, 1965; Rowe, 1964). However, other sources h suggested that goniometry has proven to be more relia than visual estimates of joint ROM (Moore, 1949a; Sal 1955). An early study using a small subject size ( demonstrated good intertester and intratester reliabi when using visual estimates to determine ROM of kn affected by rheumatoid arthritis (Marks et a!., 1978) clinical study taken with a larger sample size (43) de mined that PROM measurements were better determin goniometrically over visual estimation to minimize error of measurement (Watkins et a!., 1991). It has b traditionally suggested that a knee ROM of 290 degree necessary to negotiate elevated terrain, e.g., stairs, clines. Generally, normal ROM measurements for the knee oto 135 or 140 degrees, decreasing with age. Studies younger populations have shown that knee extension of measures less than 0 degrees. Normative measurement the knee are presented in Table 3-10. Measurement of anterior-posterior (A-P) translation ( ity) has been commonplace in knees suspected of be ACL deficient. As surgical procedures have progres with ever-newer reconstructive techniques, the interes evaluating the results of these techniques following ope tions has led to instruments specifically designed to m sure the A-P motion. Understanding that the knee not o flexes and extends in the sagittal plane but also allows A-P translation in the sagittal plane, as well as tibial rotat in the transverse plane (Nordin and Frankel, 1989)
- 91. VALUES FOR "NORMAL"ROM FOR TIlE KNEE. ACCORDING TO VARIOUS AUTHORS AND RESEARCHERS Roach & Boone Dorinson Ekstrand Esch& Gerhardt Roaas & Miles Wiechec AAOS & Azen· & Wagner et aI.t Lepley & RDBSe AMA Anderson:f: (NHANES 1)§ & Krusen Joint (1965) (1979) (1948) (1982) (1974) (1975) (1958) (1982) (1991) (1939) Knee Flexion Extension 135 143 140 144 135 130 120 144 -2 132 135 • N = 109, 18-54 y, male. t N = 25, 22-30 y, male. t N = 108, 30-40 y, male. § N = 1683, 25-74 y, male and female. AAOS = American Academy of Orthopedic Surgeons; AMA = American Medical Association. method for determining the amount of translation has become important, particularly when the pathomechanics of an ACL deficient knee is under study. During the past 10 years, special measurement of A-P joint laxity during postreconstruction of knees with deficient ACLs has been measured via an arthrometer (Daniel et a!., 1985) (Fig. 3-24). Earlier studies involving the KT-1000 (MEDmetrics Corps., San Diego, CAl, an arthrometer designed to measure tibial translation, indicated that it was a usefultool for both confirming reduction and demonstrating a mean difference in laxity in normal and injured knees (Daniel et a!., 1985). Hanten and Pace (1987) demonstrated mea surements of ICC = 0.92 and 0.84, respectively, for inter and intratester reliability when using the KT-I OOO to test 43 healthy male subjects for A-P translation. FIGURE 3-24. The use of an arthromometer for measurement of joint excursion (anterior or poste rior translation) in the sagittal plane. A, force-sensing handle; B, patellar sensor pad; C, tibial tubercle sensor pad; D, Velcro strap; E, arthrometer case; F, displacement dial indicator (the data are sent via cable to an X-V plotter as applied force versus joint displacement); G, thigh support; and H, foot support. 1, A constant pressure of 20 to 30 Newtons is applied to the patellar sensor pad to keep it in contact with the patella. 2, Posterior force is applied. 3, Ante rior force is applied. (From Dale, D. M., et al. 11985). Instrumented measurement of anterior laxity of the knee. Journal of Bone and Joint Surgery, 67AI51, 720-725) However, Forster and associates (1989) demonstrated significant inter- and intraexaminer variations in measure ments of both absolute displacement of knees and side-to side differences in pairs of knees. A more recent study (Graham et aI., 1991) of the KT-1000 presented conflict ing views, demonstrating a poor level of reliability (less than 50 percent) in determining laxity in the knee with a deficient ACL. Graham and colleagues (1991) indicated that the anterior drawer test and Lachmans test were found to be more accurate indicators of knees with deficient ACLs when compared with the KT-1000 (see Fig. 3-24). Another study (Holcomb et a!., 1993) of A-P translation using the KT-1 000 reported a high intratester reliability of ICC = 0.98-1.0, but a low intertester re)iability of ICC = 0.53 was demonstrated. A more recent study (Rob
- 92. 70 UNIT TWO~COfv1PONENTASSESSMENTS OF THE ADULT nett et aL , 1995) demonstrated an inlertester reliability of ICC = 0.67-0.75 for three different levels of force used with the KT-1 000 and found that a change of > 5 mm must take place to indicate a true change in anterior tibial displacement. This may prove to be ineffective in demon strating a possible ACL defiCiency, as a difference of 3 mm in anterior tibial position between two knees of the same patient has been cited as diagnostic for ACL deficiency (Stcaubli & Jakob, 1991). f urthermore., validity studies have suggested the KT-l 000 may underestimate A-P translation when compared with roentgen stereophotogrammetry in both operated and unoperated knees with deficient ACLs (Jonsson et aI, 1993). II! light of the conflicting results of these various studies, the reliability as well as the vatidity of this device in providing accurate measurements should be questioned. ANKLE AND FOOT The joints of the ankle and foot , because of their position and their necessity in locomotion, deserve more in the way of critical assessment in ROM, yet little research has substantiated reliabilit'y of methods or established normal ranges. This may be due in part to the significant complex ity within each joint as well as to the multiple axes and planes of movement (Root et al., 1977) found within the ankle-foot complex. Because normal ambulation requires primary movements of ankle dorsiflexion and plantar flexion, these two motions have been the main focus of research on ROM of the ankle, followed by calcaneal inversion and eversion. It has been a long-held notion that 10 degrees of ankle dorsiflexion is necessary for normal locomotion (Root et aI. , 1977). Other authors have stated that only 5 degrees of dorsiflexion is necessary, whereas still others suggest that motion past a 90-degree angle to the lower leg is sufficient for normal gait (Downey, 1987; Tanz, 1960). During gait, the maximum amount of dorsi flexion occurs just before heel lift while the knee is in an extended position (Downey & Banks, 1989). Although the maximum amount of dorsiflexion occurs during the stance phase of gait, the clinician's evaluation of ankle dorsiflexion continues to be performed while the patient is in a non-weight-bearing position (Baggett and Young, 1993; Norkin and White, 1985). A study of ankle joint dorsiflex ion by Baggett and Young (1993) measured the average amount of dorsiflexion available using the non-weight bearing method as 8.25 degrees, while being substantially higher at 20.90 degrees with the weight-bearing technique (Fig. 3-25). The effect on measurements of ankle dorsi flexion with the knees flexed versus extended appears to make a difference. Using a gravity inclinometer, Ekstrand et aI., (1982) determined the coefficient of variation of ±1.9, with mean ankle dorsiflexion of 22.5 degrees with knees straight and 24.9 degrees with knees flexed , mea- FIGURE 3-25. The weight-bearing technique for measuring ank dorsiflexion. Alignment of one arm of the goniometer should be plane of the suppoliing surface. and the other arm is aligned to the aspect of the fibula . sured in weight-bearing position. Investigating three d ent methods in measuring ankle dorsifleXion, Boha and coworkers (1989) demonstrated that the ma (83.3 percent) had a high correlation; however, s cantly different measurements between methods found, demonstrating that the use of different landm can provide a reliable indication of ankle dorsifle Although the universal goniometer appears to be the mode used for measurement of ankle dorsiflexion plantar flexion, Muwanga and associates (1985) duced a new method for measuring ankle dorsiflexio plantar flexion. The device allows the foot to rotate an ankle pivotal point, assuring that the foot is held s in a strapped position. These measurements desc AROM measurements performed·on normal volun Both intratester and intertester reliability proved to h difference of less than 3 degrees in 86 percent o measurements. Visual estimation continues to prove to be a method for determining ankle ROM when compared the goniometer (Youdas et aI , 1993). However, patient population, it has also been shown that wit universal goniometer, intertester reliability for active joint measurement is poor for ankle dorsiflexion plantar flexion (ICC =0.25 and 0.28) (Youdas e 1993). Studies on PROM have found outcomes va from good to poor in interrater reliability for ankle siflexion (ICC = 0.74-0.87; Diamond et aI , 1 (ICC = 0.50; Elveru et aL, 1988) and moderate reli (ICC = 0.72) for plantar flexion (Elveru et aI., 1 Intrarater reliability has been shown to be more subst in measuring ankle dorsiflexion for PROM (ICC = Elveru et aI., 1988) (ICC = 0.89-0.96 Diamond e
- 93. FIGURE 3-26. Measurementof hindfoot inversion and eversion performed with patient in prone-lying position. 1989), as well as PROM for ankle plantar flexion (ICC = 0.86) (Elveru et aI., 1988). Intrarater reliability for AROM has been shown to be good for ankle dorsiflexion (ICC =0.82) and plantar flexion (ICC =0.86) (Youdas et al., 1993). Reliability differences in these studies appear to be associated with lengthy training periods incorporated prior to the experiment most probably improving the methodology for measurements taken (Diamond et aI., 1989). Just as measurements of ankle dorSiflexion and plantar flexion have demonstrated variations in weight-bearing versus non-weight-bearing measurements, Lattanza and coworkers (1988) determined that an increase in subtalar eversion position was greater in the weight-bearing posi tion when examining subtalar neutral position. Of course since weight-bearing is the functional position of the ankle and foot, it should provide the necessary information as to position during gait. In the study by Elveru and colleagues (1988), measurement of hindfoot eversion and inversion and subtalar joint neutral (STIN) position has been shown TAm I :~ II FIGURE 3-27. The measurement of calcaneal position using a gravity protractor. (From Sell, K. E., et al. [1994). Two measurement techniques for assessing subtalar joint position: A reliability study. Journal of Orthopedic and Sports Physical Therapy, 19(3), l 62-167. to have moderate intratester reliability (ICC = 0.75,0.74, and 0.77, respectively) and poor intertester reliability (ICC =0.17, 0.32, and 0.25) (Fig. 3-26). However, in a study of 31 diabetics, Diamond and associates (1989) measured ankle eversion and inversion and STIN position demonstrating moderate to good interrater and intrarater reliability. It has been purported that the subtalar joint motion is an important baseline indicator of the potential for excessive pronation versus supination during gait (Root et aI., 1977). However, this supposition was based on research performed with an orthotic device deSigned as a mechanical analog of a subtalar and ankle joint system and was used during gait on only a few subjects (Wright et aI. , 1964). Techniques for assessing subtalar joint position have been conflicting. A reliability study (Picciano et aI. , VALUES FOR "NORMAL" ROM FOR THE ANKLE AND FOOT. AS USTED BY SEVERAL AUTIfORS Baggett Boone & Dorinson Esch& Gerhardt Milgrom Roaas & Wiechec MOS & Young' Azent & Wagner Lepley & Russe et aI.:j: AMA Andersson§ & Krusen Joint (1965) (1979) (1948) (1982) (1974) (1975) (1985) (1958) (1982) (1939) Plantar flexion 50 56 45 65 45 40 40 55 DorSiflexion 20 81:2191 13 20 10 20 20 15 30 Subtalor joint Inversion 35 37 50 30 40 32 30 27 Eversion 15 26 20 15 20 4# 20 27 • N = 30, 18-66 y, male and female . t N = 109, x =22.4. male. r N =272, 18-20 y, males. § N = 96, 30-40 y, males. II Non-weight-bearing. 91 Weight-bearing. # Hindfoot. AAOS = American Academy of Orthopedic Surgeons; AMA = American Medical Association.
- 94. 72 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT 1993) of three methods for measuring STJN position (open kinetic chain, closed kinetic chain, and navicular drop test) demonstrated poor intra- and intertester reliabil ity when measuring (n = 30 ft) with a goniometer (for the first two methods) and when measw-ing the distance change from the floor to the navicular mark on a marked index card (for the third method). However, a later study measuring STI N (Sellet al., 1994)using two measurement techniques (calcaneal position with an inclinometer [Fig. 3-27] and navicular drop test) in a weight-bearing position (n =60) demonstrated moderate to high reliability. Studies of normal ankle dorsiflexion demonstrated a reduction in mean values with increasing age (middle age to old age), decreasing from 20.0 degrees to 13.5 degrees in males, whereas in females these values decreased from 20.7 degrees to 10. 1 degrees (Vandervorrt et aI., 1992). Normal ROM for inversion and eversion of the subtalar joint using a method described by the American Academy of Orthopedic Surgeons (1965) was 35 degrees and 15 degrees, respectively. It has been suggested that 4 degrees to 6 degrees of inversion and eversion, for a minimal tota,1 range of 8 degrees to 12 degrees, is normal for locomotion (Root et aI. , 1977). Although norms have been cited for subtalar inversion and eversion and STIN (3 degrees varus) positions (Mjlgrom et al. . 1985), the baSis for "normal" STIN with regard to the stance phase of gait has been largely conjecture, without proven reliable or valid methods performed on any substantial-sized group during gait activities (Root et aI. , 1977; McPoU & Cornwall, 1994; Wright et a1., 1964). Table 3-11 lists norms for ankle and foot ROM. A measurement quite possibly offering the therapist increased information with regard to the biomechanical alignment and forces acting on the ankle and foot is FIGURE 3-28. Measw'ement of tibiil vara: an angle formed from a line parallel to the lower leg bisecting the horizontal (ground). measurement of tibia vara, which is the angle formed by distal third of the leg to a horizontal line to the suppor stance surface (ground). Lohmann and associates (19 demonstrated a mean absolute difference between m surements of tibia vara of 2 to 3 degrees (Fig. 3-28). Attraction methods-Measuring procedure usin tape measure to record a decrease in distance between points marked on the skin over the spine as it extend Coefficient of variation-Measure of variability in measurements relative to the mean value. Depicts variability of measurements within the subjects as wel the variability of the actual measurement. A ratio of standard deviation and the mean in terms of a percenta Distraction methods-Measuring procedure usin tape measure to record an increase in distance betw two points marked on the skin as the spine flexes. Flexicurve techniques-Measuring procedures which a tester manually molds a flexible curve to the mid contour of the subject's lumbar spine. The flexible curv then traced onto paper, and either a tangential o trigonometric method is used to ca'iculate ROM. Intraclass correlation coefficient (ICC)-Asses common variance. Examines two or more sets of score the same variable. Modified Schober technique-Skin distract attraction method using a midline point 5 CM below lumbosacral junction and a point 10 CM above it. Pearson product-moment correlation coe dent-Generalized measure of linear association. Use determining association concerning a bivariate distr tion. Pelvic incUnometer-Designed with calipers wit mounted gravity protractor. Able to measure the chang position of two separate points by the placement of ei ends of the calipers over an identifable area used a landmark. Pendulum goniometer-Goniometer usually mad metal with two movement arms. One arm is allowed move freely in accordance with. the line of gravity an used as a vertical reference. Spinal incUnometer-A circular fluid-filled disk wi weighted needle indicator, which is maintained in vertical, that is placed over the spine and used to meas ROM in degrees as the spine moves. Subtalarjoint neutral-The position in which the is neither pronated nor supinated. The position of in sion or eversion that the calcaneus assumes when the t is congruent in relation to the tibia. 3·Space lsotrak-Electomagnetic device for the m surement of three-dimensional movements.
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- 100. CHAPTER 4 A.Moneim Ramadan MO, FRCS SUMMARY This chapter discusses the normal anatomy of the various structures of the hand, with emphasis on the anatomic, physiologic, and functional importance of each anatomic entity. Important factors about the functional and surgical anatomy of the hand are outlined. A short discussion of clinical examples and a comprehensive evaluation protocol follow. The hand is involved in every aspect of our lives, from birth to death. It is hard to imagine a life without hands. Like any other organ in the human body, the hand has its own characteristics and functions and is uniquely equipped to perform its functions, to service, and to connect human beings with the outside world. It is an intricately structured and dynamic organ created with mathematic perfection and harmony between all its various parts. The ideal hand performs its function precisely and flawlessly. Disruption in anyone of its parts interferes, in a major way, with its function. Problems of the hands rarely, if ever, affect the quantity of life, but they do drastically affect the quality of life. Nothing in this chapter is new or revolutionary. The facts discussed are based on the experience of the author and the data obtained from other experts referenced. The only thing that might be unique is the emphasis the author places on the ab solute necessity and need for any health care profeSSional who will have the chance or the obligation to treat hands to be absolutely sensitive and attuned to the nor mal anatomy, the desired function, and the process of evaluation. There is no room for guess work and no place for luck. Without solid knowledge of the anatomy and function of this organ, very little will be able to be done. Medicine, at least from the anatomic point of view, is a science based on facts. When knowl edge is not adequate, the profeSSional must seek the help of colleagues and the lit- o erature. The upper extremity is present to allow the hand to perform its functions . The length of the upper extremity and the position and the type of shoulder and elbow joints are primarily designed to allow the hand to function. Consequently, the shoulder, the arm, and the elbow, as much as they are not directly a part of the hand, are directly related to the hand. Anatomically, the hand starts from the wrist joint area. Functionally, however, the hand starts from the elbow. 78
- 101. ANATOMY General Anatomy SKIN The skinis primarily the protective organ of the body, and it is unique in the hand (Barron, 1970). On the palmar or volar aspect, the skin is thicker, lighter in color, and more stably tethered in position when compared with the darker, thin, loose skin on the extensor aspect or the dorsal side. On the volar aspect, the skin is marked with creases or lines that are of utmost significance anatomically and function ally. The skin on the dorsum is more lax, is not directly attached to the bone structure underneath it, and also has wrinkles that allow the skin to stretch when one makes a fist (Fig. 4-1). If the skin on the dorsum of the hand were to be tight, then the wrinkles would disappear, and it would consequently become difficult to make a fist. SUPERFICIAL FASCIA The superficial fascia on the dorsal aspect of the hand is very thin. The superficial fascia in the palmar aspect has the fibrofatty tissue, the amount and the density of which vary from one location to the other. The palmar triangle in the center of the palm consists of the distal palmar crease as its base and the junction of the thenar and hypothenar eminence at the wrist as its tip (Fig. 4-2). It is the only area devoid of fat (Milford, 1988). In the areas where it is located, the fat acts as a pressure cushion. The absence of fat in the palmar triangle is Significant, as it keeps the skin well tethered and consequently allows the cup of the hand to deepen when a fist is made. The fat extends to the web spaces to protect the vascular bundles, especially the veins. DEEP FASCIA Within the dorsal aspect, the deep fascia is arranged in two layers. The superficial layer covers the extensor tendons and continues into the extensor hood on the FIGURE 4-1. Note the difference between the thin loose skin on the dorsum and the thick, less-mobile skin on the palmar aspect. FIGURE 4-2. Palmar triangle boundaries. extensor aspect of the fingers (Milford, 1988). The dee layer covers the interossei between the metacarpals. At th wrist level, the deep fascia is organized in the extenso retinaculum, which is divided into six compartments Wig 4-3). In the palmar aspect, the deep fascia is incorporate with the palmar aponeurosis. Specialized parts of the deep fascia are the flexo retinaculum and the digital ligaments of Landsmeer and Clel1and (Milford, 1988). This palmar fascia is a speCialize fascia that is present only in the palm and in the sole of th foot, where its functional, aspect is to give thickness an stability to the skin (Fig. 4-4). The palmar fascia starts from the heel of the hand and extends in various fiber arrange ments up to the distal interphalangeal joint crease of th fingers and thumb. The attachments of the palmar fascia the deep structures (including the bones), the skin along th various creases, and the skin of the palm restrict the skin o the hand from being freely mobile. The restriction of ski mobility is evident in the palmar triangle. The palmar fasci in the terminal phalangeal areas is replaced by strands o tough fibrous tissue called fibrous septae, which anchor th skin to the terminal phalanx and give stability to the tip o the digit (Fig. 4-5). BONES The skeleton of the hand consists of 29 bones that begin with the distal end of the radius and the head of the ulna a the wrist (Landsmeer, 1976; O'Brien and Eugene, 1988 (Figs. 4-6 and 4-7). The radius is the main forearm bon at the wrist joint, and the ulna is the main forearm bone a the elbow joint. fiGURE 4-3. Extensor retinaculum.
- 102. 80 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 4-4. A, The palmaris longus inserts in the palmar fascia B. n,e palmar fascia holds the skin of the volar aspeci at the creases and in turn is attached to the bones and the deep intermuscular septae of the hand. The carpus has eight carpal bones arranged transversely into the proximal and carpal rows and arranged longitudi nally into the central and the h,vo lateral columns. The scaphoid, lunate. triquetrum, and pisiform are in the proximal row. The trapezium, trapezoid, capitate, and Nail plate f " , Ii If'll Fibrous s Proximal nail fold Insertion of the terminal tendon FIGURE 4-5. Anatomy of the terminal phalangeal area. hamate are in the distal row. The central longitud column consists of the lunate and the capitate, and the lateral columns are made by the remaining carpal bone each side of the central column (Fig. 4-8). Each carpal b has a unique shape and size, which allows it to fit in location. The carpal bones are arranged in such a way they form the transverse carpal arch. This arch is conc toward the volar aspect and is the bony boundary of carpal tunnel (Fig. 4--9). At its center, the deepest par the transverse carpal arch forms the beginning of center of the 'longitudinal arch and runs with the mid finger ray (Figs. 4-10 and 4-11). The distal carpal articulates with the bases of the metacarpals. By itself, thumb metacarpal only articulates with the trapezium. remaining four metacarpals articulate with the other th distal row carpal bones. The hand has five metacarpals. The thumb is the shor and the widest, and the middle finger is the longest. Terminal phalanx Middle phalanx Proximal phalanx Pisiform Tmp"oid ~ H,m'"Trapezium Capitate Scaphoid ~ Triquetrum ~ ~ Lumate FIGURE 4-6 Bones of the h posterior aspect.Ulna Radius Radius Ulna
- 103. l--->"--+--Metacarpal S =Scaphoid L =Lunate T = Triquetrum P = Pisiform H = Hammate C = Capitate Td = Trapezoid Tm = Trapezium R = Radius U = Ulna FIGURE 4-7. Bones of the hand, including parts of metacarpal. metacarpals have a longitudinal gentle curve that is con cave toward the palmar aspect, with the deepest part of the curve at the middle finger metacarpal. This is part of the longitudinal arch of the hand that extends from the wrist to the fingertips (Hollinshead, 1982; Milford, 1988) (see Fig. 4-7). Each metacarpalhas a base, a shaft, and a head. The position of and the relationship between the meta carpal heads of the index, middle, ring, and little fingers make the base for the transverse metacarpal arch of the hand (Milford, 1988). The arch is concave toward the palm, with the deepest point of the arch at the metacarpal head of the middle finger. The middle finger is atthe center most, deepest part of the longitudinal arch. (see Fig. 4-7). Lateral Medial column column--- Transverse carpal arch Scaphoid Trapezoid Hammate Dorsal aspect FIGURE 4-9. Cross-seclion ofthe carpal tunnel. F.c.R. =tunnelior the flexor carpi radialis. Each finger has three phalanges (see Fig. 4 -7), and the thumb has two. Those of the thumb are the widest and the shortest. Those of the middle finger are the longes . Each phalanx has a concave wide base and a condylar head. They all have a gentle curve concave toward the palmar aspect to continue with the longitudin Iarch of the hand. The terminal phalanx is the end of the hand skeleton and does not reach the tip of the digit but ends at a levelaround the junction of the proximal two thirds and the distal third of the nail bed. The end of the terminal phalanxes has an expanded round irregular shape known as the tuft, that plays a major role in forming the hape of and contributing to the stability of the digit tip. The space between the skin of the tip at the distal end of the nail bed and the end of the terminal phalanx is occupied with fat and fibrous septae (see Fig. 4-5). It would be very painful if the end of the bone were to reach the skin because ofthe digit tip and the direct pressure of the bone on the skin. The terminal phalangeal area is supported partly by the terminal phalanx and partly by the nail plate, which compensate for the absence of the terminal phalanx in the distal third of the terminal pha langeal Clrea. JOiNTS Distal Radioulnar Joint. The distal radi ulnar joint is located proximal to the radial carpal joint. The radial side of the head of the ulna arti ulates with a notch on the radial .........::-- - Longitudinal arch Ulna Radius Transverse carpal arch Thumb FIGURE 4-8. Carpal bone columns. FIGURE 4-10. Arches of the hand. including transverse carpal arch.
- 104. 82 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT Longitudinal arch -kJ1.- f Transverse carpal arch. ~ ~ *= FIGURE 4-11. Arches of the hand. side of the distal end of the radius and with the proximal surface of the triangular fibrocartilage. It is attached between the ulnar side of the end of the radius and the base of the styloid process of the ulna. No communication occurs between the distal radial ulnar joint and the radial carpal joint or the various components of the wrist joint itself. The distal radiulnar joint allows supination and pro nation of movement to take place. Radial Carpal Joint. The radial carpal joint is the main joint at the wrist. It only involves the scaphoid and part of the lunate to articulate with the radius and the triangular fibrocartilage, but the latter is only part of the joint in certain ranges of motion of the VJTist. Intercarpal Joints. Located between the various carpal bones, the intercarpal joints are a very complex set of joints that make the wrist area very unique and very well adapted to perform its function. These joints allow some of the carpal bones to be mobile in the very l''?stricted space given, but it is the mobility of some of these bones that gives the intercarpal jOints their uniqueness. Carpometacarpal Joints. The carpometacarpal joints are formed by the distal carpal row and the basis of the five metacarpals. The basal joint, or the carpometacarpal joint, of the thumb between the trapezium and the first meta carpal is the most mobile. The carpometacarpal joint of the little finger between the base of the fifth metacarpal and the hamate bone is the second most mobile. The ring and index carpometacarpal joints have the least mobility. The middle finger carpometacarpal joint has no mobility at all, as it is the rigid, stable center of the longitudinal arch and is continuous with the central longitudinal rigid column of the carpal bones (see Fig. 4-11). All these are important facts to remember, since tures of the base of the metacarpal of the middle finge to be treated quite differently from fractures of the ba the metacarpal of the thumb or the little finger. The d ence in treatment is a result of the fact that the mo varies from one digit to the other. Metacarpophalangeal Joints. The metacarpophalan joints are located between the heads of the metacarpal the base of the proximal phalanges, which are all prim of the ball and socket variety. They allow flexion, exten abduction, and adduction range of motion. Interphalangeal Joints. The interphalangeal joint tween the phalanges are of the bicondylar variety, th they have two convex condyles at the head with a gro depreSSion, and valley in between and allow flexion extension range of motion. LIGAMENTS The stability of the joints depends on the bony stru of the joint, the shape of the articular surfaces, and surrounding muscles and tendons, but more so on th tegrity of the ligaments around the jOints ( Hollins 1982; Landsmeer, 1976; Taleisnik, 1976) Ligament specialized connective tissue structures, and their pri responsibility is to maintain stability while allowing mo of the joints. At the wrist joint, numerous intricatel ranged ligaments not only hold the carpal bones tog but also hold the carpal bones to the metacarpals di and the long bones of the forearm proximally. The ments are located in the volar, dorsal, radial, and ulnar between all the bony components, as shown in F 4-12. In the digits, however, the ligaments are in the and the lateral aspect. The dorsal aspect of the joints h ligaments. On the volar aspect, ligaments are called volar plates, but on the lateral aspect of the joints, the called the collateral ligaments (Fig. 4-13) (Kaplan's F tional and Surgical Anatomy of the Hand, 1984; L meer, 1976). The laxity or tightness of the ligament pends on the position of the joints. When the joint Capitate 5th Metacarpal ~ -+---1 st Meta PIsiform ----~+ r Trap Hammate----+_ :> ' ~ Sc I / Lunate Ulna Radius FIGURE 4-1 2 . Ligaments of the wrist, volar aspect.
- 105. ~r/-j ; ---Proximal ~~Phalallx Tightvolar plate ~--Metacarpal head :..---~,--~ J Tight collateral Lax folded volar plate----- ~ T-ligament Proximal I phalanx FIGURE 4-13. Metacarpophalangeal joint volar plate and collateral ligament in extension and in flexion. flexed, the volar plates fold and become more lax and shorter. If they fibrose in this position, they shrink and become tight, which limits the extension of involved joints. At the metacarpophalangeal joints, the collateral liga ments become tight with the metacarpophalangeal joints in 90 degrees flexion and become loose when the metacar pophalangeal joints are in the extended position and can allow abduction and adduction, as shown in Figure 4-14. At the interphalangeal joints, however, the collateral ligaments are tightest in the extended position and become loosest in the flexed position. These are important facts because in positioning the joints during treatment, the conditions of these ligaments must be understood. If the ligaments of the joints are disrupted, the joint becomes unstable. Consequently, the function of the hand is compromised. Some ligaments are much more vital than others. A good example is the ulnar collateral ligament of the metacarpophalangeal joint of the thumb, as compared Tight collateral ligament ~r/- ~----- Stretched volar plate --:>-7'-1"-- Loose collateral ligamentFolded volar plate - - - FIGURE 4-14. Interphalangeal joint in extension and in flexion. patient cannot use the thumb at all with an unstable ulnar collateral ligament. In the fingers, however, the radial col lateral ligam nt of the proximal interphalangeal joint is more critical, as it takes the stress of the opposition be tween the thumb and the finge rs. No deformities of the joints can develop without disruption to the ligaments, which renders joints unstable and sets the stage for defor mities to occur in response to the various stress factors to which the joint is exposed. MUSCLES Muscles that playa direct role in hand function insert at various locations in the hand and are grouped into two divisions based on their location of origin. The first is the extrinsic group of muscles, which are located on the flexor and extensor aspects of the forearm. They orig,inate in the forearm and are inserted in specific locations in the hand. The second is the intrinsic group of small muscles, which are located exclusively in the hand (i.e., they originate and insert inside the hand). Extrinsic Muscles. Extrinsic muscles are located on the flexor and extensor aspects of the forearm. They are frequently referred to as the long flexors and long exten sors. There are two flexor and two extensor surface muscles, which originate or insert away from the hand but indirectly affect the function of the hand. On the flexor surface. these two muscles are the pronator teres and the pronator quadratus. On the extensor aspect the two muscles are the supinator and the brachioradialis. Pronator Teres. This muscle has tvlO origins: first, a humeral origin from the lower part of the medial supra condylar ridge and medial epicondyle and second, an ulnar origin from the coronoid process of the ulna. The pronator teres inserts into the middle of the lateral surface of the radius. Nerve supply is median nerve C6-7. To test the action of this muscle, the arm is held next to the body with the elbow in partial fleXion, and the patient is asked to pronate the forearm (Fig. 4-15). Pronator Quadratus. This muscle originates in the volar aspect of the distal ulna deep to the flexor tendons and is inserted in the volar aspect distal fourth of the radius. To test the action of this muscle, the arm is held next to the body with the elbow fully flexed. and the patient is asked to pronale the forearm. Nerve supply comes from median nerve C7-Tl (Fig 4-16). Srachloradialis. The brachioradiaUs originates from the upper third of the lateral supracondylar ridge of the humerus and inserts in the radial side of the lower end of the radius. Nerve supply is the radial C5-6. To test this muscle. the arm is held next to the body, elbow partially flexed, forearm in neutral position, and the patient is asked to flex the elbow (Fig. 4-17). Supinator Muscle. This muscle originates in the lateral epicondyle of the humerus and inserts in the proximal third
- 106. 84 UNIT TWO-COMpmJE~JTASSESSMENTS OF THE ADULT FIGURE 4-15. Pronator teres. of the lateral surface of the radius nerve supply. Nerve supply is radjal nerve C5-6. To test the supinator, the forearm is held in neutral, with the elbow fiexed fully. The muscle supinates the forearm (Fig. 4-18). The long fiexors that originate in the forearm and are inserted in the hand are the following: 1. Flexors of the wrist a. Flexor carpi radialis b. Flexor carpi ulnaris c. Palmaris longus, if present 2. Long fiexors of the fingers a. Flexor digitomm superficialis "sublimis" b. Flexor digitorum profundus 3. Flexor pollicis longus (the long fiexor to the thumb) Flexor Carpi Rad/alls. This muscle's origin is in the com mon fiexor origin in the medial epicondyle. and it inserts at the volar surface base of the second metacarpal. Nelve supply is the median nerve C7-8. To test this muscle, the FIGURE 4-16. Pronator quadratus. FIGURE 4-17. A, Brachioradialis, dorsal view. B, Brachioradia view. forearm is held in supination, and the elbow is p fiexed while this muscle fiexes and radially deviates th (Fig. 4-19). Palmaris Longus. This muscle originates in the epicondyle and inserts into the fiexor retinaculum a palmar aponeurosis at the wrist and palm of the han muscle is absent in 10 percent of the population. supply is median nerve C7-8. Its action is tested by h the thumb and the little finger tip to tip and then fiex wrist. If present, its tendon becomes the most pro under the skin at the wrist area (Fig. 4-20). Flexor Carpi Ulnaris. This muscle originates in the epicondyle, the medial border of the olecranon, a upper part of the posterior border of the ulna. It is i in the pisiform bone. Nerve supply is the ulnar FIGURE 4-18. Supin(ltor.
- 107. FIGURE 4-19. Flexorcarpi radialis. C8-T1. With the forearm supinated, it flexes and ulnarly deviates the wrist (Fig 4-21). Flexor Dlglforum Superficialis "SublimIs. If The origin of this muscle is in the medial epicondyle of the humerus, the medial border of the coronoid process of the upper two thirds of the anterior border of the radius, and from the ulnar collateral ligament. The superficialis tendons insert at the volar surface base of the middle phalanx. The superfi cialis to the little finger is absent in about 20 percent of hands and, if present, it i usually of a much smaller size than the superficialis tendon of the other fingers. Nerve supply is the median nerve C7-Tl. To test for any of the sublimis units, the hand has to be held flat on the table with the forearm supinated and all the fingers blocked from movement, with the exception of the finger whose muscle unit is being tested. The patient is then asked to actively flex the proximal interphalangeal joint (Figs. 4-22 and 4-23). FlexorOigiforum Profundus. The origin of this muscle is in the upper two thirds of the anterior and medial surfaces of the ulna and from the adjoining half of the interosseous membrane. It inserts at the base of the terminal phalanx of the index, middle, ring, and little fingers. Nerve supply to the muscle belly, which gives the profundus to the index and middle fingers, is from the median nerve through its anterior interosseous branch C7-Tl. Nerve supply to the FIGURE 4-21. Flexor carpi ulnaris. muscle belly, which supplies the profundus to the ring and little fingers , is through the ulnar nerve C8-T l. The action of any unit of this muscle is tested by holding the hand in supination with the wrist and all the finger joints blocked from movement, except the distal interphalangeal joint to be tested (Figs. 4-24 and 4-25). Flexor Pol/lcls Longus. This muscle originates in the forearm from the radius and interosseous membrane and, on occasion, partly from the coronoid process of the ulna. A B FIGURE 4-22. Isolating the sublimis flexor to the index finger (AJ and to the middle finger (B) FIGURE 4-20. Palmaris longus. A B FIGURE 4-23. Isolating the sublimis flexor to the ring finger (A) and to the little finger (B).
- 108. 86 UNIT TWO-COMPONENTASSESSrviEr~TS OF THE AOULT A FIGURE 4-24. Isolating the action of the profundus tendon to the index finger (A) and to the middle finger (B). It is inserted into the base of the terminal phalanx of the thumb. Nerve supply is the median nerve through its anterior interosseus branch C7-Tl. To test for its action, the hand is held in supination, the wrist and the metacar pophalangeal joint of the thumb are stabilized, and the patient is asked to flex the interphalangeal joint of the thumb (Fig. 4-26). On the extensor side of the forearm, the following muscles are present: 1. Extensors to the wrist a. Extensor carpi radialis longus b. Extensor carpi radialis brevis c. Extensor carpi ulnaris 2. Extensors to the thumb a. Extensor pollicis longus b. Extensor pollicis brevis 3. Abductor pollicis longus 4. Extensor indicis proprius 5. Long common extensor proprius to the fingers (extensor digitorum communis) 6. Long independent extensor digiti minimi to the little finger A B FIGURE 4-25. Isolating the action of the flexor digitorum to the ring finger (A) and to the little finger (B). FIGURE 4-26. Flexor pollicis longus. Extensor Carpi Radialis Longus. This muscle's orig from the distal third of the lateral supracondylar ridge, it inserts at the base of the second metacarpal on extensor aspect. Nerve supply is the radial C6-7. muscle is tested by holding the forearm in full prona while the fingers are closed in a fist. The patient is asked to extend the wrist with radial deviation. In testin is almost impossible to isolate this muscle from the exte carpi radialis brevis (Fig. 4-27). Extensor Carpi Radialis Brell/s. This muscle originat the lateral epicondyle of the humerus, which is called common extensor tendon origin, and inserts at the ex sor aspect of the base of the third metacarpal. Nerve su and action are the same as for the extensor carpi rad longus (see Fig. 4-27). Extensor Carpi Ulnaris. This muscle originates in lateral epicondyle of the common extensor tendon. It has a partial origin in the middle part of the posterior bo of the ulna. It inserts at the base of the fifth metacarpa the extensor aspect. Nerve supp~y is the radial nerve C Its action is tested as other wrist extensors are tested with the knowledge that this muscle extends the wrist ulnar deviation (Fig. 4-28). ExtensorDig/forum Communis to the Fingers. This mu originates in the anterior surface of the lateral hum epicondyle from the fascia covering the muscle from the intermuscular septum. The four tendons of muscle insert partly in the base of the proximal pha of the fingers and partly in the extensor hood me nism. Nerve supply is the radial nerve C7-8. To test muscle, the forearm is held in pronation, the wri stabilized, the interphalangeal joints are fully flexed ,and FIGURE 4-27. Extensor carpi radialis longus and brevis. They ar difficult to isolate clinically.
- 109. FIGURE 4-28. Extensorcarpi ulnaris. FIGURE 4-30. Extensor digiti minimi. patient is asked to extend the metacarpophalangeal joints (Fig. 4-29). Extensor Digiti Minimi. This muscle originates in the epicondyle and also from its own muscle fascia. The tendon inserts partly into the base of the terminal phalanx and partly into the extensor hood mechanism. Nerve supply is the radial nerve C7-S. To test this muscle, the forearm is held in pronation, the wrist is stabilized, all fingers are flexed, and the patient is asked to extend the little finger only (Fig. 4-30). Extensor Indlcls Proprius. This muscle originates deep in the forearm from the lower part of the ulna and the adjoining interosseous membrane. Its tendon inserts partly in the base of the proximal phalanx and partly in the extensor hood mechanism. Nerve supply is the radial C7-S. The muscle is tested in the same manner as the extensor digitiminimi, the only exception being that the patient is asked to extend the index finger (Fig. 4-31). Extensor Pollicis Longus. This originates in the dorsal surface of the ulna and interosseous membrane. It inserts into the extensor hood mechanism of the thumb and through that into the base of the terminal phalanx of the thumb. Nerve supply is the radial nerve C7-S. The muscle is tested with the wrist and the metacarpophalangeal joint of the thumb stabilized in neutral and the forearm in pronation, supination, or neutral. The patient is asked to extend the thumb and, speCifically, to hyperextend the interphalangeal joint (Fig. 4-32). Extensor Pol/lcisBrevi's. This originates in the radius and the interosseous membrane and inserts in the dorsal aspect of the base of the proximal phalanx and partly into the extensor mechanism of the thumb. Nerve supply is the radial nerve C6-7. To test this muscle, the wrist is stabilized in extension, and the patient is asked to extend the thumb independent of the position of the forearm (Fig. 4-33). FIGURE 4-29. Extensor digitorum communis with isolated extension o f metacarpophalangeal joints of the index, middle. ring, and little fingers. FIGURE 4-31. Extensor indicis proprius. FIGURE 4-32. Extensor pollicis longus. Note the hyperextension at the interphalangeal joint of the thumb, FIGURE 4-33. All of the extensors of the digits in action: extensor digiti minimi, common extensor " digitum extensor. " extensor indicis proprius on the ulnar side of the common extensor part to the index. extensor pollicis longus, anatomic "snuff box, " extensor pollicis longus.
- 110. 88 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT AGURE 4-34. Abductor pollicis brevis. AbductorPol/lcisLongus.This muscle originates from the dorsal aspect of the radius. ulna, and the interosseous membrane between them. It is inserted sometimes through multiple slips into the lateral side of the base of the first metacarpal. Nerve supply is the radial nerve C6-7. With the forearm in neutral and the wrist stabilized, the patient is asked to abduct the carpometacarpal joint of the thumb. It is very difficult to isolate the function ofthis muscle from the interference of the other extensors of the thumb. Intrinsic Muscles. These are the muscles that originate and insert inside the hand. The muscles are divided into four groups: 1) thenar muscles, 2) hypothenar muscles, 3) lumbrical muscles, and 4) interossei. Thenar Muscle Group.The thenar muscles, also called the short muscles of the thumb, are located on the radial side of the hand. With the exception of the adductor pollicis and the deep head of the flexor pollicis brevis. they are supplied by the median nerve and act together as a group. It is very difficult to isolate the independent function of each muscle. Abductor Po/licis Brevis.The abductor pollicis brevis is the most superficial of the group, is located on the radialside of the thenar eminence area, and originates from the flexor reticulum at the wrist, the scaphoid. the trapezium, and, more frequently, with a slip from the tendon ofthe abductor pollicis longus and occaSionally with a slip from the tendon of the palmaris longus.That muscle is inserted into the base radial side of the proximal phalanx in the lateral tubercle and occasionally into the lateral sesanlOid of the metacar pophalangealjOint and also partlyinto the extensor mecha nism of the thumb (which will be discussed later), along with the extensor mechanism of the fingers (Fig. 4-34). AGURE 4-36. Flexor pollicis brevis. Opponens Pollicis.The opponens pollicis lies deeper t the abductor pollicis brevis and arises from the fl retinaculum and the trapezium bone. It is inserted into radial half of the shaft of the first metacarpal. Some p might reach the palmar aspect of the metacarpophalan joint and the sesamoid bone (Fig. 4--35). Flexor Pol/icis Brevis. This muscle has both a superf head and a deep head. The superficial head arises from flexor retinaculum, trapezium, and the sheath of the fl carpi radialis, and sometimes from the deep aspec the palmar aponeurosis. The deep head arises from capitate and the trapezoid, where it continues with origin of the oblique head of the adductor pollicis. The heads of the flexor pollicis brevis unite and are inserted the lateral tubercle on the radial side of the base of proximal phalanx.They also insert into the radial sesam of the metacarpophalangeal joint and into the exten expansion of the thumb. The deep head is supplied by ulnar nerve, and the superficial head, by the median n (Fig. 4-36). Adductor Pollicis. The adductor pollicis arises by heads: the oblique head from the sheath of the flexor c radialis; base of the second, third, and fourth metaca bones: trapeZOid; and the capitate bones. The transv head arises from the shaft of the third metacarpal. adductor pollicis is inserted in the tubercle 011 the ulnar of the base of the proximal phalanx into the ulnar sesam bone of the metacarpophalangeal joint and also into extensor expansion of the thumb. It is supplied by the u nerve. Its action is tested by stabilizing the wrist, regard of ·the position of the forearm, and by asking the patien adduct the thumb toward the index finger (Fig. 4-37). is the basis for Froment's sign, which occurs when patient is asked to hold a paper firmly between the thu fiGURE 4-3 5. Opponens pollicis. FIGURE 4-37. Adductor pollicis
- 111. FIGURE 4-38. Fromenlstest- with paralysis of the first dorsal interosseous and the adductor poliicis " ulnar nerve injury." the patient has to use the nexor poliicis longus to nex the interphalangeal jOints of the thumb to give power to thumb adduction. and the index finger; in case of paralysis of this muscle, the patient will not be able to hold the paper between the thumb and the index finger unless the thumb is flexed at the interphalangeal joint to hold the paper through the action of the flexor pollicis longus (Fig. 4-38). Hypothenar Muscle Group. This group of muscles is located on the ulnar side of the hand. They are all sup plied by the ulnar nerve and are easier to test independently than are the thenar muscles. With the wrist stabilized in neutral and the forearm supinated, the abductor digiti minimi abducts the little finger away from the ring finger. The flexor digiti minimi flexes the metacarpophalangeal and extends the interphalangeal joints of the little finger. The opponens digiti minimi brings the little finger toward the thumb (Fig. 4-39). Abductor Digiti Minimi. The abductor digiti minimi arises from the tendon of the flexor carpi ulnaris at the wrist from the pisiform bone and also from the fibrous arch spanning or spreading over from the pisiform to the hook of the hamate. The hamate is the roof of the Guyon's canal. It is inserted into the medial side of the base of the proximal phalanx of the little finger and partly into the extensor RGURE 4-39. Rexor digiti minimi. FIGURE 4-40. Abductor digiti minimi. tendon. With the wrist in neutral position and resting on a flat surface with the palm up to cancelthe action of the digi extensors, the little finger is abducted actively, and the rigid contracted muscle will be felt at the ulnar border ofthe hand (Fig. 4-40). Opponens Digiti Minimi. The opponens digiti minimi arises from the hook of the hamate and the flexor retinaculum. I is inserted in the dist I two thirds of the medial half of the palmar aspect of the fifth metacarpal. With the wrist .in a neutral position, the little finger is twisted actively as If to meet the thumb. The muscle will be felt in the ulnar borde of the hand (Fig. 4-41). Flexor Digiti Minimi Brevis. This muscle is absent in abou 20 to 30 percent of people, or in some cases it might jus be joined as part of its neighboring small muscles in the hypothenar area. It originate from the flexor retinaculum the hook of the hamate, and the fibrous arch which unite the muscle to the origin of the abductor digiti minimi. It i inserted into the medial side of the base of the proxima phalanx of the little finger. With the wrist in neutra position, the little finger is actively flexed at the metacar pophalangeal joint, with the interphalangeal joints held in neutral (i.e.. in full extension). Palmaris Brevis. This is a very small subcutaneous muscle that arises from the medial border of the p lmar aponeuro sis and is inserted into the skin of the medial border of the FIGURE 4-41. Opponens digiti minimi.
- 112. 90 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 4-42. Lumbrical-interossei position '·action. " hand. When present, its main function is to protect the ulnar nerve and the ulnar vessels. Lumbrical Muscle Group. There are four lumbrical muscles. The medial two arise by two heads from the adjacent sides of the profundus tendon to the long, ring, and little fingers. The lateral two arise from the lateral side of the profundus tendon to the index and long fingers. These small muscles are inserted into the lateral edge of the extensor expansion to the fingers. The two lumbricals that originate from the profundus of the index and middle fingers are supplied by the median nerve. The two lumbri cals that originate from the profundus of the ring and little fingers are supplied by the ulnar nelve. With the forearm pronated and the wrist stabilized, all the lumbricals extend the interphalangeal joints and Simultaneously flex the metacarpophalangeal joints of all the fingers. They also extend the interphalangeal joints when the metacarpopha langeal joints are extended (Fig. 4-42). Interossei Muscle Group. There are seven interossei muscles. The three palmar interossei arise from the metacarpals of the fingers on which they act. The first one arises from the ulnar side and adjoins the palmar aspect of the second metacarpal. The two remaining interossei arise from the radial side and adjoin the palmar surface of the FIGURE 4-43. Finger abduction-palmar interossei. FIGURE 4-44. Finger adduction-dorsal interossei. fourth and fifth metacarpals. The four dorsal interossei much bigger than the palmar ones and arise from adjacent metacarpals. The first dorsal interossei arise f the first and second metacarpal shafts by two heads, wh form a kind of tunnel that transmits the radial artery into palm. The three remaining dorsal interossei arise from adjoining dorsal surfaces of the second, third, third fourth, and fourth and fifth , respective'ly. They are inse into the base of the proximal phalanx and the exten expansion. All the interossei are supplied by the u nerve. With the forearm pronated, the wrist stabilized, the hand resting flat on a table to cancel the long tendo the volar interossei adducts; the dorsal ones abduct digits. The interossei also help the lumbricals with t action on the metacarpophal.angeal and interphalang joints (Figs. 4-43 and 4-44). TENDONS Muscles are the contractile structure but tendons specialized connective tissue that is designed to trans contractions of the muscle into joint action through process of gliding. Each muscle unit ends in single multiple tendon units, which attach to the bone. All tendons are primarily designed to perform a function plays a major role in the harmony of the dynamics of hand (Doy,le and Blythe, 1975; Kleineli, 1975; Klei and 5tormo, 1973; Verdan, 1964). Almost all the extri muscles have long tendons, and the short muscles in hand have short tendons. Tendons are always inse distal to the joint on which they exert their funct consequently, the flexor profundus, which flexes the d interphalangeal joint of the finger, is inserted in the bas the terminal phalanx just distal to that particular joint. E tendon unit has to follow a certain path and is attache the bone in a unique way that ultimately maximizes actions of the muscle unit. Due to the uniqueness of tenc:ons, we will discuss each tendon separately. In their journey from the end of the muscle to insertion in the bone, some tendons curve, some
- 113. FIGURE 4-45. Theextensor pollicis longus tendon is a good example of a tendon that partly goes straight, then around a curve, partly through a pulleyon the dorsum of the wrist, and partly without a pulley on the more carpal; that is why the tendon pops out, as in bowstringing, and becomes obvious. straight, and others go through tunnels (FigA-4S). The tunnels are specialized compartments located at strategic locations in the hand. The function of these tunnels is to safeguard against bowstringing, and, consequently, they maximize the pulling forces of the muscle unit. One or more tendons might go through a specialized compart ment. The compartments are located proximal or distal to joints, and if they have to cross in front of the joint, then structural changes in the pulley take place to allow the joint to move. The tendons have their own blood supply and are covered with a specialized tissue called the tenosynovium. Flexor Carpi Radialis. The tendon of this muscle starts in the lower third of the forearm and travels in a separate deep compartment that is on the radial side of the wrist. The flexor carpi radialis tunnel is hidden behind the thenar muscle origin and is outside the carpal tunnel. It is such an active tendon and is squeezed in its tunnel so deep in the wrist area that it becomes vulnerable to an inflammatory condition known as flexor carpi radialis tendinitis. Palmaris Longus. When the palmaris longus muscle is present, it has a very long tendon and short muscle belly. It is inserted in a Widespread manner into the palmar apo neurosis of the hand. It is the length and size of this tendon that make it adequate to be used as a tendon graft to recon struct another missing tendon in the hand. In addition, no specific functions are lost in its absence, making it an excel lent donor tendon. Flexor Pollicis Longus. The tendon of this muscle is fairly long and runs through the carpal tunnel deep to the flexor carpi radialis tunnel and then just distal to the carpal tunnel, it turns around superficial to it and then travels deep to the thenar muscles. It runs between the two sesamoids at the metacarpophalangeal joint of the thumb and then enters the fibrous flexor sheath or tunnel at the base of the proximal phalanx. It is inserted into the palmar aspect of the base of the distal phalanx. The tendon has a very well developed vinculum breve, which carries the blood supply to the tendon. Its synovial sheath, which extends proxi mally into the forearm, is significant because any infection in the thumb around the flexor poliicis longus can extend longus is flexion of the interphalangeal joint of the thumb and some flexion of the metacarpophalangeal joint. Flexor Digltorum Superficialis "Sublimis." Usually four tendons (one for each finger) arise from the muscle belly around the middle of the forearm . The tendons for the long and ring fingers are almost always superficial to those for the index and litde fingers. This position is maintained through the carpal tunnel but the tendons diverge (one to each finger) in the palmar triangle, and at the distal palmar crease, each tendon enters the fibrous flexor sheath along with the tendon of the profundus. Around the level of the metacarpophalangeal joint, while still in the fibrous flexor sheath, each superficialis tendon splits into two segments, or slips. Each segment passes around and then posteriorly to the joining tendon of the profundus, where the segments partially join again. Each segment or slip continues distally to be inserted almost separately into the margins of the palmar surface of the middle phalanx. The tendons of the superficialis have the vincula breve and longus, which carry the blood vessels. The vinculum breve is a small triangular band in the interval between the terminal part of the tendon and the front of the proximal interphalangeal joint and the distal part of the proximal phalanx. The vinculum longus is a slender band extending from the tendon to the proximal part of the proximal phalanx. As previously mentioned, the superfi cialis tendon to the little finger is absent in about 20 percent of the population and is very small and less developed in the majority of the remaining population. Flexor Digitorum Profundus. This tendon starts at the middle of the forearm. The most radial part of the muscle belly of the profundus forms the tendon to the index finger, and the most ulnar part forms the tendon to the little finger. The four tendons go through the carpal tunnel and lie deeply under the superficialis tendons. Each tendon of the profundus, after its exit from the carpal tunnel area, travels distally through the palmar triangle of the hand and then into the flexor fibrous sheath. As it enters the fibrous sheath, it runs behind the sublimis tendon to each digit and then goes through the decussation of the sublimis opposite the proximal phalanx. Each tendon has a vinculum breve, which is attached to the capsule on the volar aspect of the distal interphalangeal joint and is also supplied by the aforementioned long vincula. The tendon of the profundus is inserted in the volar aspect of the base of the terminal phalanx. Abductor Pollicis Longus. The tendon of this muscle becomes superficial in the distal forearm. It travels on the radial side with the tendon of the extensor pollicis brevis, crosses the tendons of the two radial extensors of the wrist, and then travels through the first extensor compartment. The two tendons cross over the radial artery after they exit out of the first extensor compartment. The abductor pollicis longus splits into multiple tendon slips, and then it becomes attached to its point of insertion in the lateral side
- 114. 92 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT of the base of the thumb metacarpal. The abductor pollicis longus tendon acts as an abductor and stabilizer of the most dynamic part of the hand, which is the thumb metacarpal. Consequently, this makes it a very frequently used tendon, and because of its anatomic relationship as it travels through the first extensor compartment and as it lies on the distal border of the radius, it is vulnerable to irrlitation and inflammation. Inflammation of this ten don, along with its companion extensor pollicis brevis (located in the first extensor compartment), is what is known as tenosynovitis of the first extensor compartment (de Quervain's disease). Extensor Pollicis Brevis. This tendon becomes superficial in the distal part of the forearm and travels along the tendon of the abductor pollicis longus through the first extensor compartment and continues distally as it inserts partly in the dorsal aspect of the base of the proximal phalanx and partly into the extensor expansion of the thumb. It extends and abducts the carpometacarpal joint and extends the metacarpophalangeal joint. It also plays a part in extension of the interphalangeal joint of the thumb, through its insertion in the extensor expansion. Extensor Pollicis Longus. This tendon stays deep in the distal third of the forearm and in the wrist joint area until it gets out of its own third compartment, which is located on the ulnar side of the dorsal tubercle of the radius. At this point, it changes its direction to all oblique radial direction, crosses superficially to the tendons of the two radial extensors of the wrist, and continues distally until it becomes attached to the dorsal expansion of the extensor mechanism of the thumb alld is inserted in a very wide flat tendon, which almost covers the whole width of the dorsal aspect of the base of the terminal phalanx. This muscle tendon unit extends all the joints of the thumb. Because of its oblique course and the side-to-side mobility on the dorsum of the first metacarpal, it can also abduct and adduct the thumb. Extensor Digitorum Proprius "Communis." The tendons of the extensor digitorum proprius to the index, middle, ring, and little fingers start proximal to the wrist and travel through the fourth compartment of the extensor retinacu lum over the center of the wrist. On the dorsum of the hand, the tendons are connected together by oblique bands, which allow these tendons to work together when the hand needs to function with the fingers extended in one unit. At the level of the metacarpophalangeal joints, these long extensors to the fingers divide into two parts. The deeper part of the tendon is inserted at the base of the proximal phalanx on the extensor aspect. The superficial part joins the extensor hood mechanism on the extensor aspect of the proximal phalangeal area of the fingers. This group of muscle tendons primarily extends the metacarpopha langeal joints. However, through the extensor hood expan sion mechanism, these tendons playa role in the extension of the interphalangeal joints. tn a hyperextended position of the metacarpophalangeal joints, these tendons have the tendency to abduct the fingers from the line of the long finger bone. The same is true for extensor digiti mini the little finger. Extensor Indicis Proprius. This tendon starts at the third of the forearm and then passes through the f compartment, along with the four common extensors the dorsum of the hand, it lies on the ulnar side o extensor digitorum communis to the index finger a inserted into the base of the terminal phalanx and th tensor hood mechanism. This muscle tendon unit, be working along with the common extensors of the fin produces the independent extension of the index fing Extensor Digiti Minimi. This tendon starts at the l third of the forearm and travels distally through a sp fifth compartment in the extensor retinaculum. Eith side the compartment or just distal to it, it splits into portions. This tendon, coupled with the extensordigit proprius to the little finger, is inserted in the extenso pansion on the dorsum of the proximal phalanx and p in the base of proximal phalanx. The muscle tendon u the extensor digiti minimi extends the little finger in junction with the other extensors but also independ extends the little finger. Lumbricals. From the muscle belly, the tendons t distally through the lumbrical canal on the radial si each digit and continue distally volar to the transverse of the metacarpophalangeal joint. The lumbrical ten join the lateral edge of the extensor expansion o extensor hood mechanism as they become the most part of what is known as the conjoint tendon of the muscles of the hand. The other part of that con tendon, which is proximal to the lumbrical, almost al belong to the interossei. As the lumbricals are volar t axis of the metacarpophalangeal joints and are dors the axis of the interphalangeal joints, they extend latter, and with the fingers extended at these joints, flex the first joints. Their attachment of origin to the f profundus and their attachment of insertion to th tensor system allow the lumbricals to play an impo role in the balance between the flexor and exte systems of the fingers. Interossei. Like the other small muscles of the hand interossei tendons travel a very short distance dorsal t deep transverse ligament of the palm but anterio the axis of flexion at the metacarpophalangeal joint. are inserted in the extensor expansion, forming proximal part of the conjoint tendon of the small mu of the hand into the digits. The action of the inter depends on whether they are palmar or dorsal. The d muscles abduct the other fingers away from the middle Those that act on the middle finger abduct the finger t radial or the ulnar side. The first dorsal interosseus ro the index finger radially at the metacarpophalangeal to allow for thumb-to-index pinching. The palma terossei adduct the fingers toward the line of the long fi Because of their line of pull and their relationship to th of the metacarpophalangeal and interphalangeal jo the interossei, like the lumbricals, flex the metacarpo
- 115. FIGURE 4-46. Extensorhood mechanism. langeal joint and, through their insertion into the extensor expansion, extend the interphalangeal joints. The Extensor Hood Mechanism. The extensor hood mechanism (Fig. 4-46), which starts at the level of the metacarpal head and extends to the middle of the middle phalanx, is a very complex area of tendon insertion and is a classic example of the uniqueness of tendon arrangement in the hand that allows it to perform its function in the most dynamic and harmonious way (Tubiana et aL, 1984). In the fingers at the level of the metacarpophalangeal joint, the long extensor tendon, joined by the independent extensor to the index and little fingers, divides into a superficial and deep portion. The deep portion, as it crosses over the metacarpophalangeal joint, becomes adherent to the dor sal capsule and is inserted at the base of the proximal phalanx. The superficial portion passes into the extensor hood mechanism. The sagittal bands, which are the proximal part of the extensor hood mechanism, are joined and overlapped on each side toward the dorsal aspect by the interosseous tendon that passes from the hand to the fingers dorsal to the transverse metacarpal ligament but volar to the axis of the metacarpophalangeal joint. The superficial part of the interosseous tendon joins the lateral aspect of the sagittal bands. The deep portion of the interosseous tendon is attached to the base of the proximal phalanx on the side through which the tendon is passing. The lumbrical tendon, however, joins the extensor hood mechanism distal to the point of attachment of the interosseous tendon. From the description just given, it becomes quite obvious that overlying the extensor aspect of the proximal phalanx is the extensor hood mechanism, which is primarily a conjunction of the superficial part of the long extensor of the fingers, the conjoint tendon of the lumbrical, and the superficial part of the interossei tendon. At that particular location overlying the distal third of the proximal phalanx, the common extensor hood splits into two major groups: the central band and the lateral bands. The central band passes over the proximal interphalangeal joint capsule to be attached to the base of the middle phalanx. The lateral parts of the extensor hood mechanism pass on the lateral aspect of the proximal interphalangeal joint and then join together about halfway over the dorsal aspect of the middle phalanx. Together, they make the terminal tendon, which is inserted at the base of the of the middle phalangeal area, just before the two later extensor bands become the terminal tendon, they ar joined together with the triangular loose ligament, whic maintains the lateral band's position dorsal to the proxim interphalangeal joints and in touch with the central:slip its insertion in the base of the middle phalanx. In the thumb the extensor hood mechanism operates on the sam principle as the other fingers but with some variation. Non of the lumbricals or interossei in the hand contribute to th extensor mechanism of the thumb. There are the tw extensor tendons that join the common extensor mecha nism. On the radial side are the tendon of the abducto pollicis brevis and the flexor pollicis brevis. On the ulna side is the tendon of the adductor pollicis. ~IERVE SUPPLY Three nerves are involved in the hand: the median nerv (C-S, C-6, C-7, C-8, and T-l), the radial nerve (C-S, C-6 C-7, C-8, and T-l), and the ulnar nerve (C-8 and T-l). I the forearm, the three nerves are mixed (motor an sensory). With the exception of the radial nerve, whic becomes purely sensory in the hand area, the ulnar an median nerves continue to the hand as mixed sensory an motor. Knowledge of the course and the location of th nerve, its branches, and the muscles it supplies is absolutel crucial to properly evaluate and manage a neurolog problem. The accuracy of locating the site of an injury t the nerve becomes clear when conSidering as an examp injury to the ulnar nerve at the elbow versus an injury to th same nerve at the wrist. In the first instance, a clinic picture of loss of sensation to the ring and little fingers, bot in the volar and dorsal aspects, along with the ulnar half o the hand, is seen. Besides the sensory loss, paralysis of th flexor carpi ulnaris, the part of the flexor digitorum profundus to the ring and little fingers, and all the inte ossei, the hypothenar muscles, the two ulnar lumbrical the adductor pollicis, and the deep head of the flexo pollicis brevis occurs. In the case of injury to the ulnar nerv at the wrist, however, the flexor carpi ulnaris, the flexo digitorum profundus to the ring and little fingers, along wit the sensory function to the dorsum of the ring and litt fingers and the ulnar side of the dorsum of the hand, will b spared from loss. The clinical presentation, the line o management, and the prognosis of an injury at any of thes locations will be totally different. The same principle does apply to all the nerves of th extremity. The only situation in which an injury to the uln nerve at the elbow will not result in intrinsic paralysis is th case of Martin-Gruder anastomosis (Fig. 4-47). Ulnar Nerve. In the forearm, the ulnar nerve (Fig. 4-48 comes through the cubital canal behind the medial ep condyle of the elbow, enters through the flexor arch, an then gives its only motor branches in the forearm to th flexor carpi ulnaris (note' 'ulnar nerve distribution") and th part of the muscle belly of the flexor digitorum profundu
- 116. 94 urm TWO-COMPONE~JT ASSESSilJ1ErHS OF THE ADULT FIGURE 4-47. Maltin-Gruder anastomosis. which inserts in the ring and little fingers (Lamb. 1970; Phalen, 1951.)The nerve continues distally in the forearm on the radial side of the flexor carpi ulnaris as it is joined by the ulnar artery until about 2 inches proximal to the wrist crease. At this point, the dorsal sensory nerve branches out and turns around to the ulnar side of the distal third of the ulna underneath the flexor carpi ulnaris musculotendinous junction to appear on the dorsal aspect of the lower end of the forearm. It then crosses over the wrist to the dorsum of the hand to supply sensory fWlction to the ulnar dorsum overlying the fourth and fifth metacarpals and continues to the extensor side of the ring and little fingers. The ulnar nerve continues to the wrist level and enters the hand through the Guyon's canal, distal to which it gives a palmar sensory branch for the hypothenar eminence area. It then divides Into two branches: the deep ulnar nerve, which is primarily motor and goes through the hypothenar arch, and the superficial ulnar nerve, which is sensory. The latter remains superficial and then splits into the palmar digital nerves to supply both sides of the little finger and the ulnar side of the ring finger. The deep ulnar branch becomes purely motor and supplies ali the small muscles of the hand, with the exception of the abductor pollicis brevis, the opponens poUicis breviS, the superficial head of the flexor pollicis brevis, and the two lwnbricals that join the index and middle fingers. Median Nerve. After the median nerve (Fig. 4-49) enters the forearm. it gives rise to the anterior interosseus (which is purely motor) that passes under the deep head of the pronator teres and continues moving toward the wrist Lamb and Kuczynski, 1981; Phalen, 1951). The median nerve itself continues distally between the two heads of the pronator teres and then under the flexor digitorum super- FIGURE 4-48. Ulnar course and distribution. including branches. FIGURE 4-49. Median nelVe course, distribution, and branch ficialis, to which it remains attached until the lower thir the forearm , where it becomes superficial under the sk under the palmaris longus, if the latter is present. Abo inches proximal to the wrist, the median nerve give palmar cutaneous branch that travels distally under the on the ulnar side of the flexor carpi radialis and crosses the base of the thenar eminence to end in the pa triangle. It is because of the superficial location of this n that any surgical incisions on the radial side of the wris to be avoided. Injury to this nerve results in a very pa disabling neuroma. The median nerve continues its jou to enter the carpal tunnel , where it lies superficial to al flexor tendons and is intimately attached to the under face of the flexor retinaculum. As it exits the tunnel, it g its smallest branch, which is the motor to the th muscles that travel a very short distance before ge buried inside the thenar muscle's bulk. The motor bra "the recurrent branch, " is a very important nerve, and of its function severely compromises the workings of hand. Distal to the carpal tunnel , the median nerve div into an independent digital nerve to the radial side of thumb and three common digital nerves. Each later div into individual digital nerves that supply the adjoining s of the thumb, index, middle, and ring fingers. In the forearm, the median nerve supplies the fl carpi radialis, the palmaris longus, the pronator teres, the flexor digitorum sublimis. Through the anterio terosseous branch, it supplies the ulnar half of the fl digitorum that inserts in the index and middle fingers, flexor pollicis longus, and the pronator quadratus. In a 15 percent of the population, a branch from the ante interosseus connects with the ulnar nerve in the fore (Martin-Gruber anastomosis). In this case, an injury to ulnar nerve proximal to the Martin-Gruber anastom results in prevention of the paralysis of the ulnar innerv intrinsic muscles (see Fig. 4-45). In the hand , the me nerve supplies the thenar muscles through its m branch. with the exception of the deep head of the fl pollicis brevis and the adductor pollicis. The two r lumbricals are supplied by branches from the com digital nerves. Besides the motor supply, the median n is the sensory nerve to the radial haH of the palm. It is the sensory nerve of the palmar aspect of the thumb, in and middle fingers and to the radial side of the ring fin
- 117. FIGURE 4-50. Radialnerve course. distribution, and branches. Radial Nerve. At the elbow, the radial nerve (Fig. 4-50) gives its first motor branches to the brachioradialis and the two radial extensors ofthe wrist. It then divides into a super ficial and a deep branch. The deep branch, purely motor, is the posterior interosseous nerve. This nerve goes through the supinator tunnel and supplies all the remaining muscles of the extensor aspect of the forearm as it moves distally toward the wrist joint. The superficial branch that is purely sensory moves distally under the brachioradialis to the lower third of the forearm, where it becomes superficial, passing on the radial side of the forearm to the anatomic "snuff box" area. At this point, it divides into multiple branches that move distally to supply the extensor aspect of the radial half of the hand and the extensor aspect of the thumb, index, and middle fingers (Barton, 1973; Lister et al., 1979; Moss et al., 1983). BLOOD SUPPLY TO THE HAND The blood supply to the hand (Fig. 4-51 and 4-52) is primarily through the dominant radial artery the less dominant ulnar artery and partly through the anterior and posterior interosseous arteries (Kaplan 's Functional and Surgical Anatomy of the Hand, 1984). The radial artery is a terminal branch of the brachial artery at the elbow. It travels distally on the radial side of the forearm, where, at the wrist level, it supplies a branch to the superficial palmar arch. Then it continues on, turning around the radial aspect d the distal end of the radius across the anatomic snuff box. deep to the abductor pollicis longus, the extensor pollicis brevis, and the extensor po!licis longus to enter in between the two heads of the first dorsal interossei muscle, through the first intermetacarpal space, to the palm between the two heads of the adductor pollicis. Finally, it ends up by anastomosing with the deep branch of the ulnar artery to form the deep palmar arch. Its branches include the two dorsal arteries to the thumb, the two dorsal arteries to the index, and a branch to the dorsal aspect of the carpus. The ulnar artery, the second terminal branch of the brachial artery at the elbow, travels distally on the flexor FIGURE 4-51. Diagrammatic representation of the arterial supply to the hand. surface of the forearm underneath the flexor carpi ulnaris, where it is joined by the ulnar nerve on its ulnar side, and then at the heel of the hand it enters Guyon's canal. As it comes out of Guyon's canal, it divides into the deep palmar and the superficial palmar branches. The deep palmar branch travels deep into the palm to join the deep palmar branch of the radial artery that makes the deep palmar arch. Its superficial branch makes the su perficial arch, and that is what the superficial palmar branch of the radial artery joins. The two vascular palmar arches (superficial and deep) are located in the palm. The superficial palmar arch is dominantly supplied by the ulnar artery and is located at the level of the midpalmar crease. Its branches are the three common palmar digital arteries that divide into the proper digital arteries for the adjacent sides of the four fingers and branch to the ulnar side of the little finger. The deep palmar arch is dominantly supplied by the radial artery and lies deeply under the flexor tendons. It gives two branches to the thumb and a branch to the radial side of the index finger Digital vessels -~f--Metacarpal vessels "--::-=-=--+-- Superficial palmar arch --t---Deep Radial artery ----',--. palmar arch - - t - Ulnar artery Anterior interosseous artery - - - - - - - - - Dorsal interosseous arter AGURE 4-52. Arterial vessels of the hand. . , - - ~.,.-=- - . .
- 118. 96 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT and to the three palmar metacarpal arteries_ These arteries pass to join the common palmar digital arteries distal to the middle palmar crease_ The vascular carpal arches, volar and dorsal, are located in the wrist area and are supplied by branches from the radial, the ulnar, the anterior, and the posterior inter osseous arteries. Various small-sized blood vessels branch out from the vascular tree in the forearm and hand to enter the bones through minute foramina or travel along and supply the various nelVes with blood and also reach the tendons along the vincula. Venous drainage from the hand is accomplished through a multitude of small veins, which eventually join and form the network of larger veins that are located on the dorsal side of the hand. The blood is returned from the hand through gravity if the hand is elevated and through the peripheral muscular pump when the hand is in action. This makes it very clear that if the hand is not working, then it must be elevated to allow for venous drainage; if not, the blood wiIl stagnate and the hand will swell. The hand also has a lymphatic draining system, which travels along the veins. THE HAIR Hair is distributed on the dorsal aspect of the hand and the forearm, and the hair pores on the hand and forearm slant toward the ulnar side. Hair on the volar aspect of the forearm is usually sparse. The texture, pattern, and color of the hair is a Significant indicator of the condition of the skin. For example, the hair is dry, brittle, and shiny in some pathologic conditions that affect the hand, as in the chronic, painful stiff hand syndrome. THE NAIL PLATE COMPLEX The nail plate complex (see Fig. 4-5) is located in the distal half of the terminal phalangeal area of the digits. It is made of the nail plate, the proximal nail fold , the lateral nail folds, the nail bed , and the root of the nail. The nail is firmly attached to its nail bed, which is in turn attached to the terminal phalanx, where the proximal end of the root reaches the insertion of the extensor tendons at the base of the terminal phalanx.The nail's main function is to support the tip of the digit. The terminal phalangeal area is sup ported on the dorsal aspect partly by the terminal phalanx and partly by the nail pJate. Absence of the nail plate de prives the tip of the digit of any dorsal support and, conse quently, the tip of the digit rolls backward. This is Significant in cases of injuries to the digit tips. Loss of the integrity and the stability of the tip of the digit interferes with the preci sion movement of the hand. It is absolutely essential that all health care professionals who are involved in hand surgery be very sensitive to the importance of the nail plate as an integral anatomic part that is necessary to the support of the terminal phalangeal area and consequently to the func tion of the digits. FIGURE 4-53. A, Scaphoid (S) and pisiform {Pl. B, Surface lan of creases. Surface Anatomy Knowledge of the surface anatomy and the land of the hand is absolutely critical, as it facilitates u standing and the process of clinical evaluation (Ka Functional and Surgical Anatomy of the Hand, (Fig. 4-53). The proximal wrist crease is in line with the radio joint. The distal wrist crease runs between the pis and the scaphoid bones and in Bne with the pro border of the flexor retinaculum. The distal palmar c begins on the ulnar border of the hand at the level metacarpal head of the little finger and then runs acro metacarpal heads transversely to the base of the finger. The proximal palmar crease starts just proxim the index metacarpal and then runs obliquely acro shaft of the third, fourth, and fifth metacarpals to the border of the hand. The thenar (the radial longit palmar crease) extends from the junction of the hea shaft of the index finger metacarpal. From the extends to the ulnar side of the proximal part of the metacarpal and then continues proximally to the tr oscaphoid joint. This joint is used as a landmar locating the point of attachment of the rubber bands flexor tendon repair (Fig. 4-54). The creases at the of the digits are approximately at the junction o proximal one third and the distal two thirds o proximal phalanx. In the finger, two transverse creas present. The proximal one is in front of the pro interphalangeal joint, and the distal one is in front distal interphalangeal joint. The flexor retinaculum tends from the distal wrist crease to a line about 1
- 119. crease S = Scaphoid L= Lunate T = Triquetrum P = Pisiform H = Hamate ~-""_ Proximal wri crease FIGURE 4-54. A, Trapezioscaphoid joint. B-F, All finger tips point to trapezioscaphoid jOint while in flexion. distally (Fig. 4-55). This line corresponds to another line across the palm from the ulnar side of the hyperextended thumb and runs transversely across the palm to the ulnar side. The pisiform can be felt at the base of the hy pothenar eminence, and the hook of the hamate is about 2.5 cm distal and radial to it. The tubercle of the scaphoid is the bony prominence felt at the base of the thenar eminence with the crest of the trapezium distal to it (Fig. 4-56). These bony landmarks are the point of attachment of the flexor retinaculum to the carpal bones. A line, extending proximally from the radial side of the ring finger to the medial side of the biceps tendon at the elbow, marks the course of the median nerve (Fig. 4-57). A line, extending distally from the anterior aspect of the medial epicondyle of the elbow to the radial side of the pisiform at the wrist, marks the course of the ulnar artery and nerve (see Fig. 4-57). [n the wrist area the median nerve lies immediately on top of the lunate bone. The thenar branch, or the recurrent branch of the median nerve, comes out from the main trunk about 1.5 inches distal to the distal wrist crease. The division of the common palmar digital nerve occurs just distal to the level of the superfiCial palmar arch, while FIGURE 4-55. Flexor retinaculum. the corresponding arteries bifurcate near the web space o the fingers at the level of he bases of the proxima phalanges. The web spaces of the fingers are located in lin with the crease at the base of the finger, which correspond to the junction between the proximal and distal two third C =Capitate Td =Trapezoid Tm =Trapezium R = Radius U = Ulna FIGURE 4-56. Surface anatomy.
- 120. 98 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 4-57. Surface anatomy of the course of the radial artery, the median nerve, the 111nar nerve, and the ulnar artery, of the proximal phalanges, The neurovascular bundles in the digits lie against the flexor sheath palmar to the line joining the ends of the palmar digital creases from dorsal to palmar being the vein, artery, and the nerve, the latter being the closest to the midline of the digit. On the palmar aspect, the metacarpophalangea'l joint is about 2 cm proximal to the edge of the web spaces of the fingers, The proximal interphalangeal joints are about 0.5 cm, and the distal joints are about 0,25 cm from the knuckles of these joints, The radial artery pulsations can be felt in the distal end of the forearm, just proximal to the wrist. Nowhere else in the hand can the arterial pulsations be felt as well, The superficial palmar arch runs obliquely between the pisiform and the midpoint between the base of the long finger and the distal palmar wrist crease, The deep palmar arch on the other hand is about 1.5 cm proximal to the location of the superficial arch, On the volar aspect of the wrist, the flexor carpi radialis is the most radial tendon (Fig. 4-58), The flexor carpi ulnaris is the most ulnar tendon. The palmaris longus tendon, if present, is seen as the most prominent tendon running obliquely from the middle of the forearm toward a point at the junction of the ulnar third and radial two thirds of the base of the thenar eminence. The palmar cutaneous branch of the median nerve runs distally between the palmariS longus and the flexor carpi radialis, At the distal forearm and the mist area, the muscles and nerves are arranged as follows, from superficial to deep: 1) palmaris longus, when present; 2) median nerve; 3) two sublimis tendons to the middle and ring fingers; 4) two sublimis tendons to the index and little fingers; 5) flexor digitorum profundus, which is the deepest; and 6) flexor pollicis longus, which lies deep to the flexor carpi radialis tendon. The radial artery and multiple branches of the superficial radial nerve are in the anatomic snuff box, on the radial side of the wrist. The snuff box is located between the extensor FIGURE 4-58. Surface anatomy of the tendons on the volar aspect of the wrist-flexor carpi radialis, palmaris, and flexor carpi ulnaris, FIGURE 4-59. The extensor pollicis is the most prominent tendon the anatomic snuff box below the tendon, pollicis longus and tendons of the extensor pollicis bre and the abductor pollicis longus. On the dorsum of the hand, the extensor pollicis lon is the most prominent tendon and makes the ulnar bou ary of the anatomic snuff box, followed by the long ext sors to the index, middle, and ring fingers (Fig. 4-59). T head of the ulna, with its styloid process, is the most pro nent bony landmark on the dorsum of the hand, with fifth extensor compartment on its radial side, the sixth co partment on its ulnar side, and the dorsal ulnar sens nerve superficial to it. On the dorsum of the hand, metacarpophalangeal joints are about 1 cm distal to knuckles. The long extensor tendons are centrally loca on top of the knuckles and held in place by the sa tal bands of the extensor hood mechanism on each s (Fig. 4-60). Any disruption in the balance of the sagi bands leads to dislocation of the tendon, This would lead disruption of the harmony of the digit movement, wh results in pain, weakness, and future deformities. Dislo tion of the long extensor tendons is an integral compon of the pathology of ulnar drift, which happens in rheum toid arthritis. The root of the nail touches the end of the exten tendon insertion in the terminal phalanx at a point halfw between the proximal nail fold and the middle creases at distal interphalangeal joint. (see Fig. 4-5) FIGURE 4-60. Extensor digitorum communis independent tend well centralized over the center of the metacarpophalangeal joint of digit and held in place by the sagittal bands, along with other structu
- 121. The hand's elementsmove around the transverse and the long,itudinal axes; therefore, they can perform their functions of various grips, pinches, and independent movements of the wrist or the digits. When the hand is in a relaxed position, the wrist joint is about 10 to 15 degrees in dorsal extension, and the fingers are in a gentle curve flexion at their joints, with flexion being minimal in the index finger and maximal in the little finger. In this position, the thumb is adducted with the tip at the level of the radial side of the distal interphalangeal joint of the index finger (Fig. 4-61). When the hand is in a functional position, the wrist is in 15 to 25 degrees dorsiflexion (Fig. 4-62). The thumb is fully abducted in opposition, and the metacarpophalangeal joint is in extension or partially flexed. The metacarpo phalangeal joints of the fingers are in at least 65 to 75 degrees flexion , and all the interphalangeal joints of the fingers are extended (Milford, 1988). The hand is involved in a wide range of functions. Besides the basic needs for normal daily activity, the hand must perform other specific functions. For instance, the required hand functions of a musician are totally different from those of a banker or manual laborer. These factors should be considered, as the functions of hands are unique to each patient. If a normal hand is the ultimate goal of reconstruction and cannot be attained, then the recon struction should aim toward making the hands as functional as possible. For the hand to function properly, either some or all of the digits must either be in a closed or open position and be constantly moving jointly or independently or in a combination of different positions. For the digits to open, they must extend at the metacarpophalangeal and the interphalangeal joints. The long extensors extend the metacarpophalangeal joints, but they cannot extend the interphalangeal joints unless the lumbricals and interossei contract to help with the extension of the interphalangeal joints and to counteract any attempt by the long flexors to contract and consequently bend the interphalangeal joints. This is perhaps the only reason why the lumbricals originate from the flexor tendons and insert into the FIGURE 4-61. Resting position. FIGURE 4-62. Functional position. extensor hood mechanism; this allows them to ade quately perform the job of "messenger" between the extensor and the flexor mechanisms of the digits. If the lumbricals become paralyzed, then when the Ilong ex tensors extend the metacarpophalangeal joints, the long flexors will also be in motion and the hand will take on the posture of clawing. For a clawing motion to occur, the lumbricals and possibly the interossei must be non functional. The long flexors are primarily responsible for the closing motion of the digits. For the digits to bend at the metacarpophalangeal joint and to extend at the interpha langeal joint, only the function of the interossei and the lumbricals is required. Power grips of the hand have been divided into the squeeze grip (which includes the simple squeeze), the hammer squeeze, the screwdriver squeeze, the hook grip, the disc grip, and the spheric grip. Precision grips include the precision rotation and the precision translation. The precision movement can include tip-to-tip, pad-to-pad, or pad-to-side actions. CLINICALCONDITIONS Trauma Traumatic injuries to the hand can be as minor as a puncture wound or as severe as a mutilation or amputation injury. Trauma can be as simple as to involve only the skin or as complex as to involve the skin and other anatomic parts such as the tendons, nerves, and bones. Trauma can be closed or open, depending on whether the integrity of the skin has been violated. The type of injury and the status of the tissue determine not only the type but also the outcome of the treatment. While some injuries may require only minor conservative or surgical management, others may require much more complex management protocols. The experience and knowledge of the health care provider, the type of patient, his or her medical condition, his or her age, and the type of work he or she does are only a few of the factors that can have an impact on the result of treatment. What follows is a discussion of some of the injuries that can occur.
- 122. 100 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT SKIN' Skin lacerations must be treated early, if possible. If no violation of any other structures has occurred, the wound is treated conservatively or surgically. If sutures are required, it is usually recommended not to remove the sutures before 3 weeks have passed. The skin of the hand is fairly thick and takes longer to heal than the skin elsewhere on the body. Also, the hand is a very dynamic organ, and the skin needs to heal properly before the sutures are removed. The pa tient is given the usual instructions on how to take care of the wound, keep it clean, and protect the hand untilit heals. FI~IGERTIP INJURIES Fingertip injuries are a common problem. The level and the shape of the amputation or tissue loss dictate the type of management needed. The goal is to achieve repair so the tip of the finger can be functional. Usually if the skin lost is less than 1 cm in diameter with no bone exposed, it will heal by itself. If any bone is exposed or if the injury is more than 1 cm in diameter, then surgical treatment is indicated in the form of skin grafts or local or distant pedicle flaps. Surgical management can be performed in one stage, as in the case of skin grafts and local flaps, or in two stages, as in the case of distant pedicle flaps. Postoperative care is in the form of wound management, along with therapy and exercises. TENDONS Tendons perform their function through gliding. Be cause of the unique conditions tendons of the hand must go through from their point of origin at the muscle belly to their point of insertion in the bone, the healing process of an injury can affect the gliding mechanism of the tendon and also affect the efficiency of its function. Through its path, the tissue surrounding the tendon can vary from one location to the next. As a result, the condition and the type of tissues respond to trauma, inflammation, and healing differently from one location to another. It is because of these factors that the tendon's path has been divided into zones. Each zone requires a unique form of management and has a unique prognosis ( Doyle & Blythe, 1975; KJeinert, 1975; KJeinert & Stormo, 1973; Lister, 1984; Verdan, 1964; Verdan, 1972). Flexor Tendons (Fig. ~3). The five zones of the flexor tendons are as follows: Zone one: Has the flexor digitorum profundus only and extends from the insertion of the sublimis at the base of the middle phalanx to the base of terminal phalanx Zone two: Contains the two flexor tendons and extends from the distal palmar crease at the level of the metacarpophalangeal joint to the insertion of the sublimis tendon Zone three: Is the middle of the palm where the lumbricals originate FIGURE 4-63. Flexor tendon zones. Zone four: Is the carpal tunnel area where the f tendons to all the digits are located Zone five: Extends from the musculotendinous jun to the carpal tunnel In the thumb, zone one extends from the middle o proximal phalanx to the insertion of the flexor po longus at the base of the terminal phalanx. Zone extends from the metacarpophalangeal joint to the m of the proximal phalanx. Zone two in the thumb is diff from zone two in the fingers because only one tend there. Zone three is located around the flexor po longus in the thenar eminence area. Repair of the flexor tendons can be either pri (within a few hours), delayed primary (within 3 wee the injury), or secondary (when it is done after 3 w of the injury). Zone five usually has the best prog after tendon repair, followed by zones three, four, one. Because of the unique condition of the pa having two large tendons squeezed in a tunnel, in to the tendons in zone two are usually the most dif with the poorest prognosis. In the past, zone two known as "no man's land," but during the last 25 y it has been renamed "some man's land. " Even in the of circumstances and with the best of care, repair o two flexor tendons when lacerated in zone two ha potential for major problems because of scarring adherence that will interfere with the tendon gl mechanism. Flexor tendon repair should only be u taken by specialists in hand surgery. After the tendon repaired, patients are then started on the proper the course, and some might require surgical tenolysis i future. Surgical tenolysis improves tendon gliding a commoilly needed in patients who had zone two te repairs. Extensor Tendons. Extensor tendons have been di into eight zones (Fig. 4-64). They are easier to repai have a much better prognosis than the flexor tend Repair, splinting, and therapy are the steps followed injury. The zones are as follows: Zone one: Over the distal interphalangeal joint Zone two: Over the middle phalanx Zone three: Over the proximal interphalangeal joi Zone four: Over the proximal phalanx Zone five: Over the metacarpophalangeal joint Zone six: Over the dorsum of the hand
- 123. FIGURE 4-64. Extensortendon zones. Zone seven: At the extensor compartments Zone eight: At the distal forearm LIGAMENTS Injuries to the ligaments can be closed or open, partial or complete, simple or associated with both bone and joint injury. They are treated conservatively or surgically, de pending on the type of ligament, its location, and the type and size of the injury. Ligaments must be protected either by casting or by splinting. The patient begins therapy later, with the goal of maintaining the integrity of range of motion with a stable joint. BONES Injuries to the bones can be open or closed, displaced or undisplayed, stable or unstable, intra- or extraarticular, simple or associated with other injuries (Lister, 1984; O 'Brien and Eugene, 1988). The bones are treated either conservatively or surgically, depending on the type of fracture , its location, and its stability. With the various surgical modalities available, broken bones in the hand can be treated surgically, and within a few days the patient can begin an active therapy program, with excellent results. JOINTS Injuries to the joints involve the articular cartilage, the ends of the bones, and the capsule. Injuries can be open or closed, simple or associated with other injuries-especially injuries to the bones and ligaments. The modality of treatment depends on the type of injury. Again, a therapy course is almost always recommended and should begin with guarded active, then active and passive, and finally with full active and passive range of motion. BLOOD VESSELS Injury to the blood vessels can be either open or closed, simple or associated with other injuries, depending on the type of injury. However, dominant arteries must be re paired surgically. If nondominant arteries are the only thing injured and the vascularity of the digit is not compromised, then in most cases, surgical repair of the artery is not indicated, and the hand needs to be protected until the wounds heal. Injuries to the nerves can be open or closed, transacte or injured in continuity, simple or associated with othe injuries. Contused or bruised nerves heal spontaneousl without treatment. However, lacerated nerves requir surgical treatment. After the surgical repair, nerves grow back at the rate of 1 inch per month. After a nerve i injured, the distal part of the nerve degenerates, while th proximal part of the nerve regenerates and grows distally Consequently, meticulous nerve repair with the prope alignment is essential so that the new nerve growth can b directed toward its proper channel. At the beginning, newl grown nerves are overly sensitive, sometimes resulting i hyperparesthesia and dysthesia. Regenerated nerves re qUire special therapeutic techniques, such as stimulatio and desensitization. NeurologicProblems Any nontraumatic problems of the nerves can either b as a result of peripheral nerve compression, inflammator peripheral neuropathies paralysis (as in leprosy or diabe tes), or because of central neurologic problems, such as i cerebral palsy. Nerve compression syndromes, which ar common in the hand are: 1. Carpal tunnel syndrome 2. Entrapment of the median nerve and/or the anterio interosseous nerve at the pronator teres 3. Entrapment of the radial posterior interosseous nerv at the supinator tunnel 4. Entrapment of the ulnar nerve at the Guyon's cana 5. Entrapment of the ulnar nerve at the cubital cana behind the medial epicondyle Occasional entrap ment of the superficial radial nerve by the brachiora dialis in the lower third of the forearm also may occur Modalities of nerve compression treatment depend o the stage at which the patient seeks treatment. At an earl stage, management might only entail a change in th patient's pattern of living along, with splinting and antiin flammatory medications. However, surgical managemen would be required in advanced cases. Paralysis of the peripheral nerves can be high or low depending on its location, and is treated according to it type. Nerve repairs or tendon transfers can be performed Cerebral palsy is a central neurologic condition, and initia splinting when an affected child is young can be helpful However, some patients might require surgical treatment Pressure Injection Injuries Industrial toxic substances under pressure that vary from 500 to several thousand pounds per square inch can b accidentally injected in the hand (most commonly th digits). What is unique about these injuries is that the
- 124. 102 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT initially appear minimal but are later followed by severe pain and swelling as a result of the pathologic changes that occur in the tissues, and the consequences are devastating. Initially, only a pinpoint injury to the skin at the site of the accidental injection is seen. The amount of damage depends on the type of chemical and the pressure under which it was injected. The toxic substance can spread from the digits to the hand and even to the forearm. Management almost always requires surgical debridement, with the wounds left unclosed. The patient is treated with therapy, whirlpool baths, elevation of the hand, exercise, and antibiotics. The wounds are left to heal by secondary intention or delayed reconstruction. The determining factor about the type of surgical modality of delayed reconstruction depends on the amount and type of tissue loss. It is very important to remember that even in the best hands and with the best of care, pressure injuries can leave a digit totally disabled to the extent that its amputation becomes necessary to allow the hand to function properly. Cold Injuries Exposure to cold can cause severe injury to the extrem ity. Early symptoms include burning, itching, and redness. The exposed extremity becomes very cold and then numb. Cold injuries, as in burns, are claSSified according to the depth of the burn. First-degree cold exposure injuries are superficial and usually recover spontaneously. Second degree injuries include partial-thickness skin loss, which can heal by secondary intention, as long as no infection occurs, which might destroy the remaining layers of the dermis. Third-degree injuries result in full-thickness skin loss and require surgical management. Regardless of the depth of injury, the initial treatment of the cold injury is in the form of rewarming with water 40°C to 42°C. During the rewarming process, the patient will, most probably, experience burning pain, aching, and paresthesia. The hand is treated either conservatively or surgically, depending on the depth of the damage. Eleva tion and exercise are necessary. Sympathetic ganglion blocks or antithrombotic therapy may be considered. Burns Burns can be either thermal, chemical, or electric and are classified according to their depth. THERMAL BURNS First-degree burns are superficial and cause redness and pain. Initial treatment is usually to rinse in cold water and then apply some dressing. The hand should heal sponta neously with some exercise if it is kept elevated. Second degree burns can be either superficial or deep. In either case, a remnant of the dermis is always left. Second-degr burns are characterized by intense pain and the presence blisters, which should be left intact, as they act as a biolo natural dressing, and they will rupture spontaneously. T patient should be seen daily and started on antibioti whirlpool baths, elevation of the hand, changes of dre ings, and exercise. The second-degree burn heals spon neously unless infection occurs, and then the remaini layers of the dermis will be lost and, consequently, the bu will be classified as a third-degree burn. Third-degree bu are characterized by almost complete loss of the skin. Wh skin is left appears white, tight, leathery, and is painless, no sensation is present. A patient with a third-degree bu should undergo surgical debridement and then reconstru tion. Again, postoperative care requires elevation a exercise until the wounds heaL CHEMICAL BURNS Chemical burns can ile caused by an alkaline or an aci agent. Initial treatment should be in the form of copio rinsing with water. In the case of alkaline burns, woun should be washed with a diluted acidic solution. For aci burns, the wounds should be rinsed with diluted sodiu bicarbonate. Phenol burns are neutralized by ethyl alcoh Hydrofluoric acid burns are treated by copious irrigation water, injection of calcium gluconate locally, and soaki the dressing with benzalkonium chloride and calciu gluconate. ELECTRIC BURNS Electric injury usually happens with exposure to curre over 500 volts, which travel through the body along t lines of the least reSistance, meaning the blood vessels a nerves. With electric current burns, the patient's conditi is critical. Such burns cause extensive and severe dama along their path. The treatment is usually surgical w intense follow-up therapy; secondary surgery is of required. Infections Infections of the hand can be superficial or deep a acute or chronic. They can be treated on an outpatient inpatient basis conservatively or surgically, depending the severity of the infection. PARONYCHIA Paronychia is an inflammation of the tissues around t nail plate complex. The most common organism is Stap ylococcus aureus. At the early stages of cellulitis, anti otics, elevation, and soaking usually diminish the proble However, in the presence of an abscess, surgical draina by removal of the nail plate is necessary.
- 125. removed, the nailbed and the nail folds need to be protected until the new nail plate grows. It is almost always necessary to apply a piece of petroleum gauze or any other sterile sheet to cover the nail bed and to be underneath the proximal and the lateral nail folds. This protects the nail bed from any injury and also prevents any future adhesion between the nail folds and the nail bed, which might result in a future deformity of the nail plate. FELONS A felon is an infection of the terminal phalangeal area and presents with swelling, redness, and intense pain. Because of the anatomic presence of the fibrous septae and also of the attachment of the palmar fascia at the distal interphalangeal joint crease, the terminal phalangeal area is considered a closed space. Unless the condition is treated, the swelling and the redness progressively become worse. Without treatment, the increased pressure and the presence of infection in the closed compartment can jeopardize the blood supplyto the terminal phalangeal area and result in osteomyelitis and necrosis of the bone. Adequate treatment of infections in the terminal pha langeal area require surgical drainage. Postoperative care includes soaking, therapy, and active and passive exercise until the wounds heal. HERPES INFECTIONS Herpes infection can affect the tips of the digits and is extremely painful. It is usually manifested in single or mul tiple variable-sized vesicles around the tip of the digit. Health care professionals who are exposed to infected pa tient saliva are the most susceptible (Louis and Silva, 1979). It also may be seen in patients with acquired immu nodeficiency syndrome or immunosuppression (Glickel, 1988). Treatment is usually symptomatic, along with anti biotics to protect against secondary infection. Diagnosis primarily depends on the history and the fluorescent antibody studies of the fluid from the vesicles. Some ointments and oral medications are available for herpes infections. SUPPURATIVE FLEXOR TE~IDON TENOSYNOVITIS Infection of the flexor tendons in the flexor tendon sheath can be secondary to trauma or may spread through the bloodstream. The diagnostic signs are known as the Kanavel's signs: 1) longitudinal swelling of the flexor tendon sheath; 2) tenderness with possible redness of the skin along the tendon sheath; 3) the digit or digits held in a flexed position to minimize the pain; and most significantly 4) severe pain on the passive extension of the joints (Neviaser, 1978). Suppurative tenosynovitis needs to be treated surgically. Besides incision and drainage, intraop erative and postoperative irrigation with antibiotic solu Sometimes the problem resolves without leaving an residual effects, but sometimes it leaves significant stiffness which might require future surgical management. Som suppurative tenosynovitis cases are so severe that eve with the best of care, the problem of management is s complex that the digit may be left stiff and deformed, so eventually must be amputated. DEEP SPACE INFECTIONS This usually happens in the thenar and the midpalma spaces. The collar button abscess is another type of dee space infection that starts between the digits in the we in the palmar surface and spreads dorsally (Burkhalte 1989). Pain is usually the most common presentin symptom, along with swelling, redness, and stiffness o the hand. Surgical incision and drainage, along wit proper administration of antibiotics, whirlpool, and ex ercise are necessary. HUMAN BITE INFECTIONS The vast majority of human bite infection cases happe as a result of clenched-fist fights. A puncture wound injure the skin, tendon, and joint structures, including cartilage o bone. The most common organism found in human bit infections is Eikenella corrodens, a gram-negative ro facultative organism (Patzakis et aI., 1987). Clinically, the patient presents with pain, redness, an swelling at the site of injury. The pathologic condition coul be cellulitis, arthritis, osteomyelitis or lymphangitis. Th condition is mostly treated surgically. The consequence o the infections that result secondary to human bites ar sometimes so severe that even with the best of care and i the best of hands, bone and soft tissue damage may lead t chronic irreparable stiffness, and amputation of the dig becomes necessary. ANIMAL BITES Cats and dogs are the most common animals that bit humans. However, bites by rare exotic animals may also b seen. Staphyloccus aureus is the most common organism in dog bite cases, and Pasteurella multocida is the mo common organism in cat bites (Snyder, 1989). As in th case of human bites, treatment can be conservative o surgical, and the prognosis is very guarded. SEPTIC ARTHRITIS Infection of the joints can either be secondary to traum or blood borne. If the infection is not treated properly destruction of the joint may occur, which results in stif ness. The most common condition of septic arthritis secondary to human bites; the most common blood-born infection of the joint is due to gonorrhea. Septic arthrit
- 126. 104 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT of the joint should be treated surgically, along with the proper antibiotics, postoperative whirlpool, and exercise. Depending on the severity of infection and the adequacy of treatment, some joints eventually will be completely distroyed and will require surgical reconstruction or even amputation later on. Inflammatory Conditions Aseptic inflammation of the tissues that affect the tendons and the synovial sheath can occur in several locations. As a result of the inflammatory process, the tissues and involved areas become swollen, painful, and tender and interfere with the function of the part involved. TRIGGER DIGIT Tenosynovitis of the flexor tendons causes the tendon to swell. When the inflamed tendon is at the level of the metacarpophalangeal joint as the tendon enters the A-I pulley, the condition is known as trigger digit. Gliding of the tendon becomes difficult as it goes through the A-I pulley and inside the flexor tunnel. Patients complain of pain and locking of the finger in flexion, and the finger snaps as the patient attempts to move it passively or actively. The pain is almost always described as coming from the last joint of the digit, when the tenderness is actually at the level of the metacarpophalangeal joint where the A-I pulley is located. Treatment of the condition can be either conservative or surgical. Nonoperative management is in the form of oral antiinflammatory medication and a cortisone-xylocaine local injection around the flexor tendon in the A-pulley area. It is very important not to repeat the cortisone injections indiscriminantly, as cortisone can cause attenu ation and eventual rupture of the tendon. Usually it is preferred to give no more than two injections of cortisone over a span of 6 to 8 weeks.If the condition persists, then surgical management in the form of release of the A-I pulley and tenosynovectomy is indicated. DE QUERVAIN'S TENOSYNOVITIS This condition is an inflammation of the abductor pollicis longus and the extensor pollicis brevis in the first extensor compartment. Symptoms of de Quervain's tenosynovitis include severe pain, swelling, and tenderness on the radial side of the wrist and an inability to use the hand. The condi tion can be treated conservatively with antiinflammatory drugs, splinting, and possible injection of cortisone. If the condition persists, then surgical management is indicated. DUPUYTREN'S FASCIITIS AND CONTRACTURE Aseptic chronic inflammation with fibrosis and scarring of the palmar fascia is very rare in African-Americans and very common in whites, especially in those who are middle aged or older. It sometimes occurs in younger people a is more common in men than in women. The disease h three stages: 1) an early stage that is proliferative; 2) active stage that is fibrocellular; and 3) an advanced sta that is fibrotic. It usually begins with a painful nodule in t palm of the hand, and the disease process progress gradually over a long period until it eventually causes flexion contracture of the metacarpophalangeal and int phalangealjoints. In the early stages ofthe disease, patien are advised to avoid any trauma to the hand. The contractures can be localized in one part of the hand, mo commonly on the ulnar side, but can be widespread. T only proper treatment is surgical excision of the involv palmar fascia, with postoperative wound care, splintin and exercise. OSTEOARTHRITIS Osteoarthritic changes can affect the joints as a part the aging process or following trauma and inflammato conditions or secondaryto systematic disease processes, in gout. The articularcartilage is destroyed, the jointspac become narrow, and the joints themselves become ve painful. Joint deformities can occur as a result of norm daily living activities or repetitive intermittent loading th is required in certain occupations. Some cases can bene from conservative treatment, but others may requ surgical management in the form of arthroplasties arthrodesis. Connective Tissue Diseases Any connective tissue disease process that affects t body in general can also affect the hand (e.g., disseminat scleroSis, lupus erythematosus, and, most common rheumatoid arthritis). The latter various pathologic entit affect soft tissues, tendons, ligaments, and the capsu around the joints. They eventually result in destruction the joints and various deformities. Treatment can conservative, surgical, or a combination of the two. THE PAINFUL HAND SYNDROME Transient pain and dystrophic response to injury, s gery, or disease to the hand is normal. Abnormal prolo gation of this response, along with the patient's inability control the pain and the associated dystrophic changes, the hallmark of the chronic painful hand syndrome. Som examples of names given to describe painful hands a reflex sympathetic dystrophy (Mitchell, 1864), pain dy function syndrome (Dobyns, 1984), the shoulder-ha syndrome (Steinbrocker, 1968), and Sudeck's atrop (Sudeck, 1900). Clinically, the entity is characterized chronic pain, stiffness, various trophic changes a functional deficits. Various theories have attempted describe the pathophysiology and the proposed mech
- 127. radiography, bone scan,thermography, and endurance testing. Various treatment modalities, both conservative and surgical, have been described. Prognosis for the chronic painful hand syndrome is very guarded. ruMORS OF THE HAND Tumors are classified as either benign or malignant. Tumors in the hand are typically benign. Most large soft tissue tumors are lipomas. Some conditions produce swellings that can be wrongly diagnosed as tumors. Ex amples are posttraumatic myositis ossificans, carpometa carpal bossa, and infections. The most common soft tissue benign tumor is the ganglion, which is most com monly on the dorsal wrist aspect or, less commonly, on the volar aspect of the wrist. In about 10 percent of hands, ganglions originate in the flexor tendon sheath. The most painful and the smallest of all benign tumors is the glomus tumor, which in 50 percent of the cases is located under the nail plate. It is characterized by pain, cold intolerance, and severe tenderness. Inclusion cysts, which occur when an injury drives a fragment of skin epithelium into the subcutaneous tissues, are another type of slow-growing and painless benign tumor. Benign bone tumors of the hand can be chondromas, osteomas, or bone cysts, but 90 percent of them are enchondromas. Malignant tumors in the hand are very rare and can be primary or sec ondary. Primary tumors are mainly sarcomas, and sec ondary tumors result from primary tumors in the lung, breast, or kidney. EVALUATION OF THE HAND The hand evaluation should not be done unless the examiner has certain forms or note pads on which to record findings. Asample hand evaluation form appears in the Appendix. The evaluation should be done consistently and in a very systematic way that is repeated with each patient. It is this organization and consistent systematic approach that will help the examiner avoid the pitfalls of missing any items in the evaluation process. Also, it is the knowledge of anatomy, function, various pathologic enti ties, and the proper systematic evaluation that will lead to the proper diagnosis and, hopefully, the proper manage ment. History Various elements make up the history part of patient evaluation, and each element must be addressed thor oughly. It is necessary to obtain a detailed description of th patient's complaint and to ask questions to clarify some o the patient's statements. ONSET OF SYMPTOMS AND DATE OF INJURY Some ailments that affect the hand start abruptly, as i the case of traumatic problems; others begin gradually, a in the case of peripheral nerve entrapment. The date, type and mechanism of injury in traumatic cases are of critica importance. PAST INJURIES AND PREEXISTING CONDITIONS History of previous problems has a direct or an indirec impact on the diagnosis, line of management, and prog nosis of the case. Previous fractures, previous medica problems, and previous operations are only a few ex amples of items about which the examiner needs to ask This list also includes previous surgeries and medica treatment, both invasive and noninvasive. The list shoul also include other general medical problems that ca directly or indirectly affect the hand, such as diabetes epilepsy, and gout. FAMILY, SOCIAL HISTORY, AND OCCUPATION These are issues that have to be explored to help she light on the current problems, as well as on their manage ment and prognosis. With the explosion of the repetitiv motion disorder syndromes, it becomes very clear tha occupation does cause and directly affect some of th pathologic conditions that can affect the hand. The socia factors, including patient habits and recreational likes an dislikes, can also influence the decisions regarding th patient. No specific scientific data exist regarding th effects of smoking, drinking, obesity, and other suc factors on the hand, but enough clinical knowledge an data exist to make us believe that these habits can influenc the pathologic status of the hand. AGE, SEX, AND HAND DOMINANCE These are also factors that need to be addressed durin the process of examination. Hand dominance is significan notonlyin relation to thediagnosis and the prognosis ofth specific current problem, but also in deciding futur impairment ordisability that will directly affect the patient' life. Some ailments that affect the hand are more commo in females than in males. Also, some problems are uniqu to females, such as the peripheral nerve entrapmen syndrome, which occurs during pregnancy, which some times will completely resolve itself when the pregnanc terminates. Patient age is particularly important in con genital anomalies that affect the hand, but some othe problems are also unique to certain age groups.
- 128. 106 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT Examination of the Hand The hand is examined from the anatomic and functional aspects. These two aspects are very important from a diagnostic and management point of view. The examiner must take certain steps to address the anatomic condition and perform tests to evaluate functional aspects. Some steps can evaluate both aspects of the hand. In addition, the hand components should be examined not only as independent units but also in association with other units of the hand. GENERAL APPEARANCE The general appearance of the hand must be assessed, including its posture and position, patient attitude, ban dages, and splints; these are only a few examples of the factors that the examiner has to observe as the process of evaluation continues. Painh~, stiff hands are usually held in a very specific, guarded posture that seems to be a comfortable position for the patient. The affect of the patient and his or her attitude can help the examiner understand the extent of the impact of the hand problem on him or her. SKIN EXAMINATION The presence or absence of wrinkles and scars is the first observation that needs to be made. The color of the skin, its texture, sweat patterns, hair pattern, and hair texture are also important factors to evaluate. The temperature of the patient's skin, as felt by the examiner's extensor aspect of the fingers , should be examined in an ascending distal to proximal manner, and the difference in temperature is noted as the examiner moves his or her fingers on the extremity (Fig. 4-65). The temperature of the skin and the presence of any changes, ulcers, gangrene, or swelling should be noted during the procedure. EXAMINIATION OF THEARTERIAL SUPPLY The blood supply to the hand comes from the subclavian artery that moves distally and ends up in the peripheral FIGURE 4-65. Checking the skin temperature from distal to proximal. FIGURE 4-66. Wright's test. small blood vessels. Interference with the blood supp the hand can occur in any location along the vascula of the extremity. Patients complain of pain, cold in ance, ischemic neuritis, and possible presence of a m the case of aneurysms. Evaluation may show change i color, temperature, and texture, as well as the presen ulcerations or gangrene, along with signs of neuriti evaluate the blood supply to the extremity, certain tes be done. Adson's Test. This test exaggerates compression o neurovascular bundle in the neck. T'he patient is direc brace the shoulder posteriorly, turn his or her head affected extremity, raise the chin, inhale, and hold her breath. A diminished radial pulse at the wrist o involved extremity results in a positive Adson's sign te compression of the neurovascular bundle in the tho outlet area (Fig. 4-66) Wright's Test. This is an extension of Adson's test patient assumes the same posture as described in Ad test. Then the affected arm is abducted to at least 9 grees and externally rotated, and the radial pulse is ch at the wrist. A diminished pulse is considered a positiv for vascular compression (Fig. 4-67). FIGURE 4-67. Adson's test.
- 129. FIGURE 4-68. AJlen'stest. A, Occlusion of the radial and ulnar arteries, B, After the blood has been pumped out. ote the paleness of the hand e, The ulnar artery is released, The radialartery is still occluded , Note the return of blood to the hand through the ulnar artery, 0 , The two arteries ar occluded again and the blood is pumped out once more, E, The pressure is released from the radial artery but maintained on the ulnar artery, The bloo flows back to the hand through the palmar radial artery, Allen's Test (Fig. 4-68). This test determines arterial supply at the hand from the radial, ulnar, and possibly the median artery. The median artery is a small, threadlike structure that runs along the median nerve in almost aU patients. Embryologically, the anterior interosseous artery atrophies and becomes the median artery as the ulnar and radial arteries mature. However, in some pa tients, a fairly decent-sized functioning median artery is present. The steps for Allen's test are as follows: locate the radial and ulnar arteries at a point 0.5 inch to 1 inch proximal to the volar wrist crease. The radial artery is located just to the radial aspect of the flexor carpi radialis tendon, and the ulnar artery is located just to the radial aspect of the flexor carpi ulnaris tendon. The patient makes a tight fist (an object such as an ace wrap can be squeezed if a complete fist cannot be accomplished) The examiner occludes the radial and ulnar arteries using a downward and lateral pressure with the terminal pha langeal area of the thumbs. The patient pumps the blood out of the hand by opening and closing his or her fist several times until the hand becomes pale. Next, the patient leaves the hand open and relaxes the fingers, after which the hand should remain pale and blanched. The hand will not blanch and be pale if the patient has a functioning major median artery, as it is the only artery not occluded by the pressure applied by the examiner's digits, or if occlusion of the radial or ulnar arteries by the examiner's thumbs is incomplete. If the hand stay blanched and pale, the examiner should release eithe radial or ulnar artery pressure. The hand should regai coloration within 2 to 5 seconds. Repeat this process b releasing the pressure on the other artery this time. A filling time greater than 7 seconds is indicative of sever problems (Koman, 1985) of the adequacy of arterial bloo flow to the hand. Special Teststo Evaluate the AdequacyofBlood Flow to th Hand. These tests are arteriograms and thermography. VEINS OF THE HAND The veins on the dorsum ofa normal hand should be ver easy to see or feel. more so in light-skinned individuals. the veins are not easy to de ect. then they should b compared with the veins on the other normal extremity Use of drugs for medical or nonmedical reasons can caus thrombosis or thrombophlebiti , and the veins could b seen or felt as painful or painless cordlike structures, or the are simply occluded and not easy to see or feel. Th presence of tenderness, pain, redness, or firmness alon the course of the veins should be noted. The puffy hand i secondary to venous thrombosis, subcutaneous fibroSiS and lymphatic obstruction (Neviaser, 1972). Venogram may be necessary to further evaluate the venous drainag system of the extremity. ·." I.~""'~
- 130. 108 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT BONES, JOINTS, AND LIGAMENTS Along with the clinical evaillation, radiographs in the three basic standard positions of anteroposterior, latera., and oblique are essential for the proper evaluation of the skeletal system of the hand. The alignment of the bones, integrity of the joint spaces, presence or absence of deformities, and type of bone structure are only a few of the elements to evaluate in the radiographs. Based on the clinical condition and the history, special studies in addition to the basic radiographs might become necessary. Polytomography is a special radiographic tech nique that takes pictures of the part being imaged in slices; it is useful for a detailed evaluation of a bone area. A computed axial tomographic (CAT) scan uses much finer slices and can be more detailed and informative. Magnetic resonance imaging (MRI) is a special radiologic procedure that gives details about masses, tumors, bones, and liga ments. An arthrogram is done by injection of a special type of dye inside joint spaces; it allows the integrity of the joint spaces, the capsule, and the ligaments around it to be evaluated. Video fluoroscopy is a radiologic examination of the area of the hand with a television monitor. This last special test is very helpful in cases of suspected instability or in cases where reproduction of symptoms at filming could be done. A bone scan is a radiologiC examination that follows the intravenous injection of a radioactive material. It is very useful in cases of pain with unknown origin, occult or difficult to see fractures, possible tumors, painful hand syndrome, and vascular lesions. The presence of any signs of swelling, redness, defor mity, or instability of an individual joint or multiple joints should be noted. Instability of the joints is checked by applying manual stress to any specific ligament. The stability of any joint is evaluated by holding the bone proximal to a joint and then by moving the bone distal to the joint to be examined in the desired position to evaluate the integrity of the various ligaments. The volar ligaments are to prevent unlimited hyperextension of the particular joint. The collateral ligaments, on the other hand, provide lateral stability to the joint. In the case of the metacarpalpha langeal joint, the joint has to be in 90 degrees flexion to check the stability of the collateral ligaments (Fig. FIGURE 4-69. Checking the integrity of the collateral' ligament on the radial-side metacarpophalangeal joint of the left index finger. Note the 90-degree flexion to stretch the collateral ligament. FIGURE 4-70. Checking the stability and the integrity of the collat ligament on the radial side of the proximal interphalangeal joint of the index finger. Note the neutral position of the joint to stretch the collat ligament. 4-69).The interphalangeal joint must be held in a neut position while the integrity and the stability of the collate ligaments are checked at that joint (Fig. 4-70). The ran of motion of any paliicular joint should be evaluated b actively and passively. The passive range of mot evaluates the integrity of the joint and all the structu related to it. The active range of motion evaluates not o the integrity of the joint and all the structures related it but also the integrity of all the elements that allow joint to work properly. Limitation of the passive range motion alone is different in its Significance from limitat of the active range of motion alone. Limitation of passive and active range of motion has different sign cance. Measurements of both should be observed a recorded. The range of motion, active or passive, eva ates not only the bone and the joint structure of the ha but also all the other elements that contribute to the ran of motion. The range of motion should be examined, n only from an individual joint aspect but also in conjunct with other joints (Figs. 4-71 to 4-78). It is very import to remember that the different parts of the hand work n only as individual units but also in conjunction with ea other; therefore, the overall mode of function of the ha must be addressed. MUSCULOTENDINOUS SYSTEM When examining the muscles and tendons, each u should be examined both individually and in conjunct with other units. It is very important that each muscle a tendon be isolated, evaluated, activated, and given individual grade. When examining the muscles, look for general appearance of tone, atrophy, and hypertrophy proper systematic muscle evaluation can enable the exa iner identify any problems. Each examiner, through ti and experience, will adopt a system of his or her own t will enable him or her to systematically evaLuate extremity. Have the patient open the fingers and make a fist to sh all the units togethe}·. Normally, in making a fist, patient's fingertips should touch the distal palmar cre and the terminal phalangeal area of the thumb. The fing
- 131. FIGURE 4-11. Ulnardeviation of the wrist. FIGURE 4-15. Full flexion of the interphalangeal joints with fu extension of the metacarpophaiangecli joints. FIGURE 4-16. Full flexion of all the joints of the fingers. FIGURE 4-12. Radial deviation of the wrist. FIGURE 4-13. Extension of the wrist. FIGURE 4-11. Full flexion of metacarpal and proximal interphalangea joints but no flexion of the distal Interphalangeal joints. FIGURE 4-14. Volar flexion of the wrist. FIGURE 4-18. limited flexion of all the joints of the fingers. ~ .~- . - ~ !~.~--
- 132. 110 UNIT TWO-COMPONENTASSESSMENTS OF THE ADLJLT FIGURE 4-79. Thumb pulp-to-pulp opposition and full flexion adduc tion. should bend to cover the distal half of the middle phalangeal areas of the index and middle fingers. If, when the patient makes a fist, the patient reaches the tips of only distal to the distal palmar crease, then the problem is usually associated with the metacarpal phalangeal unit joints (see Fig. 4-75). If the fingertips touch proximal to the distal palmar crease, the problem is usually associated with the interphalangeal joint (see Fig. 4-77). With the thumb fully adducted, full flexion at the metacarpal and interphalangeal joint should place the tip of the thumb at the palm at a point at the base of the !little finger crease and the distal palmar crease at the ulnar side of the palm (Fig. 4-79). Any limitation in the patient's ability to bring the tip of the thumb to the desired point will be because of a limitation in thumb adduction or full flexion at the metacarpophalangeal or the inter phalangeal joint. The pathologic reason for the limitation can be in the skin, tendons, muscles, bones, ligaments, or joints. The hitchhiker position (Fig. 4-80) should be with the wrist in neutral between volar and dorsal flexion and forearm pronated or supinated fully, depending on which direction, east or west, north or south, or up or down, that the hitchhiker is going. The wrist will be in about 5 to 10 degrees ulnar deviation , and the thumb will be fully AGURE 4-80. The hitchhiker position. AGURE 4-81. Relationship of jOint flexion of the index finger a other fingers. abducted and extended at the basal and the metacarpo langeal joints with hyperextension at the interphalan joint. Pulp-to-pulp opposition (see Fig. 4-79) between thumb and little finger is done with the wrist in about ne or in dorsiflexion, the forearm pronated or supinated full abduction at the basal joint of the thumb, full flexi the metacarpophalangeal joint, and extension up to ne only of the interphalangeal joint. The little finger on other hand will have full flexion adduction opposition a metacarpophalangeal joint and full extension at the i phalangeal joints. It is important to remember tha flexion at the metacarpophalangeal joint of the little f with no adduction or opposition does not allow pul pu1lp opposition to be possible. Full flexion of the interphalangeal joint of the index fi is possible with full extension of the remaining t fingers, but with full flexion of all the index finger jo there will have to be flexion at the metacarpophalan joints of the remaining fingers (Fig. 4-81). Independent full extension of the index or the little f is possible (Fig. 4-82), as they each have an indepen extensor, but the same is not possible for the middle an ring fingers (Fig. 4-83). All the flexors of the digits can flex their corresp ing joints independently, with the exception of the fundus to the middle, ring, and little fingers, which w together in one unit. An obstruction of flexion at the d interphalangeal joints of any of the three fingers bl FIGURE 4-82. Independent full extension of index and little fi
- 133. FIGURE 4-83. Independentextens.ion of the middle and ring fingers is not possible, as these two digits do not have independent extensors. flexion the profoundus action in the remaining two fingers (Fig. 4-84). This is an important fact that is utiHzed beneficially in surgical procedures and therapy when needed. In the same fingers, it is impossible to check the sublimis action without blocking the profundus of the remaining two fingers. LENGTH-TENSION TESTS Extrinsic Extensor Tightness Test:Composite Wrist Flexion Plus finger Flexion (Fig. 4-85). Under normal circum stances, the patient should be able to fully close the digits with the wrist in full volar flexion (Brand et al. , 1981). This position indicates no extensor tightness; if tightness were present, then the position mentioned would not be possible. Extrinsic Flexor Tightness Test:Simultaneous Wrist Exten sion Plus Finger Extension (Fig. 4-86). Under normal cir cumstances, the patient should be able to fully extend the digits with the wrist fully extended. This posture is not possible if any 'long flexor tightness is present. FIGURE 4-84. Note obstruction of flexion at the distal interphalangeal joint of the middle finger. which will interfere with the ability to flex the distal interphalangeal joints of the ring and little fingers. FIGURE 4-86. Extrinsic flexor tightness test. IntrinsicTightness Test (Fig. 4-87). The examiner place the metacarpophalangeal in extension and flexes th interphalangeal joints. Passive and active flexion of th interphalangeal tests should be free; any Hmitations indi cate a positive intrinsic tightness test. Tenodesis (Fig. 4-88). This is a normal phenomen caused by the length-tension ratio of the extrinsic tendon (i.e., flex wrist-fingers extend and thumb is fully abducted and extended; extend wrist-fingers flex. Thumb is ab ducted and slightly flexed at the metacarpophalangeal and interphalangeal jOints). For maximum function of the hand this ratio must be preserved, as it is used in adjusting th length and tension of tendon transfers or tendon grafts in reconstruction procedures. ExtrinsicFinger Tightness Test. It should be possible with the wrist at least in neutral or preferably in full flexion to flex all of the joints of the fingers. This demonstrates gliding ful length of the extensor mechanism. Neurologic Examination The median, ulnar, and radial nerves innervate the hand and possess a sensory and motor component. Variou sensory tests are available and include evaluations o tactile sensation, e.g., Semmes-Weinstein Monofilaments (Tubiana et al., 1984), deep sensation, temperature pinwheel test, two-point discrimination, object ,identifica FIGURE 4-85. Extrinsic extensor tightness test. FIGURE 4-87. Intrinsic tightness test.
- 134. 112 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 4-88. A and B, Tenodesis. tion (stereognosis), texture identification, and Tinel's sign. The principle behind performing the last test is to irritate an already sensitive nerve. Assessment for Tinel's sign is done by gently tapping a sensory nerve with a blunt object that has the same circumference as the nerve. Unpleasant feelings (e.g., paraesthesia, hyperparasthesias) may occur in one of three locations or directions: at the site of tapping, at a direction going distal from the tapped area, or in a direction proximal from the tapped area. !f the sensation travels proximally, it is not a positive Tinel's sign. The test is only positive when the unpleasant feelings are at the location of the tapping or in a direction distal to it. Other useful tests are Phalen's and reverse Phalen's (Phalan, 1951). The principle behind performing these tests is to put the median nerve under maximum pressure by diminishing the size of the tunnel and by kinking or stretching the nerve in either test, which eventually causes irritation of the nerve. For Phalen's test, place the wrist in 90 degree palmar flexion, with the fingers relaxed, the elbow at 90 degrees of flexion , and the shoulder at 90 degrees abduction (Fig. 4- 89). For the reverse Phalen's test (Fig. 4-90), place the wrist in 90 degrees of dorsiflexion with the fingers relaxed, the elbow at 90 degrees of flexion, and the shoulder at 90 degrees abduction. Maintain the above positions for 0 to 60 seconds, and record if patient reports symptoms o tingling in median nerve-innervated sensory territory. Special Tests FINKELSTEIN'S TEST When performing this test, you are assessing for th presence of tenosynovitis of the extensor pollicis longu FIGURE 4-90. Reverse Phalen's test. FIGURE 4-89. Phalen's test. FIGURE 4-91. Finkelstein's test.
- 135. AGURE 4-92. A,Tip-to-side grip. B, Tip-to-tip grip. C, Three-digit pinch. 0, Hook grip. E. Special grip. F, Key grip. G, Power grip (hammer grip) H, Large object circular grip. and abductor pollicis brevis tendons located in the first dorsal compartment. The pathology of de Quervain's disease includes swelling (inflammation), thickening (ten don sheath), tightness, and adhe ions. Any attempt at distal gliding of the two tendons either passively or actively will be limited and very painful. (Positive Finkelstein's test results usually indicate de Quervain's disease). To perform the Finkelstein's test, place the patient's wrist in radial devia tion and midway between pronation and supination with all the digits closed in a fist and the fingers covering the flexed thumb in the palm (Fig. 4-91). Ask the patient to relax. A gentle jerking motion in the direction of ulnar deviation is passively applied. A positive test result occurs when the movement causes pain; however, if the wrist is jerked too much, the patient may feel pain even ;f he or she does not have de Quervain's disease. The improper administration of Finkelstein's test can lead to the patient developing d Quervain's. WARTENBERG'S TEST In this test, the little finger remains abducted if the patien has a weak palmar interossei and unbalanced action of th long extensor tendon, which indicates ulnar nerve weak ness. FROMENT'STEST This is a test of active thumb adduction, using a piece o paper between thumb and first finger (see Fig. 4-38). Th patient is asked to hold paper without flexing the interpha
- 136. 114 UNIT TWO-COMPONENTASSESSMENTS OFTHE ADULT langeal joint. An inability to hold without flexing indicates a positive test result and motor ulnar nerve palsy. EVALUATION OF GRIP (FIG. 4-92) The two types of grips are the precision grip, which is accomplished with the index, thumb, and middle fingers, and the power grip, which is accomplished with all digits. Examples of a power grip include grasp grip, spheric grip, and hook grip. Examples ol precision grip include tip-to-tip grip, tip-to-side (lateral) grip, and three-jaw grip. Using a dynamometer, power grip is evaluated at all five levels. Normal grip strength and appropriate patient participation produce a bell-shaped curve. Rapid alternat ing grip pattern at all levels or comfortable grip at level two or three assess "normal gripping" ability of the patient. CIRCUMFERENCE MEASUREMENTS Measures are made at specific levels of the forearm and arm for bU'lk to compare with those of future evaluations. A point is chosen at a fixed distance from an anatomic landmark, such as the elbow crease (Fig. 4-93). The circumference of the forearm is then measured at the chosen point. The measurement in one extremity is compared with the measurement at a similar point in the other extremity and with future measurements. FIGURE 4-93. Circumference measurement. VOLUMETRIC MEASUREMENTS Measures for changes ,in size and for edema can al taken. The circumference of the extremity at a ch point is compared with measurements at a simi'lar po the other extremity. Swelling in one hand is measur the amount of water spilled out from a marked cont when the hand is immersed. The amount of water s out from one hand is compared with the amount spill immersing the other, uninvolved hand. Many other are designed to asses hand function; many of thes discussed in other chapters of this text.
- 137. PPENDIX Ramadan HandInstitute 850 E. Main Street 6241 NW 23rd Street 407 N. Hernando Street Lake Butler, FL 32054 Gainesville, FL 32602 Lake City, FL 32055 (904) 496-2323 (904) 373-3130 (904) 755-8688 HAND EVALUATION NAME: __________________________________ DATE: ______~ ~.NO: __________________________________ AGE: - - - - - - ADDRESS: _______________________________________________ OCCUPATION: ___________ HAND DOMINANCE: _____ INVOLVED HAND: ATTENDING PHYSICIAN: _________ Present problem(s) to include functional limitations: Past problems/injuries to the upper extremity: Previous surgeries/treatments/medicationsltherapy: Observations (posture of hand): Illustration continued on following page 115
- 138. 116 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT Soft Tissue Integrity: (Edema, Surface Irregularities, Moisture/Dryness, Wrinkling/Shininess, Tapering, Nod Scars-Location and Size) Diagram on last page Joint Status: (Volar Plate, Collateral Ligaments, Grind Test, Stress Test) Tendon Integrity: (Length, Glide, Excursion) RIGHT LEFT + + + + + - - - - - Middle Finger Extension Finkelstein's Adson's Froment's A of F + + + + + - - - - - TINEL'S RIGHT LEFT + + + - - - Radial Nerve Median Nerve Ulnar Nerve - + + + - - - ALLEN'S RIGHT LEFT + - Radial Artery + + Ulnar Artery + RIGHT LEFT + - Phalen's + + Reverse Phalen's +
- 139. Grip: (Level Lateral Pinch: 3Jaw Pinch: R R R Ibs. Ibs. Ibs. L L L Ibs. Ibs. Ibs. Tip Pinch: R Ibs. L Ibs. Jamar Dynamometer-5 levels in Ibs. R1 _____ 2 _____ 3 _____ 4 ______ 5 _____ L 1_____ 2 ______ 3 ______ 4 ______ 5 ______ Forearm Circumference: 3 cm, 5 cm, 7 cm below volar elbow crease R ______ 3 cm L ______ R ______ R ______ 5cm 7cm L ______ L ______ Comments: ________________________________________ Motor Nerve Innervation: (Strength, Atrophy) RADIAL Wrist Ext. Thumb Ext. Finger Ext. RIGHT LEFT RIGHT LEFT Wrist Flex. MEDIAN Thumb Flex. Thenars RIGHT LEFT Wrist Flex. ULNAR Finger Flex. Hypothenars Intrinsics Illustration continued on following pag
- 140. 118 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT Range of Motion: RIGHT PASSIVE MOBILITY ACTIVE MOBILITY I M R L MP PIP DIP I M R L MP PIP DIP THUMB MOBILITY WRIST MOBILITY MP OPP F RD IP PMP PIP WBSP POPP PWBSP E PF PE UD PRD PUD FOREARM ELBOW SHOULDER MOBILITY S F F AS IP P E E AD EP PS PF PF PAB PIR PP PE PE PAD PER COMMENTS: __________________________________________________________
- 141. LEFT PASSIVE MOBILITY ACTIVEMOBILITY MP PIP DIP MP PIP DIP I I M M R R L L THUMB MOBILITY WRIST MOBILITY MP OPP F RD IP WBSP E UD PMP POPP PF PRD PIP PWBSP PE PUD FOREARM ELBOW SHOULDER MOBILITY S F F AB IP P E E AD EP PS PF PF PAB PIR PP PE PE PAD PER COMMENTS: ______________________________ Sensory Integrity: 2 Point Discrimination RIGHT LEFT RADIAL SFC. ULNAR SFC. RADIAL SFC. ULNAR SFC. Thumb Index Middle Ring Small Illustration continued on following page - . -~-=- . . -~.~~~~~:~::
- 142. 120 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT Other: (VIBRATION AT 30, 256 CPS, VONFREy) Sensory Testing: Semmes Weinstein RIGHT LEFT Volume of the Hands: Time of Day Administered: _______ RIGHT LEFT ________ Summary of FindingsITherapist's Impression _______________________
- 143. Photo on file:__ Yes __ No Plan: To forward a copy of this hand evaluation to the attending physician for use in determining the medical stat of this patient. Examiner Date
- 144. 122 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT Abduct-To bring or move away from the center of the body. Adduct-To bring toward the center of the body. Arthritis-Inflammation of the joint. Arthrodesis-To fuse bones of a joint together and then cancel the joint. Chondroma-Cartilagenous mass attached to the skel etal system. Collateral Hgament-The ligaments on each side of the joint to hold bones together and provide stability. Contract-To shrink in size. Contracture-A deformity across a joint. Cyst-Asac inside the tissue-itcould happen insidebone or soft organs. Distal-Part away from the body. Dorsal flexion-To bend toward the dorsal aspect; to extend. Extension-Movement away from volar flexion. Extrinsic-Outside the hand. Fascia-Anatomic layer of connective tissue. Fibrous septae-Strands of fibrous tissue that anchor the skin to bone and deeper structures. Flexion-To bend. Flexor-Volar side. Intrinsic-Inside the hand. Myositis-Inflammation of the muscles. Ossificans-Calcification in tissues other than bone. Osteoma-Bone mass attached to the main bone. Palmar-Toward the volar aspect; "palmar face of the hand." Pronate-To turn toward the ground (Le., face down). Proxima1-Part toward the body or nearer to the body. Radial-Toward the radius and the thumb. Supinate-To turn away from the ground (Le., face up). Ulnar-Toward the ulna and the little finger. Volar-Pertaining to the palm; plantar. Volar flexion-To bend toward the volar aspect. Volar plate-Thick fibrous collagen structure that makes up the ligament on the volar aspect of the small joints of the fingers. REFERENCES Anatomy of the hand. (1988). CIBA Clinical Symposium 40 (3 Lampe, E. W.: Surgical): 1. Barron, J. N. (1970). The structure and function of the skin of the han Hand, 2, 93-96. Barton, N. J. (1973). Radial nerve lesions. Hand, 5, 200-208. Brand, P. W, Beach, R B., & Thompson, D. E. (1981). Relative tensi and potential excursion of muscles in the forearm and hand. Journ of Hand Surgery, 6, 209-219. Burkhalter, W E. (1989). Deep space infections. Hand Clinics, 553-559. Dobyns, J. H. (1984). Pain dysfunction syndrome IS. reflex sympathe dystrophy. American SOciety for Surgery of the Hand, 92. Doyle, J. R, & Blythe, W F. (1975). The finger flexor tendon shea and pulleys: Anatomy and reconstruction (pp. 81-87). AAO Symposium on Tendon Surgery in the Hand. St. Louis: C. V. Mosb Glickel, S. Z. (1988). Hand infections in patients with acquired immun deficiency syndrome. Journal of Hand Surgery, 13, 770-775. Kaplan's functional and surgical anatomy of the hand (2nd ed (1984). Philadelphia: J. B. Lippincot. Kleinert, H. K. (1975). Symposium on tendon surgery in the ha (p. 91). American Academy of Orthopedic Surgeons. Philadelph C. V. Mosby. Kleinert, H. K. & Stormo, A. (1973). Primary repair of flexor tendon OrthopediC Clinics of North America, 4, 865. Koman, L. A. (1985). Diagnostic study of vascular lesions. Hand Clinic 1,217-230. Lamb, D. W. (1970). Ulnar nerve compression lesions at the wrist a hand. Hand, 2, 17, 18. Lamb, D. W, & Kuczynski, K. (1981). The practice of hand surge (1st ed.). Oxford: Blackwell Scientific Publications. Landsmeer, J. M. F. (1976). Atlas ofanatomy of the hand. Edinburg 'Churchill Livingstone. Lister, G. D., Belsole, R B., & Kleinert, H. E. (1979). The radial tunn syndrome. Journal of Hand Surgery, 4, 52-59. Louis, D., & Silva, J. (1979). HerpetiC whitlow; Herpetic infections of t digits. Journal of Hand Surgery, 4, 90-93. McFarland G. B., Mayer, J. R, & Hugill, J. V. (1976). Further observati on the anatomy of the ulnar nerve at the wrist. Hand, 8, 115-11 Milford, L. (1988). The hand (3rd ed.). St. Louis: C. V. Mosby. Mitchell, S. W (1864). Gunshot wounds, and other injuries of nerve Philadelphia: J. B. Lippincott. Moss, S. H., & Switzer, H. E. (1983). Radial tunnel syndrome: Aspectru of clinical presentations. Journal of Hand Surgery, 8, 414-420. Neviaser, R. J. (1978). Closed tendon sheath irrigation for pyogenic flex tenosynovitis. Journal of Hand Surgery, 3, 462-466. Neviaser, R J. Butterfield, W, & Wieche, D. (1972). The puffy hand drug addiction. Journal of Bone and Joint Surgery, 54A, 629-63 Nicolle, F. V., & Woolhouse F. M. (1976). Nerve compression syndrom of the upper limb. Journal of Trauma, 5, 298-313. O'Brien, T., & Eugene, T. (1988). In D. P. Green (Ed.), Fractures of t metacarpals and phalanges in operative hand surgery (2nd ed New York: Churchill Livingstone. Patzakis, M., Wilkins, J., & Bassett, R (1987). Surgical findings clenched-fist injUries. Clinical Orthopaedics and Related Researc 220, 237-240. Phalen, G. S. (1951). Spontaneous compression of the median nerve the wrist. Journal of the American Medical Association, 145, 112 Snyder, C. (1989). Animal bite wounds. Hand Clinics, 5, 571-590. Steinbrocker, O. (1968). The shoulder-hand syndrome: Present p spective. Archives of Physical Medicine and Rehabilitation, 4 388-395. Sudeck, P. (1900). Veberdie acute entztindliche knochenatrophie. Arch Far Klinische Chirurgie, 62, 147-156. Taleisnik, J. (1976). The ligaments of the wrist joint. Journal of Ha Surgery, 1, 110. Tubiana, R, Thomine, J. M., & Mackin, E. (1984). Examination of t hand and upper limb. Philadelphia: W. B. Saunders. Verdan, C. E. (1964). Practical consideration for primary and seconda repair in flexor tendon injuries. Surgical Clinics of North Americ 44(4),951-970.
- 145. CHAPTER 5 Assesment al• n Robert G. Ross, MPT, CHT Paul C. LaStayo, MPT, CHT SUMMARY This chapter reviews the basic physiology of pain and the sensory and affective dimensions of the patient's pain experience. The chapter then examines a variety of scales that the physical therapist and occupational therapist can use to assess pain intensity, pain affect, and pain location in a clinical setting. Many of the measures are clinically reliable and valid, while others have not been thoroughly tested. These pain assessment tools are simple and effective and should be used clinically as part of a complete patient evaluation. Pain is a common human experience. Typically, it is pain that makes someone seek health care (Knapp & Koch, 1984). In fact, over 80 percent of all office visits to physicians are by individuals whose primary symptom is pain (Koch, 1986). Many types of diseases, injuries, and medical and surgical procedures are associated with pain (Bonica & Benedetti, 1980). Due to the ubiquitous nature of pain, one would expect that this sensation would be well understood. However, thoroughly comprehending its many characteristics remains elusive. It is commonplace for some patients to have the same type and degree of physical pathology yet have different pain experiences. In addition to physical pathology, many cultural, economic, social, demographic, and environmental factors influence an individual's perception of pain. An individual's psycho logical state, personal history, and situational factors contribute to the quality and quantity of his or her pain (Turk & Melzack, 1992). To understand and adequately treat pain (and its under lying pathology), the clinician needs to measure pain. Without effective measurement of pain, a therapist would not be able to critically evaluate the treatment tech niques used to control it. Therefore, the clinical assess ment of pain is not a trivial endeavor. Therapists must understand the physiologic factors associated with the perception of pain and the multiple dimensions of an individual's pain experience. Coupled with this, a thera pist needs a full complement of pain assessment scales that are cost effective and easily integrated into the clinical setting. It is vital for the clinician to accumulate baseline infor mation on the patient's pain to help in determining the underlying causes of the pain. Subsequent assessments are also important to determine whether treatment is effective in reducing the patient's pain or whether treatment modifications are necessary. Finally, if clinicians use assess ment tools that are we'll founded in research, the scales can be incorporated with other outcome measures, thus im pacting the quality and cost of rehabilitation (Cole et aI. , 1992). - ~ .~ '. - 123
- 146. 124 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT The goals of this chapter are to 1) review basic physiol ogy of pain, 2) identify the dimensions of pain, and 3) offer a full range of pain assessment scales available to the clinician for easy integration into the clinical setting. THE PHYSIOLOGYOF PAIN It is thought that pain is the result of tissue trauma or disease that initiates a complex set of chemical and electric events in the body. When a noxious mechanical, chemical, or thermal stimulus of sufficient intensity occurs, the body transforms this stimulus into electric activity in sensory nerve endings. Myelinated A-IJ. and unmyelinated C fibers are first-order neurons that transmit this electrically coded nociceptive information from the periphery to the dorsal horn of the spinal cord (Fields, 1988). A-IJ. and C fibers enter the dorsal horn where they synapse with second order neurons. The second-order, or relay, neurons ascend through the spinothalamic tract to the reticular formation of the brain stem, periaqueductal gray hypothalamus, and thalamus. In the thalamus, third-order neurons send axons to the somatosensory cortex and the limbic system, where the signal is interpreted as pain (Wallace, 1992). During the transmission of nociceptive information from the spinal cord to these higher centers, the individual's perception of pain can be modified (Fields, 1988). The gate control theory (Melzack & Wall, 1965) explains the inter action of the peripheral afferents with a pain modulation system in the substantia gelatinosa within the gray matter of the spinal cord . According to the gate control theory, pain modulation is the result of a balance of large-diameter A-~ neurons transmitting nonnociceptive information, including touch, proprioception, and pressure, and small A-IJ. and C sensory neurons transmitting nociceptive information. A-beta, A-delta, and C neurons ascend into the substan tia gelatinosa of the spinal cord. There, they synapse with both internuncial neurons in the substantia gelatinosa and second-order neurons called tract cells (T-cells). These T-cells are also termed wide-range dynamic neurons be cause they receive input from multiple sources, including A-beta, A-delta, and C fibers . The substantia gelatinosa acts as a "gate" or modulator to either inhibit or facilitate the transmission of noxious impulses to the T-cells. The modulation of pain occurs when excessive large diameter A-beta fiber activity stimulates the substantia gelatinosa. Excitation of the substantia gelatinosa "closes the gate" to nociceptive information transmitted by A-delta and C neurons to the T-cells and to higher centers. Excessive A-delta and C fiber activity can inhibit the substantia gelatinosa. When this occurs, the "gate opens," and increased nociceptive information is transmitted to the T-cells and higher centers, resulting in a more painful experience (Fig. 5-1). Pain can also be influenced by a Descending modulation control Large A~ Small M,e + + SG l < ,; . h'-cell, FIGURE 5-1. Diagram of the revised Melzack and Wall gate cont theory. A~-Large A-~ primary, first-order neuron; AB, C-small A- C primary, first-order neuron; SG-substantia gelatinosa; T-cell-secon order neuron. descending modulation system that includes such stru tures as the corticospinal tract in the cortex and medu (Wallace, 1992). THE DIMENSIONS OF PAIN Even with identifiable neuroanatomic pathways, it is s unclear why such great variability occurs in how peop perceive pain. Clinically, we treat some patients wi severe injuries who experience little pain and others wi minor trauma who are totally debilitated by pain. The differences may be explained partially by the fact that pa is unique among all the senses. Pain involves two maj components: the sensory component and the affecti component. The sensory component of pain has been described discomfort that can often be identified and located to particular part of the body and graded with respect intensity (Fields, 1988). Clinically, we typically define pa intensity by how much a patient hurts (Jensen & Karol 1992). The affective component of pain, however, is differen This component involves a complex series of behavio that an individual may employ to minimize, escape, terminate a noxious stimulus. It is this affective compone of pain that may explain the uniquely different wa individuals perceive pain and the variability of their painf experience. For example, why do some patients require ( demand!) pain medication when their dentist fills a cavit whereas others need none at all? Why do some wom cope with the pain of childbirth by requesting medicati whereas others use none? Clinically, the most important difference between t sensory and affective aspects of pain is the distinctio between pain detection and pain tolerance (Fields, 1988 Pain detection threshold relates to the sensory aspect an
- 147. same person atdifferent times. Pain tolerance, on the other hand, is extremely variable as it is related to the affective component of pain. Due to its multidimensional nature, no two individuals tolerate pain in the same way (Turk & Kerns, 1983). To effectively assess pain in the clinical setting, therefore, the therapist must weigh and consider both the sensory and affective components of the pain experience. ASSESSING THE SENSORY COMPONENT/PAIN INTENSITY Three methods commonly used to assess pain intensity are the Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), and the Numerical Rating Scale (NRS). Verbal Rating Scale The VRS is a list of adjectives that describe different levels of pain intensity, ranging from no pain to extreme pain (Table 5-1). VRSs are effective tools for assessing pain because they are both valid and reliable.The VRSs are valid because they measure what they intend to measure-pain intensity. The VRSs are also reliable in that the results of a VRS for pain intensity are consistent and free from error (Downie et al., 1978; Jensen et al., 1986; Jensen et al., VERBAL RATING SCALES fOR PAIN INTENSI1Y S-Point Scale" IS-Point Scalet None Extremely weak Mild Very weak Moderate Weak Severe Very mild Very severe Mild Very moderate Slightly moderate Moderate Barely strong Slightly intense Strong Intense Very strong Very intense Extremely intense • Reprinted from Gracely, R. H., McGrath, P., & Dubner, R. (1978). Ratio scales of sensory and affective verbal pain descriptors. Pain, 5, 5-18, with kind permission from Elsevier Science B. V , Amsterdam, The Netherlands. t Reprinted from Gracely, R. H. , McGrath, P., & Dubner, R. (1978). Validity and sensitivity of ratio scales of sensory and affective verbal pain descriptors: Manipulation of affect by diazepam. Pain, 5, 19-29, with kind permission from Elsevier Science B. V, Amsterdam, The Nether lands. scales of pain intensity, including the NRS, VRS, and VAS with 100 patients with a variety of rheumatic diseases Correlation coefficients were high between pain score derived from the different pain scales (Downie et al., 1978) In a second study, the effects of analgesics on pathologi pain in a double-blind study were assessed by the VRS an VAS. The comparison of the VRS and the VAS pain ratin scales by a linear regression gave a highly significan correlation (r = 0.81, P < 0.001) (Ohnhaus & Adler 1975). The clinician must be aware of several important factor when evaluating VRS scores. First,VRSs are usually score by assigning a number to each word, according to its ran on the order of pain intensity. For example, on the 5-poin scale in Table 5-1 , "none" would be given a score o 0; "mild," a score of 1; "moderate," a score of 2; "se vere," a score of 3; and "very severe, " a score of 4. Th number associated with the adjective is then used for th patient's score of pain intensity.This information is ordina data and must not be interpreted as interval data. That is the difference between a score of 2 and 3 must not b viewed as the same as the difference between 3 and 4. Fo example, during an initial evaluation and subsequen treatment of a patient after total knee replacement, th patient is given four VRSs over a speCific period o rehabilitation. The scores, using a 5-point VRS as de scribed are "very severe" (4), "severe" (3), "moderate" (2) "mild" (1), and "none" (0). How should these scores b interpreted? The clinician can say objectively that th patient's pain intensity has decreased since the start o treatment. However, these rank scores do not allow fo interpretation of the magnitude of the differences relate by the patient. Some limitations of VRSs are the inability of man patients to link the proper adjectives to their level of pai intensity and the inability of illiterate (of foreign language speaking) patients to comprehend the adjectives use (Jensen & Karoly, 1992). Numerical Rating Scale An NRS asks patients to rate their perceived level of pai intensity on a numerical scale from 0 to 10 (an ll-poin scale) or 0 to 100 (a 101-point scale). The 0 represents "n pain" and the 10 or 100, " pain as bad as it could be. Figure 5-2 outlines the NRS-l Oland the II-Point Bo Scale. With this scale, the clinician can obtain valuable baselin data and then use the scale at every subsequent treatmen or on a weekly basis to monitor whether progress occurring. Numerical Rating Scales are valid measures of pai intensity and have demonstrated sensitivity to treatment expected to ameliorate pain intensity (Jensen et al., 1986 Jensen et al. , 1989; Seymour, 1982). Furthermore, thes
- 148. 126 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT WI-NUMERIC RATING SCALE Please indicate on the line below the number between 0 and 100 that best describes your pain. A zero (0) would mean "no pain," and a one hundred (100) would mean "pain as bad as it could be." Please write only one response. AN ll-POINT BOX SCALE Zero (0) means "no pain," and a ten (10) means "the worst pain ever." On the 0 to I0 scale be low, put an "X" through the number that best pinpoints your level of pain. 10 11 I 2 I 3 141 5 16 17 I 8 I 91101 FIGURE 5-2. The 10l-point Numerical Rating Scale and an ll-point box scale. scales are extremely simple to administer and score, lending their application to a greater variety of patients than other scales (Jensen et aI., 1986; Littman et aI. , 1985). Visual Analogue Scale The VAS is another measure used to assess pain intensity and typically consists of a 10- to 15-cm line, with each end anchored by one extreme of perceived pain intensity (Fig. 5-3). The VAS has one end of its line labeled "no pain" and the other, "pain as bad as it could be." The patient is asked to mark along the line what best approxi mates his or her level of perceived pain intensity. The distance measured from "no pain" to where the patient's marks the scale represents the score. The visual analogue scale (VAS) I IPain as bad No pain as it could be I t( IPain as bad No pain as it could be Score = 6.3 em FIGURE 5-3. The Visual Analogue Scale (VAS) and an example of a completed VAS with a score of 6.3. For example, during an initial evaluation, you cho the VAS as the scale to determine the patient's perceiv pain intensity. After hearing a brief description of scale, the patient makes a pencil slash through the 10- line at a measured distance of 6.3 cm. This becomes patient's baseline score of pain intensity. Subsequen you can administer and score a new VAS at regu intervals during the rehabilitation to chart the patie progress. Visual Analogue Scales provide a high number response categories. As with the NRS-1 01 (with 1 responses), a VAS's 10-cm line can be measured increments of millimeters, from 0 to 100 mm, allow for 101 possible responses. This potentially makes VAS (and the NRS-101) more sensitive to pain inten than other measures with more limited responses su as the VRS 5-point scale. Also, the VAS may be m sensitive to changes in chronic pain rather than in ac pain (Carlsson, 1983; McGuire, 1984). While the VAS is easy to administer, two poten sources of error exist. First, some patients, particula older ones, may have difficulty working with graphic rat than verbal scales of their pain (Jensen et aI., 19 Kremer et aI., 1981). Patients may find it difficult to r their pain on the VAS because it is hard to understa Therefore, proper supervision by the clinician may crease the chance of error (Jensen et aI., 1986). Inaccur measurement of the patient's VAS is another source error. If the clinician or researcher does choose the VA thoughtful patient explanation and thorough attention scoring are vital (Jensen & Karoly, 1992). Descriptor Differential Scale Another method to assess pain intensity is the D scriptor Differential Scale (DDS) (Gracely & Kwilo 1988) (Table 5-2). Twelve descriptor items are presen in this scale. Each descriptor is centered over 21 h zontal dashes. At the extreme left dash is a minus si and at the extreme right dash is a plus sign. Patients asked to rate the magnitude of their pain in terms of ea descriptor. If their pain is equal to that of a spec descriptor, they place a check mark directly below word. If their pain is greater than the descriptor, th place a check to the right, depending on how much m intense they rate their pain. If the pain is less than specific descriptor, they place their check to the left, a so on. Each descriptor has a rating of intensity on a sc of 0 to 20. Thus, 21 responses are possible for e descriptor. One advantage of the DDS is that it is a multiple-it measure, as compared with single-item measures. T may provide more reliable and valid assessments of p than single-item scales (Jensen & Karoly, 1992). Since DDS is of recent development, however, further resea is needed to test its reliability among varying pati populations.
- 149. DESCRIPTOR DIFFERENTIAL SCAlEOF PAIN INTENSITY Instructions: Each word represents an amount of sensation. Rate your sensation in relation to each word with a check mark. Faint I (- ) - ------------------------------------------------------------------------------------- (+) Moderate I (- ) -------------------------------------------------------------------------------------- (+) Barely strong I (-) ------------------------- ----------------------------------------------------------- (+) Intense I (- ) ------------------------------------------------------------------------------------- (+) Weak I (- ) ------------------------------------------------------------------------------------- (+) Strong I (- ) ------------------------------------------------------------------------------------- (+) Very mild I (- ) -------------------------------------------------------------------------------------- (+) Extremely intense I (-) ------------------------------------------------ ------------------------------------ (+) Very weak I (-) - - --------------------------------------------------------------------------------- (+) Slightly intense I (-) ------------------------------------------------------------------------------------ (+) Very intense I (- ) ------------------------------------------------------------------------------------- (+) Mild I (- ) --------------------------------------------------------------------------------------- (+) Reprinted from Gracely, R. H., & Kwilosz, D. M. (1988). The descriptor differential scale: Applying psychophysical principles to clinical pain assessment. Pain, 35, 280, with kind permission from Elsevier Science B. V , Amsterdam, The Netherlands. ASSESSING THE AFFECTIVE COMPONENT OFPAIN Clinically, measurement of pain intensity alone is not sufficient to establish a complete picture of the patient's pain experience. It is necessary to measure the affective dimension as well, The following questions can be better understood by assessing the affective component of pain: How unpleasant or upsetting is the patient's pain'? To what extent does the patient's pain disrupt his or her behavior'? Can the patient cope with pain'? Why do such differences exist among patients' abilities to cope with pain'? Verbal RatingScale Verbal Rating Scales for assessing pain affect consist of adjectives describing increasing levels of unpleasantness, ing." Patients are asked to select a word that best describe their affective pain (Table 5-3). Verbal Rating Scales can be scored by a ranking method With this method, the word representing the lowest level o pain is given a score of " 0," the next a score of " 1," an so on until each word has a rank score associated with (Jensen et aI. , 1989). The patient's score equals the ran score of the word chosen. For example, in Table 5-3, if th patient selects the work "awful," his or her score would b an" 8. " As stated earlier, caution should be exercised whe interpreting the VRS, as this method assumes equa intervals between each descriptor This ranking metho may not produce scores that are accurate numerica representations of pain. Verbal Rating Scales for pain affect have two importan drawbacks. The first is the question of validity. For measure of pain affect to be valid, it must be distinct from measures of pain intensity. Recent research with pos operative patients (Jensen et aI., 1989) indicates tha VRSs designed to measure pain affect were not distinc from measures of pain intensity. It is recommended tha further research be conducted into the validity of VRS among different patient populations. Second, the patien must choose a descriptor even if none of the availabl descriptors adequately describe his or her affective re sponse. This may result in a false representation of th pain. Visual Analogue Scale Visual Analogue Scales for pain affect are. similar t those for pain intensity, except that the end points ar different. The affective VAS scale (Fig. 5-4) typically use a 10- to 15-cm line that is anchored at one end by "not ba TABl [;,-~ VERBAL RATING SCAlE OF PAIN AFFECT 15-Point Scale Bearable Distracting Unpleasant Uncomfortable Distressing Oppressive Miserable Awful Frightful Dreadful Horrible Agonizing Unbearable Intolerable Excruciating Reprinted from Gracely, R H. , McGrath, P., & Dubner, R. (1978). Rat scales of sensory and affective verbal pain descriptors. Pain, 5, 11 , wi kind permission from Elsevier Science B. V, Amsterdam, The Nethe lands.
- 150. 128 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT Visual analogue scale (VAS) of pain affect Not bad I IThe most unpleasant at all feeling possible for me FIGURE 5-4. The Visual Analogue Scale (VAS) of pain affect. at all" and at the other end by "the most unpleasant feeling possible for me" (Price et al., 1987). Visual Analogue Scales for pain affect are sensitive to changes in an individual's affective pain perception, mak ing them valid measurements (Price et aI. , 1987). How ever, as with VASs for pain intensity, patients using the affective VAS may have difficulty with graphic represen tations of their pain. Therefore, therapists can easily measure the scale inaccurately if meticulous technique is not used. Pain Discomfort Scale A relatively new method of assessing pain affect is via the Pain Discomfort Scale (PDS) (Jensen et al. , 1991) (Table 5-4). With the PDS, the patient is asked to indicate the level of agreement (from 0 ="This is very untrue for me" to 4 = "This is very true for me") for each of 10 items on the scale. The PDS is a valid and reliable measure of pain affect for chronic pain patients. To assess test-retest stability of the PDS, subjects were administered the scale at discharge and at 1 month and at 4 months following discharge. The discharge/I-month follow-up correlation was 0.64 (P < 0.001, one-tailed test) and the 1-month/4-month follow-up correlation was 0.76 (P < 0.001, one tailed test). The construct validity of the PDS was examined against two indices; depression, as assessed by Beck Depression Inventory (Beck, 1967), and the McGill Pain Questionnaire (MPQ) Affective Subscale (Melzack, 1975). The correlation coefficients were Beck Depression Inven tory, 0.58 (P < 0.001, two-tailed test), and Affective Subscale, 0.38 (P < 0.01, two-tailed test) (Jensen et al., 1991). The advantages of this measurement tool are that it can be quickly administered and it provides a broader range of response (10) than the VRS (choice of one descriptor) or the affective subscale of the MPQ (in which respondents choose from five categories). Also, the PDS is unique among affective measures since it is the only measure that directs patients to indicate their feetings of fear, helpless ness, annoyance, and distress in response to pain. The one drawback of the PDS is that the scale was developed and validated for chronic pain patients whose pain averaged 9 years' duration. Several of its items are inappropriate for acute and postoperative pain, such as item 4, "My pain does not stop me from enjoying life," or item 9, "I never let the pain in my body affect my outlook on life." Descriptor Differential Scale In addition to the scale for pain intensity, the DDS has a separate scale for assessing pain affect (Grac Kwilosz, 1988). Table 5-5 outlines the DDS for pain a The patient has a choice of 12 descriptor items, having a rating of "unpleasantness." Each descrip centered over 21 horizontal dashes. A minus sign is lo to the extreme left, and a plus at the extreme right patient rates the unpleasantness of each descriptor. affective nature of the pain is equal to a specific descr he or she places a check directly below the word. If the is less than the specific descriptor, a check is placed left, depending on how much less he or she rates the If the pain is greater than the descriptor, a check is p to the right, and so on. Each descriptor has 21 po responses. As previously explained, the DDS has recently developed, and further research must be conducte varying patient populations. However, its advantage its potential ability to assess the sensory and aff components of pain. McGill Pain Questionnaire The most widely used and most thoroughly resea assessment tool for pain is the MPQ. The MPQ developed from a two-part study (Melzack & Torge TAI3I .E S--4 DIE PAIN DISCOMFORT SCAlE Instructions: Please indicate by circling the appropriate numbe whether each of the statements below is more true or false f you. Please answer every question and circle only one numb per question. Answer by circling the appropriate number (0 through 4) according to the following scale: 0= This is very untrue for me. 1 = This is somewhat untrue for me. 2 = This is neither true nor untrue for me (or it does not a to me). 3 = This is somewhat true for me. 4 = This is very true for me. 1. 1am scared about the pain I feel. o 1 2 2. The pain 1experience is unbearable. o 1 2 3. The pain I feel is torturing me. o 1 2 4. My pain does not stop me from enjoying life. o 1 2 5. I have learned to tolerate the pain I feel. o 1 2 6. I feel helpless about my pain. o 1 2 7. My pain is a minor annoyance to me. o 1 23 8. When I feel pain I am hurting, but 1am not distressed. o 1 2 9. I never let the pain in my body affect my outlook on life. o 1 23 10. When I am in pain, I become almost a different person . o 1 2 Reprinted from Jensen, M. P., Karoly, P., & Harris, P. (1991). Jou Psychosomatic Research, 35 (2/3), 151 , with kind permissio Elsevier Science Ltd., The Boulevard, Langford Lane, Kidlingto 1GB, UK
- 151. DESCRIPTOR DIFFERENTIAL SCAlEOF PAIN AFfECT Instructions: Each word represents an amount of sensation. Rate your sensation in relation to each word with a check mark. Slightly unpleasant I (-) ------------- ------------------------------------------------------------------------ (+) Slightly annoying I (-) ----------------------- ------------------------------------------------------------- (+) Unpleasant I (- ) --------------------------- ------------------------------------------------------- (+) Annoying I (-) ------------------------------------------------------------------------------------- (+) Slightly distressing I (- ) ---------------------------------------------------------------------- ---------------- (+) Very unpleasant I (- ) ---------------------------------------------- -------------------------------------- (+) Distressing I (-) --------------------------- -------------------------------------------------------- (+) Very annoying I (- ) ------------------------------------------------------------------------------------ (+) Slightly intolerable I (- ) --------------------------------------------------------------------------------------- (+) Very distressing ! (-) -------------------------------------------------------------------------------------- (+) Intolerable I (- ) ------------------------------------------------------------------------------------- (+) Very intolerable I (- ) --------------------------------------------------------------------------------------- (+) Reprinted from Gracely, R. H., & Kwilosz, D. M. (1988). The descriptor differential scale: Applying psychophysical principles to clinical pain assessment. Pain, 35, 283, with kind permission from Elsevier Science B. V, Amsterdam, The Netherlands. 1971). The first part categorized 102 words that describe different aspects of the pain experience. These words were classified into three major classes and 16 subclasses. These classes were 1) words that describe the sensory qualities of the experience in terms of time, space, pressure, heat, and related properties; 2) words that describe the affectiue qualities in terms of tension, fear, and autonomic proper ties that are part of the pain experience; and 3) eualuatiue words that describe the subjective overall intensity of the total pain experience. The second part of the study determines the pain intensities implied by words within each subclass. The MPQ consists of a top sheet to record necessary patient medical information, line drawings of the body for the patient to indicate the pain location (part 1), words that describe temporal properties of pain (part 2), words that describe the pattern of pain (part 3), and a five-pOint rating scale for pain intensity (part 4) (Fig. 5- 5). of the MPQ, rather than simply handing the MPQ to th patient along with a pencil. Initially, this test may take 15 t 20 minutes to administer; with experience administerin the MPQ, the patient should be able to complete the MPQ in 5 minutes. The line drawings of the body are anterior and posterio views, onto which the patient indicates the location of hi or her pain.The patient marks an "E" for external pain, a "I" for internal pain, or an "EI" for both internal an external pain. In part 2, the patient chooses one word from each of 20 categories that best describes his or her pain at tha moment. If no single word is appropriate from an category, that category is left blank. In part 3, the patien describes the pattern of pain being experienced by choos ing words from three, three-word columns with words suc as "continuous," "intermittent," and "momentary." Wha activities the patient has found that relieve or exacerbat the pain are also written down. In part four, the patien rates the pain he or she is experiencing on a scale of 0 to 5, with 0 corresponding to "no pain," 1 to "mild," 2 t "discomforting, " 3 to "distressing," 4 to "horrible," and to "excruciating." Three important scores are tabulated from the MPQ 1. The descriptors in the first 20 categories are divided into four groups: 1 through 10, sensory; 11 throug 15, affective; 16,evaluative; and 17 through 20, mis cellaneous. Each descriptor is ranked according to it position in the category. For example, in column one "flickering" would be given a rank of 1, and "quiv ering," a rank of 2. The sum of the rank values i assigned the Pain Rating Index (PRI). 2. The number of words chosen is determined. 3. The Present Pain Index (PPI) is tabulated from th patient's response to part 4. Each MPQ score represents an index of pain quality an intenSity at the time of administration. The clinician ca administer the questionnaire before and after a series o treatment sessions. The difference can be expressed as percentage change from the initial value. For example, you might administer the MPQ to a patien who has just begun rehabilitation follOWing spinal fusion surgery. Initial scores on the PRI and the PPI are 52 an 4 ("horrible"), respectively. You decide to administer th MPQ biweekly for 1 month. The scores of the PRI and PP after the last MPQ are 21 and 2 ("discomforting") respectively; this represents an objective change in th patient's pain experience. The MPQ has been proven to be valid, reliable, an useful (Chapman et a!., 1985; Graham et a!., 1980 Reading 1989; Reading et a!., 1982; Wilke et a!., 1990) This assessment tool has also been used in over 100 studies of acute, chronic, and laboratory-induced pain. has been modified and translated into several language (Vanderlet et a!. , 1987; Melzack & Katz, 1992; Stein & Mendl, 1988). .. -- "...~
- 152. 130 UNIT "TWO-COMPONENTASSESSMENTS OF THE ADULT McGill-MeI7..ack PAIN QUESTIONNAIRE Patient's name Age ____ File No. Date ______ Clinical cah:~g01y (e.g.• cardiac. neurological. etc.): Diagnosis: _______ Analgei.ic (if already administered): I. Typc __________ 2. Dosagc ___________ 3. Time given in rcl<.llion 10 thi $ tes.t ________ Pa1ient's intelligence: circle number that represents best cSlimal~ I (low) 5 (high) This questionnaire has been designed to lell U~ more about your pain. Four major questions w(! ask are: I. Where is your pain? 2. What dOt!s it fed like? 3. How does it change with time? 4. How strong is it? It is impol1::mt that you tell us how your pain feels now. Please follow the instructions at thl.! beginning of each pan ~) R. Melz:1ck, Oct. 1970 Part I. Where is your Pain? Please mark, on the drawings below, the areas where )'ou feci p<tin. Put E if external. or I if internal. ncar the areas which ),OU mark. Put E1 if bOlh external and internal. Part 2. What Does Your Pain Feel Like? Some of the words below describe your pn:~nt pain. Cirele ONLY those words that best describe it. Lca'c out any category that is nOI suitable. Usc only a single word in each appropriate catc:;oTy-lhe one that applies best. I 2 4 Flickering Jumping Pricking Sharp Quivering Aa..l;hing Boring Cuuing Pulsing Shooting Drilling Lacerating Throbbing Stabbing Bcating - Lancinating POlmding Pinching Tugging Hot Tingling Pressing Pulling Burning Itchy Gnawing WrenChing Scalding Smartmg. Cramping Scaring Stinging Cru~hing 9 10 II 12 Dull Tender 'firing Sickening Sore Taut Exb:1u!ling Suffocating Hurting Rasping Aching Spliuing Heavy 13 14 15 16 Fe.arful Puni,..;hing Wretched Annoying Frightful Gmeling Blinding Trou bll!somc Terrifying Cruel Miserable Vicious Intense Killing Unbearable 17 18 19 20 Spreading Tight Cool Nagging Radiating Numb Cold Nauseating Penetrating Drawing Frc"Czing Agonizing Piercing Squeezing Dreadful Tearing Tortllring Part 3. How Docs Your Pain Change With Time? 1. Which word or words would you use to describe the pattern of your pain? Continuou5- Rhythmic Brief Steady Periodic Momentary Constant Intelminent Tramicnt 2. What k.ind of Ihing~ relicve your pain? 3. What kind of things increase your pain? Part 4. How Strong Is Your Pain'? Pcople agree tha.t rhe following 5 .'ords rcprc..ent pain of increasing intenSity. They arc: 3 4 Mild Discomforting Distressing Horrible Excruciating To answ~r ~ach que~tion below, write the number of the most appropriare word in the space bC5idc the question I. Which word describes your pain right now? 2. Which word de!tcribc!' il Jl its worst? 3. Which word dc!"cribcs it whcn it is lea!-I 4. Which word dcscribt!s the worst toothache you ever had? 5. Which word dt:s.cribcs the worst headache you ever had? 6.. Which word dc..;cribes the wor!"t stomach-ache you ever had? FIGURE 5-5. The McGill Pain Questionnaire. (Reprinted from Melzack, R. [1975J. The McGill Pain Questionnaire: Major properties and scori methods Pain, 1, 280,281, with kind permission from Elsevier Science B. v., Amsterdam, The Netherlands.) Perhaps one of the most interesting features of the MPQ is its potential for differentiating among pain syndromes. One study (Leavitt & Garron, 1980) found different descriptor patterns between two major types of low back pain. The authors found that patients with "organic" causes used different patterns of words from patients whose pain was "functional"-having no physical causes. In a more recent study (Melzack et aJ. , 1986), the MPQ was used to differentiate between trigeminal neuralgia an atypical facial pain. The results showed a correct predictio for 90 percent of the patients. The MPQ is the most thorough clinical tool for assessin a patient's pain. However, the clinician must consid whether the MPQ is too complex and time consuming fo the patient, since it involves answering 70 separate que tions each time it is administered (Machin et aI., 1988
- 153. PAIN LOCATION, BODYDIAGRAMS, AND MAPPING Inadditionto assessing pain intensityand pain affect, the location of the patient's pain is an important third dimen sion of the pain experience. Asking the patient, "Where is your pain?" may not be sufficient to pinpoint its location. The pain drawing is a reliable and valid instrument for assessing the location of pain (Margolis et ai., 1988; Schwartz & DeGood, 1984). The pain drawing may be an appropriate assessment of pain location, particularly in the chronic pain population (Margolis et aI., 1986; Ransford et al., 1976). Figure 5-6 is a representative example. Patients are asked to color or shade areas on the line drawing of a human body that correspond to areas on their bodies that are painful. Additional symptoms such as "numbness" and "pins and needles," as well as more detailed descriptors of pain such as "deep," "superficial," "burning," "aching," and "throbbing," can be denoted by various symbols. The pain drawing can be used to help establish treatment programs as well as a measure of treatment outcome. However, the clinician must consider how the pain drawing is interpreted. Recently, a scoring method has been FIGURE 5-7. Pain drawing scoring template. (Reprinted from Margol R. B., Tait, R. C., & Krause, S. J. [1986l. A rating system for use w patient pain drawings. Pain, 24, 60, with kind permission from Elsev Science B. V., Amsterdam, The Netherlands.) developed, based on the presence or absence of pain each of 45 body areas (Margolis et aI., 1986) (Fig. 5-7 For each of the 45 areas, a score of 1 was assigned if patient's shadings indicated that pain was present and score of 0 if pain shadings were absent. To score th drawings, weights were assigned to body areas equal to th percentage of body surface they covered. This scorin system is similar to the system used for assessing bu victims (Feller & Jones, 1973). CONCLUSIONS This chapter has reviewed the physiology of pai explored the dimensions of the pain experience, an provided a variety of scales to assess pain intensity, pa affect, and pain location in the clinical setting. Althoug every patient's pain experience is unique and influenced b numerous factors, a thorough pain evaluation shou include an assessment of pain intensity, pain affect, an pain location. Many of the measures presented are clinically reliabFIGURE 5-6. Example of a body diagram.
- 154. 132 UNIT1WO-COMPONENT ASSESSMENTSOF THE ADULT and valid, whereas others have not yet been thoroughly tested. Ironically, these scales have been used in research endeavors rather than by physical therapists and occupa tional therapists in the clinical setting. Without question, more clinical research is needed to further detail the effectiveness of these assessment tools with a variety of patient populations. Even so, these pain assessment scales are simple and effective tools that can and should be used clinically. Affective dimeasion of pain-The complex series of behaviors a person uses to escape a painful stimulus. Pain tolerance is a principal aspect of the affective dimension. First-order neurons-Myelinated and unmyelinated nerve fibers that transmit electronically coded information from the periphery to the dorsal horn of the spinal cord. Internuncial neuroas-Cells located in the substantia gelatinosa of the spinal cord that can either facilitate or inhibit the transmission of noxious stimuli. Second-order neurons-Cells that transmit informa tion from the spinal cord to the higher centers in the brain. Sensory dimension of pain-Pain that can be iden tified and located to a specific part of the body and graded by intensity. Somatoseasory cortex-A region in the posterior section of the central sulcus (in the parietal lobe) that is important in the localization of pain. Verbal rating scale-A list of adjectives to describe either pain intensity or pain effect. The patient is asked to choose a word from the list that best describes the intensity or unpleasantness, respectively, of his or her pain. Visual analogue scale-A line, usually 10 to 15 centimeters long with each end achored by extremes of either pain intensity or pain effect. A patient is asked to place a mark on the line that best describes his or her pain. Wide-range-dynamic neuroas-Cells located in the spinal cord that respond to a broad spectrum of noxious and nonnoxious stimuli. REFERENCES Beck, A. T. (1967). Depression: Clinical, experimental and theoret; calal aspects. New York: Hoeber. Bonica, J. J., & Benedetti, C. (1980). Post-operative pain. In R. E. Condon & J. J. Decosse (Eds.), A physiological approach to clinical management. Philadelphia: Lea & Febiger. Carlsson, A. M. (1983). Assessmentof chronic pain, Part I. Aspects ofthe reliability and validity of the visual analogue scale. Pain, 16,87-101. Cole, B., Finch, E., Gowland, C., & Mayo, N. (1992). In B. Cole, E. Fmch, C. Gowland, & N. Mayo (Eds.): Physical rehabilitation outcome measures (1st ed.). The Canadian Physical Therapy Association. Chapman, C. R., Casey, K. L, Dubner, R., Foley, K. M., Gracely, R. H., & Reading A. E. (1985). Pain measurement: An overview. Pain, 22,1-31. Downie, W. w., Leatham, P. A., Rhind, V. M., Wright, v., Branco, J. & Anderson, J. A. (1978). 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- 157. CHAPTER 6 Gardiovascula'r and Pulmonary Function Elizabeth T. Protas, PT, PhD, FACSM SUMMARY The measurement of cardiovascular and pulmonary function is crucial to assessing the patient's status, planning an exercise program, and establishing the outcomes of an intervention. The clinician needs to be familiar with a number of standard tests for assessing these functions. In this chapter the discussion is focused on the evaluation of exercise capacity and endurance using standard exercise test ing protocols, clinical measures of exercise capacity, and other measures of exertion. Another means for measuring the difficulty of a task is to monitor heart rate responses. The clinician must be able to accurately record the heart rate and interpret the results. Blood pressure is an easily accessible measure of cardiovascu lar and autonomic responses. Standardizing the methods of measuring blood pressure will greatly increase the reliability of these values. Another aspect of the ability to perform functional activity or to exercise is the ability of the lungs to deliver oxygen to the working muscles and to eliminate carbon dioxide. Observa tion of breathing patterns may be the simplest way for the clinician to detect the stress of an activity, but there are instruments available for recording pulmonary re sponses to activities. Finally, monitoring blood oxygenation is important, especially in an individual who has pulmonary disease. Current methods available to the cli nician are discussed. Functional activities require that an individual be able to draw on the cardiovascular and pulmonary systems to respond to a wide variety ofdemands. The reserves in these systems provide a range from resting to maximal ability. Physical and occupational therapists are interested in the patient's ability to respond to activities of daily living. Endurance from this perspective is often submaximal. Most persons would rarely need to draw on maximal capacities. On the other hand, clinicians frequently encounter indi viduals whose reserves have been severely restricted through disease, deconditioning, or both. In this ins a patient may become short of breath when transf from the bed to a wheelchair. Physical and occupa therapists need to assess a patient's endurance an these assessments to plan treatment programs. Improved endurance is one of the most common c goals for occupational and physical therapists; ho there are no widely accepted standards for measurin evaluating endurance in patient populations. This despite the fact that there are a number of good me Cl.". "
- 158. 136 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT or tests that can be used. These methods range from very simple to more complex tests requiring considerable instrumentation. In this chapter the focus is on measuring cardiovascular, autonomic, and pulmonary responses to activities; on the clinical applications of these tests; and on test interpretation. Cardiovascular responses include the ability of the heart to pump an adequate amount of blood, the distribution of the blood through changing blood pressure, and the delivery of the blood through the blood vessels. The pulmonary system responds to exercise by increasing the rate and depth of ventilation to provide adequate gas exchange. By matching ventilation with the blood perfused in the lung, the blood will be adequately oxygenated and carbon dioxide eliminated. Under normal circumstances, the cardiovascular and musculoskeletal systems or both limit exercise capacity and endurance. The pulmonary system's capacity is much greater and is not thought to normally limit exercise capacity. An additional consideration for the clinician is that cardiovascular disease is the most common chronic disease in American adults (Hahn et aI., 1990). Many patients referred for physical or occupational therapy have overt or latent cardiovascular disease. A number of therapists are also involved in cardiac and pulmonary rehabilitation programs. These programs require that the therapist recognize the normal as well as the abnormal responses of the systems. Both cardiovascular and pulmonary measures are dis cussed in this chapter. Measures of heart rate, blood pressure, and exercise capacity are presented, in addition to measures of ventilation and oxygen saturation. HEART RATE The heart rate is probably the easiest means for the clinician to monitor cardiovascular responses to activity. The validity of the heart rate as a cardiovascular measure is based on the linear relationship between heart rate, the intensity of aerobic exercise, and the oxygen consumption (Montoye et a!., 1996). (Fig. 6-1). Resting heart rate is 70 to 75 beats per minute and increases incrementally with gradually increasing aerobic activity until maximal exercise capacity is reached. Variability in heart rate responses between persons is created by age, level of fitness, and presence or absence of disease. A 65-year-old individual who is not fit will have higher submaximal heart rates and lower maximal heart rates than a fit 65-year-old. Determining the heart rate by palpating either the radial or the carotid pulse is the most common means used in rehabilitation settings. Heart rates are palpated either for a fixed period of time (i.e., 10, 15, or 60 seconds) and extrapolated to establish the beats per minute or a given number of beats are counted (i.e., 30 beats). The latter method is much easier to use during exercise activities. The 150 140 ~130 D. III 2120 ~ t m110 I 100 90' i i i i i i i i i i i i i i 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 27 Oxygen consumption (mUkglmin) FIGURE 6-1. Heart rate compared with increasing oxygen con tion during exercise for fit and unfit individuals. heart rate is determined using a conversion table (Sin & Ehsani, 1985) (Table 6-1). Standardizing the proce as much as possible should increase the accuracy of rate assessments. Procedural considerations include n the position of the measure (e.g., either supine or sitti resting heart rates), using a similar time period, avo using the thumb, and using the same artery. Exc pressure on the carotid artery can cause a reflex slow the heart rate (White, 1977). Palpated radial and c heart rates are not Significantly different from heart recorded with an electrocardiogram (ECG) during ex in healthy subjects (Sedlock et a!., 1983). TABl F. 6-1 HEART RATE CONVERSION DETERMINE BY TIMING 30 CARDIAC CYCLES nme· Ratet 220 21.0 20.0 19.0 18.0 17.5 17.0 16.5 16.0 15.5 15.0 14.5 14.0 13.5 130 12.5 12.0 11.5 11.0 10.5 10.0 9.5 9.0 Time for 30 beats. tHeart rate per minute. 82 86 90 95 100 103 106 109 113 116 120 124 129 133 138 144 150 157 164 171 180 189 200
- 159. FIGURE 6-2. Heartrate telemetry system (Polar Vantage XL) showing heart rate wrist monitor and chest belt transmitter. (Courtesy of Polar CIC, Inc., Port Washington, NY) Many clinical situations do not allow the therapist to palpate the pulse rate during an activity. For example, when doing gait training with a patient who requires contact guarding, the pulse rate may need to be taken immediately after the exercise stops. Generally, the pulse should be palpated within 15 seconds of exercise cessation because the pulse begins to decrease rapidly after the activity is stopped (Pollock et a!., 1972). The number of beats should be counted for 10 seconds and extrapolated to the minute value. Although postexercise heart rates are significantly lower, the difference is only about 4 percent lower than the heart rate recorded during exercise (Cotton & Dill, 1935: McCardle et a!., 1969; Sedlock et a!., 1983). Accuracy is improved if the pulse is located rapidty and the measure taken as quickly as possible. My colleagues and I have found intertherapist reliability of palpated carotid pulses in elderly postoperative patients performing assisted ambulation to be poor (Protas et a!., 1988) Portable heart rate telemetry systems can also be used to record exercise heart rates. These devices are composed of a chest band with a sensor and a telemetry receiver that can be worn on the patient's wrist or on the thera pist (Fig. 6-2). The heart rate can be displayed on the receiver and stored so that heart rate trends over time can be recorded. The rate is derived by averaging four beats over a period of time. The higher the heart rate, the shorter the measurement time. Many devices can also be pro grammed to record the rate at different intervals (e.g., every 15 seconds for 4 hours). Some devices have computer interfaces so that a record of heart rates over several hours or days can be determined. Some of these devices corre- others are less accurate (Leger & Thivierge , 1988; Trei et a!., 1989). Gretebeck and colleagues (1991) report that a portable heart rate monitor they tested missed f beats but that its operation was influenced by proximity a computer or microwave oven, traffic signals, and driving, among other things. The chest sensor must snugly attached to the subject and located on a rib or bo prominence to decrease the possibility of muscle interf ence. These devices have been found to be reliable duri assisted ambulation with elderly nursing home reside (Engelhard et a!., 1993); however, there is little informati on the use of these devices in clinical settings with vario patient populations. Clinicians should monitor the acc racy of these devices for their own application and settin A more detailed record of heart rate, rhythm, and t analysis of the ECG can be obtained by using standard EC monitoring. This is more frequently used in intensive ca cardiac, or pulmonary rehabilitation. Lead placement either a bipolar, single-lead system or 10 leads, which p vides a standard 12-lead ECG (Gamble et a!., 1984) (F 6-3). A bipolar system is less sensitive in detecting ischem ECG changes during exercise than a 12-lead syste (Froelicher, 1983; Hanson, 1988); however, a bipolar le is recommended for exercise testing in pulmonary patie unless ischemic heart disease is suspected (American As ciation of Cardiovascular and Pulmonary Rehabilitatio 1993). Rate determination from the recording is possi because of the standard paper speed of the ECG. An EC heart rate ruler or other methods using the interval betwe two R waves provides the rate (Schaman, 1988) (Fig. 6- ECG rate determination is accurate as long as interferen from motion artifact is minimized during exercise by prop skin preparation and the use of adequate, gelled electrod with secure placement. ECG rhythm is the determination of the interval betwe A B FIGURE 6-3. A, Bipolar lead CM5 has a positive electrode on the f rib interspace (C5) and the other on the manubrium (M). B, The 10-l placements for a standard 12-lead electrocardiogram. (A from Froelic V. F , et at [19761. A comparison of two-bipolar electrocardiograp leads to lead V5. Chest, 70. 611-616. Bfrom Gamble. P. , McManus, Jensen. D., Froelicher. V. [1 9841. A comparison of the standard 12-l electrocardiogram to exercise electrode placements Chest, 85, 6 622)
- 160. 138 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT 0 0 0 o Lf) 0 Lf) 0 C') ~ ~ r-- <D FIGURE 6-4. Heart rate determination from an electrocardiogram can be performed by using a rate scale for each heavy line on the tracing. each R wave. Normally, the rhythm should be regular with equal intetvals between each R wave. Irregular intervals between R waves are referred to as arrhythmias. Variations in rhythm can occur sporadically or at a fairly predictable interval, for example, every third or fourth beat. Although some arrhythmias can be detected while palpating a pulse as an uneven pulse rate, identification of the arrhythmia can only be done with an ECG. The value of ECG monitoring during activity or exercise is one of safety. If a therapist is working with a patient whose condition is unstable, who is at high risk for arrhythmias or coronary artery disease, or who has a recent history of cardiovascular disease, detecting abnormal re sponses may indicate the need for a different exercise intensity or pace to lessen the cardiovascular stress. Evidence from supervised cardiac rehabilitation programs indicates that the rate of myocardial infarction is 1 per 300,000 patient-hours, with a mortality rate between 1 in 790,000 patient-hours of exercise (Van Camp & Peterson, 1986) and 1 in 60,000 participant hours (Haskell, 1994). There are no published accounts of myocardia!l infarctions or sudden death during physical or occupational therapy exercise. This may suggest that medically supervised exercise programs are relatively safe with or without ECG monitoring even though the risk of a serious event cannot be eliminated. Clinicians should be aware of a number of risk classification systems available for detecting individuals at risk for a cardiac event during exercise (American College of Sports Medicine, 1995). BLOOD PRESSURE Resting and exercise measurements of blood pressure, just as heart rate, are easily monitored by most clinicians. The procedure is a bit more complicated but, if precise, is accurate. Resting blood pressure values are used to deter mine hypertenSion. Table 6-2 provides a classification system for blood pressure. The methods for taking resting blood pressure are straightforward (Altug et al., 1993; American College of Sports Medicine, 1995; American Heart Association, 1987). The patient should be seated for at least 5 minutes. The arm should be bare, slightly flexed with the forearm supinated, and supported by a table or the clinician's hand. The arm should be positioned at the level of the h the cuff wrapped firmly around the arm about above the antecubital fossa with the arrows on aligned with the brachial artery. Three cuff si available-child (13 to 20 cm), adult (17 to 26 c large adult (32 to 42 cm)-and should be used for d body sizes. The stethoscope should be placed abo below the antecubital fossa over the brachial Palpating the artery before placing the stethosc enhance accuracy. The cuff should be inflated qU about 200 mm Hg, or 20 mm Hg above the expecte pressure. The air in the cuff should be released slo to 3 mm Hg per heartbeat. Systolic pressure is the p when the first Korotkoff's sound is heard. The Kor sounds are created by turbulence when the cuff p goes below the pressure in the brachial artery. D pressure can be read at two points as the pressur cuff is released. The first is the pressure when the become muffled, called the fourth phase diastoli pressure, or when the sound disappears com known as the fifth phase diastolic blood pressure. the fourth phase measure for accuracy. Because th be differences between the pressure readings for t and left arms, the pressure should consistently b from either right or left. At least two readings sh averaged, especially if the reading differs by more mm Hg (National Heart Lung and Blood Institute Exercise blood pressures require additional c ations. First, since the patient is probably moving exercise, the arm on which the blood pressure taken should be as relaxed as possible. A standing sphygmomanometer is preferred during exercise to motion artifact. An aneroid manometer (the most c available clinically) must be regularly calibrated acco the manufacturer's instructions and is more difficul TABII: (, 2 ClASSIFICATION OF BLOOD PRESSUR FOR ADULTS· SystoUe DiastoUe (nun Hg) (nun Hg) Category <130 <85 Normal 130-139 85-90 High normal 140-159 90-99 Mild (stage 1) hyper 160- 179 100-109 Moderate (stage 2) tension 180-209 110-119 Severe (stage 3) hyp tension ?210 ?120 Very severe (stage 4 tension "Not laking antihypertensive medication and not acutely ill. Wh and diastolic pressures fall into different categories, the highe should be selected. Reprinted with permission from National Heart, Lung, a Institute. (1993). The fifth report of the Joint Committee on D Evaluation, and Treatment of High Blood Pressure. Archives o Medicine, 153, 154-183.
- 161. POTEN11AL SOURCES OFERROR IN BLOOD PRESSURE ASSESSMENT Inaccurate sphygmomanometer Improper cuff size Auditory acuity of clinician Rate of inflation or deflation of cuff pressure Experience of clinician Reaction time of clinician Improper stethoscope placement or pressure Background noise Arm not relaxed Certain physiologic abnormalities (e.g., damaged brachial artery) Reprinted with permission from American College of Sports Medicine. (1995). ACSM's Guidelines for Exercise Testing and Prescription (5th ed.) Baltimore: Williams & Wilkins. with motion. A mercury manometer should be at approxi mately eye level of the clinician. The systolic pressure should increase with increasing intensity of exercise activ ity. Abnormal responses include a systolic pressure that does not increase with increasing exercise or a systolic pressure that falls with increasing exercise. Blood pressure should be taken again immediately if the systolic pressure seems to be decreasing with increasing exercise (Dubach et aI., 1989).Table 6-3 summarizes potential sources of error in blood pressure measurement. The time of day in which the measurements are made does not impact exercise blood pressure responses in some clinical populations. For example, there appear to be no significant differences beween morning and afternoon blood pressure during walking in frail elderly persons (Engelhard et aI., 1993). EXERCISE TESTS Many standardized exercise or stress testing protocols have been developed (Balke & Ware, 1959; Bruce et aI., 1973; Naughton et aI., 1964; Taylor et aI., 1955). The most common applications of exercise tests in physical and occupational therapy are (1) exercise prescription, (2) assessment of exercise endurance, (3) treatment evalu ation, and (4) to ensure patient safety. These applications are conSiderably different from the more usual application of exercise tests in relation to the detection, diagnosis, and prognosis of coronary artery disease (Bruce et aI. , 1973). Reviews of the most common protocols are available elsewhere (Altug et al., 1993; American College of Sports Medicine, 1995). The test selected may depend on the purpose of the test, the test environment, the availability of special equipment, and the characteristics of the pa tient. For example, different tests may be needed for home care than in a hospital setting. The most common method of distinguishing exercise tests is by the endpoint of the test. Tests can be classified as maximal versus submaximal. A number of criteria are used change ratio (RER =volume of carbon dioxide exhale volume of oxygen consumed) over 1.15, reaching ag predicted maximal heart rate, and a plateau in the oxyg consumption (an increase of less than 150 ml/min w increasing exercise) (Froelicher, 1994). These criteria a often difficult to obtain with elderly persons and individu with various disabilities (Shephard, 1987). Repeated m sures derived from maximal exercise tests tend to reliable regardless of the population being tested. Coe cients of variation for maximal oxygen consumption ha been reported of between 2.2 and 6 percent (Shepha 1987; Wright & Sidney, 1978). Submaximal tests can ended when a predetermined heart rate or workload reached, signs of myocardial ischemia occur, or sympto cause the test to be terminated (Altug, 1993; Americ College of Sports Medicine, 1995; Astrand & Rhymin 1954; Sinacore & Ehsani, 1985). Submaximal tests a used (1) to determine the relationship beween heart r response and oxygen consumption during exercise predict maximal oxygen consumption, (2) to screen safety during an activity, and (3) to estimate cardiovascu endurance during functional activities. Submaximal te are of more value to most physical and occupat,io therapists because these tests can determine the patien current status, be used to establish a treatment plan, a assess the outcomes of the treatment. The clinician shou be aware that submaximal tests when used to pred maximal capacity introduce considerable inaccuracy in the estimate. Maximal oxygen consumption can be und estimated by between 5 to 25 percent for anyo individual (Ward eta1., 1995). If you look at Figure 6-1, y can see that an extrapolation from several of the measu of submaximal heart rate and oxygen consumption for a versus an unfit individual can result in Significantly differ predictions of the maximal values. Also in some popu tions, such as the elderly and individuals with chro disabiJ,ities, a linear relation between heart rate and oxyg consumption may not exist. Prediction of maximal valu based on submaximall responses assumes a linear relatio ship between heart rate and oxygen consumption (Skinn 1993). Exercise tests can also be distinguished by the mode a protocol of the test. The mode refers to the method or ty of equipment used. Treadmills, cycle ergometers, ar crank ergometers, and wheelchair ergometers are the m common equipment used for exercise tests. There a advantages and disadvantages for all of these devic Individuals can achieve the highest maximal oxygen co sumption when tested on treadmills; therefore, the high estimates of exercise capacity are determined with trea mills (McKiran & Froelicher, 1993). Treadmills have t additional advantages of having normative values based thousands of tests, requiring the familiar activity of walk or running, having many potential workloads, and bei the least limited of the testing devices by local mus
- 162. 140 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT fatigue. Cycle ergometers are useful for testing individuals who have gait or balance disturbances such as in Parkin son's disease or cerebral palsy, whereas arm-crank or wheelchair ergometers are used in testing individuals who have limited use of the lower extremities, such as patients with spinal cord injuries (Pitetti et aI. , 1987). Maximal oxygen consumption and maximal heart rate are 20 to 30 percent lower during arm-cranking than treadmill or cycle ergometry (Pollock & Wilmore, 1990; Protas et al. , 1996). As a result, there is a poor correlation between maximal values achieved during upper extremity and lower extrem ity testing (McCardle et al., 1991). This makes it difficult to predict responses to upper extremity exercise from lower extremity tests (Protas et aI. , 1996). Exercise programs for enhancing cardiovascular endurance of the upper extremi ties should be based on upper extremity exercise tests. Arm-crank activities, however, are less familiar to most persons and are more difficult to perform. The test-retest reliability of exercise tests is quite high. This is true for treadmills, bicycle ergometers, and arm crank ergometers (Bobbert, 1960; Ellestad et al., 1979; Fabian et aI., 1975; Pollock et al. , 1976; Protas et aI., 1996). Several factors influence the outcomes of exercise tests. In elderly persons, higher maximal oxygen consump tions are reached with a repeated test; therefore, an elderly person may require more than one exercise test session to become familiar with the test (Thomas et al., 1987). The work increments used in the test changes the maximal oxygen consumption reached. If the increment is too large or too small, a lower maximal oxygen consumption occurs (Buchfuhrer et al., 1983). For example, the increment between stage 3 (3.4 mph, 14 percent grade treadmill elevation) and stage 4 (4.2 mph, 16 percent grade) of a Bruce protocol is the difference between fast walking up a slight hill and running up a moderate hill. This may be an accurate increment for a healthy young person but too challenging for a frail elderly person. On the other hand, if the increment is too small, it makes the test excessively long (Lipkin et aI., 1986). It is recommended that exercise test increments be individualized so that the test length is 8 to 12 minutes (Froelicher, 1994). CLINICAL TESTS AND OTHER MEASURES OF EXERCISE INTENSITY An increase in the physical and occupational therapy care administered in the home or in sites such as nursing homes and community health centers has enhanced the need for measures of exercise tolerance that do not require much equipment. Several tests that are based on walking or running for a specific time or distance have been developed (Balke, 1963; Cooper, 1968; Guyatt et aI. , 1985; Kline et al., 1987). The timed tests measure the distance covered when walking or running as fast as possible for 15, 12, 9, 6, or 5 minutes. Higher distances and faster walking are associated with a greater estimate of exercise capacity. Distances covered in the 6-minute walk test can di tiate between healthy elderly persons and individua New York Heart Association Class II and III heart d My colleagues and I have found the 5-rhinute distanc moderately correlated with peak oxygen consump elderly women (Stanley & Protas, 1991) and that walking distances are reliable in elderly postop patients (Protas et aI. , 1988). Nursing home p walked significantly farther in the late afternoon than morning with a walk test (Englehard et al. , 1993). observations suggest that distance walked during walking tests in several patient populations are va reliable if readministered during the same time of day 6--4 presents some of the distances and the po clinical meaning of these values. A more useful approach to a walk test for clinicia be looking at what a clinically significant improv might be after an exercise intervention. Price and ates (1988) reported an increase from 1598 feet to feet (176 feet) during a 5-minute walk after a 3- exercise program consisting of flexibility and strengt exercises and walking to improve endurance in 5 p with either osteoarthritis or rheumatoid arthritis. A absolute increase in walking distance of 161 fe reporteci for 47 individuals with osteoarthritis af 8-week exercise intervention compared with a group not participating in the exercise program (Pe et aI., 1993). A change in 5-minute walk distanc elective total hip replacement was reported from 894 feet at 3 months after surgery and 1115 feet years of recovery (Laupacis et al., 1993). Tes reliability of a 5-minute walk test with elderly person a standard error of the measurement of 135 feet, su ing that a clinical improvement should be at least 1 to be meaningful and greater than the variability of th A continuous, progressive chair step test has developed for exercise-testing frail elderly indi (Smith & Gilligan, 1983). Subjects sit comfortably in and kick up to a target that is 6, 12, or 18 inches hig kicking rate should be controlled at l / second, alter right and left legs so that there are 30 kicks/second target is used for a 3-minute period. For the fourth an stage, the subject continues to kick to the 18-inch while simultaneously raising the ipsilateral upper extr Heart rate is observed for each stage of exercise. T "lABJ f ()- 4 PERFORMANCE ON A 5-MINUTE WALK TEST FOR MlDDLE-AGm OR OlDER SUBdECfS Classification Distance (fee Average or above >1500 Fair (moderate impairment) 1000-1300 Poor (severe impairment) <1000
- 163. RATINGS OF PERCEIVEDEXERTION Original Scale Revised Scale 6 0 Nothing at all 7 Very, very light 0.5 Very, very weak 8 1 Very weak 9 Very light 2 Weak 10 3 Moderate 11 Fairly light 4 Somewhat strong 12 5 Strong 13 Somewhat hard 6 14 7 Very strong 15 Hard 8 16 9 17 18 Very hard 10 • Very, very strong Maximal 19 Very, very hard 20 From Noble, B.J ., Borg, G. A. v., Jacobs,I., Ceci, R., & Kaiser, P. (1983). A category ratio perceived exertion scale: Relationship to blood and muscle lactates and heart rate. Medicine and Science of Sports Exercise, 15, 523-528. lasts between 6 and 12 minutes. The endpoints are volitional fatigue (particularly hip muscle fatigue) , inability to maintain the pace, knee pain, or 70 percent of age-predicted heart rate is reached. Ihave found that many frail nursing home residents can perform this test safely. Ratings of perceived exertion have been devised for use in reflecting individual exercise intensity (Borg, 1982; Noble et al., 1983). Table 6-5 shows the rating scales used, either a 6 to 20 or a 0 to 10 point scale. An explanation of the scales must be given before the exercise. The patient is told that a 6 on the 6 to 20 scale is comparable to walking at a comfortable pace without noticeable strain, whereas a 20 is the most difficult exercise the patient has experienced comparable to exercise that cannot be continued without stopping. The ratings can be differentially used to indicate central exertion from the heart and lungs, local muscle fatigue , or a combination of both. The scale values are strongly correlated with exercise intensity, oxygen con sumption, heart rate, and, for the 0 to 10 scale, blood lactate levels and ventilation. An intensity necessary for a cardiorespiratory training effect and a threshold for blood lactate accumulation can be achieved at a rating of "somewhat hard" or "hard" or between 13 and 16 on the 6 to 20 scale or 4 or 5 on the 0 to 10 scale (American College of Sports Medicine, 1995). This may be an easier method to use than to teach a patient to take his or her pulse as a means of monitoring exercise intensity. Much of the application of ratings of perceived exertion have been with healthy normal subjects and individuals with cardio vascular disease. One method of nonexercise estimation of maximal oxygen consumption has been suggested (Jackson et al., 1990). The estimate is based on regression equations that use age, physical activity status, and percent body fat or body mass index to derive maximal oxygen consumption. a wide age range (20 to 59) and fitness levels. Physi activity status (PA-R) is grossly classified according to subject's usual activity pattern. The percent body fat mo is slightly more accurate (r =.81, SEE =5.35 ml/Kg/m than the model based on body mass index (r = .7 SEE = 5.70 ml/kg/min). The equations are as follows Percent Body Fat Model: V02peak = 50.513 + 1.589 (PA-R) - 0.289 (age) - 0.552 (% fat) + 5.863 (F = 0, M = 1) Body Mass Index (BMI): V02peak =56.363 + 1.921 (PA-R) - 0.381 (age) - 0.754 (BM!) + 10.987 (F =0, M = 1) These equations have not been validated with populatio with chronic disabilities seen by physical and occupatio therapists, nor with an aging population, but the simplic may make this an option for estimates of exercise capac by the therapist. The clinician should keep in mind t considerable error may occur with these estimates. RESPIRATORY RATE Observing respiratory rate can be easily done by m clinicians. The resting rate in adults is generally 12 to . breaths per minute. A fuJI breath occurs from the beginn of inspiration to the end of expiration. The accuracy of observation of resting ventilation is enhanced if the pati is unaware that the therapist is noting breathing frequen (Wetzel et al. , 1985). Breathing frequency increases up 36 to 46 breaths per minute during maximal exerc (Astrand 1960; Wasserman & Whipp, 1975). Low maximal breathing rates occur in older individuals (Astra 1960). Exercise breathing frequencies that exceed breaths per minute are associated with ventilatory lim tion (Wasserman et al., 1994). Breathing frequenc during exercise are most reliably measured with op circuit methods. Normal maximal ventilatory breath values during exercise are shown in Table 6-6. TARLE 6-6 NORMAL MAXIMAL BREAnDNG VALUES DURING EXERCISE Value Rate Respiratory frequency < 50 breaths per minu Tidal volume (VT) < Inspiratory capacity Minute ventilation/ maximal volun 72% ± 15 tary ventilation (VE/MW) Breathing reserve (MW - VE max) 38 ± 22 L/ min ,.- L i4J4!b .. .. ........ .,-:. ~ . ~ '
- 164. 142 UNIT 1WO-COMPONENTASSESSMENTS OFTHE ADULT TIDAL VOLUME AND MINUTE VENTILATION Tidal volume is the volume of air breathed in one inhalation or exhalation. The resting tidal volume is 0.50 ml ± 0.10 ml. Tidal volume can increase to an average of 1.9 to 2.0 L during maximal exercise (Astrand, 1960). The absolute value of the maximal tidal volume is related to an individual's height, age, and gender. The highest values are seen in tall, 20-year-old men. The maximal tidal volume is between 50 and 55 percent of the vital capacity for men and between 45 and 50 percent for women (Cotes, 1975; Spiro et al. , 1974). The maximal tidal volume is generally 70 percent of the inspiratory capacity (Wasserman & Whipp, 1975). Exercise, even at a maximal value, does not use all of the lung capacity but only uses up to 70 percent of the available capacity. This is another way of looking at the fact that, under normal circumstances, exercise is limited by the cardiovascular and musculoskeletal systems, not the lungs. In individuals with restrictive lung disease the maximal exercise tidal volume approaches 100 percent of the inspiratory capacity, suggesting that lung capacity is implicated in limited exercise when restrictive lung disease is present. The minute ventilation is the product of the tidal volume times the breathing frequency . Minute ventilation increases linearly with increasing exercise until the ventilation thresh old is reached, where ventilation increases faster than the oxygen consumption. During mild to moderate exercise, the minute ventilation is increased primarily by increasing the tidal volume (the depth of breathing.) With harder exercise, increased minute ventilation is accomplished by increased breathing frequency (Spiro et al. , 1974). The maximal minute ventilation is between 50 and 80 percent of the maximal voluntary ventilation (Hansen et al. , 1984). The maximal voluntary ventilation is the volume of air that can be breathed in 12 to 15 seconds. The difference between the maximal voluntary ventilation and the maxi mal exercise minute ventilation reflects the breathing reserve, or the functional difference between respiratory capacity and what is used during exercise. The breathing reserve tends to be reduced in individuals with chronic obstructive lung disease (Bye et al., 1983; Pierce et al. , 1968). DYSPNEA SCALES Dyspnea is a primary symptom that limits exercise in individuals with pulmonary or cardiovascular disease. Dys pnea is the subjective sensation of difficulty with breathing. The patient often reports being "short of breath" or not being able to "catch" his or her breath. Dyspnea occurs when the demand for ventilation outstrips the patient's TABLE 6-7 RATING OF DYSPNEA DYSPNEA INTENSITY" I-Mild, noticeable to patient but not to observer 2-Some difficulty, noticeable to observer 3-Moderate difficulty, but can continue 4- Severe difficulty, patient cannot continue DYSPNEA LEVELSt O-Able to count to 15 easily (no additional breaths necessary I-Able to count to 15 but must take one additional breath 2-Must take two additional breaths to count to 15 3-Must take three additional breaths to count to 15 4-Unable to count The patient is asked to inhale normally and then to count out to 15 over a 7.5- to 8.0-second period. Any shortness of b can be graded by levels. "From Hansen, P. (1988). Clinical exercise testing. In S. N. Painter, R. R. Pate et al. (Eds.). Resource manual for gUidel exercise testing and prescription (p. 215). Philadelphia: Lea & t From Physical therapymanagement of patients with pulmonary Downey, CA: Ranchos Los Amigos Medical Center, Physical T Department. ability to respond to the demand and is distinct tachypnea (rapid breathing) or hyperpnea (increase tilation) (West, 1982). Several methods have bee scribed for rating the intensity of the dyspnea. methods are based on ordinal scales and opera definitions of dyspnea intensity (Table 6-7). These have not been well validated; however, the clinician keep in mind that it is difficult to measure a sub sensation. PULMONARY FUNCT:ION TiESTS Pulmonary function tests provide information o functional characteristics of the lung. These tests m air flow and air flow resistance, lung volumes, an exchange. For a review of individual tests and me ment issues related to pulmonary function tests the is referred elsewhere (Protas, 1985). Pulmonary function tests have limited applicati many rehabilitation settings. For instance, rehabilitat terventions for individuals with chronic lung disease do not change pulmonary function values of diseased even though the patient may demonstrate improved tion. The relationship between pulmonary function sures, walking ability, and submaximal exercise p mance has been shown to be poor in individual chronic bronchitis (Mungall & Hainesworth, 1979) wise, there is no correlation between regional lung tion clearance as measured by a radiolabeled techniq maximal expiratory flow during either a cough or a expiratory technique (e.g. , "huffing"), viscoscity or e ity of the sputum, and the amount of sputum expect
- 165. that maximal expiratoryflow during a cough or forced expiratory technique and the sputum production provide no guide to the efficacy of secretion clearance in the lung. On the other hand, pulmonary function values do improve in individuals with cystic fibrosis who were hospitalized for an acute exacerbation of the disease and who underwent either cycle ergometer exercise and one bronchial hy giene treatment or three bronchial hygiene treatments alone each day during the hospital stay (Cerny, 1989). Likewise, pulmonary function tests have been used to assess treatment outcomes after either inspiratory resis tive muscle training or abdominal weight training in a group of individuals with cervical spinal cord lesions. A 7-week period of training produced significant increases in pulmonary function values for both treatment inter ventions, but there were no differences between the two interventions (Derrickson et aI. , 1992). The value of pulmonary function measures to the clinician may depend on the type of patients seen, as well as on the inter ventions used. The clinician may need to monitor the pulmonary function of the individual with a high cervical spinal cord lesion more closely than the individual with stable, chronic obstructive pulmonary disease. EXERCISE TESTS Although exercise tests have been previously discussed in this chapter, several additional comments are appropri- Name: DOE, JOHN ID: 89-20795-4 VT V02 Max Time Min 5:47 7:37 V02 672 995 RER 0.92 1.21 HR 125 149 VE 20 44 VEN02 30 44 Pet02 106 122 Watts I: 43 77 FIGURE 6-5. A comparison of the ventilatory equivalent for carbon di oxide ryE!VC02) and the ventilatory equivalent for oxygen ryE!VOz) dur ing increasing exercise. The ventila tion threshold is the point at which 'I/E!VC02 begins to increase. (Cour tesy of Medical Graphics Corp., 5t. Paul, MN.) Temp: 23 Pbar: 746 DS: 115 Date: 8/16/ Sex: MAge: 57 yr Ht: 157.0cm Wt: 73.5 'kg BSA: 1.74 m VC02 RER PET02 VE ml/min mmHg o ¢ 2000. 1800 1.40 1600 ¢¢ ¢¢ ¢ 1400 1.20 1200 1000 800 600 400 200 V02 ml/min Exercise tests with the observation of pulmonary exchange provide important information about the fu tional status of an individual patient that cannot be provi by pulmonary function tests. In essence, what the clini wants to know is whether a patient's ability to function to exercise is limited. Using a standard, incremen progressive exercise testing protocol offers the chanc observe cardiopulmonary responses under controlled ercise conditions. Several pulmonary measures provide information on ventilation, gas exchange, and metabolism. The resp tory exchange ratio (RER) is the ratio between exha carbon dioxide and oxygen consumed (VC02/V02)' RER is normally 0.70 at rest (less carbon dioxide produ per unit of oxygen) and increases to greater than 1 :1 w maximal exercise. As exercise increases, the metab demands increase and the pulmonary system begin buffer the blood pH by eliminating more carbon diox (Wasserman & Whipp, 1975). Observing the ventila equivalents for carbon dioxide and oxygen (mi ventilation/carbon dioxide exhaled, VE/VC02, and min ventilation/oxygen consumed, VE/V02) gives a nonin sive, indirect measure of ventilation-perfusion (VA matching or the physiologic dead space to tidal volu ratio (VD/VT). The ventilatory eqUivalents normally decrease until ventilatory threshold for VE!VC02 or lactate threshold VE!V02 (Fig. 6-5).The VE!VC02 value is normally betw 26 and 30, while the VE!V02 is between 22 and (Wasserman et aI., 1994). Elevated ventilatory equival
- 166. 144 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT indicate either hyperventilation or uneven IA/Q (increased IDNT). Individuals with obstructive lung disease often have IA/Q mismatching and have increased ventilatory equiva lent values. OXYHEMOGLOBIN SATURATION The degree to which arterial blood is oxygenated (partial pressure of arterial oxygen, Pa02) is reflected by the oxyhemoglobin saturation of arterial blood (Sa02)' Arterial oxygenation at rest decreases with age from approximately 100 mm Hg for a 20-year-old to 80 mm Hg for an 80-year old (Marini, 1987). During heavy exercise in individuals without cardiopulmonary disease, the Pa02 values may increase slightly. Hypoxemia is decreased Pa02 and is a condition that can be harmful to a patient. The Sa02 values at rest are 95% or higher and do not normally decrease with exercise (Wasserman, 1994). The Sa02 can be monitored using an indwelling catheter to draw blood samples; however, outside the intensive care unit the use of catheters in most clinical situations is impractical. Pulse oximeters are a noninvasive method of monitoring Sa02 under a variety of circumstances. In one review it was suggested that the accuracy of pulse oxime ters is variable, even within the same model; however, versions that use finger-probe sensors may be more accurate than devices that use earlobe sensors (Men gelkoch et al., 1994). Accuracy is improved when Sa02 is greater than or equal to 85 percent in nonsmokers. Because these devices are most useful during exercise, the clinician should carefully secure the probe to the finger and should select activities that will reduce motion artifact (cycle ergometer vs. treadmill). The estimates of Sa02 when saturation is below 78 percent tend to be inaccurate and can miss undetected hypoxemia. Thus, the value of these devices is limited in individuals with severe pulmonary disease. Body mass index-Weight in kilograms per height in meters squared. Breathingreserve-Difference between maximum vol untary ventilation and the maximum exercise minute ventilation. Chair step test-A progressive test with four levels or stages conducted sitting by kicking to increaSingly higher targets. The laststage adds reciprocal arm movements with kicking. Dyspnea-The subjective sensation of breathing diffi culty. Dyspnea scales-Numeric ratings of dyspnea intensity. Electrocardiogram rhythm-Determination of the interval between each R wave on the ECG. Exercise test mode-Type of equipment used fo Exercise test protocol-Standard combinati intensities, stage progressions, and stage durations. Fifth phase diastolic blood pressure-Blood sure when the Korotkoff's sounds disappear comp Fourth phase diastolic blood pressure-B pressure when the Korotkoff's sounds become m Hypox.emia-Decreased partial pressure of a oxygen. Korotkoff's sounds-Created by turbulence wh blood pressure cuff goes below the blood pressure brachial artery. Maximal exercise test-Maximal ability to pe exercisewith large muscle groups. The individual is no to continue the exercise and reaches several other c indicating maximum exercise. Maximumvoluntatyventilation-Volume of a can be breathed in 12 to 15 seconds. Minute ventilation-Volume of air breathed minute. Measured in liters per minute. Oxyhemoglobin saturation (Sao2 )-Oxygen ration of hemoglobin in arterial blood. The resting n value is generally 95% of higher. Partial pressure of arterial oxygen (Pa Degree of arterial blood oxygenation. Percent body fat-Measured by skin calipers or i ance devices, which determine the percent of body w that is attributed to fat. Pulse oximeters-Noninvasive measure of oxy globin saturation. Respiratoty ex.change ratio (RER)-Ratio o ume of exhaled carbon dioxide to volume of o consumption. Respiratoty frequency-Number of breath minute. Submaximal exercise test-A test which end predetermined endpOint, such as a heart rate of 150 or with the appearance of significant symptoms. TIdalvolume-Volume of air breathed in one inha or exhalation. Ventilation perfusion matching (VAlQ)-Ra alveolar ventilation to pulmonary circulation. Ventilation threshold-Ventilation increases than oxygen consumption. Approximately the poin increasing exercise intensity where more carbon d needs to be exhaled. Ventilatoty equivalent for oxygen or ca dioxide-Ratio of minute ventilation to oxygen or c dioxide consumed. Walktest-An indirect means to measure cardiova endurance in the clinical setting by noting the di walked in a fixed period of time such as 5,6, or 12 m with the patient walking as far and as fast as possib
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- 169. CHAPTER 7 PsychosocialFunction Melba J. Arnold, MS, OTR/L Elizabeth B. Devereaux, MSW, ACSW/L, OTR/L, FAOTA SUMMARY Since the early 1800s, the assessment of psychosocial functional per formance has existed as a philosophical foundation for occupational therapy in support of "holistic" therapy. Occupational therapy promotes the concept of ho lism in treatment, operating under the belief that full recovery from illness requires both physical and psychological treatment. Implementation of the holistic approach involves the use of a variety of occupational therapy theories and assessment techniques. Assessment of psychosocial dysfunction may be performed indepen dently or as a component of a major functional performance evaluation. Psychoso cial assessment addresses the loss of functional performance in areas of work, play or leisure, and interpersonal and emotional behavior. Psychosocial dysfunction can be a result of physical illness or a psychological condition. Treatment approach is determined by results from the psychosocial functional evaluation. HISTORIC PERSPECTIVE Ocupational therapy for psychosocial dysfunction dates back to the era in which "moral treatment" was advocated. Moral treatment evolved in the early 1800s in response to unbearable and inhumane conditions that existed for people who were mentally ill. Those identified as mentally ill were thought to be demonic and a danger to society and, as such, were totally isolated from their environment of origin. The emphasis of moral treatment was humanitari anism. The moral movement occurred during a time of political change and was based on the belief that "man could control his environment and improve his life on earth" (Hopkins & Smith, 1993, p. 27). Numerous people were major promoters of the mo ral treatment movement, the first of whom was Philippe Pinel, who promoted reform throughout Europe and America. A strong influence in England was the Tu family, who prOVided mentally ill individuals with cloth educated them in self-control, and engaged them employment situations for self-reliance. Other support included Benjamin Rush, a physician considered to be father of American psychiatry and the first to use mo treatment in the United States, and Dr. Thomas Kirkbride, who organized what is now known as American Psychiatric Association (APA). The "arts and crafts" movement followed the mo treatment period. Later, the movement was viewed as b educational and therapeutic with a vocational and diversional approach, respectively. The diversional proach became synonymous with the therapeutic pract of occupational therapy in psychiatry, and the vocatio approach became the basis for occupational therapy people with physical disabilities. Promoters of the arts a crafts movement engaged mentally and physically ill in 1
- 170. 148 UNIT1WO-COMPONENTASSESSMENTS OFTHE ADULT viduals in the production of various useful goods and services, which encouraged self~reliance. Guidedby changes in thought by the APA on the etiology of mental illness, the occupational therapy approach progressed from moral treatment, promoted by Adolph Meyer, psychiatrist and founder of the occupational therapy profession, to that of "habit training." Habit training was introduced by Eleanor Clarke Slagle, co founder of the occupational therapy profession. Slagle's concept of healthy habits included behavior that was "industrious, hard working, neat, clean, polite, self con trolled, and emotionally restrained." Slagle's treatment approach consisted of training in socially acceptable con duct (Hopkins & Smith, 1993). Because habit training and moral treatment neglected the affective and interpersonal experiences of clients, both perspectives were eventually abandoned (Mosey, 1986). By the mid~1900s, the occupational therapy approach had progressed from a symptomatology perspective pro moted by William Rush Dunton, also a cofounder of the profession, to that of a psychoanalytic and SOciological orientation. Major proponents of this new perspective were Gail S. Fidler and Jay W. Fidler, coauthors of Introduction to psychiatric occupational therapy (1954) and Occupational therapy: A communication process in psychiatry (1963). The writings and clinical contributions made by the Fidlers provided a stable treatmentfoundation in psychiatric occupational therapy that continues to exist as a component of present-day approaches (Mosey, 1986). The remainder of this chapter presents three major psychosocial theories and examples of assessments used in occupational therapy: the analytic perspective of the Fidlers, the cognitive disability perspective by Claudia Allen, and the model of human occupation by Gary Kielhofner. Finally, occupational therapy assessment of interpersonal skills and emotional behavior is specifically addressed. PSYCHOSOCIAL FUNCTION DYSFUNCTION Successful psychosocial functioning requires harmony between one's psychological capability and the skills required to perform routine daily tasks. It is the ability to be able to take care of one's daily needs in a responsible and safe manner. An individual may experience the loss of this harmony for various reasons. Specifically, the effects of a psychiatric illness, a physical illness or accident, or a neurologic impairment that affects the function ofthe brain can result in a range of performance difficulties or psycho social dysfunction. Literature from a variety of sources indicates that successful psychosocial functioning involves both emo tional and cognitive components (Allen, 1985; Levy, 1993; Mosey, 1986; Perry & Bussey, 1984). How perform daily routine tasks and the manner in which socially interact with others and exhibit psycholog behavior depend on emotional, as well as cogniti abilities. Recovering from a mental illness or a psycholo cal condition is considered by some theorists to be a re of an analytic process that addresses ego functioning a unconscious actions leading to need fulfillment. A return cognitive functioning is thought to be a result of the natu healing process of the neurologiC structures of the br combined with environmental adjustments. These neu logic structures are responsible for functions of the br referred to as occupational performance compone (American Occupational Therapy Association [AOT 1994). Occupational performance components incl three main categories: sensory motor components, cog tive integration components, and psychosocial or psyc logical components (AOTA, 1994). According to "Uniform terminology for occupatio therapy" (AOTA, 1994), human function occurs in th performance areas: activities of daily living (ADL), wo and play or leisure activities. The lowest level of functio independence in humans is the ability to perform ba self-care needs. If the primary self-care skills of feedi hygiene, grooming, toileting, and dressing are lost due illness or disease, a loss of independent functioning occur (AOTA, 1994). Additional performance skills t can be affected by functional impairment are known instrumental activities of daily living (IADL). These IA are tasks that are vital to total functional independence a involve greater complexity in skill and cognitive capabil Examples of IADL include following a medication routi shopping, preparing a meal, doing housework, usin telephone, managing money and time, and travel (Hopkins & Smith, 1993). When effective psychosocial function is interrupted psychiatric or physical illness or by an injury to the bra some aspects of the occupational performance com nents and occupational performance areas may beco affected. Those areas affected can be revealed throu psychosocial assessment processes as a part of the to evaluation. Assessment of performance may be requi for one or several performance components or areas. T type of psychosocial assessment performed should supported by a frame of reference. The chosen frame reference would support the underlying purpose of assessment process being utilized and would gUide overall treatment approach. ACTIVITIES THERAPY AND ANALYTIC FRAMES OF REFERENCE In occupational therapy, the use of activities a therapeutic process was first based on the psychoanal and psychodynamic theoretical perspectives of Sigm
- 171. Mahler, and others(Bootzin et aI., 1993; Gallatin, 1982; Mears & Gratchel, 1979). The psychoanalytic theorists postulate that abnormal behavior is a result of unconscious intrapsychic motivational conflict of a sexual or aggressive nature, a result of an inferiority complex, or problems with object relations involving strong emotional ties. These intrapsychic conflicts are believed to be established during childhood and are thought to be a result of interpersonal interactions that at some point involve one or both par ents. The intrapsychic conflicts are thought to be the impetus for how one thinks, feels, or behaves (Bootzin et aI., 1993). According to the psychoanalytic theory, a return to normal function is accomplished by exploring the origin and symbolism of the unconscious conflicts and bringing them into conscious awareness, thus developing greater insight on the part of the individual about the nature of the behavior. The establishment of insight is thought to occur through an analytic process that also includes what Freud termed "loose association," in which the patient is able to freely express thoughts without judgment from the thera pist to allow repressed content to surface and to achieve need fulfillment. The patient's ability to return to the community at a productive level is thought to occur only after successfully working through the intrapsychic conflict (Fidler, 1982). From the psychoanalytic perspective, dysfunctional be havior among patients varies Significantly and does not present in any particular order because dysfunction is considered to be any form of behavior that is unexplain able. Mosey (1986) identified categories that could serve as individual function-dysfunction continuums: (1) intra psychic conflict that is developmental in nature accord ing to Freud; (2) nondevelopmental types of intrapsychic conflict such as conflicts concerning love, hate, auton omy, trust, aggression, and others; and (3) intrapsychic conflict areas involving maladaptive ideas about self or others. In occupational therapy, Fidler and Fidler (1963), Fidler (1982), and Mosey (1970, 1973, 1986) have made significant therapeutic contributions using the analytic frames of reference that reflect the treatment of intrapsy chic conflict through the use of activities and objects. They believe that effective treatment in the psychoanalytic process must go beyond logistical dialogue that reveals the origin of intrapsychic conflict to include symbolic activities that provide further confirmation of conflict and engage the patient in attempts to alter maladaptive be havior. According to Mosey (1970, 1973, 1986), thera peutic intervention based on the analytic frames of ref erence is most effective with patients who possess a high degree of cognitive ability. Average intelligence is required for the thinking, problem-solving, and psychological fi nesse that is necessary for insight that leads to the resolution of intrapsychic conflict and need gratifica tion. therapy intervention is based on the disease and med model focusing mainly on the pathology and nature of mental illness. The pioneers in occupational ther treatment using the analytic frames of reference were Fidlers. Although their work occurred during a time w the medical model defined most health profeSSions, t theoretical approach included emphasis on rehabilita and the resumption of responsibilities within the envir ment (Fidler & Fidler, 1963). The Fidlers' theoretical base and function-dysfunc continuum were similar in focus to that of other psyc analytic theorists, e.g., unconscious conflict, interperso relations, communication, object relations, and symb activity. Identification of specific behavior is not poss under this frame of reference, since dysfunction is defi as any unexplainable form ofconduct(Bootzin etaI., 19 Gallatin, 1982; Mosey, 1986). Three evaluationcatego are offered: the patient's relationship to the therap group, and activity. The clinician is required to interpret individual's behavior according to the theoretical base function-dysfunction continuum. Consistent with the sence of specific behavior identification, the process change is also unclear and relegated to examples of h occupational therapy as a modality could be included in overall treatment process (Mosey, 1986). Object relations analysis as a part of the analytic fra of reference is a process based primarily on the contr tions of theorists such as Freud, Jung, Azima, Masl Mahler, Fidler and Fidler, Mosey, Naumberg, and oth For this reason, the object relations analysis is conside to be an eclectic process involving the synthesis of sev theories. In the object relations analysis, the individu relationship and interaction with objects for need gra cation and self-actualization are explored. Objects defined as people, things, and ideas (Bruce & Borg, 19 Mosey, 1970, 1986). Because this framework is eclec the theoretical base involves several concepts: "nee drives and objects, affect, will, attending and the forma of complexes, cognition, and symbolism" (Mosey, 19 pp.37-62). Mosey (1970, p. 232) defines a complex as "a gesta repressed affect, energy and intrapsychic content ass ated with some type of conflict." Almost any experie can form the nucleus of a complex. The complexes c great Significance, as they serve as indices for the funct dysfunction continuum. Examples of the complexes clude feelings related to inferiority, trust, gratification needs for safety, and love and self esteem. Assessment Instruments. Projective techniques h been the primary evaluation approach utilized in occu tional therapy with the psychoanalytic treatment conc (Fidler & Fidler, 1954, 1963; Fidler, 1982; Hemp 1982; Mosey, 1986). The distinguishing feature of pro tive techniques exists in the assignment of a relati unstructured task, Le., one that permits an almost un ited variety of possible responses. To encourage
- 172. 150 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT unlimited variety of possible responses, only brief, general instructions are provided to the examinee. Projective testing is based on the hypothesis that "the way in which the individual perceives and interprets the test material, or structures the situation, will reflect fundamental aspects of psychological functioning" (Anastasi, 1971, p. 464). In projective testing, the procedures are disguised in that the individual is usually unaware of the type of psychological interpretation that will be made ofthe responses (Anastasi). Projective testing involves an interview and discussion process followed by interpretation of the examinee's performance by the examiner. The following are examples of psychoanalytic projective techniques used in occupational therapy (Hemphill, 1982; Hopkins & Smith, 1993; Moyer, 1981). 1. The Fidler Diagnostic Battery: Projective testing that consists of presenting the examinee with three sequential tasks; drawing, finger painting, and clay. The examinee is required to discuss each task pro duction. The examiner makes interpretations of the examinee's performance and discussions. (Devel oped by Fidler and Fidler; from Hopkins & Smith, 1993.) 2. Azima Occupational Therapy Battery: Projective I: battery using pencil drawing, figure drawing, finger painting, and clay modeling. (Developed by Azima and Azimaj from Hemphill, 1982.) 3. B. H. Battery: Projective test with finger-painting and tile. (Developed by Hemphill; from Hemphill, 1982.) 4. Draw-A-Person: Projective drawings of people. (Developed by Urban; from Western Psychological Services, Los Angeles, CA.) 5. House-Tree-Person: Freehand drawing by examinee of a house, a tree, and a person. (Developed by Buck, revised manual; from Western Psychological Ser vices, Los Angeles, CA.) 6. Magazine Picture Collage: Pictures are cut out of available magazines and glued on a sheet of paper. (Unstructured reporting format by Buck and Lerner, 1972 and by Ross, 1977.) 7. Object History: The examinee is asked to remember something that was important or valued at earlier periods of life and also to explain why. (From Hopkins & Smith, 1993.) 8. Shoemyen Battery: Contains four tasks: mosaic tile, finger painting, plaster sculpture, and clay mod eling with an interview-discussion to gain informa tion about attitudes, mood, cognitive and social skills, dexterity, attention, suggestibility, indepen dence, and creativity. (Developed by Chemin; from Shoemyen, 1970.) 9. Goodman Battery: Consists of tasks of decreasing structure. Purpose is to assess cognitive and affective ego assets and deficits affecting function. (Developed by Evaskus; from Hemphill, 1982.) COGNITIVE DISABILITY Mosey (1986, p. 45) defines cognitive function a cortical process that involves the use of information for purpose of thinking and problem solving." Cogn function involves the following occupational performa components: arousal, orientation, recognition, concen tion, attention span, memory, intellect, problem solv and learning (AOTA, 1994; Abreu & Toglia, 1987). integrative effects of the cognitive components result in ability to problem-solve and make decisions. These abil result in the capacity to exhibit independent functionin the occupational performance areas, enabling the vidual to carry out his or her daily living skills. In situat in which this integrative effect is absent, cognitive dysf tion exists. The cognitive disability model (CDM) developed Claudia Allen was initially designed as an evaluation treatment format for clients with psychiatric illnes Further refinement of the model led to its use in treatment of a variety of clients whose cognitive disab had physical disability origins. Based on her research and on accounts published Piaget, other theorists, and Soviet psychologists, A learned that the manifestations of psychiatric illne revealed strong similarities to those of medical illne (Allen, 1985; AOTA, 1988). Allen ruled out theories involved learning and normal memory based on presumption that with cognitive impairment, these a ties would be permanently impaired. To this end, pursuit of evaluation and treatment methods that w provide measurable results of cognitive performance clients with psychiatric illnesses led to the developm of the CDM. According to Allen (AOTA, 1988), the theoretic f dation ofthe CDM is a neuroscience approach that is b on the belief that cognitive disabilities are due to illnes injury to the brain, resulting in limitations in functi capability. Although the nature of the illness or in results in a variety of effects on cognitive ability, diagnostic category may be any condition that can hav effect on the brain. Diagnostic categories may inc cerebrovascular accidents, acquired immunodefici syndrome, schizophrenic disorders, acute and chr organic brain syndromes, traumatic brain injury, prim affective disorders, personality disorders, eating disord substance abuse, and developmental disabilities. With e condition, cognitive ability that influences normal per mance of human activities may be temporarily or per nently affected. The CDM places emphasis on the f tional consequences of cognitive impairments. Use of the CDM requires an understanding of nor human function, disability impairment, and functi independence. Allen presents the CDM in the form o cognitive levels that are graded from normal functionin severe functional disability. The cognitive levels mea
- 173. how information isprocessedduring task performance. To use the COM, the clinician must acknowledge that im provements in cognitive levels of performance are due to natural healing or the use of medication. Evaluation and treatment are directed toward making necessary adjust ments to the remaining cognitive abilities a client may possess. Cognitive Levels. The COM describes six levels of cog nitive dysfunction. The following is a summary description of function-dysfunction for each level (Allen, 1985, 1987; Allen et aL, 1992; Allen and Reyner, 1991). 1. Level one: Patient does not respond to the environ ment, including primary aspects such as eating and toileting. Change is gradual, but food and water intake remains a primary concern. Arousal level is very low; thus, training is usually impossible. 2. Level two: Patient often exhibits unusual postures, gestures, or repetitive motions. Gross motor activity for proprioceptive experiences may be exhibited when the patient is gUided. 3. Level three: Actions are directed toward physical objects in the environment. Patient lacks awareness of the connection between his or her actions and goal achievement. Actions are guided, repetitive, and may have a destructive nature. 4. Level four: Patient exhibits actual attempt at task completion, usually an exact match of a sample provided. Attention is concrete, so objects in periph eral field cause confusion. Patient is compliant, so routines can be followed and situational training can occur. 5. Level five: Patient demonstrates more flexibility in attending to elements of the physical environment, but the deficit is still present. He or she learns by exploration and trial and error, as he or she is unable to preplan or anticipate the consequences of his or her actions. 6. Level six: Patient is able to calculate a plan of action and to use symbolic cues, images, and words to gUide own behavior. Motor behavior is spontaneous and based on ability to associate with symbolic cues. Cognitive Disability Model Assessment Process. The COM involves three phases of assessment that are used in determining functional level of performance: the routine task inventory, the Allen Cognitive Level (ACL), and the lower cognitive level (LCL) test (Allen, 1985). The rou tine task in ventory (RTf) is an interview process that is administered to either the patient or the caregiver or by observation of the patient's performance. It includes 14 routine tasks in two subscales, the physical scale and the instrumental scale. The physical scale contains six tasks: grooming, bathing, toileting, dreSSing, feeding, and walk ing. The instrumental scale has eight tasks: housekeeping, preparing food, spending money, taking medication, doing laundry, traveling, shopping, and telephoning. Each of the reflect each of the cognitive levels. The behavioral desc tions may also serve as potential observations of per mance. By matching the patient's reported or obser performance to the descriptions under each task, therapist is able to determine the patient's level ofcogni functioning, as well as make discharge recommendati (Allen, 1985). The ACL test is a screening tool designed to provid quick assessment of a person's ability to function. The A involves the use of a leather lacing activity to identif patient's cognitive level of functioning. The leather acti is graded according to complexity, ranging from a sim running stitch (levels two and three) to a whip stitch (l four) to a more complicated single cordovan stitch. though each stitch involves repetitive manual activity, running stitch is thought to be more universal in term familiarity and the absence of biases. The administra and scoring of the ACL have been standardized. A la version of the ACL is also available for individuals w visual impairments (Allen, 1985). The LCL test was designed to assess the performanc patients functioning at levels one, two, and three, e patients who are diagnosed as having senile dementia. LCL uses the imitation of motor action to assess patient's cognitive level of function. The patient is structed to imitate hand-clapping actions. Lack of pat response reveals level one function; one or two inaud responses or other imitated movements reveal level function; three consecutive audible responses reveal l three function (Allen, 1985). To assist the clinician with the assessment and treatm process, Earhart and coworkers (1993) developed Allen Diagnostic Module (ADM), which is a set of standardized craft activities that have been rated accord to their cognitive complexity. Use of the AOM provides clinician with the opportunity to observe general functio performance as well as the ways in which the indivi may process new information. The AOM is intended to used follOwing the ACL but prior to the RTI. Task analysis is also a viable part of the COM. With COM, task analysis is a systematic process ofidentifying complexity of task procedures step by step, with emphasis on those steps that the patient is unable perform. By performing task analysis, the therapist guide the patient in accomplishing routine daily ta Through task analysis, any activity can be adapted eliminate procedures that patients cannot do while per ting them to use remaining abilities. Research. Allen (1985) cited several research finding support of the effectiveness of the COM in determin cognitive deficits. Research done on the COM involve study of four patient populations. In a study of hospitalized patients diagnosed w schizophrenia, the ACL was found to have an interr reliability of r 0.99 with the Pearson product-mom correlation. Validity of the ACL was determined by ra
- 174. 152 UNIT mO-COMPONENTASSESSMENTS OF THE ADULT the patient's performance for appropriateness of group placement. Before establishing validity, the interrater reli ability for group performances was determined where r = 0.69. The validity for group placement was r = 0.76 (Allen, 1985). Group placement categories were limited to cognitive levels three and four versus five and six. A study of schizophrenic subjects from a work rehabili tation unit of a psychiatric hospital investigated the rela tionship between cognitive levels at the time of discharge and social adjustment in the community. While results revealed a significant but low correlation between cognitive function and pay earnings at the time of discharge (r = 0.33, P < 0.05), no comparative information was available following discharge. Additionally, a very low correlation between cognitive function and social adjust ment (r = 0.2 to r +0.3) was evident by the end of 3 months following discharge. Similar studies involving schizophrenic subjects, cognitive levels, and community adjustment revealed no conclusive results (Allen, 1985). A criterion-related validity study of the ACL was done with patients diagnosed with major depression to investi gate cognitive impairment and its relation to ability to function. The results revealed Pearson r correlation be tween all test scores for admission ranging from 0.01 to 0.42 when compared with the ACL (n = 32). The Pearson r between all test scores and the ACL at discharge ranged from 0.05 to 0.24 (n = 32). Other results supported the ACL as a sensitive measure of cognitive levels based on the significant increase of the mean score from admission to discharge; 75% rating at levels four to six and 91% rating at levels five to six, respectively, with n = 32 (Allen, 1985). Comparisons were made between the studies for both schizophrenia and depression, which supported the con struct validity of the ACL. Results revealed significant differences, which indicated that the ACL was able to differentiate between the two patient populations, identi fying the schizophrenic patients as being more severely impaired in cognitive ability. A study between disabled and nondisabled adult popu lations investigated their similarities and differences in performance on the ACL. Results also supported construct validity, revealing the disabled adults to be functioning at a lower cognitive level than the nondisabled group. Another important finding that is difficult to interpret was that demographic data such as social class, level of education, and others were greater indicators of cognitive ability than was the ACL (AOTA, 1988). Lastly, a study involving subjects with senile dementia was designed to investigate the relationship between cognitive disability and the performance of ADL. Results of the study revealed that cognitive impairment produces observable limitations in routine task behavior. Results further supported validity, revealing a significant relation ship between the ACL scores and the scores on the Physical Self-Maintenance Scale and the Instrumental Activities of Daily Living Scale in patients with senile dementia. The aforementioned studies primarily involved obser tion of performance. Findings by Ottenbacher revea that cognitive assessment was mainly a result of subject determination based on clinical observations and, as su it is difficult to verify treatment success (Abreu & Tog 1987). Backman (1994) concluded that because of its nove the RTI has yet to undergo the intense standardizat process necessary to legitimize its claim as a valid a reliable tool in assessing change in behavior. Backm asserts that without standardization, the RTI's greatest is to provide an explanation of a client's ability (or disabil to perform self-care tasks. Thus, although some stud have provided data in support of the validity and reliabi of the Allen tests, much work is still needed before they c be accepted by rehabilitation professionals as valid a reliable assessment tools. Because of the precise descr tion inherent in the Allen tests and the favorable attitu their author holds toward research, investigations of th assessment instruments are continually in progress. HUMAN OCCUPATION Early formal work that identified occupational behav as a core philosophy in occupational therapy was f presented by Mary Reilly in her 1961 Eleanor Clarke Sla lecture (Reilly, 1962). Other occupational therapy co tributors to the philosophy of occupational behavior clude Matsutsuyu, Florey, Shannon, Burke, and Ba (AOTA, 1986). Overthe years, Reilly's development of occupational behavior model has provided a foundation other perspectives in identifying the relationship betwe human occupational behavior and occupational thera "A model of human occupation," originally published Kielhofner and Burke in 1980, was based on Reilly's wo This earlier model was based on the postulate that hum behavior is innate, spontaneous, and occurs because of ur.seJo_eW1ore and master the environment (AOT 1988; Kielhofner, 1985; Miller, 1993). In his most rec edition of A model of human occupation: Theory a application, Kielhofner (1995) revised his theoreti perspective of the human being, basing it on t~enera dynamical, and open systems theories. This revised mo ~()ntinues to view the human as a system but as one tha complex and dynamic. The dynamiCal concept is based the dynamical systems theory relative to the physi sciences. AccJ)rding to Kielhofner, the complexity a dynamical aspects of the human system are inherent in system's ability to readily adjust to varying situations. T human system's ability to readily adjust is accomplished creating a form of new energy to establish new order one's life situation. Kielhofner (1995) refers to this proc as self-organization through behavior. The model cont ues to incorporate the holistic approach to occupatio dysfunction and involves synthesizing other theoreti
- 175. The revised modelmaintains the view of the human system consisting of three subsystems that interact with the environment. These three subsystems make it possible for the human system to choose based on motivation, to organize, and to produce occupational behavior. Volition is the subsystem responsible for motivation, choices, and will. Habituation is the subsystem responsible for organizing behavior into patterns and routines. The mind-body-brain performance subsystem is responsible for the skills that produce behavior for interacting with the environment (Kielhofner, 1985). These three subsystems interact in a collaborative manner to influence occupational behavior. The revised model's view of dysfunction is based on the inabilily of an individual to organize, choose, or per form what David Nelson refers to as occupational forms (Kielhofner, 1995). Occupational forms are the inherent aspects of a task that guide how an individual should perform. Occupational forms are "rule-bound sequences of action which are at once coherent, oriented to a purpose, sustained in collective knowledge, culturally recognizable and named" (Kielhofner, 1995, p. 102). Occupational dysfunction exists when an individual is unable to demonstrate behavior that would meet his or her own needs or the demands of the environment. A number of factors may influence occupational dysfunction, which can result in a negative effect on the structures of the human system, i.e., the volition, habituation, and mind body-brain subsystems. Clinicians attempting to under stand occupational dysfunction must determine the restric tions placed on each subsystem and the environment as a result of dysfunction and understand the collaborative effect on the human system. Change in occupational behavior is the result of the interaction of the three subsystems with the environment. Change is initiatedthrough the volition subsystem based on the client's motivation, sense of efficacy, interests, and values. Treatment is directed toward organizing occupa tional behavior so that adaptive functioning is restored, resulting in a balance between the individual's inner needs and the environmental requirements. Use of the model is not limited to a specific patient population (Kielhofner, 1995). Assessment Instruments. Assessment of occupational status involves an interactive analysis of the three sub systems as well as environmental constraints. The assess ment process involves the use of a collection of instruments to gather information on the patient's current occupational status, including occupational performance history data. Evaluation results are interpreted and synthesized to deter mine the client's current occupational status. Because of the constant interaction between the human system and the environment, collection and syntheSis of assessment data are ongoing (Kielhofner, 1995). Numerous psychosocial assessment tools are applicable to the model. Because of the assessment diversity, each performance dysfunction (See Table 7-1). Additional observation of behavior during the assessment proce provides necessary information about social interacti and self-management skills. Table 7-1 is based on Ki hofner's (1985) assessment "instrument library," whi provides descriptive information on 64 instruments. In h instrument library, Kielhofner identifies the contents each assessment tool, standardization information, app cable patient populations, and reference sources. Ea assessment tool is matched to the components of t model of human occupation to assist the examiner effective application ofeach instrument to the model. In t revised edition (1995), Kielhofner provides more rece and expanded assessment information for greater rei forcement and support of the model. Assessment Tools and Research Data. The follOwing is partial collection of data on assessment tools common used under this model. 1. Bay Area Functional Performance Evaluatio (BaFPE): A task performance and observation rati scale used to evaluate dailiz livi~lIsjn~-D cognitlo!l,. Clff,?cJ,~Cll.1dp~rfQr!l1anf~ (Task-Orient Assessmen~+~cale and Social Interaction Ski [SIS) Scale. The SISJs.~ rating scale used to asse patients' socia ehavior based on observation self-report. Interrater reliability was determined through fo pairs of occupational therapiSts, each of who studied an individual group of 25 patients. The fo patient groups were titled county inpatient men health center, longer term; Veteran's Hospital, acu inpatient; private, for-profit acute psychiatric; a univerSity-affiliated psychiatric, acute inpatient. Interrater reliability was determined for the TO and the SIS. Correlations for the TOA are in exce of 0.90, with 80 percent of the correlations equali or exceeding 0.80 in three of four test groups. Another reliability study investigated comparis of the correlations for items changed in the revis TOA with those in the original version. Findin revealed improvement in 10 of the original 16 scal on the TOA Results also showed high correlatio for the items added to the revised TOA Final internal consistency among certain subscales with the TOA was studied. Findings revealed an avera correlation of 0.60, with a range of 0.29 to 0.8 Interrater reliability correlations for the SIS a lower than those for the TOA, with a range of 0.7 to 0.79. To improve the validity of the SIS, fi observation situations were substituted for those the Original version. With these substitutions, resu revealed an increase in all correlations, includi reliability (Asher, 1989; Kielhofner, 1985; William & Bloomer, 1987).
- 176. PSYCHOSOCIAL ASSESSMENT INSTRUMENTS r~ f ~ f ~ ~ l ~i 0 -10 i~ rs: s: - - == ~ f ~ S' ~f ~= ~t > ~ o " ti 0 .. ~.. aQ. ~ ':" ~ ~ ~ 2-2 ~ 2 _Ill I 'i 0 ~ s. ![ :2e. Cl s:! ~ ~ " ~."Cl ~ !i i c &.a or s. If "a ~ 1 { i i i' "Cl aI ~(') ... .. ~ ~ III - III o 1:1 III ~ [;' =: ~ ~ i So a- I a- Ea r r- III 1:1 1:1 1:1 a I~ fI a ~ I':" 0 0 0 I (') 1:1 ... ..a ('r. 1;a ~ 1:1 ~ a ~ ~ I f 1:1 1:1 1:1 ct. 1:1" ~ .. e.1:IIII ~ ~ I I!, III ... ~ III 1:1 ~ ~ III 0 III £) .....i ~ . f it ! - ( III !to ~e. 1:1 a ~ ~. ." ~ 02 ~ ~ c ~a 0 a- f I III C 0 ~ i tr 0 - III III I!, 0 i' ~ e: l ~ 9: 1:1 III a 1:1 1:1 ~ a ~ g f I ... a il 1:1 -= i' So ~ " a; i· ~ 0 e.~ g I l1:1 i f 0 ..g III e. i' = 0 ~ 1::1 ...go 0 1:1 III 1:1 02 e. i' IQ aPerformance Components a IQ I 02 ...• Psychosocial S iriUs and Psychological I I Components 1. PSYCHOLOGICAL A. Values X X X I X IX X X X X X X X B. Interests X X X X X X X X C. Self-concept X X X X X X X X X X 2. SOCIAL A. Role performance X X X X X X X c B. Social conduct X X X X X X C. Interpersonal skills I I X I X X X X X X D. Self-expression X X X X X X X 3. SELF-MANAGEMENT A. Coping skills X X X X X I B. Time management X X X X X X X X C. Self-control X X X X X Performance Context A. TEMPORAL ASPECTS 1. Chronological X X X X X X X X X X X X X X X X X X X X I l 2. Developmental X X X I 3. life cycle I X X 4. Disability status X I B. ENVIRONMENT 1. Physical X X X I • r 2. Social X X X X X r 3. Cultural X X X X X Based on information from American OccupationalTherapy Association. (1994). Uniform term inology for occupational therapy. American Journal of Occupational Therapy, 48(11), 1047-1059; In Kielhofner, G. (ed). (1985) model of human occupation. Baltimore, MD; Williams & Wilkins.
- 177. (1989) and Mannand Klyczek (1991), use of the BaFPE was effective in identifying deficits in the three component areas of cognition, performance, and affect. In the 1989 study, the authors presented normativedata for the total TOA in the form of actual scores and "z" scores on 144 psychiatric inpatients. A significant difference was identified between pa tients evaluated within the first 14 days of admission and those evaluated after more than 14 days of hospitalization. A table of standard scores that re sulted from the study allows the clinician to compare information acquired on recently tested patients with the normative data provided by Mann and associates (1989). Data comparison may reveal a need for or a lack of treatment in a certain component area. In the study by Mann and Klyczek (1991), results from the 1989 study were used to determine norma tive data for 266 psychiatric inpatients. Study results revealed standard scores for cognitive, performance, and affective components for each task; each param eter of the cognitive, performance, and affective components; and each total task summary score. Standard scores were presented in table form for comparing and reporting results of testing patients. Data comparison may reveal a need for treatment in either a component area or in a specific parameter. In summary, Mann and coworkers (1989) and Mann and K1yczek (1991) concluded that the BaFPE is a valid tool to be used in identifying performance diffi culties of psychiatric inpatients. They further suggest that for best results, clinicians should establish local norms and standard scores for comparison based on test results from their own inpatient environment. The BaFPE is available through Maddak, Inc., Pequannock, NJ. 2. Occupational Case Analysis Interuiew and Rating &ale (OCAIRS): A semistructured interview and rating scale designed for data gathering, analysis, and reporting a client's occupational adaptation. Results of the interrater reliability study revealed 57 percent of the components with correlation coefficients rang ing between 0.50 and 0.80; 36 percent had lower than 0.50, and 7 percent had in excess of 0.80 (Kaplan & Kielhofner, 1989). Investigation of content validity revealed 81.8 percent to 100 percent correct matches between the interview questions and 9 of the 11 model compo nents (Kielhofner, 1985). The OCAIRS is available through the Model of Human Occupation Clearinghouse, Department of Occupational Therapy, M/C 811, University of Illinois at Chicago. 3. Role Checklist: A self-report checklist for adult psychiatric patients designed to assess productive roles in life by indicating their perception of their past, present, and future roles. Reliability is based on on categorical responses between the test and retes Findings were based on 124 nondisabled adul ranging from 18 to 79 years of age. Results wer as follows (Asher, 1989; Kielhofner, 1985, 1995 Oakley et aI., 1986): a. Individual roles for a given time category-kapp estimates ranged from slight to near perfec agreement. Percent agreement was 73 to 97 with an average of 88 percent. b. Each role over three time categories-kapp estimates ranged from moderate to substantia Percent agreement was 77 to 93, with an averag of 87 percent. c. Each time category for the 10 roles assessed kappa estimates were substantial for present tim and moderate for past and future. Percent agree ment averaged 87 across time categories. d. Age of subjects (two age groups) and time betwee test administration-kappa estimates were mod erate to substantial. Percent agreement was 7 to 95. e. Valuation of each role-kappa estimates wer moderate. Percent agreement was 79. f. Reportedly has content validity founded on litera ture review. The Role Checklist is available through the Mod of Human Occupation Clearinghouse. 4. Self-Esteem Scale: A self-report scale that measure feelings about oneself, abilities, and accomplish ments. Primarily used with adolescents but has als had a history of use with elderly clients. Reliabilit based on Guttman scale, with correlations of 0.92 fo reprodUcibility and 0.72 for scalability. Test-rete reliability was 0.85 (Asher, 1989; Kielhofner, 1985 The Self-Esteem Scale is available through Prince ton University Press, Princeton, NJ. 5. Occupational Functioning Tool (renamed Assess ment of Occupational Functioning, 1995): A interview and observation screening tool for assess ing the three subsystems; volition, habituation, an performance. Primary use is with institutionalize clients. Standardization results were based on 4 institutionalized older adults. Reliability measure revealed interrater correlation coefficients of 0.48 t 0.65, with 0.78 as a total score. Test-retest coeff cients ranged from 0.70 to 0.90 based on Pearso product-moment correlations (Kielhofner, 1985 1995). Criterion-related validity moderately supported b significant correlations of - 0.42 to - 0.84 when re lated to similar screening tools (Kielhofner, 1985 1995). The Assessment of Occupational Functioning available through the Model of Human Occupatio Clearing House.. .
- 178. 156 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT 6. Assessment of Communication and Interaction Skills (ACIS): an observation assessment tool de signed to measure social performance in personal communication and group interactions. Studies re vealed (Kielhofner, 1995) modest interrater relia bility, indicating a need for further refinement of the tool. Subsequent studies for construct validity, based on revision of the tool, revealed that the assessment items do form a single unidimensional scale (Kielhofner). The ACIS isavailable through the Model of Human Occupation Clearinghouse. 7. Fisher's Assessment of Motor and Process Skills (AMPS): An observation assessment tool designed to evaluate quality and effectiveness (not impairment) of motor and process performance skills while the individual performs IADL, e.g., meal preparation, driving (Kielhofner, 1995). Studies support the reliability and validity of the AMPS. Construct validity, test internal consistency, score stability overtime, and interrater reliability have all been supported (Kielhofner, 1995). A major advantage of the AMPS is that test task choice is t. . available to the patients. Administration of the AMPS requires formal train Ii ing. Training is available through the AMPS Project, .' Occupational Therapy Building, Colorado State Uni versity, Fort Collins, CO. INTERPERSONAL SKII.LS AND EMOTIONAL BEHAVIOR Interpersonal skills are defined as the ability to use verbal and nonverbal communication to interact with others in casual and formally sustained relationships in individual and groupsettings (AOTA, 1994; Mosey, 1986). Interpersonal skills involve both social interaction and emotional behavior. The ability to successfully interact in society and process emotions is perhaps the greatest challenge for humans. Social interaction and emotional control are psychosocial daily life tasks that are interwoven into major daily life tasks of work, school, leisure, and family relations, as well as numerous other routine activities (AOTA, 1994). Interpersonal skill dysfunction results in an inability to effectively communicate and interact with others in various settings. Mosey (1986) describes the communication and interaction as processes that involve skills and abilities in initiating and responding to sustained verbal exchanges, assertiveness, expression of ideas and feelings, awareness of others' needs and feelings, compromise and negotia tion, and the ability to take part in cooperative and competitive events. Assessment of interpersonal skill dys function should reflect the appropriate life task area(s) affected. Mosey (1986) identified two methods ofassessing social interaction: the Interpersonal Skill Survey and Group Interaction Skill Survey. Both are used to co data while observing clients in an evaluation group set The Interpersonal Skill Survey is a six-item forma interaction and affective behaviors that are rated on a s of 1 to 4. The rating results are followed by an .inter process involving a discussion between the client and therapist to review and clarify any discrepancies betw the therapist's and the client's observations. The Group Interaction Skill Survey is a for arranged according to group types: parallel, pro egocentric-cooperative, cooperative, and mature gro The survey is used as a guide to determine the client's of social interaction development. Scoring involves ch ing off behaviors exhibited by the client in the evalua setting. The completion of the survey is followed by interview process to highlight the client's successes an discuss social interaction behaviors that may not have b mastered. Mosey (1986) also provides the clinician with evalua tools and guidelines to assess social interaction in life t for work, school, family relations, and play or leisure. E survey lists behaviors typical to the life task area and ca utilized as a preassessment tool to record responses b on an interview with the client, family member, or c giver, or the survey may be used as a guide in sco observed behavior during evaluation or in simulated t ment situations. Fidler addresses the evaluation of interpersonal skil the context of a Life-style Performance Profile (AO 1988). The profile identifies and organizes performa skills and deficits according to the client's sociq<:::u envirQI1JIlent. The profile can also provide firtormatio potential resources for impr:ovil}g_sKins~can--iden factors that may interfere- ~ith skill development or gression. By creating a profile about the client'~J}i.st performance including all components and lite task ar a-distinct pattern of behavior is revealed regarding so interaction in work, school, play or leisure, and fa relationships. Emotional behavior as defined by the AOTA's " form terminology for occupational therapy" (1994 self-management and includes coping skills and control. The ability to maintain emotional control w faced with stressful events depends on coping skills de oped during childhood and carried forward into adulth Theorists on emotional development agree that c hood is the point of origin; however, they disagree on primary source of emotional behavior (Bee, 1985; Per Bussey, 1984). Bee (1985) identified three theore viewpoints on the development of emotional behavior temperamen t theory operates on the beliefthat emoti behavior is of a biologic origin and that individuals are b with certain characteristics that influence how they inte with the environment and how others may respond. psychoanalytic theorists hypothesized that emoti behavior is influenced by the three personality structu
- 179. influenced by socialdemands that occurred throughout life in stages of development. Lastly, social theorists postulate that one's emotional behavior is learned through observa tion of modeled behaviors. The occupational therapy evaluation and treatment process strongly supports the social theorist's position on learned behavior. Occupational therapy assessment of emotional behavior is typically performed as a component of an overall functional evaluation, Le., observation of social interaction, frustration tolerance, problem solving, judgment, and overall coping relative to the productive use of defense mechanisms. The following are examples of assessment tools commonly used in determining an indi vidual's emotional capability: 1. AAMD Adaptive Behavior Scale: Evaluation of the subject's effectiveness in coping with environmental demands through behavioral adaptation. Twenty four areas of'social and personal behavior are addressed. Reliability measures revealed interrater reliability correlations of 0.86 for part one (psycho social, sensory-motor, and daily living skills) and 0.57 for part two (maladaptive behaviors, behavior disor ders, and medication). (Developed by the American Association on Mental Deficiency, Washington DC; from Asher, 1989; Moyer, 1981.) 2. Bay Area Functional Performance Evaluation (BaFPE): Includes the SIS, which rates behavior in seven parameters. Behavioral information can be acquired through an interview process with a care giver or by actual observation of performance. Al though the greatest emphasis is on social interaction, the seven-item scale also addresses related emotional aspects of behavior. Refer to the section on model of human occupation for research data related to the SIS. (Developed by Bloomer & Williams; from Maddak Inc., Pequannock, NJ.) 3. Emotions Profile Index: A brief, standardized per sonality test for adolescents and adults. The profile index provides information about various basic traits and conflicts. Literature search did not reveal re search data on this index. (Developed by unknown source; from Moyer, 1981.) 4. Functional Independence Measure (FIM): A seven level scale assessment tool ranging from independent to dependent behavior that is designed to measure disability regardless of the actual diagnosis. The FlM measures self-care, sphincter control, mobility, loco motion, communication, and social cognition. Al though the FlM is primarily deSigned to measure physical dysfunction, the psychosocial aspects re lated to patient treatment are also addressed by assessing social interaction skills relative to patient progress. Standardization measures were based on the use of the FlM by clinicians. Measures revealed an ANOVA correlation of 0.86 on patients admitted to rehabilitation services and 0.88 for those discharged areas: 88 percent did not have difficulty understa ing the FlM, 97 percent believed there were unnecessary items in the FlM, and 83 perc believed there was not a need for additional ite (Developed byThe Center for Functional Assessm Research, State University of New York at Buff from The Center for Functional Assessment search, 1990.) SUMMARY This chapter is by no means conclusive regarding psychosocial assessment tools available in occupatio therapy. What has been provided is a manner in which assessment process can be approached based on a cho theoretical frame of reference. Interpersonal skills emotional behavior have been addressed to identify th manifestation in the psychosocial assessment process occupational therapy and to provide examples of ins ments commonly used to determine the degree dysfunction. Cooperative group-A homogeneous non-ta oriented group whose aim is to promote sharing thoughts and feelings and acceptance among its membe Egocentric cooperative group-A task-orien group whose aim is to promote self-esteem throu activities that emphasize cooperation, competition, le ership, and other group roles. HoHstic-Relates to the "whole" and assumes the wh isgreaterthan the sum of its parts. In occupational thera treating the whole of the patient, both the phys condition and the associated psychosocial situations. Loose association-A type of thinking that is typica schizophrenic patients in which they may ramble or fre express their thoughts during therapy. Medical JDOdel-Patient treatment that is based on nature of the disease and considers the disease to b separate entity from the patient. Treatment does consider the patient's functional capabilities. Parallel group-An activity group in which interact is not required. Projective tedmique--A method of studying pers ality in which the individual is given an unstructured ! that allows for a range_gfchgrg~1eristic~s. T responses are interpreted or analyzed byJh~. examin Task analysis-A systematic-pr~;;of identifying complexity of task procedures step by step. Emphasi placed on steps that the patient is unable to perform.
- 180. 158 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT REFERENCES Abreu, B. c., & Toglia, J. P. (l987). Cognitive rehabilitation: A model for occupational therapy. American Journal of Occupational Therapy, 41(7), 439-448. Allen, C. K (1987). Activity: Occupational therapy's treatment method, Eleanor Clarke Slagle lecture. American Journal of Occupational Therapy, 41(9), 563-575. Allen, C. K. (1985). Occupational therapy for psychiatric diseases; Measurement and management of cognitive disabilities. Boston, MA: Uttle, Brown & Co. Allen, C. K, & Allen, R (1987). Cognitive disabilities: Measuring the social consequences of mental disorders. Journal of Clinical Psychia try, 48(5), 185-190. Allen, C. K, Earhart, c., & Blue, T. (1992). Occupational ther apy treatment goals for the physically and cognitively disabled. Bethesda, MD: The American Occupational Therapy Association. Allen, C. K, & Reyner, A (1991). How to start USing the cognitive levels. Colchester, CT: S & S Worldwide. American Occupational Therapy Association. (1988). FOCUS; Skills for assessment and treatment in mental health. Rockville, MD: Ameri can Occupational Therapy Association. American Occupational Therapy Association. (1986). SCOPE; Strate gies, concept, and opportunities for program development and evaluation in mental health. Rockville, MD: American Occupational Therapy Association. American Occupational Therapy Association. (1994). Uniform terminol ogy for occupational therapy. American Journal of Occupational Therapy, 48(11), 1047-1059. AnastaSi, A (1971). Psychological assessment. New York: Macmillan. Asher, I. E. (1989). The annotated index of occupational therapy evaluation tools. Bethesda, MD: American Occupational Therapy Association. Backman, C. (1994). Assessment of self-care skills. In C. Christiansen (Ed.). Ways of living (1st ed.) (pp. 51-75). Bethesda, MD: American Occupational Therapy Association. Bee, H. (1985). The developing child (4th ed.). New York: Harper & Row. Bootzin, R, Accoella, J., & Alloy, L. (1993). Abnormal psychology: Current perspectives. New York: McGraw-Hill. Bruce, M. A, & Borg, B. (1987). Frames of reference in psychosocial occupational therapy. Thorofare, NJ: Slack, Inc. Buck, R, & Provancher, M. A.. (1972). Magazine picture collages as an evaluative technique. American Journal of Occupational Therapy, 26(1), 36-39. Center for Functional Assessment Research. (1990). Guide for use of the uniform data set for medical rehabilitation including the func tional independence measure (FIM). Buffalo, NY: State University of New York at Buffalo. Earhart, C., Allen, C. K, & Blue, T. (1993). Allen diagnostic module. Colchester. CT: S & S Worldwide. Rdler, G. (1982). The lifestyle performance profile: An organizing frame. In B. Hemphill (Ed.), The evaluation process in psychiatric occupa tional therapy. Thorofare, NJ: Slack, Inc. Fidler, G., & Rdler, J. (1954). Introduction to psychiatric occupational therapy. New York: Macmillan. Rdler, G., &Rdler, J. (1963). Occupational therapy: A communicat process in psychiatry. New York: Macmillan. Gallatin, J. (1982). Abnormal psychology; Concepts, issues, tren New York: Macmillan. Hemphill, B. J. (1982). The evaluative process in psychiatric occu tional therapy. Thorofare, NJ: Slack, Inc. Hopkins, H., & Smith, H. (1993). Willard and Spackman's occu tional therapy. Philadelphia, PA: J. B. Uppincott Kaplan, K, &Kielhofner, G. (Eds.). (1989). Occupational case analy interview and rating scale. Thorofare, NJ: Slack, Inc. Kielhofner, G. (Ed.). (1985). A model o/human occupation. Baltimo MD: Williams & Wilkins. Kielhofner, G. (Ed.). (1995). A model of human occupation (2nd e Baltimore, MD: Williams & Wilkins. Kielhofner, G., & Burke, J. (1980). A model of human occupation, p one. Conceptual framework and content. American Journal Occupational Therapy, 34(9), 572-58l. Lerner, C., & Ross, G. (1977). The magazine picture collage: Devel ment of an objective scoring system. American Journal of Occu tional Therapy, 31(3), 156-16l. Levy, L. (1993). Cognitive disability frame of reference. In H. Hopkin H. Smith (Eds.), Willard and Spackman's occupational thera (8th ed.) (pp. 67-71). Philadelphia, PA: J. B. Lippincott. Mann, W. C., & K1yczek, J. P. (1991). Standard scores for the Bay A Functional Performance Evaluation Task Oriented Assessment. Oc pational Therapy in Mental Health, 11(1), 13-24. Mann, W. C., Klyczek, J. P., & Fiedler, R. C. (1989). Bay Area Functio Performance Evaluation (BaFPE): Standard scores. Occupatio Therapy in Mental Health, 9(3), 1-7. Mears, E, & Gratchel, R. J. (1979). Fundamentals of abnorm psychology. Chicago, IL: Rand McNaUy. Miller, R. (1993). Gary Kielhofner. In R. Miller & K. Walker (Ed Perspectives on theory for the practice of occupational thera (pp. 179-218). Gaithersburg, MD: Aspen Publications. Mosey, A. C. (1973). Activities therapy. New York, NY: Raven Pre Mosey, A. C. (1986). Psychosocial companents of occupatio therapy. New York, NY: Raven Press. Mosey, A. C. (1970). Three frames of reference for mental hea Thorofare, NJ: Slack, Inc. Moyer, E. (1981). Index ofassessments used by occupational therap in mental health. Birmingham, AL: University of Alabama. Oakley, E, Kielhofner, G., Barris, R., & Reichler, R. K. (1986). The r checklist: Development and empirical assess of reliability. The Oc pational Therapy Journal of Research, 6(3), 157-170. Perry, D. G., & Bussey, K (1984). Social development. Englewood, C Prentice-Hall. Reilly, M. (1962). Occupational therapy can be one of the great idea twentieth century medicine. The Eleanor Clarke Slagle lecture. T American Journal of Occupational Therapy 16, 1-9. Shoemyen, C. W. (1970). Occupational therqpy orientation and eval tion: A study of procedure and media. American Journal of Occu tional Therapy, 24(4), 276-279. Smith, H. D. (1993). Assessment and evaluation: Overview. In H. H kins &H_ Smith (Eds.), Willard & Spackman's occupational thera (pp. 169-191). Philadelphia, PA: J. B. Uppincott. Williams, S. L, & Bloomer, J. (1987). Bay Area Functional Per mance Evaluation (BaFPEl. Pequannock, NJ: Maddak, Inc.
- 181. -- - CHAPTER 8 Julia Van Deusen, PIlD, OTR/L, FAOTA SUMMARY In this chapter, I discuss assessment of body image disturbance of adult patients likely to be evaluated by occupational or physical therapists in a rehabili tation setting. Three models related to assessments are described. Body image assessment is pertinent to intervention for patients with neurologic disorders, acute dismemberment, other kinds of physical impairment, and some psychiatric diag noses. Two illustrative case reports are given. I discuss the instrumentation for body image disturbances in which neural scheme disturbance is primary and for body image disturbances in which the psychological representation is the dominant dis turbance. The validity and reliability of the various instruments are documented. The construct of body image is a complex one (Cash & Pruzinsky, 1990; Tiemersma, 1989). It incorporates both the neural body scheme, which is subject to disturbance from lesions, and its psychological representation formed through cultural and environmental input, also subject to disturbance. This latter aspect of body image includes a perceptual component involving estimation of the real body shape and size, as well as its attitudinal aspect pertaining to knowledge of and feelings about the body. Of particular importance to occupational therapy and to physical therapy is the notion that our body image incorporates images of the function of the body and its parts necessary for skilled performance, images dependent on both its psychological and physical components (Cash & Pruzinsky, 1990; Keeton et al. , 1990). A social aspect to the body image also exists and is researched by addreSSing subjects' ideal body image (Fallon & Rozin, 1985; Keeton et al., 1990). It is assumed that the ideal body image is based on cultural influences. Since body image is complex and many faceted, it logically follows that disturbances are diverse. Body image disturbance refers to problems in the integration of the neural body scheme and its psychosocial representation. Problems can result from neural lesions, which result bodily inattention, or in misperception of body sha size, or relationships. They can result from actual physi bodily impairments such as loss of a limb, or fr psychosocial influences affecting the mental represen tion of some aspect of the body. Body image is a holi construct and seldom is encountered without psycholo cal and physical manifestations. Consequently, asse ment of body image has been addressed by both n rology and psychology. Because of their relation to th disciplines, applied fields such as occupational thera have also been concerned with body image instrum tation. Typically, several instruments addreSSing the ma aspects of body image are needed for adequate asse ment (Butters & Cash, 1987; Lacey & Birtchnell, 19 Thompson, 1990; Van Deusen, 1993). HISTORY According to Tiemersma (1989), body image is a v old construct. The notion of body image extends back - - ~ --~ - 1
- 182. 160 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT ancient and medieval times, and actual medical records of body image phenomena date from the 16th century. In clinical neurology during the first part of the 20th century, the notion was elaborated and popularized through the works of Head and Schilder (cited in Tiemersma, 1989). Headdefined the neural bodyscheme as a dynamic schema resulting from past postures and movements. Schilder emphasized the mental image from psychosocial and psychoanalytic perspectives. Following the period of classical definition of body scheme in clinical neurology, interest in this area declined until the introduction of assessment tools by psychologists in the 1950s. This was the time of development of body image projective tests and attitude scales and the refine ment of neurologic evaluation. Although body image concepts were compatible early in the century with those of Gestalt psychology, the midcen~ tury work of Fisher and Cleveland (cited in Tiemersma, 1989) was the first major body image research from the field of psychology. Their primary work, in which body boundary relationships were focal, was strongly influenced by the psychoanalytic theorists. Assessment was through projective technique (Fisher, 1990). However, Fisher re cently advocated the multidimensional complexity of the body image construct, necessitating a diversity of measur ing tools. His explanation of the vast amountof body image research in psychology over the decades was that''Human identity cannot be separated from its somatic headquarters in the world. How persons feel about their somatic base takes on mediating significance in most situations" (p. 18). DUring the 1970s, interest in body image research temporarily declined for a number of reasons, such as the nebulousness of its definition and incompatibility with popular theoretical positions. The widespread concern about anorexia nervosa brought a resurgence of body image research by the late 1970s and 1980s. This was a period in which body image test development flourished (Thompson, 1990). In the current era, deliberate attempts have been made to integrate approaches from neurology and psychology (Lautenbacher et aI., 1993; Tiemersma, 1989). Body image authority, Thompson, writing in 1990, predicted "... an expanding role into the 1990s for the researcher and clinician interested in the assessment ... of body image disturbance" (p. xiv). Appropriately, at the present time, the creation of new tests has declined, but refinement of old tests has not. BODY IMAGE MODELS Many theories concerning body image exist (Tiem ersma, 1989; Thompson, 1990). Several theoretical positions are of particular relevance to assessment in occupational therapy and physical therapy. The neuro physiologic explanation of body scheme is fundamental to assessment for body image disturbances associated neural lesions. The sociocultural model and the sch model in cognitive psychology can be useful guide assessment procedures for body image disturbance re to problems with mental representation. Neurophysiologic Theory Tiemersma (1989) described a neurophysiologic e nation for body scheme. The Finger Localization (Benton et aL, 1994) and the Behavioural Inattention (Bin (Wilson et aL, 1987a) are sample assessments re to neurophysiologic theory. According to Tieme (1989), the muscle spindles, tendon organs, joint, cutaneous receptors are the sensory receptors of parti importance to the body scheme. Information from t receptors is transmitted by means of afferent tracts to somatic sensory association area of the parietal corte primary site for body scheme function. The brain has m somatosensory maps, each specialized for a speCific dality, such as joint position. Somatosensory processi by means of a complex network within the central ner system, which is considered very plastic since damag the nervous system results in much cortical reorganiza From this perspective, body scheme can be viewed a function of patterns of excitation in the brain. The li system is associated with affective aspects of body im and the motor system with images of bodily performa Although he has described body scheme in term neuroscience, Tiemersma's position on body image no means limited to this domain. The position of Lautenbacher and colleagues (199 not inconsistent with that of Tiemersma (1989). T authors believe there is strong agreement that the m representative of the body is dependent on the integr of sensory stimuli. The first stage of central nervous sy processing (in sensory cortical areas) results in many schemes, schemes that can be affected by disturbanc sensory input. If the discrepancy among these m schemes is not too great, they become integrated (in temporal lobes) into one "body selL" Like Tiemer Lautenbacher and associates consider the body self pl and integration subject to cognitive and affective ences. Final integration of the bodyself is dependent o activity of widespread cortical and subcortical areas. Sociocultural Model Many authors, including Cash and Pruzinsky (19 Lacey and Birtchnell (1986), and Van Deusen (1993), recognized the influence of culture on body image. H ever, Thompson (1990) emphasized the importance o sociocultural body image modeL Inherent in the soci tural model is the assumption that current societal dards are the major factor relating to body image di
- 183. our society: 1. Physicalattractiveness is highly valued 2. Thinness equals beauty, and obesity is negatively valued 3. Beauty equals goodness so that thinness is also equated with goodness 4. Society encourages women's preoccupation with the pursuit of beauty 5. Society reinforces the bodily alteration of women to enhance society's notion of beauty 6. A build emphasizing upper extremity musculature is the ideal masculine body 7. Men show less body image disturbance than do women Assessments relating to this sociocultural model include those dealing with ideal size and shape relative to the personally known or.felt body image. An example of this kind of instrument is the Body Image Assessment devel oped by Williamson (1990). Model From Psychology Another model of theoretical interest for assessment of body image disturbance is the schema organization in cognitive psychology, especially when integrated with the ecologic perspective. In general, it is agreed that schemata are cognitive structures that organize prior, guide new, and retrieve stored information (Safran & Greenberg, 1986). Paradoxically, with the advent of cognitive psychology in the 1970s, body image research decreased (Tiemersma, 1989). Probable contributing factors were the close ties of body image research with the gestalt and psychoanalytic views of psychology. However, the schema model in cognitive psychology derives quite basically from the body image writings of Sir Henry Head, which influenced the ideas about schema elaborated by Bartlett, by Piaget, and by Neisser (Safran & Greenberg, 1986; Tiemersma, 1989). Furthermore, it has at least a limited theoretical link with cognitive behavioral therapy, a major current treatment approach for body image disturbances (Butters & Cash, 1987; Freedman, 1990; Van Deusen, 1993). Safran and Greenberg (1986) believe that the work of Neisser in particular integrates the two positions in cogni tive psychology with value for therapy. According to their perspective, Neisser combined the best of the information processing position, the idea of schemata, with the eco logic position, which emphasizes environmental interac tion. Neisser maintained that we both act on and are acted on by the environment. Because of this action, internal schemata experience ongoing revision. The Feelings of Fatness Questionnaire (FOFQ) (Roth & Armstrong, 1993) is a particularly good example of an assessment tool congruent with this theoretical perspective. KINDS OF BODY IMAGE DISTURBANCES Lacey and Birtchnell (1986) have categorized b image disturbances into four groups: 1) those due neurologic disorder, 2) those following acute dismemb ment, 3) those associated with actual physical proble and 4) those accompanying psychiatric diagnosis without physical disability. Van Deusen (1993) used th groups to organize body image disturbances likely to encountered in patients treated by rehabilitation spec ists. Although assessment tools may be useful for m than one type of disturbance, often instruments have d related to only one category. Neurologic Disorder Lesions of the central nervous system leading to paired neurologic function can disturb the body schem Under these conditions, psychosocial factors may add the body image disturbance beyond that from the neu logically impaired scheme. Cumming (1988) described various body scheme disturbances from neurologic di ders. Many problems have been observed, including 1) nial of paralysis or paresis of the involved limbs, 2) inab to identify body parts or relationships, 3) a special condit of inability to identify parts, namely finger agnosia, 4) ability to distinguish right from left on one's own body or a confronting body, 5) disturbed use of body pa particularly in writing, 6) perception of body parts abnormally large or small, 7) inability to identify the are body part touched, 8) inattention to the stimulated b side contralateral to the brain lesion, 9) extinction of stim to the involved side when Simultaneously administered the uninvolved side, and 10) inability to use body part address the hemispace contralateral to the side of br lesion. Patients treated in rehabilitation facilities who may h one or more of these neurologic body schemedisorders those challenged by stroke, by traumatic head injury, substance abuse, by brain tumor, or by other patholo conditions affecting the central nervous system. B psychologists and neurologists have developed many struments for assessment of body image disturbances this category (Van Deusen, 1993). ACIIte Dismemberment This category of body scheme disorders includes th patients who experience the phantom phenomena foll ing amputation of a body part. The temporary phant sensation of the missing part is almost universal after a limb loss. Phantom sensation is attributable to contin
- 184. 1.1 162 UNIT 1WO-COMPONE~TASSESSMENTS OF THE ADULT existence of the neurologic scheme after loss of the actual physical part. Because of interactions of central nervous system mechanismsand loss ofthe sensory receptorsofthe missing part, phantom pain may occur but, as yet, is not fully understood. A logical estimate is that more than 60% of adults experience phantom pain follOwing limb ampu tation. Although phantom sensation may actually aid rehabilitation by providing the trainee with a complete body perception, phantom pain must be considered a disturbance of body image that can greatly interfere with performance. Phantom pain can also occur after breast surgery orspinal cord injury but has not been as extensively studied as for limbs. Phantom pain can be assessed in rehabilitation settings by use of instruments designed to evaluate chronic pain in relation to functional activity (Van Deusen, 1993). Actual Physical Problem Adults who are challenged by physical disabilities such as bums or rheumatoid arthritis may be susceptible to body image disturbances. Persons in this category may L. be baSically well adjusted, but because of unfavorableI'" societal input can suffer body image disturbances in the process of adjusting their image to their new physical reality. The body image disturbance in this category is secondary to the physical problem (Lacey & Birtchnell, 1986). Attitudinal body image assessment is necessary for this category of disturbances since disturbances would be in the psychological representative aspect of the body image. Psychiatric Diagnosis Body image disturbances are a condition of many psychiatric diagnoses and problems. Persons with distur bances in this category have no visible physical problem to account for the body image disturbance. Disturbances vary widely from that of the person with a normal nose inSisting on surgeryto correct the deformity to the major body image distortions of the person challenged by schizophrenia (Lacey & Birtchnell, 1986). Although manydisturbances in this category are seldom encountered by occupational and physical therapists, some, such as the attitudinal body image problem of the youth with bulimia nervosa, may be seen. Others may be encountered by occupational therapists in psychiatric settings where as sessment would involve projective techniques or psychiat ric interviews, making it beyond the scope of this chapter. Assessment for this category involves instrumentation addressing the psychological representation of the body image. Illustrative Cases Occupational therapists and physical therapists s address intervention only for body image disturb Rather, enhanced or improved body image is one complex of rehabilitation goals. The illustrative ca ports presented here are hypothetical, particularly i they address only one facet of the total assessment pr in the rehabilitation setting. An example is given patient requiring body image assessment for neuralsc disturbance and for a patient requiring body image a ment for disturbance of psychological representatio Neurologic Disorder: Neural Scheme Disturbance. M is a 52-year-old African-American homemanager m to an executive in Pasadena, California. She is a hemisphere stroke survivor with mild hemiparesis left upper and lower extremities. Mrs. B. is in the re tation unit being assessed by the occupational therapi physical therapist, and the language pathologist language pathologist has found no speech impair While evaluating Mrs. B.'s status in activities of daily (ADL), the therapistsfound her unable to respond to s presented to her left. The BIT (described in the Instr tation section) was administered, and scores confirm presence of severe left side neglect. Major obje incorporated into Mrs. B.'s rehabilitation program were for enhanced left body side awareness an improved function with objectsto her left. Although M anticipates being able to afford weekly assistance wi home chores when discharged, improved body sche vital for her return to her full role as a homemanage conservative residential setting. PhYSical Problem: Disturbance of Psychological R sentation. J. T. is a 23-year-old white man severely b in a camping accident. The involved areas include m the shoulder and neck area and lower face. H undergone two surgeries as well as rehabilitation well-known institution. His girlfriend of 2 years be involved with another man a month after J. T.'s acc His parents are divorced. He lives with his mother, w a waitress at a local chain restaurant, and J. T essentially no contact with his father. He was enrol general education courses at the community college time of his accident. Since his discharge from the re tation center, J. T. has been unwilling to resume c work. He applied for two retail sales positions an rejected. He has recently been admitted to a work ha ing program for assessment by occupational therap physical therapy. The initial impression of the ther was that J. T. has the physical capacity for many ki employment. Several sarcastic comments by J. T. abo appearance led to administration of an attitudinal image self-report questionnaire. Results indicated s body image disturbance. The therapists recommen psychological consultation since J. T.'s body image lem was apparently a major hindrance to employ
- 185. INSTRUMENTATION Because of itsmany facets, innumerable instruments for assessing body image are described in the literature. Many of these tools are appropriate for use by rehabilitation personnel for assessing body image dysfunction. Others are better used as research instruments. Furthermore, the various instruments can be categorized as to whether they are primarily used to assess disturbances of the neural scheme or to assess disturbances in the psychological representation component of the body image. I have necessarily had to limit the number of instruments dis cussed and have categorized those selected under their function relative to the neural scheme or psychological representation. My selections were based on the desire to 1) provide examples of the different kinds of tools available (e.g., self-report questionnaires, size estimation tech niques), 2) include instruments suitable for clinical interven tion and for research purposes, 3) include samples of instruments for assessment of all four categories of body image disturbance, and 4) provide information on those tools that my literature review showed to be best re searched. In addition, I have prOvided some examples of the more recent, innovative instruments that hold promise for future development. From a practical pointofview, it must be understood that much overlap in assessment occurs. Clear-cut categoriza tion by function is not always possible. A tool or technique may be designed to ascertain presence of a neural body scheme deficit but ultimately be more useful for assessment of a psychological disturbance. An example is the size estimation technique widely used for perceptual body image research in anorexia nervosa studies. Directions requesting responses of how subjects feel about their bodies or comparison of actual image with their ideal have differentiated subjects with eating disorders from those without, although both groups have been found to overes timate their size (Keeton et al., 1990; Van Deusen, 1993). Neural Scheme Disturbances Disturbances of the neural body scheme were tradition ally evaluated by neurologists and psychiatrists by means of interviews or clinical observations. This tradition was incorporated into occupational therapy assessment proce dures (Zoltan et aI., 1986) and is widely in use today, despite the availability of standardized instruments. Some clinicians prefer the flexibility of patient assessment al lowed by nonstandardized tools and appreciate such practical advantages as low cost. From those standardized or semistandardized instru ments discussed in the literature and appropriately used by occupational therapists and physical therapists, I have body image disturbances associated with disruption of central nervous system scheme. Assessments are for categories of neurologic disorder and acute dismemb ment. I have also included a computerized tool t deserves further research. These instruments are 1. Right-Left Orientation Test (Benton et al., 1994) 2. Finger Localization Test (Benton et al., 1994) 3. BIT (Wilson et aL, 1987a) 4. Pain Disability Index (Pollard, 1984). 5. Computerized Test of Visual Neglect and Extinct (Anton et aI., 1988) RIght-Left Orientation Test. Among the tests for neu psychological assessment developed byArthur Benton his colleagues is the Right-Left Orientation Test (Bento al., 1994). There are four forms of this test, the orig form (A), a "mirror image" version (B) for use as alternate form, and forms Rand L, designed for use w patients unable to use their right or left hands. Form R shown in Rgure 8-1. Performance on this 5-minute requires verbal comprehension and slight motorskillas w as the spatial-symbolic aspects of right-left discriminatio is designed to evaluate. Items included to assess hierarchical skills in right-left orientation are orientat toward one's own body (lowest on hierarchy), orientat toward a confronting person, and orientation toward on own body combined with a confronting person. Normative data are available from 126 men and 1 women without brain disease and from 94 adults with br disease (Benton et al., 1994). Various problems in right- disorientation can thus be identified from the stand administration of this test. Data are provided that defin generalized defect, a confronting person defect, and own body defect. If systematic reversal occurs (all left w it should be right), it is assumed that right-left orientatio intact butthe personis confused with verbal labels, as mi be the case with patients challenged by aphasia. I found no reliability data on this specific measure right-left orientation. However, Baum obtained an in rater reliability coefficient of r = 0.94 for a similar ins ment used with adults having had head injury (cited Zoltan et al., 1986). Also, some evidence of constr validity was found. An early version of Benton's Right-L Orientation Test (Sauguet et aI., 1971) as well as current test (Benton et aI., 1994) discriminated apha from nonaphasic persons in respect to orientation to on own body. Benton and collaborators believe that right- orientation has symbolic as well as spatial determinants case study of Gerstmann syndrome (Mazzoni et al., 19 also supported the construct validity of this test. T complex of dyscalculia, dysgraphia, right-left disorien tion, and finger agnosia was shown to be present i patient with a very proscribed area of cerebral traum Although the specific items of Benton's test for right- orientation were apparently not used, the instrum ~ ~--- - -.;;;;;==-~- ~--
- 186. 164 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT RIGHT-LEFT ORIENTATION, FORM R (For use with patients who cannot execute commands with the right hand) Name Age Sex Education Own Body 1. Show me your left hand. 2. Show me your right eye. 3. Show me your left ear. 4. Show me your right hand. 5. Touch your left ear with your left hand. 6. Touch your right eye with your left hand. 7. Touch your right knee with your left hand. 8. Touch your left eye with your left hand. 9. Touch your right ear with your left hand. 10. Touch your left knee with your left hand. 11. Touch your right ear with your left hand. 12. Touch your left eye with your left hand. Examiner's Body 13. Point to my right eye. 14. Point to my left leg. 15. Point to my left ear. 16. Point to my right hand. 17. Put your left hand on my left ear. 18. Put your left hand on my left eye. 19. Put your left hand on my right shoulder. 20. Put your left hand on my right eye. Performance Pattern A. Normal B. Generalized Defect C. "Confronting Person" Defect D. Specific "Own Body" Defect E. Systematic Reversal No. Date ________ Handedness Examiner ______ Response Scor +-R + + + + + + + + + + + SUM ____________________ +-R +-R +-R +-R +-R +-R +-R +-R SUM ____________________ Total Score __________ Reversal Score _________ Comments: __________ FIGURE 8-1. Right-left orientation test, Fonn Rfor persons unable to use their right hand. (From Benton, A. L., deS. Hamsher, K., Varney, N. R & Spreen, O. CONTRIBUTIONS TO NEUROPSYCHOLOGICAL ASSESSMENT. Copyright ©1983 by Oxford University Press, Inc.)
- 187. - - -- - - Benton's hierarchy and used similar items. Benton and associates (1994) cited a studyshowing smallbutsignificant relationships between right-left orientation scores and the pertinent variables of brain atrophy, EEG slowing, and educational background. Finally, construct validity was further supported by Fischer and colleagues (1990). These researchers showed that the "confronting" items on the Right-Left Orientation Test discriminated persons with dementia of the Alzheimer type at all stages not only from control subjects but also from persons with multiinfarct dementia. Scores for visuospatial dysfunction and aphasia did not differentiate these groups. An abbreviated version of the Right-Left Orientation Test was used because of the age of the subjects. Further research is needed for docu mentation of the reliability and validity of Benton's test of right-left orientation. Particularly, the relationship between right-left orientation and task performance must be deter mined to support the,use of the Right-Left Orientation Test in rehabilitation assessment. Finger Localization Test. A second test designed by Benton and colleagues (Benton & Sivan, 1993; Benton et aI., 1994) pertinent to an aspect of the body scheme is that for the localization of fingers to assess finger agnosia. Again, verbal comprehension and a slightamount of motor skill are required to perform. This test is in three parts graded as to ease of localization. Tasks require localization of single fingers with vision and then without vision, followed by localization of pairs. Depending on the pa tient's choice, responses can be made by verbal name or finger number or by pointing to a finger on a drawing. Normative data were collected from 104 hospitalized patients aged 16 to 65 years with no history of psychiatric or brain disease. Data also were obtained from 61 patients with brain disease (Benton et al., 1994). From the norma tive data, several problems in finger localization were defined from those scores outside the total score limits, outside single hand score limits, and outside the difference score between hands. Borderline scores were also re corded. I could not locate any report of reliability studies with Benton's Finger Localization Test. However, evidence of its construct validity suggests that it must measure in a consistent manner. On an early version of this test, controls made no errors and response mode was only nonverbal. This test discriminated between persons with and without aphasia (Sauguet et al., 1971). When vision was not used, Benton's Finger Localization Test discriminated between subjects with brain disease and control subjects (Benton etal., 1994). The case reported by Mazzoni and coworkers (1990), which I discussed in relation to right-left orientation, also supported the con struct validity of the Benton test of finger localization. I found no study relating scores on Benton's Finger Localization Test with those from tests of ADL or occupa tional performance, although occupational therapists have suggested that finger agnosia is related to poordexterity for other (Zoltan et al., 1986), It would be of interest research the Finger Localization Test in this respect to obtain other data to further verify its reliability validity. Behavioural Inattention Test. The BIT (Wilson et 1987a, 1987b) was designed in England as a measur unilateral visual neglect (UN). According to Heilman collaborators (1985), the neglect syndrome includes b lack of intention to act in the space contralateral to the of the brain lesion and inattention to sensory input to body side contralateral to the site of the lesion. The addresses the former aspect of the neglect syndrome is concerned with the body function aspect of body im rather than identification of the body parts. Tests such that by MacDonald (1960) have long been used occupational therapists to identify patient problems w body part recognition, including those resulting fr inattention to sensory input to a body side. The BIT has changed through the usual developme process involved in test construction, and the curr version (Wilson et al., 1987a) is distributed in the Un States. The unique feature of the BIT is that it includes A tasks. The intent of these ADL behavioral subtests i increase the tester's understanding of the specific d living problems of a patient with unilateral neglect tow more effective rehabilitation procedures. Content vali was sought by having these behavioral tasks selected occupational therapists and psychologists who underst the daily living problems of patients challenged by unilat neglect (Stone et al., 1987; Wilson et al., 1987a). Initia the criterion-related validity of these ADL subtests measures of neglect was estimated by correlation w scores from six conventional tests of UN. Except for a bisection test, coefficients ranged from r = 0.59 to 0. The current test manual (Wilson et al., 1987a) give coefficient of r 0.67 for the relation between questi naire responses by patient therapists and the scores patients on the ADL subtests. Estimates of reliability w also acceptable for these ADL subtests, with alternate fo reported as r 0.83 and 100% agreement between raters (Wilson et al., 1987b). The currentversion ofthis (Wilson et aL, 1987a) has the following nine behavi (ADL) subtests: Picture scanning, in which subjects identify daily liv items in three color photographs, and omissions scored Telephone dialing, in which the task is to dial a disc nected telephone Menu reading, in which a menu is opened and items read (or pOinted to) and omissions scored Article reading, in which a short newspaperarticle is r aloud and errors scored; this subtest is not given language-impaired persons Telling and setting time, in which the time is read fro digital and an analogue clock, and the time is set on analogue clock - ,
- 188. 166 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT Coin sorting, in which 18 coins are prearranged and must be pointed out when named by the tester Address and sentence copying, in which an address and a sentence are copied Map navigation, in which three sets of sequential directions are traced with a finger on a maplike item Card sorting, in which the person points to a selection of playing cards as named by the tester Test materials are presented opposite the subject's midline, and, although other errors may be noted for further investigation, only errors of omission are scored. In addition to the ADL behavioral subtests, the BIT has six simple pencil and paper conventional subtests of UN: line crossing, letter cancellation, star cancellation, figure and shape copying, line bisection, and representational drawing. According to the test authors (Wilson et al., 1987a), these subtests may be used to diagnose the presence or absence of unilateral neglect. Small and Ellis (1994) found these six subtests of the BIT discriminated between theircontrol subjects and a patient group withdual diagnoses of anosognosia and visuospatial neglect. A principal components analysisclearlyshowed that thesesix conventional subtests were contributing to the same con struct, defined as visual neglect. The star cancellation was the most sensitive measure of the six subtests (Halligan et al., 1989). In a New Zealand study (Marsh & Kersel, 1993), 13 subjects were found to have visual neglect when assessed with the line crossing and star cancellation subtests and two other tests of neglect. The star cancella tion was the most sensitive of these four measures and the only one found to correlate Significantly with scores from a measure of ADL, the Modified Barthel Index (r = 0.55). The test manual gives a correlation coefficient of r = 0.92 between scores from the ADL behavioral subtests and those from the six conventional subtests for 80 rehabilita tion patients with unilateral cerebral lesions. The BIT is being used in research because of its functional relevance. One group (Robertson et al., 1990) considered it as their principal measure in a controlled study of the effects of computerized treatment for UN patients after stroke. Although the BITdid not discriminate between groups, neither did five of their other six measures of UN. In another intervention study using single system design, the researchers found that with two subjects, the BIT did discriminate between pretest and six-month per formances (Cermak et al., 1991). The suggestion of Cermak and Hausser (1989) that the behavioral subtest items be validated against real-life ADL performance makes sense in view of the use of the BIT for its functional properties. The current test manual (Wilson et al., 1987a) shows excellent reliability data for the Behavioural Inattention Test in its entirety. The IS-day interval test-retest coeffi cient for 10 subjects with brain damage was r 0.99; the interrater coefficient was r 0.99; and the parallel form coefficient was r = 0.91. Small and Ellis (1994) observed two control subjects, testing them each week with the six conventional BIT subtests for a I-month period. T scores did not vary by more than one point over t Considering the evidence for test stability of the BIT, it interest that Small and Ellis (1994) found inconsis scores from a long-term follow-up studyof neglect patie These authors attributed this inconsistency to brief per of remission in the unilateral neglect of their sample. The BIT (Wilson et aI., 1987a) was standardized on rehabilitation patients averaging 2 months post str The manual provides normative data from only 50 per without cerebral lesion. Cermak and Hausser (1989) h justifiably criticized these normative data. On the pos side, the cutoff score from these data defined as ha neglect the expected greater proportion of subjects had right hemisphere, as opposed to left hemisph strokes. Research should address improved normative for the BIT. Although there is little reason to expect from the United States to differ from the British dat study confirming this expectation would also be of inte to the American therapist. Stone and colleagues (1991) successfully shortened BIT for use with short-term acute stroke patients. shortened version was validated by comparing the scores with occupational therapists' assessments of un eral neglect from ADLevaluations. Furtherresearch on shortened BIT is needed. Pain Disability Index. No instrument was found spe cally designed to assess the phantom pain associated dismemberment. The Pain Disability Index (POI)develo by Pollard (1984) is an easily administered scale asses chronic pain in relation to activity and, conseque applicable to phantom limb pain. The POI, consistin self-report ratings of the extent that chronic pain interf with seven categories of life activity (family and h responsibilities, recreation, social activity, occupat sexual behavior, self-care, and life support activity), well-researched tool (Gronblad et aI., 1993; Gronbla al., 1994; Jerome & Gross, 1991; Taitet aI., 1987; T al., 1990). Originally, ratings of the seven categories w summed, but factor analyses by the Tait research gr (1987, 1990) showed the instrument to have a two-fa structure, discretionary (voluntary) versus obligatory ac ties, so that an overall score has little meaning. The results should be interpreted in terms of ratings of dis tionary activities (home, recreation, social, occupation, sexual) and of ratings of the obligatory activities esse for living (self-care, such as dressing, and life support, as eating). Reasonable internal consistency was obta for each factor (alpha = 0.85, discretionary; 0.70, ob tory). The test-retest reliability coefficient was low for Tait research group (1990), but a 2-month time span explain the coefficient of r 0.44 (n = 46). The Gron group (1993) obtained I-week, test-retest intraclass co lation coefficients of 0.91 (total POI), 9.87 (discretio factor), and 0.73 (obligatory factor) for 20 subjects domly selected from their total of 94 patients with chr back pain.
- 189. the construct validityof the POI. Initially, Pollard (1984) showed that this scale discriminated between nine persons with lower back pain with a current work history from nine who had just received surgery. The Tait research group (1987, 1990) showed that the POI discretionary and obligatory factors discriminated outpatients with pain from inpatients with pain, the former, as expected, being less disabled by their pain. In a major study, 197 POI high scorers (greater disability) were compared with 204 low scorers. The high scorers reported more psychological distress, pain, and disability, stopped activity more, were in bed more during the day, and spent more total time in bed than did low scorers. Two other studies also supported the construct validity of this instrument. Multiple regression procedure showed that time in bed, stopping of activity, psychological distress, and work status predicted POI scores. Patients who were employed had lower POI scores than did those unemployed. Finally, it was found that high POI scorers had higher rates of pain behaviors such as verbal complaints and grimaces than did low scorers. Gronblad and collaborators (1993, 1994) provided still further support for the construct validity of the POI, since the POI total values correlated r = 0.83 with those from the extensively used and researched Oswestry Oisability Questionnaire. The coefficient for the discretionary factor was r = 0.84 but only r = 0.41 for the obligatory factor, showing less support for the validity of this part of the POI. The POI was also related to a measure of pain intensity at r = 0.69. Further work showed the POI to discriminate persons with chronic pain who were working from those on sick leave. Since the POI is a self-report measure, Gronblad and associates (1994) studied its relation to objective physical therapist observations of activities requir ing back and leg muscle use. Subjects were 45 outpatients with chronic back pain. Activities included a sit-up test emphasizing abdominal muscles, an arch-up test for back muscles, and a squatting test for lower extremity muscles. Although correlation coefficients were low (0.30s and 0.40s), these researchers did find significant relationships between POI results and observed activity scores, even after adjustment for age and gender. Jerome and Gross (1991) were concerned that the POI scores might not provide any useful information beyond that of a pain intensity scale. For 74 subjects from a university pain clinic, they correlated POI results to several variables used to assess functional status in chronic pain. Although pain intensity was highly related to POI, when intensity was partialled out, discre tionary POI scores were still related to level of depression, lack of employment, and use of pain medication. Thus, the POI does provide information on disability beyond that provided by a pain intensity scale. In summary, an impressive bodyof research supports the construct validity of the POI with chronic pain patients. I concur with the researchers who consider the POI a feasible clinical instrument if used as part of a battery to assess the relation of chronic pain and activity level. The POI should pain, but specific research in this area would be valuab The POI would be an instrument of choice for assessm in longitudinal studies of rehabilitation in which chro pain is a factor. Computerized Tests. In this information age, compu aided testing is a given. However, because of time and c constraints, use of a well-developed paper and pencil t often may be of more practical value in the clinic than use of elaborate electronic measuring devices. Comput ized tests that are useful to the clinician are obviou desirable. Anton and colleagues (1988) reported such a t designed to assess visual neglect and extinction. In this t situation, the subject, with gaze fixed centrally, respond to randomly appearing lights (Fig. 8-2). Lights appeared the subject's right side, to the left, or simultaneouslyto ri and left sides. Testing with 30 "normal" volunteers show that, although errors were made, no difference was ma in the number on the right and left sides. When used w patients after right cerebrovascular accident (CVA), grea response to right than to left lights would indicate negle Response only to right with simultaneous lights would sh extinction. Relative to clinical evaluation by a physician a identification by occupational therapists from paper a pencil testing, the computerized test was found to be hig sensitive, identifying visual neglect in 16 and extinction 13 of 24 subjects with right CVA. In every instance, wh neglect and extinction were identified by the physician occupational therapist, they were also identified by computerized testing, but the computerized test identif five more cases of extinction than did the physician and more cases of neglect than did the occupational therap FIGURE 8-2. Computerized test for visual neglect and extinction. (F Anton, H., Hershler, c., Lloyd, P., & Murray, D. [1988]. Visual neg and extinction: A new test. Archives of Physical Medicine and Re bilitation, 69, 1013-1O16.)
- 190. 168 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT Anton and coworkers (1988) reported limited informa tion on reliability, merely stating that three each of control and experimental subjects were retested within 2 to 3 weeks, with no change in test results. Construct validity was supported. The data from this computerized test supported the position of neurologists that neglect is a severe manifestation of extinction since neglect never occurred in the absence of extinction. Because this computerized test of Anton and colleagues (1988) appears to be well worth the effort of those researching this type of testing, I was surprised to locate only one later study. Beis and collaborators (1994) de scribed a modification of the Anton test, which was designed to detect visual field deficits as well as visual neglect. From 63 subjects with brain injury, 17 were identified as having visual field defects and 12 as having neglect. Identifications of visual field defects by the com puter test did not differ significantly from those by ophthal mologist tests. The array of 64 light emitting diodes (LEDs) for this study (in a somewhat tighter semicircular arrange ment than that for the Anton test) allowed for well-defined control data. All errors by the 31 control subjects were limited to the final five lightsto the right orleftsides. Further research is needed on this type of testing for unilateral neglect. To summarize, one aspect of body image that needs assessment in rehabilitation is neural scheme disturbance. Persons with conditions such as phantom limb pain or unilateral neglect are examples of patients needing such assessment. Five examples of instruments of research and clinical interest were discussed. Disturbances of Psychological Representation Many instruments were reviewed that purport to assess body image disturbances associated strongly with psycho logical or social conditions. These tools have been used for assessment of body image disturbances of persons with actual physical disabilities or with psychiatric diagnoses but with no known neural lesion to distort the neural scheme. Thompson (1990) was among those who recognized that, even with the neural body scheme disturbance excluded, body image disturbance remained a multidimen sional construct. Thus, he discussed measures designed to assess the perceptual and the subjective components of disturbances. Keeton and associates (1990) also catego rized assessment tools for the psychological representation aspect of the body image into these same categories (perceptual and attitudinal). Measures of body size estima tion (width of body parts) and whole-image distortion procedures have been termed perceptual, but this term can cause them to be confused with measures used to assess neural body scheme disturbances often classified as per ceptual (Zoltan et al., 1986), so I prefer the term used by Meermann (1983), psychophysical methods. These psychophysical methods are of two types: b size estimation procedures and the whole-image disto methods. In the former, using lights, calipers, or o instruments, subjects estimate the width of their var body sites (such as hips or chest), and distortion score computed by comparing estimates to actual measu typically taking variables such as height and weight consideration. The whole-image distortion procedures photographic or video methods for subjects to estim their bodies as a whole (Van Deusen, 1993). I select body size procedure, the Body Image Detection De (BIDD) (Ruff & Barrios, 1986) to illustrate this kind of b image assessment instrument. The attitudinal measures have been subdivided various ways (Ben-Tovin & Walker, 1991; Thomp 1990; Van Deusen, 1993). I believe that three c goriesincorporate instruments of major use to occ tional therapists and physical therapists: 1) self-re tools requiring responses to figures or Silhouettes; 2) report tools requiring responses to verbal statem about size, shape, or other aspects of body image; 3) the semantic differential technique (Van Deu 1993). The instruments I selected to illustrate the wide arra measures of the psychological representation aspec body image include examples from each category: 1. Body Image Detection Device (BIDD) (Ruf Barrios, 1986)-psychophysical measure 2. Body Image Assessment (Williamson, 1990)-s report, silhouette measure 3. Multidimensional Body-Self Relations Questionn (MBSRQ) (Cash & Pruzinsky, 1990)-self-rep verbal statements measure 4. Body Shape Questionnaire (BSQ) (Cooper et 1987)-self-report, verbal statements measure 5. Body Image Assessments Using the Semantic D ential Technique (Isaac & Michael, 1981)-bip adjective attitude scales Ialso included two recently developed instruments minimal research work, the FOFQ (Roth & Armstr 1993) and the Color-a-Person Body Dissatisfaction (CAPn (Wooley & Roll, 1991). These tests provide va scores as body image changes within situational con and both instruments deserve further research attent Body Image Detection Device. Of those devices techniques developed for research investigating body estimation accuracy, particularly for subjects challenge anorexia or bulimia nervosa, one tool receiving rese attention was the BIDD originated by Ruff and Ba (1986). The BIDD projects light onto a wall for the sub to adjust to their estimated body site widths by manipula the templates of the apparatus. The subjects' site (face, chest, waist, hips, thighs), estimated one at a t are compared with their actual widths measured by investigator, so that a ratio can be computed for ove underestimation of size (estimated/actual discrepanc
- 191. sizes, a self/idealdiscrepancy index can also be computed. Data from college students, 20 with bulimia and 20 with out, in the Ruff and Barrios study (1986) showed internal consistency coefficients (Cronbach's alpha) of 0.79 to 0.93. Interrater reliability coefficients were r = 0.98 or bet ter. A1I3-week test-retest reliability coefficients were in the O.70sand 0.80s for bulimic and control subjects, exceptfor the waist estimate of bulimic subjects (0.44). The authors' second study (Cited by Thompson, 1990) showed much lower coefficients among college women. Keeton and as sociates (1990) in their use of the BIDD found a coefficient (alpha = 0.93) indicating high interrater reliability of the measurement of the actual body site sizes. Considerable evidence exists for the construct validity of the data obtained from the BIDD. The estimated/actual index discriminated between three weight groups, 12 each of normal, over-, and underweight nonclinical subjects (Cash & Green, 1986), between 20 each of bulimic subjects and controls (Ruff & Barrios, 1986), and between 47 male and 78 female college students (Keeton et al., 1990). The self-estimate scores and self/ideal discrepancy index showed moderate correlations (0.42 to 0.67) with those from a silhouette tool. For women, the self/ideal discrepancy index was also significantly related to scores on a test for bulimia, but the coefficient was low at r 0.38. Evidence indicated that BIDD results were independent from those of attitudinal measures (Keeton et al., 1990). A modification of the BIDD, the Adjustable Light Beam Apparatus, allows the projected light to be Simultaneously adjusted for the three body sites (waist, hips, and thighs) after practice with the face (Thompson & Spana, 1988). The authors provideddetaileddirections for construction of this device. It has also received research attention showing acceptable reliability coefficients and evidence that size estimation data are independent from those of attitudinal measures (Altabe & Thompson, 1992; Coovert et al., 1988; Thompson & Spana, 1988). used figures or silhouettes graded from very thin to v obese as stimuli for response by subjects in their b image studies (Bell et al., 1986; Fallon & Rozin, 1985) computer program version has also been evalua (Dickson-Parnell et al., 1987). One such silhouette assessment procedure for b image was designed and researched by Williamson a colleagues (Williamson, 1990; Williamson et al., 19 Williamson et al., 1993). Nine silhouettes (Fig. 8-3) grad from thin to obese are presented to subjects on car Cards are presented in a fixed order since no difference w found from the random display originally used. Stand instructions are used to request first accurate and th preferred body size choices from the cards. Administrat time is less than 1 minute. Normative data of subje height and weight were established by cluster analy (Williamson et al., 1989). These data may be used determine if testees show body images outside of norm limits. Data estimating the reliability and validity of the B Image Assessment were obtained (Keeton et al., 19 Williamson, 1990; Williamson et al., 1989; Williams et al., 1993). Test-retest reliability data were gathe from I-week, 2-week, and 3- to 8-week intervals betw administrations. All reliability estimates were in the 0.7 0.80s, or 0.90s. Williamson and colleagues provided evidence for construct validity of the Body Image Assessment (Willi son, 1990; Williamson et al., 1989; Williamson et 1993). In two separate studies, as hypothesized, itdiscri nated between persons with bulimia nervosa and con subjects and between persons with anorexia nervosa a control subjects. No score differences were found betw eating-disordered subjects. As hypothesized, relationsh were found between scores on tests of eating attitudes a bulimia and those of the Body Image Assessment. Furth more, another research team, Keeton and cowork FIGURE 8-3. Silhouettes for the Body Image Assessment by Williamson. (From Williamson, D. A. [1990]. Assessment ofeating disorders: Obe anorexia, and bulimia nervosa. Needham Hights, MA: Allyn & Bacon.) - , ' . --~ - "" . " ;:~~=
- 192. 170 UNIT lWQ-COMPONENTASSESSMENTS OF THE ADULT (1990), also supported the construct validity of a modified version of the Body Image Assessment in their study examining a number of body image measurements. Body-Self Relations Questionnaire. Many self-report scales of the Likert type using verbal statements have been used by body image researchers for investigation of disturbances of persons challenged by anorexia ner vosa, mastectomy, severe burns, and other problems (Van Deusen, 1993). The self-report questionnaire de vised and researched by Winstead, Cash, and collabora tors (Cash & Pruzinsky, 1990) is an outstanding example of this type of assessment procedure. Their conceptual framework was a multidimensional, psychosocial one in which body image was originally assessed by the nine subscales of the Body-Self Relations Questionnaire (BSRQ), which addressed the cognitive, affective (evalu ative), and behavioral dimensions of three somatic domains: physical appearance, fitness, and health. For the various subscales, internal consistency coefficients were reported from alpha = 0.68 to 0.91 (Winstead & Cash, cited in Cash & Pruzinsky, 1990), alpha = 0.91 (Noles et al., 1985),0.83 to 0.92 (Cash & Green, 1986), and the 0.80s (Butters & Cash, 1987). Test-retest scores from the physical appearance domain over 1 month were 0.85 to 0.91 (Cash & Green, 1986). Evidence exists of the construct validity of the physical appearance domain items from the BSRQ. Noles and asso ciates (1985) found the affective dimension to discriminate depressed from nondepressed subjects. Cash and Green (1986) showedthese items to discriminate among nonclini cal subjects by weight group. Pasman and Thompson (1988) found these itemsto differentiate between male and female runners, the latter being less satisfied with their physical appearance. Keeton and collaborators (1990) found scores from the affective/appearance domain to be related to several other attitudinal body image measures, as well as to a measure of eating disorders. Thompson and Psaltis (1988) found BSRQ scores related to those from a figure rating scale. Of particular importance was the evi dence provided by Butters and Cash (1987) that the BSRQ (all domains) showed Significantly improved body image follOwing cognitive-behavioral treatment of experimental relative to control subjects. Although these experimental subjects had shown dissatisfaction with their body images, they were functioning college students, not patients. From a magazine survey (Cash, 1990; Cash et aL, 1986), data were obtained on the BSRQ from 30,000 persons. Norms were established (N = 2000) from a random sample of these data stratified for age and gender. Since this sample contained 91% white, 84% college educated subjects and 37% never-married persons, it is not representative of the general population. These BSRQ data clearly differentiated persons who did poorly from those who did not on a psychosocial adjustment scale included with the survey. The BSRQ also showed women as having less positive body images than men, although not to the extent anticipated. Adolescents showed less positive body images than did other age groups. From their survey data, Cash and collaborators (Bro et aL, 1990) refined the BSRQ. The current instrume the Multidimensional Body-Self Relations Questionna (MBSRQ), was reduced to 69 items from the original 1 and to six subscales from the original nine. Because of correlation of data, the cognitive and behavioral dim sions were combined to one orientation dimension, w the affective (evaluation) dimension maintaining indep dence. The revised BSRQ part of the MBSRQ 54 items, and the other items make up a body ar satisfaction and a weight attitude scale. Sample items "Most people would consider me good-looking" and "I very well coordinated" (Cash & Pruzinsky, 1990). validate their conceptual frame of reference, Brown colleagues (1990) analyzed the factor structure of BSRQ with separate split-sample factor analyses for e gender. The survey data from 1064 women and 988 m were used. It was expected that the analyses would rev factors that could be defined by the six subscales: appe ance, fitness, and health evaluation; and appearan fitness, and health orientation. The six predicted fact were generated by each of the four analyses plus a seven an illness orientation factor. Items loading on the illn orientation factor pertained to alertness to symptoms illness, as distinguished from items about motivation ward bodily wellness, which loaded on the health orien tion factor. Further study showed marked stability of factor structure between and within genders. The constr validity of the MBSRQ as a measure of the psycholog representation aspect of body image has continued to demonstrated through research results obtained with use of this instrument (Cash et al., 1991; Denniston et 1992). Unquestionably, the MBSRQ is a body image t with very acceptable reliability and validity data. Compu software is available to facilitate the use of this instrum (Cash & Pruzinsky, 1990). Body Shape Questionnaire. British researchers Coop Taylor, Cooper, and Fairburn (1987) perceived the lack a body image tool dealing specifically with body sh concerns. They developed a measure directing subject respond in terms of how they felt about their appeara over the past four weeks. Sample items from their B follow: Have you felt so bad about your shape that you h cried? (p. 491) Have you felt excessively large and rounded? (p. 4 Have you felt ashamed of your body? (p. 492) Have you pinched areas of your body to see how m fat there is? (p. 493) Items were obtained through interviews with wom having eating disorders and with nonclinical univer women. From statistical analyses of data from nonclin and clinical female samples, 51 items were reduced to A single score is obtained by adding items (Cooper et 1987). That the BSQ has a unitary structure has b supported by several factor analytic studies(Mumford et 1991; Mumford et al., 1992). Internal consistency relia ity was excellent (alpha = 0.93).
- 193. and attitude tests(Cooper et al., 1987). Concurrentvalidity was substantiated by other researchers (Rosen et aI., 1990) with a correlation of r = 0.78 between eating disorder scales and the BSQ in a sample of 106 female subjects. Research with the BSQ showed it to discriminate between patients with bulimia nervosa and comparable nonclinical women, between women rated as concerned and not concerned about their shape, and between prob able bulimics and other women in a community sample (Cooper et al., 1987). In a discriminant analysis (Rosen et al., 1990), eating disorder scales contributed nothing beyond the BSQ to group placement (control vs. eating disordered subjects). Cross-cultural validity of the BSQ was shown in several studies, including one on subjects from New Zealand and Asia. According to these authors, evidence was strong because of similar factor structures across cultures (Mum ford et al., 1991, 1992). By modifying items slightly for male subjects, Kearney-Cooke and Steichen-Asch (1990) used the BSQ to divide 112 male college students into those at risk for eating disorders and those not at risk. These authors then found the expected differences be tween these groups on eating attitudes and body satis faction; even greater differences were found with their clinically diagnosed anorexiclbulimic subjects. To sum marize, considerable evidence supports the construct va lidity of the BSQ. Because the BSQ is measuring only one construct (Mumford et aI., 1991, 1992) and because of the current need for efficient measures, Evans and Dolan (1993) investigated short forms of the BSQ. Their analysis and replication showed internal consistency coefficients in the 0.90s for the short, 16-item alternate forms. These authors supported constructvalidity of these short forms by obtaining results consistentwith their hypotheses in several instances. For example, moderately high correlationswere found with eating attitude scores, and the short form BSQ could separate subjects reporting eating problems from those not reporting them. Certainly, more efficient meas urement tools are necessary in view of current health care trends. The Semantic Differential Technique. Citing the work of Osgood and collaborators, Isaac and Michael (1981) described the use of the semantic differential method for measuring the meaning of concepts. It consists of a five- to nine-step scale anchored by bipolar adjectives. On a form with items randomly arranged, the subject marks the step best describing his or her attitude toward the concept being conSidered (Fig. 8-4). The semantic differential has been a very useful tool, and literally thousands of references verify its value. This technique is well suited to the assessment of body image. For this purpose, its use with clinical samples challenged by anorexia nervosa, burns, and rheumatoid arthritis is next described. I chose the semantic differential technique for assess ment of body image in our studies with adults diagnosed : _ Unimpaired Incomplete Impaired Complete Unsuccessful _ : _: _ : Successfu Negative Positive Bad Good Painful Pleasurable Ugly Beautifu Boring Interesting Awkward Gracefu Unimportant Importan Hands image: RA ( .--) and controls (e-- ). FIGURE 8-4. Semantic differential technique for hand imag persons with rheumatoid arthritis. (From Van Deusen, J. [19931. B Image and perceptual dysfunction In adults. Philadelphia: W Saunders.) with rheumatoid arthritis (Van Deusen, 1993). It was u simply as an attitude scale consisting of scales for s reports on trunk, arms, hands, and legs (see Fig. 8- Harlowe, my coinvestigator, and I found this seman differential to discriminate subjects with rheumatoid art tis from nonclinical control subjects. The scale for ha also discriminated between subjects with arthritis who traditional programming from those subjects participat in an experimental dance experience. The semantic differential also was found to be effective method to assess body image of persons w severe burns. Orr and colleagues (1989) used this too showthat perceived socialsupport (especiallyby peers)w the variable most highly associated with body im adjustment of young adults with burns. A study reported from Germany (Steinhausen & V rath, 1992) used the semantic differential approach assess body image of adolescents with anorexia nervo Bipolar adjectives used were beautiful-ugly, desirab undesirable, dirty-clean, soft-hard, proportion unproportional, light-heavy, powerful-weak, pleasa unpleasant, fragile-massive, attractive-repulsive, lar small, inactive-active, firm-flabby, bad-good, a uncomfortable-comfortable. This scale differentiated subjects with anorexia from 109 control subjects. T analyses showed a similar factor structure (attractiven and body mass dimensions) for the subjects with without anorexia nervosa. This semantic differential a showed sensitivity to the therapeutic body image chan of anorexic subjects. To summarize, the semantic differential technique
- 194. 172 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT been found from my personal experience, as well as from reports in the literature, to be a valuable method for assessing, from an attitudinal perspective, the body image of clinical subjects. I am not aware of any study in which this technique has been used to assess body image in changing environments. Because of a recent interest in measuring a "dynamic" body image in varying environments, research of this type is desirable. Contextual Body Image Tools. It is likely that two newer instruments will be receiving increased research attention: the CAPT and the FOFQ. These body image assessment instruments apparently measure a dynamic body image, so that scores can be expected to vary with context. Research has shown CAPT score fluctuation with environmental change, and the FOFQ was designed as a dynamic measure. The CAPT (Wooley & Roll, 1991) consists of a figure of the same sex as the subject. Five color markers are used by subjects to indicate their level of satisfaction with various body parts. With nonclinical and clinical subjects, internal consistency and test-retest reliability coefficients were in the 0.70s.and 0.80s. CAPT scores were sig nificantly greater (P < 0.0001) after bulimic subjects received therapy. Moderate correlations with traditional tests (0.50s) were obtained. Haimovitz and collaborators (1993) showed that the CAPT scores varied under dif ferent environmental situations. Face, hair, and hands were the only aspects of body image unaffected by beach, lunch, private, and dressing room situations for a sample of 144 undergraduate women. Furthermore, the CAPT appeared to measure body image when subjects were especially self-critical rather than body image in gen eral. Unlike the CAPT, the FOFQ was designed specifically as an affective measure of body image across contexts. The authors of FOFQ (Roth & Armstrong, 1993) proposed to measure the subjective experience of fatness across a variety of situations. Content validity was established by contributions of items from experienced mental health professionals expressing feelings of fatness in achieve ment, affective, social, somatic, and self-focused situations. Internal consistency reliability was 0.98. Analysis showed two factors defined as troubles and satisfactions. Test scores were related to eating attitude scales but not with a psychophysical size estimation measure. Through statisti cal procedures, considerable variability of test scores was found across situations in a sample of 132 undergraduate women. A need exists for thorough investigation of body image tests that can be used to assess body image changes within varied contexts. To summarize, instrumentation for assessment of body image has received much attention across disciplines. Because the construct of body image is so complex, assessment must deal with both neurologic and psychoso cial aspects. Because body image is not stable, assess ment also must consider context. Body image disturbance-Problems in the inte tion of the neural body scheme and its psychoso representation. Body scheme disturbance-Interference with patterns of excitation in the brain that are basic to pos and movement. Cognitive behavioral therapy-Psychological in vention that emphasizes restructuring of attitudes in area of the patient's dysfunction. Concurrent vaHdity-Favorable comparison of scores to other variables, considered to provide a di measure of the characteristic under consideration. Construct vaHdity-Definition of explanatory c cepts reflected in test performance by supporting log hypotheses related to test scores. Demonstration of c current validity may be part of the construct valida process. Factor anaIysis-A statistical process in which a la number of variables can be reduced to a small numbe concepts through the interrelationship of these variab Finger agnosia--Confusion in identification of o fingers. Internal consistenqr re6abi6ty--Consistency performance on the items of a test. Phantom pain-Painful sensations referred to a body part. Phantom sensation-The feeling that an amputa part is still present. Psychophysical method-Procedures developed researchers of eating disorders that allow subjects estimate their body size by such means as adjusting lig calipers, or video images. REFERENCES Altabe, M., & Thompson, J. K. (1992). Size estimation versus fi ratings of body image disturbance: Relation to body dissatisfaction eating dysfunction. International Journal of Eating Disorders 397-402. Anton, H., Hershler, C., Lloyd, P., & Murray, D. (1988). Visual ne and extinction: A new test. Archives of Physical Medicine Rehabilitation, 69, 1013--1016. 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- 197. CHAPTER 9 Eleotrodiagnosis ofthe Neuromuscular System Edward J. Hammond, PhD SUMMARY In this chapter, traditional electrodiagnostic studies including nelVe con duction velocity studies, the electromyogram, and somatosensory evoked potential are sUlVeyed. Newer techniques, the motor evoked potential, the surface EMG, and dermatomal evoked potentials, are also considered. Detailed technical consider ations and interpretations are not discussed, but emphasis is placed on assisting the nonelectrophysiologist in understanding basic prinCiples of, and indications for, commonly used diagnostic tests. Limitations and benefits of each technique are clearly stated, and areas for future improvement and research are discussed. The anatomic system of interest in clinical electrodiagnosis consists of the pe ripheral nelVes, the neuromuscular junction, the skeletal muscles, and the soma tosensory and motor pathways in the spinal cord and brain. During normal move ments, these components interact with each other to bring about the contraction and relaxation of muscle. Various types of electrodiagnostic tests discussed in this chapter can be used to determine physiologic abnormalities occurring in one of these anatomic subdivisions. Historically, specific electrodiagnostic tests were devel oped because careful clinical examination is sometimes not enough for accurate diagnosis (and, therefore, treatment). The degree to which electrodiagnostic tests are pertinent to diagnosis and treatment depends on the extent to which we can in tegrate this "subclinical neurology" with clinical neurology. This chapter discusses basic principles, limitations, and benefits of currently used electrodiagnostic tests. Tests of peripheral nelVes and muscles are discussed first, then central nelVous sys tem testing. The chapter necessarily contains many technical and specialized terms, and the reader unfamiliar with electrophysiologic terminology is urged to consult the glossary at the end of the chapter. 1
- 198. 176 UNIT 2-GOMPONENTASSESSMENTS OF THE ADULT NERVE CONDUCTION STUDIES Classification of Peripheral Nerves. The peripheral nerve contains sensory and motor fibers of various diameters and conduction speeds. Peripheral nerve fibers can be classified into different types known as the A, B, and C fibers. The largest fibers transmit nerve impulses the fastest. The A fibers are large myelinated fibers that innervate skeletal muscle (efferent or motor fibers) and also conduct impulses from proprioceptive receptors in skeletal muscles and other receptors in the skin (afferent or sensory fibers). The B nerves are small myelinated, efferent, preganglionic autonomic nerves. The C fibers are unmyelinated auto nomic nerve fibers. Some C fibers serve as sensory afferents that mediate various types of sensation, mostly deep pain. A typical peripheral nerve contains A and C fibers. Within a peripheral nerve, all nerve fibers are not of equal size but actually cover a wide range of diameters. Another classification is frequently used to describe sensory nerve fibers. In this classification, the fibers are also grouped according to diameter, but a Roman numeral classification is used: Group I contains the largest afferent fibers; Group II, the nextlargest; Group III, the third largest; and then Group N, which corresponds to the small unmyelinated C fibers. Within these main groups are further subdivisions-labeled a, b, c. One often sees a nerve classified as Ia; this means that the nerve is of the largest diameter and fastest conduction. Classification of Peripheral Nerve Injuries. Peripheral nerve injuries are often classified as neuropractic, axonot metic, or neurotmetic. Neuropraxia is a reversible injury in which some loss of distal function occurs, with no associ ated structural change of the nerve axon. Causes of neuropraxia caninclude neural ischemia or local electrolyte imbalance or trauma (e.g., as in the transient alteration in sensation sometimes associated with leg crossing or in a nerve block caused by a local injection of an anesthetic). Acute compression neuropathies such as Saturday night palsy or crutch palsy of the ulnar nerve, as well as chronic entrapments such as carpal tunnel syndrome or tardy ulnar palsy, are considered neuropraxic (although the latter two can later be associated with focal demyelination). In neuropraxia, nerve action potentials can be generated above and below the injury site but are not recorded across the site of injury; therefore, the lesion can be preCisely delineated electrophysiologically. Axonotmesis is of more increased severity and is characterized by a loss ofaxons and myelin, with preservation of the surrounding connec tive tissue. A more severe type of peripheral nerve trauma is neurotmesis. In this case, the axons and myelin are destroyed, with additional disruption of the surrounding connective tissue. An example of this would be a complete nerve transection. Pathophysiology of Peripheral Nerves. Neuropraxia, ax onotmesis, and neurotmesis produce certain eiectrophysi ologic alterations, which can be classified into disorders ..... ./ - Recorded - V waveform URecording electrode +++++++-+++++++ A-------+-----------~~ Recorded wave form URecording electrode ++-++++++++++++++++ B--+----------------~~ FIGURE 9-1. The action potential. An idealized diagram. In A, t potential arises underneath the electrode and propagates away from The plus and minus signs represent ions situated outside and inside t nerve. This is recorded as a biphasic negative-positive wave. T waveform (as seen on an oscilloscope screen) of the potential recorded the electrode is drawn above the electrode; negativity is drawn upwa Another situation common in clinical practice is shown in B; the potent (i.e., ion exchange) approaches the electrode and passes underneath it. this case, a positive-negative-positive triphasic wave is recorded. characterized by the much more usable terms conductio slOWing and disorders with conduction block. Disorde with slowing ofconduction can occur with demyelination the axons; a conduction block occurs with a metabol alteration in the membrane, as with anesthetic block or structural alteration in the axon. Reduced or abse responses are the result of nerve degeneration after axon interruption. Electrophysiology of Peripheral Nerves. Current electr physiologic techniques and concepts are the result continual refinements made over 300 years. The ner "impulse" or "discharge" is a wave of changing electr charge that passes down the axon from the neuron's c body (Fig. 9-1). A resting or unstimulated neuron has an active mech nism that maintains the interior of the cell in a state negative charge while the area immediately outside the c membrane is positively charged. When a neuron is stim lated, the permeability of the membrane alters, which le in positively charged sodium ions. This momentarily r verses the charge on both sides of the nerve membran This area of reversed charge is the nerve impulse, which recorded by electrophysiologic recording equipment. T nerve impulse induces an identical change in the area the axon adjacent to it, and the impulse then travels dow the nerve axon. Once the nerve impulse has passe sodium ions are pumped back out of the cell, and after brief recovery period, the original charged {polarized} sta
- 199. axon (the synapse),it causes release of a chemical neu rotransmitter, which travels across the narrow gap between one neuron and the next, triggering an impulse in the second. TECHNIQUE AND WAVEFORM NOMENCLATURE Nerve conduction studies (NCSs) assess peripheral sen sory and motor function by recording the response evoked by stimulation of selected peripheral nerves. Sensory NCSs are performedby electrically stimulating a peripheral nerve and making a recording at a measured distance, either proximally ordistally from the stimulation site. Motor NCSs are performed by stimulating a peripheral nerve and recording from a muscle innervated by that nerve (Figs. 9-2 through 9-5). These studies have been used clinically since the 1950s to localize peripheral nerve disease and to differentiate it from disorders of the muscle or neuromus cular junction. Comprehensive reviews are found in refer ences (Aminoff, 1992; Ball, 1993; Buchthal et al., 1975; Daube, 1985, 1986; Gilliatt, 1982; Johnson, 1988; Kimura, 1983, 1984; Oh, 1984). Motor Nerve Conduction Studies. The clinical utility for motor NCSs was first described by Hodes and associates (1948). The functional integrity of motor fibers in any peripheral nerve can be evaluated by motor conduction studies if this nerve can be adequately stimulated and the response of one or more of the muscles that it innervates can be recorded. Typically, the more accessible nerves the median, ulnar, tibial and peroneal nerves-are more readily studied. The musculocutaneous, radial, facial, femoral, phrenic, suprascapular, intercostal, and others can also be studied. The electric response of the muscle is called the compound muscle action potential (CMAP). This CMAP is the summated electric activity of the muscle fibers Stimulus j "Ir--- M wave Peak to peak amplitude FIGURE 9-2. Idealized compolll1d muscle action potential, Stimulus A-+---- A B-+-- b Response FIGURE 9-3. General scheme for motor nerve conduction studies general idea in conducting peripheral nerve conduction studies stimulate the peripheral nerve with a bipolar electrode and th calculate the so-called conduction velocity of the nerve. The electr applied to the skin over the nerve, which is stimulated. This produc activation of the nerve fiber. The response to stimulation is recorded the muscle. The muscle response is usually measured with su electrodes. The earliest muscle response is termed the M wave interval between the time of stimulation and the onset of the M w the latency of the response. To calculate a pure nerve conduction city, the nerve is stimulated at two separate points (A and B), an latency measurements are then obtained (a and b). The distance be points A and B is measured in millimeters. The conduction veloc meters per second is equal to distance between A and B in mm conduction time between A and B (in msec) The conduction time between A and B is equal to the latency ( from point A minus the latency at point B. in the region of the recording electrode that are innerv by the nerve that is stimulated. The CMAP recorded after stimulation of a periph nerve is called the M wave. With supramaximal stimula all of the fibers in a muscle innervated by the stimu nerve contribute to the potential. The earliest part of th wave is elicited by the fastest-conducting motor axons. Mwave is described by its latency, amplitude, and con ration. The latency is the time in milliseconds from application of the stimulus to the initial recorded deflec from baseline, and this is the time required for the ac potentials in the fastest-conducting fibers to reach nerve terminals in the muscle and activate the muscle f (see Fig. 9-2). As mentioned before, the latency v directly with the distance ofthe stimulating electrode to muscle. Typically, the peripheral nerve is studied at more one sitealong its course to obtain two ormore CMAPs. latencies, amplitudes, and configuration of these ev responses are then compared (see Figs. 9-3 through 9
- 200. 178 UNIT 2-GOMPONENTASSESSMENTS OF THE ADULT Normal conduction velocities in the upper extremities range from 50 to 70 meters per second and in the lower extremities, from 40 to 55 meters per second. Sensory Nerve Conduction Studies. Sensory nerve action potential studies were first demonstrated in humans by Dawson and Scott in 1949. Evaluation of sensory axons in peripheral nerves may be directly evaluated by electrically stimulating the nerve and recording sensory nerve action potentials (SNAPs). Recording of SNAPs is technically more difficult than recording M waves because of much smaller amplitudes; nevertheless, potentials can readily be recorded from the median, ulnar, radial, plantar, and sural nerves, and, with some difficulty, from the musculocuta neous, peroneal, lateral femoral cutaneous, and saphenous nerves, as well as others. Gilliatt and Sears (1958) demon strated the clinical utility of such responses, and since that time these tests have been widely used and an immense literature has emerged. By 1960, performing motor and sensory NeSs was considered the standard of care by most physical medicine specialists. The latency of the evoked response is directly related to the speed of conduction of the nerve and the distance B Response Stimulus ",' ~: : I -':,., " .,." A A ' a c b ' FIGURE 9-4. General scheme of motor conduction testing in focal injury. This type of lesion is seen with mild to moderate degrees of nerve compression or other neuropractic local change, such as neural ischemia or local eiectrolyte imbalance. The nerve is normal except for a localized area of partial injury indicated at point B. The axons are intact and therefore are conductive. This means that as many normal nerve axons are below the lesion as above. If 20 percent of the fibers in the region of the lesion can still conduct impulses, then stimulating at point A only 20 percent of the fibers will conduct through the lesion (the other 80 percent being "blocked" by their dysfunction). The resulting CMAP will be small. Stimulating below the lesion at point C, the recorded CMAP will be of normal amplitude since all of the fibers under thisstimulating electrode will conduct normally. Therefore, by merely recording the amplitude of the CMAP, a focal conduction blockofthe nerve can be readilydemonstrated. In addition, if the conduction velocity is measured at various points along the nerve (see discussion in legend for Fig. 9-3), a local slowing of conduction can also usually be found across the area of the lesion. I A Response Stimulus A ' B ' b FIGURE 9-5. General scheme for motor conduction velocity stu axonal neuropathies (axonotmestis). Ifaxons are damaged in add myelin, then nerve conduction studies will show only 1) a dim amplitude CMAP, 2) normal or only slightly slowed conduction v and, paradoxically, 3) no evidence of conduction block. The CMAP look the same regardless of whether one has stimulated above o the lesion. This is because wallerian degeneration (which takes on 5 days to complete) would make it impossible to stimulate damage below the site of the lesion. For example, if some process destro percent of the axons, stimulating above the lesion would excite al fibers, but only20 percent would conduct past the lesion, whilestim below the lesion would excite only the same 20 percent of the fibe the other 80 percent have degenerated. To localize the site of the the physician has to rely on clinical information and electromyog between the stimulating and recording electrodes differences in latency and distance at different sites for calculations of conduction velocity. Late Responses (F Waves and H Reflexes). From foregoing discussion and from Figures 9-3 through 9 might be apparent that these techniques for asse peripheral nerves' are not applicable to studyin proximal segments of nerves. However, techniques been developed for studying these proximal segm including the anterior and posterior roots and the int nal segments, which are inaccessible using tradi sensory and motor nerve conduction stimulation. T responses are generally called long latency respons late responses. The so-called Fwave is a late respons can be recorded from numerous muscles (Fig. 9-6). initial studies, potentials were studied in the foot mu hence, the designation F wave. To elicit an F wave f muscle, a supramaximal stimulus is delivered to a m nerve and potentials ascend up to the spinal cord and descend from the spinal cord out to the muscle. The la of the F wave then includes the time required for the a potential to ascend (antidromically) to theanterior ho and then descend (orthodromically) from the anterior cell to the muscle fibers. F waves, then, provid
- 201. Intervertebral : foramen Vertebral body Medial aspect offoot ) I ~Record F-wave -------------- -----------~,, +--- Spinous process To muscle ---------------:~ .. ---------, . Record H-reflex ,/Dorsal - root ganglion FIGURE 9-6_ Anatomic pathways for the F wave and H reflex. For the F wave, the motor fiber is the afferent as well as the efferent pathway, and for the H reflex, the Ia peripheral nerve fiber is the afferent pathway and the motor fiber is the efferent pathway. There is a monosynaptic reflex arc in the H reflex pathway but nosynapse involved for the F wave. The insert shows an axial view showing anatomic relationships of dorsal and ventral nerve roots, spinal cord, and intervertebral foramen. opportunity to measure conduction along the most proxi mal segment of motor axons, including the nerve root. Usually the F wave does not occur at a constant fixed latency from trial to trial but varies slightly; therefore, the electromyographer generally records 10 or more F wave potentials and reports on the best (shortest) latency. The latency of this "late response" is between 20 and 50 meters per second, depending on the nerve stimulated and muscles in the upper and lower extremities. 9-6). Its name derives from itsdiscoverer, Paul Hoffman adults, it is generally only studied in the gastrocnem soleus muscle after stimulation of the tibial nerve at popliteal fossa. It is thought that this electric respons analogous to the monosynaptic ankle jerk. The afferent of this reflex is mediated by the large afferent nerves synapse in the spinal cord on the efferent alpha mo fibers of the nerve root. thought to reflect activity of the proximal segments of peripheral nerve as well as the S1 nerve root. In clin reports, one sees reference to the "predicted latenc which is the time that the H reflex should occur. ( electromyographer knows how fast conduct and also has measured the length of the patie leg.) The electromyographer then reports on the obser latency and then also makes a left/right comparison. F this, inferences often can be made about the functio integrity of the S1 nerve root. reflexes have their proponents (Shahani & Young, 198 who find them extremely useful, and those who find th diagnostically disappointing (Wilbourn, 1985). A m benefit of these responses is that abnormalities in th responses can be detected long before nerve degenera occurs. F waves and H reflexes have been shown to reli document slowed proximal conduction in hereditary acquired demyelinating neuropathies and neurogenic racic outlet syndrome but are somewhat limited in diagnosis of radiculopathy. The F wave is rarely abnor without abnormal EMG changes (discussed later). S larly, the H reflex is rarely abnormal without signifi alteration of the ankle jerk. the case in clinical electrophysiology, whenever a poten is termed a response, inevitably an latency response is soon discovered; the H reflex an waves are no exception. Although these are called l latency responses, known and have interesting properties. muscles have been described in voluntarily contrac muscles. These long latency reflexes can be elicited various stimuli, including muscle stretch, electric stim tion of pure muscle afferents, cutaneous afferent nerves. At least for the muscles actin the wrist and fingers, evidence exists that indicates th responses are mediated pathways ascending the sp cord up to the brain and then down from the brain thro the spinal cord out through the motor neurons. A la and somewhat difficult to read, literature concerns var reflexes in this category. In a review, Deuschl and Luck (1990) summarize the different terminologies for var The H reflex is another type of late response (see If the soleus muscle is studied, then the H refle the nerves sho Like all other electrophysiologic tests, F waves and Long Latency (Long Loop) Reflexes. As has always b short latency response or a long late even shorter latency or lon even longer latency responses Long latency reflexes of human hand and fore mixed nerves, or p
- 202. 180 UNIT 2-COMPONENTASSESSMENTS OF THE ADULT components of these responses. Another readable and thorough review was presented by Marsden and colleagues (1983). Although no special equipment (other than normal NCS equipment) is required for analysis of these responses, they are typically not studied in the neurology/physical medi cine clinic, partly because clinical correlations are not as well established for these potentials. These responses obviously reflect integrated activity in ascending and de scending pathways involved in neuromuscular control, but the functional significance of these responses is a matter of much discussion. _ _ _ _~__, ~".o=o, __,_"" CLINICAL UIILll'Y OF NERVE CONDUCTION STUDIES Peripheral Neuropathies. Peripheral neuropathy can af fect peripheral nerve axons, their myelin sheaths, or both. Various types of pathologic changes in peripheral neurop athy can result in different patterns of electrophysiologic abnormality. Peripheral neuropathies are manifested by sensory, motor, and autonomic signs and symptoms. NCSs are sensitive tests for evaluating polyneuropathies, and such studies can define the presence of a polyneuropathy, the location of the nerve injury, and usuaily the pathophysi ology (demyelination vs. focal axonal block). Common types of peripheral neuropathy are a mono neuropathy of the median nerve at the wrist (carpal tunnel syndrome), ulnar neuropathy at the elbow, and peroneal nerve at the knee with localized slowing of conduction or conduction block in these regions. Jablecki and colleagues (1993, p. 1392) reviewed 165 articles on the use of NCSs in carpal tunnel syndrome and concluded that "NCSs are valid and reproducible clinical laboratory studies that confirm a clinical diagnosis of CTS with a high degree of sensitivity and specificity." In diabetes, a wide variety of abnormalities can be seen in NCSs (Kimura, 1983). In the Guillain-Barre syndrome, or inflammatory polyradiculopa thy, a wide range of electrophysiologic abnormalities also exists (Kimura, 1983). Often, electrophysiologic studies can provide longitudinal information concerning the course of a polyneuropathy and can usually be used for prognosis, as in the Guillain-Barre Syndrome. Axonal neuropathies can often be found in toxic and metabolic disorders. The major abnormality found by nerve conduction studies is a reduction in amplitude of the CMAP or SNAP, simply because fewer nerve fibers are present. Some axonal neuropathies, such as vitamin B12 deficiency, carcinomatous neuropathy, and Frie dreich's ataxia, predominantly affect sensory fibers, while others such as the lead neuropathies seem to affect motor nerve fibers more. Radiculopathies. Electrophysiologic studies can identify the specific level of root injury and also differentiate between root injury and other peripheral nerve probl that might cause similar symptomatology. Evaluatio functional integrity of nerve roots can be important patient management with regard to further diagno evaluation and surgical intervention. Usually in radiculopathies the most common cli presentation is with sensory symptoms. In nerve dysfunction, the locus of the injury is at or proximal to foraminal opening (see Fig. 9-6, insert). Normal studie sensory nerves in the distribution of the sensory compla or abnormal clinical sensory examination would be con tent with a radiculopathy, while abnormalities of sen conduction would indicate a more distal site of in Similarly, slowing of motor conduction velocity w argue for peripheral nerve dysfunction rather than n root dysfunction. The H reflex can be effectively used to assess the dorsal root, but somatosensory evoked potentials cussed later) are needed to adequately study nerve roo other levels. Abnormal H reflexes or Fwaves by themse do not establish a diagnosis of a radiculopathy but complement other electrophysiologic information. C ventional nerve conduction studies are usually norma cervical and lumbosacral radiculopathies (Eisen, 1987 radiculopathy, most lesions can occur proximal to dorsal root ganglion; therefore, the sensory nerve fibers intact, and, consequently, distal sensory nerve poten are normal, even if the patient has a sensory de However, in radiculopathy, damage to motor nerve fi may occur, and, consequently, a slowing of motor con tion can often be detected. Plexopathies. Diagnosis of nerve root damage local to nerve plexi often poses a clinical challenge. N techniques that can localize lesions to the plexi available. Such studies can also provide evidence aga peripheral nerve abnormalities, which could produce s lar symptoms. Serial studies can follow the course of pl injuries and aid in management and prognosis. System Degenerations. Some system degeneration the central nervous system involve either the dorsal ganglia or the anterior horn cells. Motor neuron dise such as amyotrophic lateral scleroSiS, spinal muscular a phy, Charcot-Marie-Tooth disease, Kugelberg-Wela disease, and others are characterized by degeneratio anterior horn cells and, therefore, loss of peripheral m axons. This is reflected by a reduction in amplitude of CMAP, which is proportional to the loss ofaxons inner ing the muscle. Sensory system degenerations are foun spinal cerebellar degeneration, vitamin B12 deficiency, carcinomatous sensory neuropathy. The degenera seen in sensory pathways in the spinal cord is due to de eration of the cells of origin in the dorsal root ganglia; t cells are the source of the large sensory fibers in the per eral nerves and therefore show abnormalities with sen nerve testing. A moderate number of sensory axons m be involved before SNAP amplitudes become notice
- 203. result in anabnormally low amplitude CMAP. Disordersofthe NeuromuscularJunction. The myasthenic syndrome and botulus poisoning are likely to showchanges in nelVe conduction studies. Both of these conditions result in a low rate of release of acetylcholine from nelVe terminals and, therefore, a block of neuromuscular trans mission to a large portion of the muscle fibers. The CMAPs are usually of low amplitude. Disorders of Involuntary Activity. Some disorders are manifested as stiffness of muscles, myokymia, and cramp ing. These are due to excessive discharges in peripheral motor axons. Numerous clinical patterns and a wide varia tion in electric abnormalities have been seen. Each has different findings on clinical needle electromyography (dis cussed below), but abnormalities can also be seen on nelVe conduction studies. In these cases, motor nelVe stimulation produces a re petitive discharge of the muscle. Instead of a single CMAP after a single stimulus, a group of two to six potentials can be seen. ELECTROMYOGRAPHY In 1938, Denny-Brown and Pennybacker pointed out the clinical utility of analyzing the electric activity of muscle, and electromyography has been in clinical use since that time. The term electromyography (EMG) has sometimes been used to refer to the entire array of electrodiagnostic tests for nelVe and muscle diseases, but strictly speaking, it refers only to the examination of the bioelectric activity of muscles with a needle or surface electrode. The EMG examination, then, unlike NCSs, assesses only muscle fibers and, indirectly, motor nelVe fibers but not sensory nelVes. Some Anatomy Discussion of much of the scientific basis for these tests is relegated to the figures and legends in this chapter, and the reader is urged to consult these frequently. The motor nelVe fibers that innelVate voluntary muscles (except those in the head) are axons of cells in the anterior gray matter of the spinal cord (Rg. 9-7). The junction between the terminal branch of the motor nelVe fiber and the muscle fiber is located at the midpoint of the muscle fiber and is called the motor end-plate (see Fig. 9-7). Each axon generally contributes to the formation of a single end-plate innelVating one muscle fiber. Where the motor nelVe enters the muscle is termed the motor point. Each mammalian skeletal muscle fiber is innelVated by only one motor neuron, but a motor neuron innelVates more than one muscle fiber (see Rg. 9-7). In the 1920s, Sir Spinal cord Motor Muscle fibe Action potentials seen on oscilloscope screen recor from needle electrode FIGURE 9-7. The motor unit. The motor unit consists of the m neuron and the population of muscle fibers that it innervates; three m neurons and their population of muscle fibers are shown. The m fibers innervated by a single motor neuron generally are not adjace one another. However, a needle electrode inserted into the muscle record a motor unit potential when the unit is activated, because syn transmission at the neuromuscular junction ensures that each a potential in the nerve produces a contraction in every muscle innervated by that motor neuron. The size of the motor unit poten varies as a function of the number of muscle fibers that contri (Adapted, with permission, from Kandel, E., & Schwarz, J. H. 11 Principles of Neural Science. Stamford, CT: Appleton & Lange.) Charles Sherrington introduced the term motor uni refer to the motor neuron in the spinal cord and population of muscle fibers that it innelVates. The mo unit, then, is composed of three components: 1) the body of the motor neuron, 2) its axon, which runs in peripheral nelVe, and 3) muscle fibers innelVated by neuron (see Rg. 9-7). The number of muscle fi innelVated by a single motor neuron varies according t function: Motor units involved in fine movements (e.g the small muscles of the hand) consist of only three to muscle fibers, but motor units of the gastrocnemius mu of the leg can contain as manyas 2000 muscle fibers. G reviews on the anatomy and physiology of motor units be found in Buchthal (1961) and in Burke (1981).
- 204. 182 UNIT 2-GOMPONENTASSESSMENTS OF THE ADULT Most diseases of the motor unit cause weakness and atrophy of skeletal muscles. Various types of motor unit diseases were characterized by pathologists in the 19th century. Some patients showed pronounced pathologic changes in the cell bodies of the motor neuron but no or minor changes in the muscle (motor neuron diseases). Other patients had a degeneration of muscle with little or no change in motor neurons (myopathies). Other patients had pathologic changes that affected only the axons of peripheral nerves (peripheral neuropathy). Diseases of the motor unit can be divided into two classes: 1) neurogenic diseases, which affect the cell body or peripheral axon; and 2) myopathic diseases, which affect the muscle (Figs. 9-8 and 9-9;. FIGURE 9-8. Diagram of motor unit in motor neuron disease. The motor neuron on the left is degenerating. Its muscle fibers have become atrophic (symbolized by dotted lines), and units innervated by the degenerated nerve no longer produce motor unit potentials. This is apparent on the oscillograph screen by decreased rate ofaction potentials (compared with Fig. 9-7), However, the neuron on the right has sprouted additional axonal branches that reinnervate some of the denervated muscle fibers, These muscle fibers produce a larger than normal motor unit potential (compared with Fig, 9-7), and they also fire spontaneously at rest (fascicuiations), (Adapted, with permission, from Kandel, E., & Schwarz, J, H. [1981]. Principles of Neural Science. Stamford, CT: Appleton & Lange.) Spinal cord Motor neuro Reinnervated muscle fiber ~,f Motor neuron , V Regenerating axon ,Q (l Action potentials seen on oscilloscope screen recorded from needle electrode I I I I I I I I I I I inserted into muscle Atrophied muscl JLAction potentials seen on oscilloscope screen reco from needle electrode inserted into muscle FIGURE 9-9. Diagram of motor unit in muscle disease (myopa Some muscles innervated by the motor neuron have become dise The motor unit potential is reduced in amplitude. (Adapted, permission, from Kandel, E., & Schwarz, J. H. 11981]. Principl Neural Science. Stamford, CT: Appleton & Lange.) Technique and Waveform Nomenclature The clinical utility of EMG lies in its ability to de abnormalities in muscle activity resultant to injury to nerve innervating that muscle. The EMG examina includes four phases: the evaluation of spontaneous ( ing) muscle activity, insertional activity, activity du minimal muscle contraction, and activity during max muscle contraction. During these four phases, the e tromyographer looks for abnormal electric activity of muscle. The activity from the needle electrode is led powerful amplifiers, and the activity is displayed on oscilloscope screen. The electromyographer often l the output of the amplifier to a loudspeaker; var abnormal patterns produce distinctive sounds, which often facilitate recognition. These needle EMG changes discussed under "Abnormal EMG Activity." The waveforms of various types of normal EMG act are shown in Figure 9-10. Spontaneous Activity. A very important point is normal muscle fibers, with normal nerve supply, show spontaneous (Le., at rest) electric activity.
- 205. SPONTANEOUS VOLUNTARY WAVEFORMSOF MUSCLE ACTIVITY CONTRACTION UNIT POTENTIALS Muscle unit potentials A Normal Fasciculation Positive sharp wave B Neurogenic ~C Myopathy 1IIIIIJlIIII FIGURE 9-10. Some general features of the EMG in normal subjects (A), in patients with neurogenic diseases (B), and in myogenic diseases (C) rising and falling pattern of action potentials (bottom trace) seen on the oscilloscope is referred to as "myotonic discharge." (Adapted, with permis from Kandel, E., & Schwarz, J. H. [19811. Principles of Neural Science. Stamford, CT: Appleton & Lange.) Voluntary Activity. The motor unit potential (MUP) is the sum of the potentials of muscle fibers innervated by a single anterior horn cell. Motor unit potentials are characterized by their firing pattern and their morphology. Recruitment is the initiation of firing of additional motor units as the active motor unit potentials increase their rate ofdischarge, as when a patient is asked to contract a muscle. Abnormal EMG patterns are diagrammed in Figure 9-10B and C. Neuromuscular diseases can show abnormal spontane ous discharges or abnormal voluntary MUPs. Abnormal spontaneous activity includes fibrillation potentials, fas ciculation potentials, myotonic discharges, neuromyo tonic discharges, complex repetitive discharges, myo kymic discharges, and cramps. Only the first two are encountered frequently in the EMG laboratory. Motor unit potentials are characterized by their morphology-they can have abnormal duration, be polyphasic, or can vary in size. The recruitment pattern of MUPs can be altered; all of these are noted by the elec tromyographer. Early on, Adrian and Bronk (1929, p. 10) noted that recognition of abnormal EMG patterns was made easier if the amplified electric activity was run into a loudspeaker, " ... for the ear can pick out each new series of slight differences in intensity and quality which are h to detect in the complex electrometer record." For rea who might visitan EMG laboratory, these various "soun are described. Fibrillation Potentials. Fibrillation potentials are ac potentials of single muscle fibers that are twitching sp taneously in the absence of innervation. Fibrillation po tials can have two different forms: a brief spike or a pos wave. Spikes are considered to be muscle fiber ac potentials recorded extracellularly, and positive waves muscle fiber action potentials recorded from an injured of the muscle fiber. When run into a loudspeaker, fibrilla potentials sound like the "ticking of a clock," i.e., occur at regular intervals. Any muscle fiber that is de vated can produce fibrillation potentials, and becaus this, a wide variety of both neurogenic and myopa processes can show fibrillation potentials. Fibrillation tentials can therefore be seen in lower motor neu diseases, neuromuscular junction diseases, and mu diseases. Fibrillation potentials do not appear immedia after motor axon loss but have an onset 14to 35 days a injury. They persist until the injured muscle fiber either reinnervated or degenerates due to lack of nerve su (generally about 1.5 to 2 years after denervation).
- 206. 184 UNIT 2-COMPONENTASSESSMENTS OF THE ADULT Fasciculation Potentials. Fasciculation potentials are the action potentials of a group of muscle fibers innervated by an anterior horn cell, Le., action potentials of an entire motor unit. When run into a speaker, fasciculation poten tials sound (to some) like "raindrops on a roof." As opposed to fibrillation potentials, fasciculation potentials require an intact motor unit; their appearance indicates motor unit "irritation." Fasciculation potentials can occur in normal subjects and in a wide variety of neuromuscular disorders. Myotonic Discharges. These discharges consist of high frequency trains of action potentials that are provoked by electrode movement or percussion or contraction of the muscle. The frequency and amplitude of these potentials wax and wane and, consequently, if the signal is run into a speaker, it produces a sound like that of a "dive bomber." The pathogenesis of the myotonic discharge is uncertain but it is thought to be related to a disorder of the muscle fiber membrane. NeurolDyotonic Discharges (Neurotonic Discharges). These are motor unit potentials associated with continuous muscle fiber activity. The activity is rapid-100 to 300 per second. Such activity can be seen in chronic spinal muscu lar atrophy, tetany, and anticholinesterase poisoning. COlDplex Repetitive Discharges (Bizarre High-Frequency Potentials). Complex repetitive discharges are the action potentials of groups of muscle fibers discharging at high rates (3 to 40 persecond.). The sound of the signal run into a speaker has been described as a "motorboatthat misfires occasionally." Complex repetitive discharges are seen in a variety of myopathic and neurogenic disorders, such as poliomyositis, amyotrophic lateral sclerosis, spinal muscu lar atrophy, chronic radiculopathies, chronic neuropathies, poliomyositis, and other myopathies. An experienced electromyographer can distinguish complex repetitive dis charges from other trains of high-frequency discharges such as neuromyotonic discharges, myokymic discharges, cramps, tremor, and others. MyokylDic Discharges. Myokymic discharges are sponta neous muscle potentials associated with fine quivering of muscles, usually in the face. Myokymic discharges rise in the lower motor neuron or axon. They are differentiated from fasciculation potentials by their distinct pattern (flut tering and bursts), and the discharges have been described as the sound of "marching soldiers." Myokymic discharges have a distinct clinical Significance. They are seen in patients with multiple scleroSiS, brain stem neoplasm, polyradiculopathy, facial palsy, radiation plexopathy, and chronic nerve compression. CralDp Potentials. Cramp potentials resemble MUPs. They fire at a rate of 30 to 60 per second. They fire when a muscle is cramping, Le., when it is activated strongly in a shortened position. Cramps are a normal phenomenon but can also be indicative of some disorders, including salt depletion, chronic neurogenic atrophy, and uremia. A common "complaint" about conventional NCS and EMG testing is that very little has changed over the last 40 years. The founder of modern EMG, Adrian, would right at home in a modern EMG laboratory, as would developers of sensory and motor NCSs. This is in mar contrast to the almost yearly advances in imaging t niques such as computed tomography (CT) and magn resonance imaging (MRI). However, several new E techniques to study the fine points of motor unit ph ology have been developed over the last decade or These are single fiber EMG, macro EMG, and scann EMG. Despite the enthusiasm of "early adopters" these techniques, they are, for the most part restricte research laboratories or at least very large acade centers. These techniques are concerned with measu activity in individual muscle fibers, or displaying the tiotemporal activity of an entire motor unit. The intere reader should consult the article by Stalberg and oszeghy (1991), which discusses normal and clinical amples and has a good reference list. For purposes h discussion of these emerging techniques is relegated the glossary. CliI'lical Utility The reader is referred to some of the numerous c prehensive references on clinical correlations of E (Aminoff, 1992; Ball, 1993; Brown and Bolton, 19 Daube, 1985, 1986; Johnson, 1988; Kimura, 19 1984; Oh, 1984; Shahani 1984; Willison, 1964). On brief summary is presented here. Myopathy. Disorders of muscle can be often defined examining the characteristics of motor units. Such cha teristics include the morphology of individual motor u as well as recruitment and interference patterns. physiologic abnormality in myopathies is lessened ten generated by muscle fibers. This is accompanied decreased size, increased duration, and increased comp ity of motor unit potentials. In many muscle disea electromyographic abnormalities of resting muscle du disruption of the normal connections between the n and muscle are present. By evaluating these change myopathic process can be ruled in or ruled out. Elec neurophysiologic studies are important for patient m agement, as they can establish the presence of a myopa and can also be helpful prior to muscle biopsies identifying exactly which muscles are clinically invol Serial studies can be used to follow the course o myopathy and monitor the effect of therapy. Nerve conduction should be normal in patients with p myopathy. However, in many myopathies, including m tonic dystrophy, hypothyroidism, sarcoidosis, polymy tis, and carcinomatous neuromyopathy, peripheral n ropathy is usually present. Regarding electromyogra abnormalities, an increased amount of insertion act (I.e., electric activity recorded immediately on insertio the needle electrode) may be found in myopathic disord and abnormal spontaneous activity is often present.
- 207. unit potentials duringa strong voluntary contraction. A full interference pattern is recorded, but the potentials are lower in amplitude and have altered wave forms. Neuromuscular Junction Disorder. Electrophysiologic ex aminations can accurately localize clinical disorders of neu romuscular transmission to the neuromuscular junction. These disorders include myasthenia gravis, Lambert-Eaton syndrome, botulism, and the congenital myasthenic syn dromes. Disturbances of the neuromuscular junction can also be seen in certain peripheral neuropathies, neuronop athies, myopathy, and myotonic disorders. These can be distinguished from primarydisturbance ofthe neuromuscu lar junction by clinical examination and by peripheral NCSs. Individual motor unit potentials show a marked variation in morphology because of blocking of impulse transmission to individual fibers within the motor unit. Radlculopathy. Abnormalities in a myotomal distribution can define a root injqry. Needle EMG in radiculopathies is abnormal only when the injury is of sufficient degree to produce axonal transection or a conduction block. SURFACE ELECTROMYOGRAPHY In traditional needle EMG, action potentials are recorded intramuscularly through thin needles. In contrast, the frequency and amplitude of single motor unit firing meas ured with surface EMG muscle activity is recorded from the surface of the skin via a disk electrode. What is measured is a summation of muscle action potentials, providing a general measure of muscle contraction. Thus, needle EMG cannot provide general information concerning whole muscle contraction, and surface EMG cannot give specific information regarding individual motor units. The use of surface EMG has been in two main areas: 1) as biofeedback in pain management; and 2) to try to quantify low back pain due to muscular dysfunction. The use of surface EMG as a biofeedback modality has been extensively reviewed by Headley (1993). Since the 1960s, biofeedback has been used as a technique to promote muscle relaxation. The basic premise of the relaxation model of pain management is that pain causes stress, and this stress in turn increases anxiety of the patient, thereby further increasing the pain. The use of biofeedback for relaxation was based on the assumption that muscle activity is at a higher level because of anxiety or stress and that muscles are overreactive to stressful activity. In 1985, Bush and colleagues demonstrated that many patients with chronic low back pain do not have elevated paraspinal EMG activity, and they raised the question of whether relaxation training of chronic low back patients was a desired protocol. Most research papers, at least early ones, on surface EMG and low back pain are hampered by lack of control subjects and unclear relationship between the experience of pain and surface EMG measurements. pain syndromes has explained many patients' compla (Travell and Simons 1983,1992), and Headley (1993) described a role for surface EMG in various phenome which could be attributable to trigger points. One is concept of referred reflex muscle spasm caused by act tion of a trigger point in another, sometimes dist muscle. Another phenomenon described by Headle reflex inhibition of muscle activity by a trigger point distant muscle. This inhibition may be movement spec Le., a given muscle might work normally during movement but not during another movement. Headley provided intriguing examples of how surface EMG can used to study such phenomena, and she uses this techni as part of a treatment protocol. The relationship b€ltween paraspinal surface e tromyography and low back pain is controversial. Pertin studies can be found in Deluca (1993), Roy and associ (1989,1990), and Sihvonen and colleagues (1991). A problem with selecting patients with low back pain Scientific studies is picking patientswith similar pathoph ology. Aside from disk disease, a number of musculos etal disorders need to be conSidered, including muo tension, lumbosacral sprain, strain, and mechanical p Clearly, many more studies with large numbers of pati are needed to clarify the role of surface EMG in elec diagnosis. It should be emphasized that surface EMG is curre considered to be a technique that is not diagnostic useful, and its performance is generally not reimbursed third-party payers. Traditional electromyographers ge ally tend to totally discount surface EMG as being of v limited usefulness. One reason is that the technique se to be technically unsophisticated, but a more impor reason is that consistent deSCriptions of surface E characteristiCS in back pain patients have not been sented. Every possible result has been reported in literature. For example, some studies have shown pati to have an elevated EMG activity, some have shown th to have a similar EMG pattern to normals, and some rep lowered EMG activity. In some studies, patients with back pain have been found to have asymmetries betw left and right paraspinal muscles. Asymmetries in E activity are thought to be the result ofexcessive and chro bracing and guarding. For patients with elevated E activity, high muscle tension is proposed in a muscle sp model, and in patients with lowered amounts of E activity, low muscle tension is proposed by a mu deficiency model. EVOKED POTENTIALS Evoked potentials are electric potentials that are ge ated in the central nervous system in response to sens (auditory, visual, somatosensory) stimuli. The existenc
- 208. 186 UNIT 2-GOMPONENTASSESSMENTS OF THE ADULT these potentials has been known for over 100 years, and a century of literature of data obtained in experimental animals and humans exists. Just in the period of 1966 to 1993, Index Medicus lists over 32,000 papers on evoked potentials. Some adequate comprehensive reviews have been performed; the reader should consult the books by Aminoff (1992), Chiappa (1983), Halliday (1992), and Spehlmann (1985), and chapters by Cole and Pease (1993) and Eisen and Aminoff (1986). Based on the pioneering studies on evoked potentials by George Dawson in the 1940s and 1950s (1947, 1954), techniques and equipment were developed in the 1960s that allowed these potentials to be recorded from the scalp of human subjects. Initial studies were per formed with custom-built computers at the Massachusetts Institute of Technology in Boston and the Central Institute for the Deaf in S1. Louis. Since the introduction of "user-friendly" special-purpose computers into hospital settings in the 1970s, a vast amount of clinical data has been obtained. Basically, potentials are recorded from the scalp using conventional electroencephalogram electrodes, which are fed into a so-called averaging computer. This specialized computer enables potentials that are evoked by sensory stimuli to be extracted from the ongoing brain activity. Techniqueshave beendeveloped thatenableus to record from the scalp electric activity generated deep within the brain stem. Auditory brain stem eIJoked potentials have ,tj' proven very useful in detecting structural lesions affecting the auditory pathway; therefore, they are useful in detect ing acoustic neuromas or cerebellopontine angle tumors. Various studies report a 95 percent accuracy with this technique. Visual eIJoked potentials (VEPs) are used to document structural abnormalities in the visual pathway and, as such, have become routine in the workup of patients suspected of having multiple sclerOSiS. Even if such a patient had transient visual symptoms a decade prior to testing, VEPs still accurately register the now subclinical abnormality. Over the last 20 years, many reports have documented 90 to 100 percent accuracy in detecting generalized demyeli nating disease. Somatosensory eIJoked potentials (SEPs or SSEPs) are generated in response to an electricstimulus to a peripheral nerve. These potentials mostly are used to document lesions proximal to the spinal nerve root. See Figure 9-11 for the anatomic pathways involved in SEP generation. A segmental analysis can be readily performed by stimu lation of a variety of nerves that enter the spinal cord at different levels. Traditional nerve conduction tests and EMG often fail to detect lesions that are proximal to the dorsal root ganglion, so this procedure, which is very well tolerated by patients, provides complementary and"very often essential information documenting the source of sensory disturbance in, say, patients suspected ofhaving spinal stenosis. Thalamu Medial lemniscus ----------1 ~--Medulla Cuneate fasciculus Gracile fasciculus - - - - I . 1 Spinal cord la fibers peripheral nerve FIGURE 9-11. Anatomic pathways for SEPs. Moderate-int electric stimulation of the peripheral nerve excites the largest myel fibers. The axons terminate in the spinal cord and then travel upw theipsilateraldorsal column pathwaysofthe spinal cord. Thesetract cross over to the other side of the brain at the lower brain stem. continue upward in the mediallemniscal system of the brain stem thalamus. The fibers then project to the cerebral cortex: Nerves fro upper extremity project to the sensory cortex located in the parietal and fibers mediating information from the lower extremities projec more midline area of sensory cortex. In the last 10 years, techniques have been develope intraoperative monitoring of sensory pathways in spinal cord and brain, as well as various cranial n pathways at risk during neurosurgical or orthopedic cedures. Imaging studies (MRI and CT) give information, so times exquisite, about the anatomy of the central ner system. In contrast, the clinical history, neurologic amination, and electrophysiologic studies give info tion concerning the physiology and functional integri the nervous system. It is common to find anato abnormalities that do not cause neurologic dysfun (Boden et aI., 1990; Jensen et aI., 1994), and conver it is often not possible for imaging techniques to d onstrate an anatomic basis for a disturbance of cere
- 209. imaging techniques arecomplementary diagnostic pro cedures rather than alternatives. The anatomic and physi ologic information obtained from these procedures needs to be integrated with the clinical history and status of the individual patient. Evoked potential studies, like EMGs and NCSs, should be regarded as an extension of the clinical examination, with the added advantage of pro viding objective, reproducible, and quantitative data con cerning these various pathways in the nervous system. Electrophysiologic procedures are somewhat more sen sitive in detecting lesions in the brain stem, where MRI is not quite so sensitive. Evoked potential testing is considerably less expensive than MRI and therefore can often serve as a useful screening test, i.e., if a battery of somatosensory, visual, and possibly auditory evoked po tentials is normal in a patient with a diagnosis of "possible multiple sclerosis," then a series of expensive imaging studies of the brain, -cervical, thoraciC, and lumbar spinal cord might be deferred, depending on the clinical situation. NEAR-FIELD AND FAR-FIELD POTENl'lALS So-called near-field recording methods are utilized to record evoked potentials in which the recording electrode is relatively near the generator site, such as cortical evoked potentials, in which the scalp electrode is placed above the cortical area of interest-visual, auditory, or somatosen sory. These cortical, near-field, evoked potentials have relatively high amplitude, restricted scalp distribution, and relatively long latencies. Typically, one scalp electrode is placed close to the area under study (active electrode), and the other (reference electrode) is placed at a relatively less active area. Far-field recording methods are used for recording potentials that are thought to be generated a relatively long distance from the recording electrode, i.e., in the brain stem or spinal cord. Far-field potentials were first described by Jewett and Williston in 1970 (1971) in studies of the auditory system. These investigators described a series of potentials generated in the auditory centers of the brain stem that could be recorded at the level of the scalp. This finding was basically not accepted by the authorities at that time and was initially widely ridiculed as being impossible. However, Jewett's pioneering studies were quickly cor roborated by others, and clinical uses were found. Soon far-field potentials were also discovered for the somatosen sory system. Far-field potentials recorded at the scalp have an extremely low amplitude (1 microvolt or less, three orders of magnitude smaller than potentials recorded with NCSs on EMG) and require sophisticated techniques and high-quality eqUipment. SOMATOSENSORY EVOKED POTENTIALS Technique Stimulus Technique. Although somatosensory potent can be elicited by mechanical stimulation, most clinical research work utilizes electriC stimulation of periph nerves. The most commonly studied nerves in the up extremity are the median, ulnar, superficial radial, a sometimes, the musculocutaneous and digital nerves in fingers. In the lower extremities, the mostly commo studied nerves are the posterior tibial, sural, superfi peroneal, saphenous, and common peroneal. Less co monly studied are the pudendal and lateral femoral c neous nerves. For mixed nerve stimulation, the intensit the electric stimulus is adjusted to obtain a twitch in eit a thumb (for median nerve), little finger (for ulnar nerve) big toe (for posterior tibial nerve) stimulation. It has b shown that this intensity is adequate to stimulate the la myelinated nerve fibers, and no further benefit is obtai by recording in raising this intensity. Generally, stimulus is well tolerated by patients, particularly patie who have already undergone a peripheral nerve cond tion test, which utilizes a much stronger stimulus intens In 15 years of performing this test, the author encountered onlytwo patients who found the stimulus u for this test to be intolerable. For purely cutaneous ner such as the sural nerve, the patient feels paresthe radiating into the peripheral distribution of the nerve be studied when adequate stimulus intensity (for record evoked potentials) is attained. Recording Technique. For recording somatosensory tentials, it is of paramount importance that the patien as relaxed as possible and endeavor to minimize scalp neck muscle tension because these large muscles can, usually do, cause considerable myogenic contaminatio the recording ofthe evoked potential. Therefore, it is us to have the patient either lying down or lying back i reclining chair and as comfortable and as relaxed possible. The recording protocol suggested by Chiappa (19 has proven to give clinically useful results. BaSica Chiappa proposed for upper extremity stimulation reco ing the peripheral volley over the brachial plexus from location known as Erb's point and then from electro placed over the posterior neck recording potentials gen ated in the spinal cord or lower brain stem, and t recording from somatosensory cortex over the lateral sc area. The reference (inactive) electrode is placed over frontal midline region (Fig. 9-12). Some purists h objected to this technique, but this recording mont provides good clinical data and has been used by present author since 1980 with excellent clinical corr tion. For lower extremity stimulation, analogous potent =. ~"--
- 210. 188 UNIT 2-COMPONENTASSESSMENTS OF THE ADULT N14 20 30 40 50 Stimulus msec FIGURE9-12. Schematic diagram of a normal SEP in response to arm stimulation. Recordings from top to bottomshow the scalp recorded N20; the celVical SEP, N13; and the clavicular (Erb's point), NIO. can be recorded from the peripheral nerve over the popliteal fossa, lumbar region of the spinal cord, and over the foot sensory area of the cortex (Fig. 9-13). In 1994, the International Federation for Clinical Neu rophysiology published recommended standards for SEP recordings(Nuwer et al., 1994). Recording montagesdiffer/ .. slightly from the protocol described here. In the author's opinion, this new guideline introduces arguably unneces '11 sary complications into what should be a simple test, and, as with Chiappa's (1983) recommendations, there are 1,:1, published objections (Zeyers de Beyl, 1995). Waveform Nomenclature and Neural Generators The scalp-recorded SEP is thought to be mediated solely through activation of the large Ia peripheral nerves (Burke et al., 1981). Various components of the SEP are often described in clinical reports and in the literature, so these are briefly summarized here. By convention, an evoked potential component is designated by its electric polarity (by a P or N, for positive or negative) and by its latency in milliseconds. Thus, an N10 potential is a negative potential with a peak latency of 10 milliseconds. For several of the SEP components, the polarity depends on the choice of reference electrode, so several authors designate the polarity as PIN. Consult Figure 9-11 for pertinent ana tomic pathways. Upper Extremity stimulation (see Fig. 9-12). In the clinical setting, SEPs in response to stimulation of nerves in the upper extremity are usually recorded from the following three levels: a) Clavicle (NIO). Potentials at this level are best re corded from Erb's point in the supraclavicularfossa or from just above the midpoint of the clavicle. Under these conditions, a triphasic wave (positive-negative positive) with a very prominent negativity is reco The negativity occurs with a peak latency of ar 10 milliseconds for median nerve stimulation a generally referred to as the N10 potential (some called the Erb's point potential, or N9). This near-field potential generated in the nerve fibers brachial plexus underlying the electrode. b) Posterior neck (N12, N14). TheN12isthough generated at the level of the cervical dorsal root the N14 generated either in the dorsal co pathway or at the cuneate nucleus in the medu possibly in the caudal portion of the mediallernni c) Sensory cortex (N20). This potential, a neg potential with a peak latency of around 20 mi onds, is recorded from a scalp electrode overlyin sensory cortex, which is in the contralateral cer hemisphere (Le., for right upper extremity sti tion, the potential is recorded from left brain). Lower Extremity Stimulation (see Fig. 9-13). SE response to stimulation of nerves in the lowerextremit be recorded at the following levels: a) Lumbothoracic spine (N20). This potential corded best by placing an active skin electrode the spinous process of L1 or T12 and using a d lateral reference (e.g., over the iliac crest). Wit recording set-up, a negative deflection with a la of around 20 milliseconds is recorded (N20). investigators agree that this potential reflects ac in the dorsal spinal cord. b) Neck (N27). Here, the main potential consists negative deflection of around 27 milliseconds probably generated at the level of the for magnum, either in the dorsal columns themselv in the dorsal column nucleus (nucleus gracilis perhaps in the caudal part of the medial lemn (For routine clinical use, potentials recorded ov 30 P65 40 50 60 FIGURE 9-13. Schematic diagram of a normal SEP in respo stimulation of the posterior tibial nerve at the ankle. The recording top to bottom show the scalp recorded P40 and P65, low thorac lumbar spinal SEPs, and peripheral nerve potential recorded popliteal fossa.
- 211. somewhat difficult torecord, mainly due to myogenic contamination by paraspinal muscles. They are best recorded in very thin people and cannot be recorded in overweight people with any reliability. Because of poor reproducibility and excessive false positives, these potentials are often not used in routine clinical screening exams.) c) Cortex (P40). This potential is best recorded from a scalp electrode overlying the foot area of the brain, which lies midline just posterior to the middle of the top of the head. A well-formed positive wave peaking at 40 to 45 milliseconds is recorded in response to posterior tibial nerve stimulation at the ankle. Obvi ously, patient height and limb length are some determinants of the latency of this potential. Poten tials evoked by sural nerve stimulation at the same level have a slightly longer latency because of slightly smaller (and therefore slower conducting) peripheral nerve fiber diameters. Clinical Utility In evaluation of the central nervous system, the main role for SEPs is for the detection of lesions. A primary use for neurologists has been for confirmation of this diagnosis in a patient with a presumptive diagnosis on the basis of clinical and imaging studies. The presence of somatosensory ab normalities has often been useful in detecting subclinical lesions in multiple sclerosis and thus in establishing the presence of multiple lesions in the central nervous system. As with NCS or EMG, evoked potential abnormalities never provide a diagnosis by themselves. They must be interpreted within the clinical context of the case. Somatosensory evoked potentials can also be abnormal in a wide variety of other disorders affecting the brain and spinal cord such as tumors and strokes, depending on whether these lesions affect the afferent pathways. With regard to a hemispheric stroke or in the evaluation of patients following anoxic-ischemic events, SEP findings are often useful in providing a guide to the prognosis of such patients. For example, Hume and coworkers (1979) correctly predicted the outcome in 38 of 49 comatose patients; basically, the principle is that the worse the morphology of the somatosensory evoked potentials, the worse the prognosis. An important use for SEPs is in the operating room to monitor spinal cord and brain functioning during surgery. Discussion of this widespread but somewhat controversial topic is beyond the scope of this chapter. The interested reader can consult several textbooks on this subject or the chapter by Owen (1991). For routine clinical testing, Eisen and associates (1983) popularized a technique of analyzing "segmentally spe cific" evoked potentials in an attempt to increase specificity of SEPs when trying to isolate a radiculopathy. Basically, nerves in the extremity being studied in an effort to loc slowing at one particular nerve root. Unfortunately, m peripheral cutaneous nerves contain fibers from two more roots. Therefore, an abnormality restricted to root might be masked by activity in the normal ro Another problem in using SEPs for the diagnosi radiculopathies is that one is attempting to detect a s segment of conduction slowing, usually only a few mill ters long, and this small area can easily be masked or dil along the long length of the normally conducting n distal to the root. This is true for stimulation of both up and lower extremities. Despite these practical and theor difficulties, the author has found this technique to be q sensitive and easy to perform and interpret. Peripheral Neuropathy. There are several indication using SEPs to evaluate the integrity of peripheral ner 1. Some peripheral nerves, such as the lateral fem cutaneous or pudendal nerve, are not easily ac sible for stimulation or recording using standard E methods, and SEPs can be used to measure con tion along such nerves. 2. In processes such as Charcot-Marie-Tooth dise the peripheral neuropathy makes NCSs difficu quantify. 3. For the evaluation of radiculopathies, espec when sensory signs and symptoms are present discussed previously, often peripheral nerve testi inadequate because in such problems the ac conduction deficit lies proximal to the dorsal ganglion. 4. SEPs can be used to evaluate plexopathies. Usually, however, it is considered good practice to more routine techniques such as peripheral nerve con tion and EMG, and if these are shown to be of little va then SEP testing might then be employed. Radiculopathy. In SEP testing, a bilateral segmental a ysis (described earlier) is often useful for pinpointing a diculopathy. Eisen and colleagues (1983) studied 28 tients with either cervical or lumbosacral pathology found that 16 (57%) had abnormal SEPs. Using the t nique of segmental stimulation, Perlik and collea (1986) studied 27 patients with low back pain; 21 pati had SEP abnormalities that correlated with symptoma ogy and CT scanning. The authors also described 15 c in which no associated clinical deficit or peripheral nerv EMG, electrophysiologic abnormality was present and lieved that the SEP was often useful for detecting subclin nerve root pathology. These authors found the most c mon abnormality to be a prolongation in the evoked po tiallatency. Walk and colleagues (1992) studied SEPs in patients with signs or symptoms suggestive of lumbosa radiculopathy and compared them with CT myelogra MRI, and other electrophysiologic studies. Thirty-eigh tients had abnormal CT myelograms, and 32 of th had abnormal SEPs, but only 11 demonstrated EMG normalities. Interestingly, all 21 patients with nor
- 212. 190 UNIT 2-COMPONENTASSESSMENTS OF THE ADULT CT myelograms had normal SEPs. Saal and colleagues (1992) studied SEP results from 100 consecutive patients referred for the evaluation of upper lumbar radiculopathy and offer some statistics with regard to the sensitivity, specificity, and predictive value of SEP and EMG with ref erence to anatomic imaging tests. For example, for L4 radiculopathies, they found the SEP to be in 100 percent agreement with the imaging study, whereas EMG was only in agreement 64 percent of the time. For L2 and L3 radicu lopathies, the SEP was in agreement 88 percent of the time. In this study, EMG testing was negative in 23 of 26 cases in which SEP abnormalities corresponded to ana tomic pathology. Although there are many other studies in the literature, these studies are representative. Although most investiga tors summarize their results as finding that the SEP is "useful," it is dear that studies with much larger numbers of patients with proven pathology are needed to quantify the actual usefulness of this technique. Like other electro physiologic studies, SEP testing is sometimes more an art than a science; in both test administration and interpreta tion and patient selection, a certain amount of subjective ness is acceptable. Plelopathy. SEPs can often provide accurate localization of root avulsion in traumatic plexopathies. As mentioned, needle EMG can only show abnormalities after nerve degeneration has progressed distally. Thus, shortly after trauma, SEP testing can give a fair amount of information, sometimes prognostic, about the continuity between pe ripheral and central nervous systems, Le., ability to elicit SEPs when evidence of plexopathy exists suggests a more favorable prognosis than if the SEP cannot be recorded at all. Cervical Spondylotic Myelopathy. It has been the author's experience that SEPs are quite helpful in the work-up of patients with cervical spondylosis. Paradoxically, in pa tients with definite cervical spinal cord compression, potentials from upper limb nerves are sometimes normal, but stimulation by lower extremity nerves usually detects this. For example, in the study by Perlik and associates (1986), in 13 patients with cervical spondylitic myelopa thy, all patients had abnormal posterior tibial SEPs. In patients with cervical spondylOSiS, then, who are likely to develop a Significant cord deficit; this diagnostic procedure can suggest surgical or other intervention as a preventive measure. Although a variety of imaging studies such as MRI, CT myelography, and radiography are all very useful, this is quite expensive and sometimes still provides an equivocal diagnosis. Therefore, using imaging studies in conjunction with physiologic studies can often provide much diagnostic information. Hysterical Sensory Loss, Malingering. Electrophysiologic studies, both NCS and SEP testing, can be useful in the determination of whether sensory complaints have an organic basis, as might be in the case in a hysterical or malingering patient. Sometimes convincing sensory symp tomatology can be manifestation of an effort to obtain secondary gain or a conversion reaction, and this is q commonly commonly encountered in the neurology physical medicine clinic. Electrophysiologic measures provide support for the clinical impression, but nor electrophysiologic tests certainly do not rule out any neu logic disorder. DERMATOMAL EVOKED POTENTIALS Theoretically, one should be able to stimulate over skin of specific dermatomes (as opposed to stimula directly over a nerve) and record cerebral responses ( 9-14). Ascalp recorded potential so recorded is referre as a dermatomal (somatosensory) evoked potent Theoretically, such a potential should be a reflection input from justone sensory nerve root. This is a popular controversial technique at present. Dermatomal stim C5 / ..T12/ l· L2 C7 L3 L4 L5 FIGURE 9-14. Sites of stimulation for producing dermatomal S
- 213. amplitude and poorlydefinedpotentials are often obtained. The most comprehensive study of normative data of this technique was presented by Slimp and colleagues (1992). There are several clinical studies in the literature-some have suggested that this is definitely a useful technique (Katifi and Sedgwick, 1987), and others have found it to be definitely not so useful (Aminoff and Goodin, 1988). Again, studies with large numbers of patients are needed. Because of the difficulty in recording potentials and often the poor definition and also the increased amount of time used to conduct a complete dermatomal examination, such testing is often not warranted or practical in screen ing examinations; however, in selected individuals in which some need to verify involvement of a particular nerve root exists (e.g., in a surgical candidate), such techniques might be useful after mixed nerve SEP testing, peripheral nerve testing, and imaging studies have all proven to be equivocal. MOTOR EVOKED POTENTIALS The term motor evoked potential (MEP) refers to an electric potential recorded from muscle, peripheral nerve, or the spinal cord in response to stimulation of the motor cortex in the brain or the motor pathways within the brain or spinal cord (Fig. 9-15). In 1980, Merton and Morton presented an electric stimulator that could effectively stimulate the motor cortex of the brain via electrodes placed over the scalp. A single shock of very high voltage of very short duration was used. This is referred to as transcranial electrical stimulation. In 1985, magnetic stimulation of the brainwas introduced. This entails placing a circular coil over the scalp; a high-voltage electric current flows through the coil. When the coil is placed over the scalp, the magnetic field generated by the current passes through the skull unattenuated and activates neurons in the underlying motor cortex. The reason that magnetic stimu lation was developed and now is the preferred technique is that it is much less painful than electric stimulation. Although this technique is used in Europe, it is not approved for routine clinical use in the United States at present. Nevertheless, since this technique was developed in the mid-1980s, a large literature on the theoretic and practical aspects of this technique has emerged (Cho kroverty, 1990; Cros etaI., 1990; Levyetal., 1984; Meyer et al., 1993; Murray, 1992; Olneyet al., 1990). The parameter of interest with transcranial electric or magnetic stimulation has been the so-called central motor conduction time (CMCT). This is a measure of the functional integrity of the motor pathways in the brain and spinal cord. A fairly extensive literature exists of clinical correlations in diseases such as multiple sclerosis, motor neuron disease, cervical spondylosis, stroke, hereditary FIGURE 9-15. Schematic diagram of setup for producing transcr motor evoked potentials. The stimulation can also be placed at locations such as posterior neck or brachial plexus. At present, tran nial stimulation is not approved for use in the United States stimulation at other sites, e.g., peripheral nerves, is approved. neurodegenerative diseases, movement disorders, her tary motor and sensory neuropathies, polyneuropath functional weakness, and intraoperative monitoring. the chapter by Murray (1992) for a concise review. Magnetic coil stimulators can also be used for stimula peripheral nerves and are quite useful for stimulating d nerves, such as in the brachial plexus. This type stimulation is approved for routine clinical use in the Un States. Nevertheless, applications are limited, and equipment is somewhat expensive. This technique is st its infancy, and more clinical applications should forthcoming. ELECTRODIAGNOSIS OF MOVEMENT DISORDERS Electrophysiologic evaluation of movement disor involves much equipment and elaborate paradigms therefore is usually restricted to research laboratorie very large clinical centers. Such physiologic analysis ca useful in the classification of certain types of movem and can often provide information not obtainable clinical observation. Such physiologic studies can also
- 214. 192 UNIT 2-COMPONENTASSESSMENTS OF THE ADULT used in guiding therapy and in basic knowledge of the pathophysiology of movement disorders. Since these techniques are not in widespread use, they are not presented here. The interested reader should consult the survey by Hallett (1992). GUIDELINES FOR ELECTRODIAGNOSTIC TESTING The American Association for Electrodiagnostic Medi cine has published fairly speCific gUidelines (1992) as to what is the appropriate testing for various neuromuscular disorders. These gUidelines should be consulted to see if a particular test on a patientwas adequate to makediagnostic inferences. Basically, the guidelines merely propose com mon sense, i.e., studying several nerves before making a diagnosis of polyneuropathy, studying several muscles within a myotome, and studying several muscles outside that myotome when assessing for radiculopathy. These guidelines, however, only make recommendations for peripheral nerve testing and needle electromyography and do not address evoked potentials, motorevoked potentials, Single-fiber EMG or surface EMG. Guidelines for clinical evoked potential studies have been published by the American EEG Society (1994). .. it,. =I.:. ." WHO SHOULD PERFORM ELECTRODIAGNOSTIC TESTING? Improper performance of a test employing electric stimuli or needle insertion can be dangerous to the patient, and improper interpretation can be misleading to a refer ring physician. This is particularly important when such tests are used to play a large role in a diagnosis of such diseases as multiple sclerosis and amyotrophic sclerosis, as well as for critical use in surgical dec making, e.g., for treatment of carpal tunnel syndro during intraoperative monitoring during spine or surgery. The goal of the electrodiagnostic consultation electrophysiologic evaluation of the peripheral n nerve roots, central nervous system, neuromuscular tion, and muscles and correlation of these results wi whole clinical picture to arrive at an accurate diagno the patient. It is the position of the American Acade Eiectrodiagnostic Medicine that the electrodiagnosti sultant should be a physician who has had special tr in neurologic and neuromuscular diseases and also application of the techniques described in this chapte electrodiagnostic consultation is an extension of the rologic examination; unlike most laboratory tests testing is not done in a standard fashion and must of modified for an individual patient. Certain electrodia tic technicians who are certified in evoked potent peripheral nerve testing often conduct these tests b not render the final interpretation. A controversial a the performance of needle electromyography.Techn are often employed to perform this test to cut cost many authorities believe that only physicians shoul form any examination that requires needle insertion is the position of the American Association of Elec agnostic Medicine, the American Medical Associatio American Academy of Neurology, the American Aca of PhYSical Medicine and Rehabilitation, the Am Neurologic Association, and the Department of Ve Affairs (Veterans Administration). ACKNOWLEDGEMENT The author thanks Justine Vaughen, MD, for a c review of the manuscript and Patricia Strand and D Szot for typing the manuscript. .
- 215. PPENDIX The followingare numbers and addresses of organiza tions involved in electrodiagnostic testing. In addition to these national organizations, there are many state and regional suborganizations. AAEM (American Association of Eledrodiag nostic Medicine). (Formerly the American Asso ciation of Electromyography and Electrodiagnosis.) Blackenridge Skyway Plaza, 21 Second Street, S.W., #103, Rochester, Minnesota 55901. (507) 288-0100. MET (American Association of Electrodiagnos tic Techs). P.O. Box 79489, North Dartmouth, Massachusetts 02747. (508) 771-1220. AAN (American Academy of Neurology). 2221 University Avenue, S.w., Suite 335, Minneapolis, Min nesota 55414. (612) 623-8115. AEEGS (American EEG Society). p.o. Box 30, Bloomfield, Connecticut 06002. (203) 243-3977; (203) 286-0787. ASET (American Society of Electroneurodiag nostic Technologists). 204 W. 7th Street, Carroll, Iowa 51401. (712) 792-2978. Action potential-The all-or-none, self-propagating, nondecrementing voltage change recorded from an excit able muscle or nerve. Commonly, the term refers to the (nearly) synchronous summated action potentials of a group of cells, e.g., motor unit potential. Amp6tude-With reference to an action potential or evoked potential, the maximum voltage difference be tween two points, usually baseline to peak or peak to peak. Anode-The positive terminal of a source of electric current. Antidromic-Refers to an action potential or the stimu lation causing the action potential that propagates in the direction opposite to the normal (Le., orthodromic) one for that fiber-Le., conduction along motor fibers tow the spinal cord and conduction along sensory fibers aw from the spinal cord. Cathode-The negative terminal of a source of elec current. Cerebral evoked potential-Electric waveforms biologic origin recorded over the head and elicited sensory stimuli. See specific evoked potentials, e.g., som tosensory evoked potential, visual evoked potent auditory evoked potential. Crampdischarge-Repetitive firing ofaction potent with the configuration of motor unit potentials at a h frequency in a large area of muscle, associated with involuntary, painful muscle contraction (cramp). Depolarization-A decrease in the electric poten difference across a membrane from any cause, to degree, relative to the normal resting potential. polarization. Electrode-Adevice capable of conduction ofelectric Electrodes may be used to record an electric poten difference (recording electrodes) or to apply an elec current (stimulating electrodes). In both cases, two e trodes are always required. Electromyography (EMG)-Recording of electric tivity of muscles can be accomplished with needle surface electrodes. End-plate activity-Spontaneous electric activity corded with a needle electrode close to muscle end-pla Evoked compound muscle action potential-T electric activity of a muscle produced by stimulation of nerves supplying the muscle. See M wave, F wave, H wave reflex. Evoked potential-Electric waveform elicited by temporally related to a stimulus, most commonly electric, visual, or auditory stimulus delivered to a sens receptor or nerve. See action potential, cerebral evo potential, somatosensory spinal evoked potential, sual evoked potential. 1
- 216. 194 UNIT 2-GOMPONENTASSESSMENTS OF THE ADULT Fasdculation-The random, spontaneous twitching of a group of muscle fibers that may be visible through the skin. The electric activity associated with the spontaneous contraction is called the faSciculation potential. FibriUation-The spontaneous contractions of indi vidual muscle fibers that are ordinarily not visible through the skin. Frequency analysis-Determination of the range of frequencies composing a potential waveform, with a measurement of the absolute or relative amplitude of each component frequency. It is similar to the mathematic technique of Fourier analysis. F wave-A long latency compound action potential evoked from a muscle by supramaximal electric stimulus to a peripheral nerve. Compared with the maximal amplitude M wave of the same muscle, the F wave has a reduced amplitude and variable morphology and a longer and more variable latency. It can be found in many muscles of the upper and lower extremities, and the latency is longer with more distal sites of stimulation (see Fig. 9-6). H wave reflex-A long latency compound muscle ac tion potential having a consistent latency evoked from a muscle by an electric stimulus to a peripheral nerve. It is regularly found only in a limited group of physiologic extensors, particularly the calf muscles. A stimulus in tensity sufficient to elicit a maximal amplitude M wave reduces or abolishes the H wave. The H wave is thought 1" to be due to a spinal reflex, the Hoffman reflex, with" electric stimulation of afferent fibers in the mixed nerve ,1 to the muscle and activation of motor neurons to the muscle through a monosynaptic connection in the spinal cord (see Fig. 9-6). Insertional activity-Electric activity caused by inser tion or movement of a needle electrode. Interference pattern-Electric activity recorded from a muscle with a needle electrode during maximal volun tary effort, in which identification of each of the con tributing action potentials is not possible because of the overlap or interference of one potential with another. When no individual potentials can be identified, this is known as a full interference pattern. A reduced interference pattern is one in which some of the individual potentials may be identified, while other indi vidual potentials cannot be identified because of over lapping. Sitter-In single-fiber EMG, the jitter is characterized by the mean difference between consecutive interpotential intervals (MCD). The MCD is 10 to 50 Ilsec in normal subjects; when neuromuscular transmission is disturbed, the jitter (i.e., MCD) is increased. Latency-Interval between the onset ofa stimulusand the onset of a response unless otherwise specified. Latency always refers to the onset unless specified, as in peak latency. Generally, in cerebral evoked potential studies, peak latency is measured (see Fig. 9-2). Macroeledrom.yography-In this technique, el activity within a muscle is recorded by a modified elec that is used for Single-fiber EMG. During a voluntary m activity, an averaging computer is triggered from ac arising in a single muscle fiber. It is thought tha resultant wave form measures the contribution from entire motor unit. As such, macro motor unit a potentials reflect abnormalitiesseen in myopathies an show when reinervation has occurred in perip neuropathies. MeDlbrane instabiDty-Tendency of a cell memb to depolarize spontaneously or after mechanical irrit or voluntary activation. Monopolar needlee1ectrode-Asolidwire, usua stainless steel, coated (except at its tip) with an insu material. Variations in voltage between the tip ofthe n in a muscle and a conductive plate on the skin su (reference electrode) are measured. This recording se referred to as a monopolar needle electrode recordin Motor unit potential (MUP)-Action potential re ing the electric activity of that part of a motor unit t within the recording range of an electrode. M wave-A compound action potential evoked fr muscle by a single electric stimulus to its motor nerv convention, the Mwave elicited by supramaximal stim tion is used for motor nerve conduction studies. Myokymia--Involuntary, continuous quivering of m fibers that may be visible through the skin as a vermi movement It is associated with spontaneous, rhyt discharge of motor unit potentials. Myotonicdischarge-Repetitive discharge of 20 Hz recorded after needle insertion into muscle. Needleelectrode-An electrode for recording ors lating, shaped like a needle. Nerve conduction studies-Refers to all aspec electrodiagnostic studies of peripheral nerves. How the term is generally used to refer to the recording measurement ofcompound nerve and compound m action potentials elicited in response to a single s maximal electrical stimulus. NeurolDyotonic discharges-Bursts of motor potentials firing at more than 150 Hz for 0.5 to 2 sec The amplitude of the response typically wanes. Disch may occur spontaneously or be initiated by needle m ment. Orthodromic-Refers to action potentials or st eliciting action potentials propagated in the same dire as physiologic conduction, e.g., motor nerve condu away from the spinal cord and sensory nerve condu toward the spinal cord. Contrast with antidromic. Polarization-The presence of an electric pot difference across an excitable cell membrane. The p tial across the membrane of a cell when it is not excit input or spontaneously active is termed the resting p
- 217. difference across themembrane. Depolarization describes a decrease in polarization. Hyperpolarization describes an increase in polarization (see Fig. 9-1). Positive sharp wave-Strictly defined, one form of electric activity associated with fibrillating muscle fibers (see Fig.9-10B). Recording e1eetrode-Device used to monitor electric current or potential. All electric recordings require two electrodes. The electrode close to the source ofthe activity to be recorded is called the active electrode, and the other electrode is called the reference electrode. The commonly used term monopolar recording is, strictly speaking, not correct because all recording requires two electrodes; however, it is commonly used to describe the use of an intramuscular needle active electrode in combination with a surface disk or subcutaneous needle reference electrode. Recruibnent-The orderlyactivation of motor units with increasing strength of voluntary muscle contraction. Repetitive stimulation-The technique of utilizing repeated supramaximal stimulation of a nerve while ana lyzing M waves from muscles innervated by the nerve. Resting membrane potential-Voltage across the membrane of an excitable cell (nerve or muscle fiber) at rest. Scanning electromyography-In this technique, an electrodeused for single-fiber EMG is inserted into a slightly contracted muscle and advanced in small steps (on the order of 50 llm). What is displayed is a spatiotemporal analysis of firing of the motor units. This term is also used in surface EMG to describe the recording from several muscles. Single-fiberelectromyography (SF-EMG)-A rela tively new technique that allows for recording activity in individual muscle fibers with a very small needle electrode. The muscle is under slight voluntary activation, and the electrode is positioned so activity is recorded from one or two individual muscle fibers. A temporal variability, the jitter, is analyzed. This is the time between two consecutive discharges (see jitter). Measurement of jitter is a sensitive means of evaluating neuromuscular transmission. This technique can be used for analysis of myopathic and neurogenic disorders. The technique has also been used to estimate the number of motor units in a muscle. Somatosensory evoked potential (SEP or SSEP) -Electric waves recorded from the head or trunk in response to stimulation of peripheral sensory fibers. Re cordings over the spine may be referred to as spinal evoked potentials (see Figs. 9-12 and 9-13). Spike-Transient wave with a pointed peak and a short duration (a few milliseconds or less). See end-plate spike and fibrillation potentials. Spinal evoked potential-Electric waves recorded from the head or trunk in response to stimulation of be referred to as spinal evoked potentials (see Fig. 9-1 Spontaneous activity-Action potentials recor from muscle or nerve at rest after insertional activity subsided and when no voluntary contraction or exte stimulus occurs. Stimulating electrode-Device used to apply elec current. All electric stimulation requires two electrod the negative terminal is termed the cathode, and positive terminal, the anode. By convention, the sti lating electrodes are called bipolar if they are roug equal in size and separated by less than 5 cm. Elec stimulation for nerve conduction studies generally quires application of the cathode to produce depolar tion of the nerve trunk fibers. Stimulus-In clinical nerve conduction studies, an e tric stimulus is generally applied to a nerve or muscle. W respect to the evoked potential, the stimulus may be gra as subthreshold, threshold, submaximal, maximal, or pramaximal. Ordinarily, supramaximal stimuli are used nerve conduction studies, and submaximal stimuli are u for SEPs. Surface EMG-Recording of electromyographic acti with recording electrodes attached to the surface of skin. Contrasted with needle electromyography. Visual evoked potential-Electric waveforms of logic origin recorded over the cerebrum and elicited by l stimuli. Volume conduction-Spread of current from a pot tial source through a conducting medium, such as the b tissues. Voluntary action-In electromyography, the elec activity recorded from a muscle with conSciously contro muscle contraction (see Fig. 9-10). Waveform-The shape of an electric potential (wa REFERENCES Adrian, A. D" & Bronk, D, W. (1929). The discharge of impulses m nerve fibers. Part II. The frequency of discharge in reflex and volun contractions. Journal of Physiology (London), 67, 119-151. 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- 221. C HAP TE R 1 0 Prosth,et,ic an'dOrthotic Assessments Lower Extremity Prosthetics Robert S. Gailey, MSEd, PT SUMMARY When a lower limb is lost, an artificial limb or prosthesis is provided with the intent of restoring function to the individual. The primary goal for the ma jority of people in this situation is the restoration of the ability to walk. Unfortu nately for most, the manner in which they walk with a prosthesis does not resemble their style of walking prior to their limb loss. They are labeled as having gait deviations and identified as persons with a disability. The ability to identify the cause of these gait deviations, construct the appropriate treatment plan, and re assess the ongoing treatment gives the clinician the tools to restore the ability to walk with minimal impairment. While there are many contributing factors that dic tate an amputee's ability to walk, the assessment of gait is a critical component in determining which course of treatment will best serve the patient. This chapter reviews the common gait deviations associated with lower extremity amputation. The intent is to provide a global understanding of the lower extremity amputee's gait, which will allow the clinician to see how even the smallest depar ture from normal gait biomechanics can have an effect throughout the kinetic chain. The actual assessment portion of the chapter builds on the amputee gait bio mechanics section by introducing a series of questions that clinicians should be asking themselves as they observe the amputee walking in the clinic. The answers to the questions assist in directing the clinician's assessment as well as help in the planning of the treatment program. The use of functional scales for categorizing the level of ambulation and functional potential of amputees is discussed. The assessment of specific gait deviations and the identification of the cause are pre sented using a systematic method of gait evaluation. The most commonly observed deviations and potential causes are outlined in chart form for easy reference.
- 222. 200 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT The application of scientific investigation to the ampu tee's gait began just after World War II with the return home of thousands of veteran amputees. It was at this time that the Committee on Prosthetics and Research Development of the National Research Council established the Biome chanic Laboratories to study prosthetics and amputee rehabilitation. The University of California (UC) at Berkley and UC San Francisco were primarily concerned with lower limb study, and the UC Los Angeles' focus was the upper limb (Sanders, 1986). Inman and colleagues (1981) were charged with the investigation of the fundamentals of human walking and the role of prosthetics with respect to the amputee. Measurement techniques included the use of motion picture cameras positioned along the walkway for sagittal and frontal views. Transverse plane data were collected using the cameras placed below glass walkways (Eberhart & Inman, 1951). Ground reaction forces were measured using forceplates, and electromyography (EMG) study provided information concerning muscle activity (Gage &Hicks, 1985). The remarkable amount of research and the number of publications produced by this distin guished group of investigators helped establish the stan dards in prosthetic fabrication, alignment, and amputee assessment. The tl..vo noted publications authored by this exceptional gathering of scientists, Human Limbs and Their Substitutes (Klopsteg et al., 1968) and Human Walking (Inman et al., 1981), continue to provide the time-tested foundation for prosthetiC researchers and clinicians today and have been described as the final statement on gait analysis of the precomputer era (Ca vanagh & Henley, 1993). Saunders and colleagues identified six major determi nants of gait (Saunders et al. , 1953). What they were essentially describing was the ability of humans to control the center of mass (COM) over base of support (BOS) during walking. Any deviation from the delicate rhythmic movement of COM over BOS could have an effect on the individual's gait pattern and overall energy expendi ture during walking. The more harmonious the displace ment of the COM within the body, the less muscular effort is required to maintain upright posture and allow mo mentum to carry the body from one foot to another in a balanced and efficient manner. The identification of critical events that maintain normal displacement of COM over BOS gives the observer insight into the events that assist humans in maintaining balance and minimizing effort during walking. For the amputee, regardless of the level of amputation, prosthetiC fitting and gait training should be focused on the restoration of ambulation while minimizing any deviation from the natural plane of pro gression of the body's COM over its BOS. Compensatory mechanisms for an imbalance in the displacement of the COM over the BOS in amputees result in asymmetric gait patterns and the increased metabolic cost of walking (Engsberg et al., 1990; Engsberg et al., 1992; Hannah & Morrison, 1984). As with any assessment, if the evaluator understands the underlying cause of the observed signs and symptoms, the the evaluation can be more thorough. The followin sections outline what the literature has described as typic gait variations or deviations associated with transtibial an transfemoral amputees. The majority of these imbalance do not act independently of each other; in fact, many act combination, depending on the cause of the asymmetry Bearing in mind the similarities and associated pattern betl..veen the gait variations described will help the clinicia to better visualize the amputee's gait pattern. TRANSTIBIALAMPUTEE-VARIATIONS FROM NORMAL GAIT Engsberg and coworkers (1990) found that childre with transtibial amputations tend to walk with greater forward flexion of the trunk. This has also been observed in adult amputees. Altered posture, relocation of the COM to a more anterior position and loss of proprioception in the prosthetiC limb resulting in the need to view the floor are some of the common explanations when loss of range of motion at the hip or trunk is not at fault. In the frontal plane, the COM remains over the nonprosthetic limb in children throughout the gait cycle. Additionally, the trunk has a tendency to shi toward the nonprosthetic limb during both non prosthetic and prosthetic support (Engsberg et al., 1992). While this study focused on children, adults may also tend to maintain relatively greater body weight support over the sound limb throughout stance, suggesting an adaptation to lack of function or lack of confidence in the prosthetic limb. • Increased hip extensor activity in the prosthetic limb is present during early stance and mid-stance. This burst of muscular activity is believed to assist i propelling the body forward and compensating for the lack of energy generated during late stance due to the absence of the ankle (Czerniecki et al., 1991; Gitter et al. , 1991; Winter & Sienko, 1988) • The time from initial contact on the ground to load ing response when the prosthetiC foot is flat on the ground is greater for the amputee because of the rigid prosthetic ankle (Winter & Sienko, 1988). CI The loss of plantar flexion at terminal stance repre sents a significant loss in the mechanical power generated during the normal gait cycle. As previ ously described, the increased hip extensor output is the major compensatory mechanism for this loss (Czerniecki et al., 1991; Gitter et al., 1991; Winter & Sienko, 1988). To compensate for the loss of active plantar flexio "energy storing" or "dynamic response" prosthetic fe were designed to give the amputee some "spring" ju
- 223. TRANSTlBIAL AMPUTEE MEANVELOCITY. CADENCE. AND STRIDE LENGDI Author Cause Velocity (mlmin I±» Cadence (steps/min I±» Stride Length (m Winter and Sienko (1988) NR 58 (4.8) Waters et al. (1976) D 45 (9) Robinson et al. (1977) M 64.2 (138) Waters et al. (1976) T 71 (10) Pagliarulo et a. (1979) T 71 (10) D = Dysvascular; M =multiple causes; NR =not reported; T =traumatic. prior to the swing phase of gait. The "stored energy" is mechanical energy that is absorbed as the force of the amputee's body weight is placed over the foot's deflector plate during mid-stance and returned as the limb moves toward swing. Gitter and associates (1991) did report a difference in the mechanical efficiency, the ratio of energy absorbed during mid-stance to the energy released during terminal stance, between prosthetic feet. The solid ankle cushion heel (SACH) foot efficiency was 39%, Seattle Foot 71%, and Flex Foot 89%, which was considerably less compared with the efficiency ratio generated (264%)by the active contraction of the intact plantar flexors. Interest ingly, there is no significant difference in the pattern or magnitude of power output generated by the knee and hip between dynamic prosthetic feet and nondynamic pros thetic feet (Gitter et aL, 1991; Winter & Sienko, 1988). Therefore, there appears to be little or no compensation by the hip or knee moving the limb into swing to make up for the loss of plantar flexion. The prosthetic limb typically has a longer step length, and the time to complete the step is less than that of the nonprosthetic limb. As a result, greater acceleration is accomplished by the pros thetic limb (BreakIy, 1976; Robinson et aL , 1977). The faster the amputee walks, the greater the asymmetry in step length, with the prosthetic limb taking longer and faster steps (Robinson et aI., 1977). This could be attributed to the amputee at tempting to increase walking speed by overcom pensating with the limb that is at fault for slowing him or her down. Stance time is longer on the nonprosthetic limb than the prosthetic limb (BreakIy, 1976; Robinson et aL, 1977). Greater stance time on the nonpros thetic limb may provide greater stability and an opportunity to maintain balance. The reduction in stance on the prosthetic limb is frequently attrib uted to one or more of the following: poor balance, weakness, pain, lack of confidence while on the prosthesis, or a combination of factors. Alteration in normal walking patterns over many years may result in degenerative changes to weight-bearing joints on the sound limb (Burke et aL, 1978; Hungarford & Cockin, 1975; Klopsteg et aL , 1968; Powers et aL, 1994). However, other 92 (5) 1.27 (0.07) 87 (7) 1.02 (0 13) 96 (11) 1.32 (0.18) 99 (9) 1.44 (0.16) 99 (9) 1.44 (0.15) studies report that forces acting across the sou limb joints of amputees are no different from joint forces experienced by non-amputees, sug ing no predisposition for degenerative change (Hurley et aL, 1990; Lewallen et aL, 1986). In study, Hungarford and Cockin (1975) found t the knee on the amputated side had severe qu ceps atrophy, marked osteoarthritis, and mod ate joint space narrowing. However, the ampu group had fewer complaints of pain than the control group with similar findings. • Asymmetry of prosthetic gait results if optima alignment is not achieved. Prosthetic foot dors ion is the most important prosthetic alignmen change, and hip flexion-extension motions are most sensitive to alignment changes (Hannah Morrison, 1984). Walking velocity and cadence have been consi tently demonstrated as less than those in nona putee ambulators (Pagliarulo et aL, 1979; Rob & Smidt, 1981; Waters et aL , 1976; Winter & Sienko, 1988) (Tables 10-1 and 10-2). Wate colleagues (1976, 1988) demonstrated that ca of amputation has a direct relationship to walk velocity and cadence, with vascular amputees ing more slowly than traumatic amputees. Ho ever, it appears that walking speed is not relat length of residual limb or the weight of the pro thesis (Gailey et aI., 1994). The metabolic cost of ambulation for the trans amputee is greater than that for nonamputee lators (Huang et aL , 1979; Pagliarulo et al., 1 TABLE 10--L NONAMPUTEE MEAN VELOCI1Y. CADENCE. AND STRIDE LENGDI Cade nce Velocity (steps/min Stride L Author (mlmin I±I) I±» (m I± Drillis (1958) 87 113 1.53 Finley (1970) 78 114 1.38 Waters et a. 80 113 1.42 (1988)
- 224. 202 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT TABLE 10-3 OF AMBUJATION Rate of Oxygen Uptake Net Oxygen Cost Heart Rate Author Type (mVkg/min I±]) (ml/kg/m I±]) (beats/min I±]) Waters et al. (1976) 0 11.7 (16) Waters et al. (1976) T 15.5 (2.9) Pagliarulo et al. (1979) T 15.5 (28) Huang et al. (1979) T 10.0 Waters et al. (1988) N 12.1 o = Dysvascular; N =nonamputee; T =traumatic. Waters et al., 1976). In an attempt to reduce oxygen uptake and heart rate, amputees may adopt a slower walking speed (Table 10-3). Other influencing factors such as age, self-selected walking speed, prosthetic weight (Gailey et a1., 1994), and the type of prosthetic foot, such as the "energy storing" prosthetic feet or dynamic feet versus the use of conventional prosthetic feet such as the SACH foot, do not reduce the metabolic cost of amputee walking (Lehmann et a1. , 1993; Perry & Shanfield, 1993). The length of the residual limb (Gailey et aI. , 1994; Gonzalez et aI., 1974) and the cause of amputation (Waters et al., 1976) appear to have the most Significant effect on the metabolic energy cost of walking for transtibial amputees. TRANSFEMORAL AMPUTEES VARIATIONS FROM NORMAL GAIT Transfemoral amputees have been described as having an increase in stride width during ambula tion, increasing the displacement of the COM lat erally (James & Oberg, 1973; Murray et aI. , 1964; Zuniga et aI., 1972). One suggested reason for the increase in walking width is prosthetic side hip abductor weakness, which would require greater lat eral stability (Jaegers et al., 1995; James & Oberg, 1973). Another possible explanation expands on the lateral stability concept. As with transtibial am putees, the COM of the transfemoral amputees may have a tendency to shift over the nonpros thetic limb, providing greater stability; therefore, the sound limb adducts. If the prosthetic limb were to follow the natural forward progression, the width of walking base would be more narrow, resulting in the prosthetic limb's having to exert greater mus cular stability as the COM moves laterally during prosthetic stance. If the prosthetic limb is slightly more abducted, a strut effect occurs during stance, requiring less muscular effort and greater lateral sta bility. Increased lateral bending of the trunk over the 0.26 (0.05) 105 (17) 0.20 (0.05) 106 (11) 0.22 (0.4) 106 (10) 0.20 0.15 99 prosthetic limb is a common gait deviation (Jae gers et al., 1995; James, 1973c; Klopsteg et al., 1968). James (1973c) noted that with a decrease i the width of the walking base, there is decreased lateral trunk bending. The assumption is that decreasing step width decreases the lateral displace ment in COM; consequently, less contractile effort would be necessary to control trunk movement. An other reason for lateral trunk bending over the prosthetic side is that the amputee is attempting to reduce weight-bearing directly over the prosthetic limb because of pain, instability, poor balance, or lack of trust in the prosthesis. • The inability of the prosthetic knee to flex during early stance results in an upward acceleration of the trunk as the body progresses over the prostheti limb toward mid-stance (Klopsteg et aI., 1968). The most Significant consequence is the loss of smooth progression of the vertical displacement of COM and, as a result, an increase in the metabolic cost of walking (Peizer et al., 1969). Because of the loss of musculoskeletal tissue, there is a loss of muscle strength and a greater difficulty in balanCing over the prosthesis. Balance problems and loss of strength are directly related to the length of the residual limb: amputees with shorter limbs experience greater difficulties than those with longer limbs (Jaegers et al., 1995; James, 1973a; James, 1973c; Ryser et aI., 1988). Consequently, transfemoral amputees compensate for the decreased ability to maintain Single-limb balance over the prosthesis by taking a shorter stride length with the sound limb, a faster prosthetiC step, or a lateral lean of the trunk over the prosthetic limb in an attempt to reduce weight bearing and main tain balance. • Lack of ankle plantar flexion in the prosthetic limb results in the amputee relying on the hip flexors to flex the hip and prosthetic knee during terminal stance. To flex the knee, a contraction of the hip greater than normal is required, and in addition, flexion must be initiated conSiderably earlier than normal (Hale, 1991; Klopsteg et al., 1968). How ever, most transfemoral amputees tend to flex the
- 225. - - ------ (Jaegers etaI., 1995). Additionally, medium- to short-limbed transfemoral amputees demonstrate faster transition from hip extension to hip flexion to assist in flexing the prosthetic knee (Jaegers et aI., 1995). Restoration of rotation of the pelvis in the transverse plane assists in passively flexing the knee (Inman et aI., 1981 ; Peizer et aI., 1969; Stokes et aI., 1989) and may eliminate the need to over compensate with the hip flexors. Unfortunately, many amputees lose pelvic rotation because they use their hip flexors to "kick" the prosthetic leg for ward. More time is spent on the anatomic heel-midfoot and midfoot-toe and less at midfoot than on the prosthetic side (Zuniga et aI., 1972). The loss of smooth transition and normal timing of weight transfer over the sound stance limb may be attrib uted to altered pelvic and hip mechanics of the prosthetic limb. Because the amputee typically at tempts to generate sufficient momentum to flex the prosthetic knee by "kicking" the prosthesis for ward, there is a tendency to keep the COM over the heel of the stance limb. The posterior rotation of the pelvis and the increased hip flexion on the prosthetic side do not permit the smooth transition of the COM from the heel to toe on the stance limb. Instead, the COM remains over the heel for a longer period of time as the swing limb recovers from the upward thrust initiated to propel the pros thetic limb forward. To make up for the increased time spent on the heel, there is a need for a rapid transition over the midfoot to get to the toe in time as the prosthetic limb descends during terminal swing and the sound limb prepares to leave the ground. Transfemoral amputees typically take a longer step with the prosthetic limb and demonstrate an increased stance time on the sound limb (James & Oberg, 1973; Murray et aI., 1981; Skinner and Effeney, 1985; Zuniga et aI., 1972). As previously discussed, the amputee has greater confidence during single-limb support over the sound limb and TA [~[ r: 1(l-4 over the prosthesis produces a shorter step le with the nonprosthetic limb. There is an increase in the double-support ph indicating a need for additional stability (Jaege aI., 1995; James & Oberg, 1973; Murray et 1981). To maintain balance, the amputee inc the period of double support before progressi to the next phase of Single-limb support. A slight increase in knee flexion on the nonpr thetic limb during stance may be present to as in absorbing increased ground reaction forces (Jaegers et aI. , 1995; James & Oberg, 1973) • As with transtibial amputees, in transfemoral tees Hungarford and Cockin (1975) found on graphs of the nonamputated limb hip greater dence of osteoporosis and joint space narrow than in nonamputee controls and an absence teophytes. Only 10 percent of 54 transfemor amputees had normal radiographs. Patellofem osteoarthritis in the sound limb was found to considerably higher in the amputees than in n amputees, with 63 percent of the transfemora putees, 41 percent of transtibial amputees, an only 22 percent of the control group demons positive findings. Transfemoral amputees have decreased velOC cadence as compared with transtibial ampute nonamputee ambulators (Godfrey et aI., 1975 James, 1973b; Murray et aI. , 1981; Waters e 1976) (Table 10-4; see also Table 10-2). Inte estingly, it has been suggested that walking sp not related to residual limb length (Jaegers et 1995). • The metabolic cost of ambulation for the transfemoral amputees is also greater than th for the transtibial amputees and nonamputee (Table 10-5). RedUCing the speed of ambulati assists in lowering the energy cost and heart r (Huang et aI., 1979; Waters et aI., 1976). Mo over, each of the previously described variatio from normal gait has some impact on the ove metabolic energy cost of walking. Therefore, TRANSFEMORAL AMPUTEE MEAN VELOCITY, CADENCE, AND STRIDE lENG11I Author Cause Velocity (mlmin(±J) Cadence (stepslmin(±J) Stride Length Murray et al. (1981) D Godfrey et al. (1975) D Waters et al. (1976) D Waters et al. (1976) T James (1973) T Jaegers et al. (1995) T D = DysvascuJar; T = traumatic. 60 (9.6) 52 36 (15) 52 (14) 59 (7) 60.6 (10.8) 97 84 72 (18) 87 (13) 88 (5) 89.4 (9) 136 (0.15) 1.21 1.00 (0.20) 1.2 (0.18) 1.34 (0 14) 1.33 (0.16) - ~ ~ -.:" . -
- 226. 204 tJNIT TWO-COMPONENTASSESSMENTS OF THE ADULT TABLE 10 S TRANSFEMORAL AMPUTEE METABOUC COST OF AMBUIATION Rate of Oxygen Uptake Net Oxygen Cost Author Type (mllkglmin (±)) (mlIkglm (±)) Heart Rate (beats/min (± Waters et al. (1976) D 12.6 (2.9) Waters et al. (1976) T 12.9 (3.4) Huang et al. (1979) T 12.6 Waters et al. (1988) N 12.1 D = Dysvascular; N = nonamputee; T = traumatic. need for reducing the extent of the deviations becomes paramount during the gait training and prosthetic fitting process. Comprehension of the principles of gait permits the clinician to have greater insight into the variance that exists between normal and prosthetic gait, as well as the differ ences within the various levels of amputation. Moreover, once the cause of the deviation is identified, an appropriate treatment plan may be designed to address the specific needs of the individual. If the amputee lacks the physical strength, balance, or gait biomechanics to walk correctly, then these issues may be addressed. Conversely, if the prosthesis is at fault and requires an alignment adjustment or modification, then the necessary prosthetic action may be taken. CRITICAL ELEMENTS OF GAIT WITH RESPECT 10 LEVEL OF AMPUTATION AND PROSTHESIS The causes for amputation in North America can be divided into four categories; however, estimate.s on the percentages do vary. Approximately 70 to 90 percent are the result of vascular disease, less than 20 percent are for traumatic reasons, approximately 4 percent are because of tumor, and 4 percent are congenital (Glattly, 1963; Glattly, 1964; Kerstein, 1974; Sanders, 1986; Tooms, 1980). During the period leading to amputation, there frequently exist secondary complications that could affect gait or function. Amputees with vascular disease commonly have problems associated with diabetes, heart disease, and other debilitating diagnoses. Traumatic amputees present with fractures, soft tissue injuries, or neuromuscular impair ments associated with the accident. Congenital amputees may have more than one extremity involved or associated neuromuscular complications. Age can influence the amputee's ability to ambulate with a prosthesis, just as age influences the gait of nonamputee ambulators. This is not to say that age alone dictates the amputee's capabilities. On the contrary, level of activity prior to amputation has a greater influence on the reha 0.35 (0.06) 126 (17) 0.25 (0.05) 111 (12) 0.28 0.15 99 bilitation outcome than age, level of amputation, number of limbs involved (Brodzka et aI., 1990; Chan Tan, 1990; Medhat et aI., 1990; Nissen & Newm 1992; Pinzur et aI. , 1992; Walker et aI., 1994). The level of amputation can have a Significant impact the amputee's ability to adjust to learning to ambulate w the prosthesis. There are several individual factors t must be considered when determining the expected gait a particular level of amputation. The inability to adequat master anyone of these contributing factors can prevent amputee from reaching an optimal level of gait. Yet, amputee with a high-level amputation who goes on master each of the components of gait can achieve higher-quality gait than an amputee with presuma greater potential who does not learn to walk properly fo multitude of reasons (Medhat et aI., 1990; Pinzur et 1992). The following is a summary of the influenc elements associated with the level of amputation a prosthetic componentry. A brief statement of each e ment is followed by a sample question the clinician m want to consider when assessing the amputee. The degree of displacement of the COM over the BOS in all three planes of movement. Maintainin normal displacement of COM over BOS optimize anatomic movement and metabolic cost of gait. Any alteration of COM displacement results in compensatory movements and increased metabol cost (Engsberg et aI., 1992; Peizer et aI., 1969; Saunders et aI. , 1953). Can the amputee maintain the expected displa ment of the COM over the BOS without compen satory movements such as unequal stance time, increased lateral trunk leaning, or decreased arm swing? Asymmetry of motion secondary to an imbalance the muscle groups between the lower extremities (Breakly, 1976; Engsberg et aI., 1992). Frequent muscle groups become abnormally hyperactive during the gait cycle as a compensatory mechani or to provide a sense of security to the amputee (Gitter et aI. , 1991 ; Winter & Sienko, 1988). Can muscle of the residual limb be reeducated prevent unwarranted hyperactivity during certain phases and to create a smooth progression of the
- 227. --- trunk, and arms? Diminishedcoordinated movement between the re maining anatomic joints secondary to the loss of proprioceptive feedback and absence of muscu lature on the prosthetic side (Mensch & Ellis, 1986; Skinner & Effeney, 1985; Waters et al., 1976). Can the amputee move the prosthetic foot/ankle assembly, knee, and hip joint fluidly and effiCiently with the remaining musculature and without proprioceptive feedback from the absent jOints? • The loss of the normal biomechanics of the ana tomic ankle and foot and the inability of the pros thesis to simulate specific movements. This would include the loss of not only muscle and joints but also their roles in gait, such as propelling the body forward during late stance or functioning as shock absorbers (Fisher & GoUickson, 1978; Radcliffe, 1962). Will the amputee be able to compensate for this loss physically or with a prosthetiC device? • Anatomic limitations of the residual limb or physi ologic requirements result in a compromise in prosthetiC design or alignment. The effect of the prosthetiC design on the mechanics of gait may cause the amputee to deviate from a normal gait pattern (Murphy & Wilson, 1962; Radcliffe, 1955; Radcliffe, 1957; Radcliffe, 1961; Radcliffe, 1962). Will the compensations made in prosthetic de sign because of predisposing physical abnormalities significantly affect the overall gait pattern? The kinetic energy normally stored as potentiallen ergy in the anatomic limb during gait is absent (Ganguli et al., 1973; Gitter et ai., 1991; Yoshihiro et a!., 1993). The prosthetic limb offers limited ki netic energy return. More dynamic prosthetiC components available today offer some mechanical potential energy storage; however, this varies tre mendously between components, amputees, and a variety of other conditions. Does the amputee have the ability to produce or receive maximum benefit from the kinetic energy return stored within the prosthetiC limb? • The loss of the skeletal lever arm. The proximal muscle groups acting on the remaining bone must overcome a longer lever arm to control the entire lower extremity during the gait sequence (Ganguli et al., 1973; James, 1973c; Mensch & Ellis, 1986). Does the amputee have the ability to sufficiently control the prostheSis with the remaining bone length? • The loss of contractile tissue results in diminished potential strength (Ganguli et ai., 1973; James, 1973c; Mensch & Ellis, 1986; Winter & Sienko, 1988). The changes in insertions of the remaining musculature are altered, consequently changing Will the amputee be able to maximize the u of the remaining muscles that may have been altered in length, length-tension relationship, by surgical technique? • The potential increase in body temperature se ary to loss of skin surface area disrupts the bo natural homeostasis. This leads to an overall increase in metabolic cost during all activities (Levy, 1983; Mensch & Ellis, 1986). Will the amputee reach a level of cardiopulm nary fitness to overcome the physiologic defic minimize the metabolic cost of ambulation? The amputee's gait can vary significantly depend the cause of amputation, associated diagnoses, a level of amputation and the critical elements asso with each level of amputation. Because there are so variables regarding amputee gait, it is difficult to i one particular pattern that can be associated w particular "type" of amputee. It is for this reaso normal gait may be used as the gold standard for al of amputation, realizing that in the majority of amp predisposing factors beyond their control limit their to obtain a "normal" gait pattern. FUNCTIONAL GAIT ASSESSMENT OF THE AMPUTEE Because amputee gait is complex and there are so critical elements, the idea of observing an amputee and simply identifying one or two causes for a par deviation may result in a misdiagnosis or inco assessment. Therefore, it may be worth the eval time to perform a more in-depth assessment in an a to gain greater insight into the ';big picture. " Ambulation profiles are defined as clinical te locomotion skill (Craik & Oatis, 1995; Reimers, Wolf, 1979) or as quantitative methods of ass ambulatory function (Craik & Oatis, 1995; Olney 1979; Wolf, 1979). The information obtained from tests can provide a more global view of the patient's to maintain standing balance, negotiate turns, an from a chair,and, in some cases, of physiologic factor as decreased cardiorespiratory or muscular endu Used along with a standard gait evaluation, the ambu profile tests can determine how a patient walks and functional limitations may prevent him or her from ing an optimal level of gait. The clinical adminis requires only an assessment form, walkway, sta rehabilitation equipment, and minimal time and Moreover, interrater reliability for ambulation profil generally is good. Currently, no one assessment too to evaluate the amputee's locomotive function. Ho - - - = - -
- 228. 206 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT in keeping with the concept OJ an ambulation profile or comprehensive evaluation of gait in terms of function, the reader is referred to Nelson (1974), Tinetti (1986), and Olney and associates (1979) for a comprehensive descrip tion of selected assessment tools. Although these evalua tive tools were not specifically designed for the amputee and to date no data exist to demonstrate the validity of administering these tests to amputees, these tests appear to readily lend themselves to this population. TEMPOROSPATIAL OBJECTIVE MEASURES Optimal walk is defined as a walk of such speed and step frequency that the energy expenditure per meter walked is minimal (Zatsiorsky et a!., 1994). When given the oppor tunity to choose a particular step frequency or cadence, people choose a speed that is most comfortable for them (Inman et aI., 1981). Many amputees tend to adopt a gait pattern that has been described as asymmetric and slower than that of nonamputee ambulators. As the level of amputation increases, symmetry and velocity decrease. This is not to suggest that increased asymmetry is indicative of an optimal gait for the amputee; however, the evaluator must be aware of the common patterns of gait observed in amputees. The classic combination of events that compose the asymmetry in gait include the following: Decreased stance time on the prosthetic 6mb. resulting in a faster, shorter step with the sound limb, with an increase in Jateralleal1ing of the trunk over the prosthetic stance limb to decrease weight-bearing into the prosthesis. Increased stride length with the prosthetic 6mb as a compensation for the shorter stride with the sound limb. The amputee attempts to maintain walk ing velocity by taking a longer stride with the pros thetic limb since maintaining sufficient stance time on the sound limb is possible. Altered stride width in an attempt to maintain the body's center of gravity (COG) over a stable BOS the amputee brings the sound limb to midline, more directly under the COG. Therefore, the sound limb becomes the primary BOS, having earned the am putee's trust as the more stable limb. To maintain some distance between the limbs, the prosthetic limb abducts slightly and acts as a strut or post over which the amputee advances during the prosthetic stance phase. Reduced velocity can be attributed to several factors including, but not limited to, cause of amputation, ability to use the prosthesis, gait deviations, neuro muscular, skeletal, or cardiopulmonary limitations or pathology, general physical conditioning, and aerobic endurance. TEMPOROSPATIAL ASSESSMENT Objective measures of temporospatial gait charac istics can assist in documenting improvement in training or help to detect when there is a loss of qua of gait. Typically, temporospatial information is relati easy to collect. Clinically feasible methods to objecti measure the temporospatial characteristics of a subje gait can be used with inexpensive equipment. Sim items such as a stopwatch and a tape measure, mask tape to create a floor grid to measure length and w of stride, a number grid, powder or ink on the shoe mark foot placement, or special paper designed to m each step can be used to assist in the assessment of amputee's walking pattern. Velocity is easily measured by determining the tim cover a distance. As the amputee walks, the time to wa given distance is measured with a stopwatch and divided the total distance walked. Cadence is obtained by coun the number of steps taken per minute. Step length width are measured after the amputee walks on a grid the foot placement marked by an agent such as powde ink. Robinson and Smidt (1981) describe a method which the therapist walks behind the subject and reco into an audio tape recorder each foot placement o numbered grid. FUNCTIONAL SCALES Several authors have attempted to classify an amput functional ability by categorizing his or her abilities (K et a!. , 1978; Medicare Region C Durable Medical Eq ment Regional Carrier, 1995; Volpicelli et aI., 1983). focus of these scales is the ability to ambulate, the assis device required for locomotion, and the environment the patient is capable of negotiating. The merit of th scales is that allied health professionals familiar with description of classes within the functional scale system readily assume the functional level of the amputee ide fied with a particular functional level. As with any labe system, there is a danger of forgetting that performa can improve or diminish and that reassessment on a reg basis is always a good idea. The Functional Scale (Table 10-6) has been adop by Medicare and the division of Durable Medical Eq ment Regional Carriers (DMERC) (Medicare Region Durable Medical Equipment Regional Carrier, 1995 the indicator to determine what prosthetic compone an amputee functioning at a particular level is quali to receive. There is a strong possibility that most eld amputees' rehabilitation potential will be assessed p to initial prosthetic fitting, and they will be assigne classification level.
- 229. DURABl£ MEDICAL EQUIPMENT REGIONALCARRIER AMPUTEE FUNC'nON lEVELS Level 0 Does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility. Levell Has the ability or potential to use a prosthesis for transfers or ambulation in level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2 Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator. Level 3 Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational. therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Level 4 Has the ability or potential for prosthetic ambula tion that exceeds basic ambulation skills, exhibit ing high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. From Medicare Region C Durable Medical Equipment Regional Carrier. (1995). Supplier Update Workshops. Winter. .1 GAIT ASSESSMENT OF THE AMPUTEE The most common variables described in gait are the joint angles or the kinematic events. Knowing the accept able joint angles in relation to the appropriate phase of the gait cycle allows the evaluator to assess the quality of a particular individual's gait. If the joint angles do not fall within the established norms or fall out of expected phase of gait, then that deviation from "normal" gait must be identified and recorded. However, identifying abnormal temporal or kinematic patterns does not yield enough information to distinguish the cause of the deviation. For example, the joints of the lower limb and trunk of two different subjects may have near identical joint angles at a particular phase of gait. Yet the joint moment of force and musculoskeletal forces or mechanical power acting on each limb may be very different. Therefore, the forces that cause motion are the cause, and the kinematic and temporal events observed by the clinician become the result. Winter (1985) puts forth additional difficulties in identi fying the forces and EMG events that are acting on the limb. Two other problems face clinicians. First is indeterminacy (Seireg & Arvikar, 1975), or the fact that biomechanists do not have equations for all of the unknowns acting on a limb. Second, there is not a unique solution to the equation for moments of force at the ankle, knee, and hip (Winter, 1985). In other words, just because the knee and ankle angles are similar does not mean that the muscle patterns are the same (Winter, 1985). In most cases, a biomechanist with a full compliment of kinetic and EMG data will derive the most complete biomechanics laboratory will not m absolute statements concerning various events during Moreover, clinicians performing observational gait as ments should proceed with even greater caution an aware that there could exist multiple reasons for w single event occurred. Observational gait analysis (OGA) is often viewed a most practical of assessment tools for the amputee d the gait training process. Although there appears to be moderate reliability with OGA or videotaped OGA, t currently the most pragmatic method for clinicians. Fr by-frame slow-motion video analysis has improved observer's ability to be consistent in gait assess (Eastlack et aI. , 1991; Krebs et aI. , 1985). With the ad of personal computers and advanced video display pabilities, relatively inexpensive computer systems offer a future of on-screen measurements providing matic and temporospatial information that may be o tively measured. Gait analysis has proven to be a usefu for the study of prosthetiCS and amputee gait (Harris Wertsch, 1994).The use of OGA in the clinic, while no most reliable, is the most sensible because aU it requi simple observation of a subject's gait without the use o equipment. Because the exact cause cannot alway correctly identified immediately owing to the absen measurable kinetic, EMG, and kinematic data, an ap priate method of assessment would include a system evaluation of the subject's gait. Observational gait analysis is best done by systemat concentrating on one body segment and then ano Perry's (1992) description of a well-organized meth gait evaluation permits clinicians to use a problem-so approach to assess gait. The use of an itemized form assist the clinician with identifying the presence, abse or alteration of important events throughout the gait (Observational Gait Analysis, 1993; Winter, 1985). ther application of reference materials aids in the ide cation of the underlying cause of the pathologic associated with commonly observed combinations o deviations. Limitations of OGA include identificatio multiple events occurring at multiple body segments currently or Simultaneously (Saleh & Murdoch, 19 Gage and Qunpuu (1989) have illustrated that e occurring faster than 1112 of a second (83 msec) cann perceived by the human eye. As a result, the Rancho Amigos Medical Center staff recognizes that the tradit eight phases of gait may be an inappropriate metho analysis. Therefore, their gait assessment chart has further simplified into the three basic tasks of gait: w acceptance (initial contact to loading response), single support (mid-stance to terminal stance), and limb adv ment (preswing to terminal swing) (Perry, 1992). As with any evaluative procedure, once the cause fo gait deviation has been identified, it must be appropri treated. The degree to which the deviation is decreas
- 230. 208 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT GAIT ANALYSIS: FULL BODY Rancho Los Amigos Medical Center, Physical Therapy Department Reference Limb: LD RD A~! ~JlA r I i( ltlI IMajor deviation r- Minor deviation Weight Single-Limb Swing Limb Accept Support Advancement [C LR MSt TSt PSw ISw MSw TSw Trunk Lean: B/F Latera[ lean: RlL Rotates: B/F Pelvis Hikes Ti[t: PIA Lacks forward rotation Lacks backward rotation Excess forward rotation Excess backward rotation Ipsilateral drop Contralateral drop 1---+----+---1----1---1---1----+----11 Acceptance Hip F[exion: limited excess Inadequate extension Past retract Rotation: [RiER Ad/Abduction: Ad/Ab 1---r---I----r---I----r---r- +----~ISupport----- Knee F[exion: limited excess Inadequate extension Wobbles Hyperextends Extension thrust Varus/valgus: VrN[ Excess contralateral flex 1---1-------1------+------+------+------+------+------11 Advancement Ankle Forefoot contact Foot-f[at contact Foot slap Excess plantar flexion Excess dorsiflexion Inversion/eversion: Iv/Ev Heel off No heel off !Drag Contralateral' vaulting I I ~--~----~-----+----~r-----t----II----_t----~IName Toes Up Inadequate extension Clawed D ! MAJOR PROBLEMS: Weight Single-Limb Swing Limb IExcessive UE Weight Bearing D Diagnosis © 1991 LARE[, Rancho Los Amigos Medical Center, Downey, CA 90242 FIGURE 10-1. Form for ful[-body gait analysis. (Courtesy of Rancho Los Amigos Medica[ Center, Physical Therapy Department.)
- 231. Sagittal Weight Single-Limb ViewAcceptance Support Swing Foot/Ankle foot flat vaulting (excessive plantarflexion) foot slap increased dorsiflexion external rotation Knee hyperextension decreased knee flexion increased flex (excessive he increased flexion or terminal impa (knee instability) Hip flexed Pelvis posterior rotation posterior rota anterior rotation Trunk lordosis flexed Arm Swing uneven uneven decreased decreased Stride Length increased decreased Stance Time increased decreased Toe Clearance increased decreased Anterior! Weight Single-Limb Posterior View Acceptance Support Swing Foot/Ankle external rotation walking on lateral border of foot I walking on medial border of foot Knee valgus medial whip varus lateral whip Hip abducted adducted circumduction Pelvis pelvic drop off pelvic rise Trunk lateral bending Arm Swing uneven uneven decreased decreased Stride Width IIncreased increased decreased decreased FIGURE 10-2_ Prosthetic obser vational gait assessment form. (From Gailey, R. S. (1996) One step ahead: An in tegrated ap proach to lower extremity pros thetics and amputee rehabilita tion. Miami, FL: Advanced Reha bilitation Therapy.) eliminated depends on whether the assessment was correct and the treatment appropriate and on the patient's ability to respond to the treatment. Consequently, there is a need for a confirmation of the original diagnosis, reassessment of the current treatment plan, and an appraisal for future treatment plans. The process of reassessment must be performed whether an elaborate motion analysis, EMG, and ground force gait evaluation are performed or if the therapist used OGA to evaluate and prepare the rehabili tation treatment. PROSTHETIC OBSERVATIONAL GAIT ASSESSMENT Assessment of the amputee's gait does not differ from the evaluation of any other patient diagnosis. A form such as Rancho Los Amigos Medical Center's Full Body Evalu ation (Fig. 10-1) is an excellent tool to assist the ev in systematically identifying the minor and major tions that occur during each phase of gait. The ev must then determine the cause of the deviation{s general categories-{I) impaired motor control, (2) mal joint range of motion, (3) impaired sensation (in balance), and (4) pain (Observational Gait A 1993)-are potential amputee causes, while on tional category-(5) prosthetic causes-must be in for amputee assessment. It should be emphasize there are four major categories for potential cause deviations that are amputee related and one that i thetic related. This is an important note because t quently the prosthesis is distinguished as being for the amputee's gait deviations. When attempts to the prosthesis are performed and the deviation p becomes worse, or is replaced by another deviation cians may want to further explore the potential am causes rather than persisting in modifying the pros
- 232. 210 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT The Prosthetic Observational Gait Assessment Form (POGA) (Fig. 10-2) and the corresponding Prosthetic Gait Deviation Identification Charts (Tables 10-7 and 10-8) are designed to simplify the process of identifying a gait deviation and determining the cause of the deviation (Gailey, 1996). The assessment form lists the most com- TABLE 10- 7 mon deviations observed with all levels of lower extremi amputees, and the corresponding Gait Assessment Char suggest the possible causes for the observed gait devi tions. To use the assessment system, the evaluator systemat cally observes the various body segments from the groun TRANSnBlAL AMPUTEE PROSTHETIC GAIT DEVIATION IDENTIFICATION CHART Gait Deviation Prosthetic Cause Amputee Cause Weight Acceptance (Initial Contact to Loading Response) Foot flat 1. Flexed socket> 5°-15° 1. Knee flexion contracture 2. Foot is dorsiflexed 2. Weak quadriceps 3. Poor balance or proprioception 4. Lack of confidence Foot slap 1. Too soft a heel cushion or plantar flexion 1. Too-forceful driving of prosthesis into bumper ground to ensure knee stability 2. Too Iowa heel cushion 3. Too short a heel lever External rotation of the prosthesis 1. Too hard or too high a heel cushion 1. Poor pelvic control 2. Too much toe-out 2. Weak internal rotators 3. Suspension too loose 3. Striking the ground with excessive force Increased flexion of the knee 1. Too hard or too high a heel cushion 1. Knee flexion contracture 2. Socket set too far anterior to foot 2. Weak quadriceps 3. Too long a heel lever 4. Flexed socket> 5°-15° 5. Foot is dorsifllexed 6. Suspension too loose 7. Prosthesis too long Hyperextension of the knee 1. Too soft or too Iowa heel cushion 1. Weak quadriceps 2. Too short a heel lever 2. Excessive extensor force 3. Socket set too far posterior to foot 4. Insufficient socket flexion 5. Foot is plantar flexed 6. Suspension too tight 7. Prosthesis too short Single-Limb Support Phase (Mid-Stance to Terminal Stance) Walking on the lateral border of 1. Abducted socket the foot 2. Laterally leaning pylon 3. Inverted foot Walking on the medial border of 1. Adducted socket the foot 2. Medially leaning pylon 3. Everted foot Increased dorsiflexion 1. Foot too dorsiflexed 2. Insufficient socket flexion Decreased knee flexion 1. Socket set too posterior to foot 1. Poor pelvic control 2. Posterior leaning pylon (socket in too 2. Weak knee flexors much extension, foot too plantar flexed) 3. Too-hard dorsiflexion bumper 4. Restrictive suspension Valgus moment at the knee 1. Outset foot 1. Short residual limb 2. Excesive medial tilt of socket 2. Ligament laxity 3. Pain over fibular head 4. Too loose a socket or not enough socks Varus moment at the knee 1. Inset foot 1. Short residual limb 2. Excessive lateral tilt of socket 2. Ligament laxity 3. Too loose a socket or not enough socks Abducted gait 1. Prosthesis too long 1. Poor balance 2. Outset foot 2. Adducted sound limb 3. Habit Pelvic drop off 1. Toe lever too short 2. Excessive knee flexion 3. Foot too dorsiflexed 4. Socket set too anterior to foot
- 233. TRANSTIBIAL AMPUTEE PROSTHETICGAIT DEVIATION IDENTIFICATION CHART Continu Gait Deviation Prosthetic Cause Amputee Cause Single-Limb Support Phase (Mid-Stance to Terminal Stance) Continued Pelvic posterior rotation Lateral bending of the trunk 1. Pylon too short toward the prosthetic side 2. Outset foot 3. Prosthetic pain Decreased stance time 1. Pain from socket Increased stride width 1. Prosthesis too long 2. Outset foot Decreased stride width Swing Phase (Preswing to Terminal Swing) 1. Inadequate transverse pelvic rotatio 1. Inability to balance over prostheSis 2. Inability to fully bear weight in pros 3. Muscle weakness (hip abduction) 4. Pain 5. Habit 1. Inadequate weight-bearing 2. Poor balance 3. Insecurity 1. Poor balance 2. Abducted prosthetic limb 3. Habit 1. Adducted sound limb Pelvic rise 1. Posterior leaning pylon 1. Poor pelvic control 2. Toe lever too long 2. Insufficient knee or hip flexion 3. Insufficient socket flexion 4. Prosthesis too long Decreased stride length on pros 1. Anterior leaning pylon 1. Pain in the sound limb thetic side 2. Prosthesis too short 2. Hip flexion contracture on sound si 3. Inadequate suspension 3. Knee flexion contracture on prosth side Increased stride length on pros 1. Painful socket 1. Compensation for decreased stride thetic side 2. Prosthesis too long sound limb 2. Insecurity during prosthetic stance 3. Hip flexion contracture on prosthet 4. Knee flexion contracture on sound Decreased toe clearance 1. Prosthesis too long 1. Improperly donned prosthesis 2. Pistoning (inadequate suspension, insuffi 2. Muscle atrophy cient socks, socket too large) 3. Loss of weight 4. Weak hip or knee flexors Increased toe clearance 1. Excessive hip or knee flexion 2. Vaulting Lateral whip 1. Internally rotated socket 1. Improperly donned prosthesis 2. Inadequate suspension Medial whip 1. Externally rotated socket 1. Improperly donned prostheSis 2. Inadequate suspension Sound limb and Arm Swing Adducted limb 1. Uses sound limb as principal base o support Vaulting 1. Prosthesis too long 1. Habit 2. Inadequate suspension Uneven arm swing 1. Poorly fitted socket causing pain or insta 1. Poor balance bility 2. Fear and insecurity 3. Habit Extended rotation 1. Poor balance 2. Fear and insecurity 3. Habit Increased stance time 1. Poor balance 2. Fear and insecurity 3. Habit From Gailey, RS.(1996). One step ahead: An integrated approach to lower extremity prosthetics and amputee rehabilitation. Miami, FL: A Rehabilitation Therapy. up as the amputee walks. Each of the three general phases ing the evaluation. Without the necessary informatio of gait-weight acceptance, single-limb support, and both planes, deviations may be missed or misinter SWing-should be partitioned in the observer's mind to Interestingly, Krebs and coworkers (1985) found assist in isolating the deviation. Finally, the evaluator must reliability with sagittal view assessment, whereas E consider both the sagittal and frontal views when perform- and colleagues (1991) found that frontal plane asse
- 234. 212 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT TAI3LE lOS TRANSFEMORAL AMPUTEE PROSTHETIC GAIT DEVIADON IDENTIFICADON CHART Gait Deviation Prosthetic Cause Amputee Cause Weight Acceptance Phase (Initial Contact to Loading Response) External rotation of the prosthesis 1. Anterior or medial brim pressure 2. Too-stiff heel cushion or plantar flexion bumper 3. Too long a heel lever 4. Too much built-in toe-out Knee flexion or instability 1. Knee axis too far ahead of TKA line 2. Insufficient socket flexion 3. Too-long heel lever arm 4. Too-stiff heel cushion or plantar flexion bumper 5. Too much dorsiflexion Foot slap 1. Too-soft heel cushion or plantar flexion bumper 2. Too short a heel lever Single-Limb Support (Mid-Stance to Terminal Stance) 1. Extension force too great 2. Poor residual limb muscle control 3. Improperly donned prosthesis 1. Weak hip extensors 2. Severe hip flexion contracture 3. Altered height of shoes 1. Too-forceful driving of prosthesis to the ground ensuring knee stability 1. Abduction contracture 2. Fear or habit 1. Weak gluteus medius stance limb 2. Poor balance 1. Inadequate transverse pelvic rotation 2. Weak hip abductors 3. Abduction contracture 4. Painful residual limb 5. Very short residual limb 6. Inability to weight-bear 7. Habit or fear 1. Tight hip flexors 2. Weak hip extensors 3. Weak abdominals 4. Habit 1. Flexion contracture 2. Poor proprioception 3. Habit 1. Inadequate weight-bearing 2. Poor balance 3. Insecurity 1. Poor balance 2. Abduction contracture 3. Adducted sound limb 4. Habit Abducted gait Pelvic lateral tilt Pelvic drop off (during late stance on the prosthetic side) Pelvic posterior rotation Lateral bending of trunk Trunk lordosis Trunk flexion Decreased stance time Increased stride width 1. Prosthesis too long 2. Too-high medial wall 3. Improper relief for distal femur on lateral wall 4. Foot too much outset 1. Inadequate adduction of the socket 1. Toe lever too short 2. Anterior leaning pylon foot too dorsi flexed 3. Socket set too anterior to foot 1. Inadequate adduction of the socket 2. Prosthesis too short 3. Too-high medial wall causing pain 4. Outset foot 1. Insufficient socket flexion 2. Posterior wall promotes anterior pelvic tilt 1. Too much socket flexion 1. Pain from socket 1. Prosthesis too long 2. Outset foot 3. Socket too abducted 4. Medial wall pressure 5. Medial-leaning pylon Swing Phase (Preswing to Terminal Swing) Increased knee flexion (excessive heel rise) Increased knee extension (terminal impact) Medial whip 1. Insufficient knee friction 1. Insufficient knee friction 1. Excessive external rotation 2. Too-tight socket 3. Excessive valgus of prosthetic knee 4. Scilesian belt too tight laterally 1. Too-strong hip flexion 1. TOO-Vigorous hip flexion followed by strong hip extension 2. Security to ensure knee extension l. Improper donning of prosthesis 2. Excessive adipose tissue with poor muscl control
- 235. TRANSFEMORALAMPUI'EE PROS11lETIC GAITDEVIATION IDENTIFICATION CHART Conti Gait Deviation Prosthetic Cause Amputee Cause Swing Phase (Preswing to Terminal Swing) Continued Lateral whip 1. Excessive internal rotation 1. Improper donning of prosthesis 2. Too-tight socket 2. Excessive adipose tissue with poor 3. Excessive valgus of prosthetic knee control Circumduction 1. Too-long prosthesis 1. Abduction contracture 2. Too~thick medial brim 2. Insecurity regarding knee control 3. Too much knee stability (alignment or resistance 4. Improperly aligned pelvic band Pelvic rise 1. Too-long toe lever arm 2. Too much knee stability (alignment or resistance) Pelvic posterior rotation 1. Inadequate transverse pelvic rotatio Decreased stride length on pros 1. Anterior-leaning pylon 1. Pain in the sound limb thetic side 2. Prosthesis too short 2. Hip flexion contracture on sound s 3. Inadequate suspension Increased stride length on pros 1. Painful socket 1. Compensation for decreased stride thetic side 2. Prosthesis too long sound limb 2. Insecurity during prosthetic stance 3. Hip flexion contracture on prosthet 4. Knee flexion contracture on sound Decreased toe clearance 1. Prosthesis too long 1. Loss of weight 2. Pistoning (inadequate suspension, insuffi 2. Muscle atrophy cient socks, socket too large) 3. Improperly donned prosthesis 3. Prosthesis too long 4. Weak hip or knee flexors Increased toe clearance 1. Insufficient knee friction 1. Excessive hip flexion 2. Vaulting Sound Limb and Arm Swing Adducted limb 1. Uses sound limb as principal base o support Vaulting 1. Too-long prosthesis 1. Limb not properly down in socket 2. Too much knee friction leading 2. Fear of stubbing prosthetic toe or o 3. Excessive built-in knee stability; knee jOint knee control too far posterior to TKA line 3. Weak hip flexors 4. Habit Uneven arm swing 1. Poorly fitted socket causing pain or insta 1. Poor balance bility 2. Fear and insecurity 3. Habit Unequal step length 1. Improperly fitted socket causing pain 1. Fear and insecurity 2. Unaccommodated hip flexion contracture 2. Poor balance 3. Weak residual limb musculature Increased stance time 1. Poor balance 2. Fear and insecurity 3. Habit From Gailey, R. S. (1996).One step ahead: an integrated approach to lower extremity prosthetics and amputee rehabilitation. Miami, FL: A Rehabilitation Therapy. was more reliable when performing OGA Clinically, however, the evaluator should observe from both planes and in many cases must be aware of the amputee's endurance level to ensure that an accurate picture of the walking pattern can be observed before fatigue becomes a factor. Once the gait deviation(s) have been identified by using the POGA form, the cause for the gait deviation should be confirmed by using the Prosthetic Gait Deviation Identifi cation Chart. The evaluator must determine if the deviation is related to physical or prosthetic causes. The potential amputee and prosthetic causes for gait deviations most commonly observed for transtibial and transfemo putees are listed in the Prosthetic Gait Assessment Other excellent resources offer a more complete li potential deviations, many of which are rarel (Bowker & Michael, 1992; Lower-Limb Pros 1980; Mensch & Ellis, 1986; Sanders, 1986). To confirm the assessment, the evaluator may w attempt to correct the deviation by instructing the am on how to physically overcome the impairment o the appropriate prosthetic adjustment. Unfortu when it comes to physical limitation, it is not possible to correct the deviation immediately. In
- 236. 214 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT cases, because of physical deconditioning, diagnosis, or other impairment, the amputee might have to adopt a less than satisfactory gait pattern. However, it is important to note that prosthetic componentry and gait training meth ods introduced over the last decade have offered many fit and motivated amputees the ability to learn how to walk with barely a detectable gait deviation. CONCLUSIONS The assessment of the amputee's gait can be a complex task when all the potential causes leading to a less than optimal gait pattern are considered. However, if a system atic approach to the evaluation process is employed, taking into account both the functional aspects of gait and the observable gait deviations, the reasons for an unfavorable gait pattern often become more clear. The clinician will find that regular assessments throughout the rehabilitation period not only assist in monitoring the progress of the amputee during the rehabilitation process but also aid in the design and modification of the treatment program. G~[_OSSA ·R·Y Base of support (BOS)-The area of the body in contact with a resistive surface that exerts a reaction force against the body. Cadence-The number of steps per minute. Center of mass (COM)*- The point on a body that moves in the same way that a particle subject to the same external forces would move. Displacement*-The change in body position. Kinematic*-Describing motion. Kinetics*-The study of forces that cause motion. Oxygen cost-The amount of oxygen used per me ter walked (milliliters/kilogram of body weight/meter walked). Single-limb supportt-Total weight-bearing on one lower extremity. Stride length-The measurement from one initial con tact to the ipsilateral initial contact. Stride width-A measurement of distance from medial point of contact from the right metatarsal head to that of the left. Swingt-The period in the gait cycle when the foot is not in contact with the floor. 'From Rodgers, M. M., & Cavanagh, P. R (1984). Glossary of biomechanical terms, concepts, and units. Physical Therapy, 64(12) tFrom Perry, J. (1992). Gait analysis: Normal and pathological function. Thorofare, NJ: Slack, Inc. Temporospatial- The relationship of time and spac Transfemoral amputee-A person with an ampu tion site through the femur bone (above-knee ampute Transtibial amputee-A person with an amputati site through the tibial/fibula bone. The site must be abo the malleoli but not past the knee joint (below-kn amputee). Weight acceptancef- The initial period in the g cycle when body weight is dropped onto the limb. T phases of initial contact and loading response are involve REFERE~ICES Bowker. J. H. , & Michael, J. W. (1992). Atlas of limb prosthetics (2 ed.). SI. 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- 238. 216 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT problems in elderly patients. Journal of the American Geriatrics Society, 34(2}, 119-126. Tooms, R. E. (1980). Incidence of amputation. In A. Edmonson & A. H . Greenshaw (Eds.), Campbell's Operative Orthopedics (6th ed.). Vol. 1. St. Louis. MO: C. V. Mosby. Volpicelli, L. J., Chambers, R. B , Wagner, F. w., et al. (1983). Am bulation levels of bilateral lower-extremity amputees. J Bone Joint Surg 65A(5}, 599-605. Walker, C. R C. , Ingram. M. G., Hullen, M. G, et al. (1994). Lower limb amputation following injury: A survey of long-term functional outcome. Injury, 25, 387- 392. Waters, R L. , Lunsford, B. R, Perry, J., et al. (1988). Energy-speed relation of walking: Standard tables. Journal of Orthopedic Research, 6,215-222. Waters, R L. , Perry, J., Antonelli, D., et al. (1976). Energy cost of amputees: The influence of level of amputation. Journal of Bone and Joint Surgery, 58A(1}, 42-46. Winter, D. A. (1985). Concerning the scientific basis for the diagnosis of pathological gait and for rehabilitation protocols. Physiotherap Callada, 37(4}, 245-252. Winter, D. A. (1984). Kinematic and kinetic patterns in human gait Variability and compensating effects. Human Movement Science, 3 51-76. Winter, D. A., & Sienko, S. E. (1988). Biomechanics of below-kne amputee gait. Journal of Biomechanics, 21(5), 361-367. Wolf, S. L. (1979). A method for quantifying ambulatory activities PhYSical Therapy, 59, 767-768. Yoshihiro E., Masatoshi, B., Nomura, S., Kunimi, Y, & Takahashi, S (1993). Energy storing property of so-called energy-storing prostheti feet. Archives of Physical Medicine and Rehabilitation, 74,68-72 Zatsiorsky, V. M., Werner, S. L. , & Kaimin, M. A. (1994). Basi kinematics of walking: Step length and step frequency. A review Journal of Sports Medicine and Physical Fitness, 34(2), 109-134 Zuniga, E. N., Leavitt, L. A., Calvert, J. c., et al. (1972). Gait patterns i above-knee amputees. Archives of Physical Medicine and Rehabili tation, 53, 373-382. Upper Extremity Orthotics andProsthetics Julie Belkin, OTR, CO Patricia M. Byron, MA SUMMARY The determination of the optimal orthosis or prosthesis to fit employs a variety of assessment tools and the familiarity of the evaluator with the availability of fabrication materials. A decision tree is given as a process by which the clini cian can gather the objective and subjective data to determine which purpose, de sign, components, and materials best meet their client's need. The process draws on numerous objective and subjective assessment tools and on the experience and expertise of the evaluator to determine the decision pathway. Orthotic and pros thetic systems and material choices are described to aid the evaluator. A myriad of assessment tools are available to aid in the determination of a prescription for an upper extremity orthosis or prosthesis. This has led to the development of a wide range of descriptive forms used to record informa tion and organize the results of these many assessments. Authors well noted for their expertise in the fields of orthotics, prosthetics, occupational and physical therapy, and medicine have published many of the evaluations in use today. A series of technical analysis forms for orthotic and prosthetic prescription was published in 1975 by the Committee on Prosthetics and Orthotics of the American Academy of Orthopedic Surgeons (1975). These form provide a means to diagrammatically record a biomechani cal analysis of the upper extremity and to translate thi analysis into an orthotic or prosthetic prescription. The assessments recorded in this form include patient vari ables, status of the upper limb, range of motion (ROM) volitional motor strength, sensibility, and an orthotic recommendation. Fess and Philips (1987) present a series of uppe extremity evaluations including prescription forms and checkout forms for both orthotics and prosthetics. The forms presented were created for use in independen
- 239. include those componentsnoted above with the addition of functional assessments of one's ability to perform activities of daily living (ADL). These forms record and organize information but do not assist in the analysis of that information or in the decision making process that culminates in an optimally prescribed orthosis or prosthesis.This chapter presents a decision tree that organizes the flow of information toward a final functional outcome-the custom-fabricated and -fit ortho sis or prosthesis. The decision tree utilizes the data from the necessary evaluation tools described in depth throughout this text. The branches of the tree guide the clinician through the process of assessment, analysis, and decision making to choose the most appropriate path utilizing objective data and empiric evidence as necessary. TERMINOLOGY In an attempt to create a common terminology with which to describe orthoses, the American Academy of Orthopedic Surgery suggests the use of acronyms (1975). These acronyms are based on the joints an orthosis crosses. A hand orthosis becomes an HO, a forearm-based orthosis that crosses the wrist and hand becomes a WHO. Further information is added by describing the components added to the base orthosis. A WHO with MCP (metacar pophalangeal) extension assist 2-5 is a forearm base with an outrigger providing a dynamic force to assist the second through fifth digits into MP joint extension. The intent of this terminology was to facilitate communication among team members to ensure understanding and compliance with the ultimate prescription. The terminology has found its greatest acceptance in the description of lower extremity orthoses. The upper extremity terminology and the tech nical analysis forms, however, have not yet found universal acceptance in the medical or therapy communities. The American Society of Hand Therapists has published a Splint Classification System (SCS, 1992) that describes upper extremity splints in functional rather than in design terms. The SCS describes three overriding purposes of splints: restrictive, immobilizing, and mobilizing. Splints may fulfill more than one function or purpose, depending on the method of fabrication and the problems being addressed. This results in rather extensive descriptive terminology that has not as yet been incorporated into the majority of clinical recording forms. Upper extremity orthotics terminology is further hin dered by the common usage of two different terms, orthosis and splint, to describe the same device. In the presentation of any measurement tool, uniform terminol ogy must be used if there is to be agreement on what is being measured and on how the measurement is to be described. The term orthosis is used throughout this nyms describing the anatomic parts it crosses and u description of the mechanical action on that body Therefore, the orthosis mentioned earlier is describe dynamic WHO with MCP extensor assist digits 2-5 Terminology in the prosthetics community has rem stable, with little deviation noted from utilizing the nyms of BE for a below-elbow prosthesis, AE f above-elbow prosthesis, and SD for a shoulder disar tion prosthesis. Consistent acceptance of this termin makes for clear communication between team mem with less room for misinterpretation. DECISIONTREE (Fig. 10-3) Evaluation is by its nature a hierarchic proc investigation. Information gleaned from one asses often leads to the choice of another evaluation too tool may further define the original data, or it may l an altogether different path of investigation. The chosen for the evaluation are dependent on avail familiarity, and the skill and knowledge level o investigator. An assessment tool is instructive only to the exte the analysis of the information it provides is relevant question being asked. The decision tree is suggeste means to assist in the formulation of appropriat necessary questions. With the ever-increasing ar assessment tools and the ever-decreasing time avail use those tools, it is imperative that the questions ask answered lead to appropriate clinical decisions. DIAGNOSIS It is the ultimate responsibility of the treating clini understand the implications of a given diagnosis. Ad ments in medical technology have furthered the refin of the diagnostic process. The results from ma resonance imaging and arthroscopic surgical explo provide the clinician with in-depth knowledge o structures involved in a diagnosis. They do not, ho lead to improved orthotic treatment for that dia unless further assessment is performed to identi biomechanical effects of the given disease or traum The treating clinicians, whether specialists or ge ists, must take it on themselves to clarify any question have when presented with a diagnosis and a prescr for an upper extremity orthosis or prosthesis. The d sis is very simply only a first clue in the investi process. The diagnosis should guide the clinician to a questions and perform the biomechanical assessmen prove or disprove the efficacy of the prescription. Per
- 240. 218 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT DIAGNOSIS Primary PURPOSE Upper Extremity Orthotics Rest or protect Restore motion Restore function Prevention Upper Extremity Prosthetics Replace grasp Extend control Body image ADL independence PATIENT VARIABLES Age Sex Cognition Socioeconomic Work history Avocation Expectations DESIGN AND ASSESSMENTS COMPONENTS MATERIALS Upper Upper Extremity Extremity Orthotics Orthotics Single surface ROM Circumferential Sensibility Dynamic Strength Serial static Volume Static progressive Plaster Pain Semiflexible Leather Function Resilient Rubber and Circulation Tissue Proximal stability Upper Extremity Prosthetics ROM Sensibility Muscle control Wound Immediate postoperative fitting Edema control Strength components Outriggers Hinges External power Upper Extremity Prosthetics Body powered Myoelectric Cosmetic Terminal device Wrist unit Socket Hinges Elbow unit silicone Low-temperatur plastic Foam Fabric High-temperatur plastic Laminates Metal FIGURE 10-3. The decision tree is presented to assist the clinician through the process of determining and providing the optimal orthosis or prosthes Use of the decision tree is a hierarchic process whereby information at one branch leads the clinician to the next higher level of decision making. questions must consider the status of skeletal involvement, soft tissue structures, and neurologic involvement. A necessary question to be asked is "How long has it been since the onset of disease or trauma?" Soft tissue, including muscle, tendon, and skin, undergoes structural changes with the onset of trauma, edema, or long-term immobilization. With long-term flexion contractures, the shortening of the musculotendinous junctures, along with reabsorption of volar skin, may make reduction of a contracture with intermittent orthotic application unfea sible. l ong-term posturing of the neurologically impaired hand may have led to functional contractures, which, if reduced, would lead to loss of fW1ction rather than func tional gains. In the case of the upper extremity prosthetiC prescrip tion, the diagnosis of partial hand, wrist disarticulation, long below-elbow, short below-elbow, elbow dislocation, long above-elbow, short above-elbow, or shoulder disar ticulation amputation is only the description of the level of amputation. The diagnosis must also be considered in terms of the cause of the absence, be it traumatic or congenital. Upper extremity amputations can result from a variety of trauma, including avulsion or crush-type injury; thermal injury, including frostbite, electric burns, or chemi cal burns; vascular disease, including arteriosclerosis o vasospastic disease; tumors; infections; or neurotroph disease, such as diabetes. In the case of congenit problems, terminal deficiency is the type seen mor frequently; however, patients also present with termin deformity and with permanent nerve loss, such as brachi plexus injury with flail arm. PURPOSE-ORTHOTIICS It is wise to consider at this point in the decision proce what an orthosis cannot do, as well as what it can do. A orthosis can provide mobility or stability to a joint b generally not both. An orthosis cannot proVide dexterity and it can generally supply only one type of prehension. can provide gross strength but with little or no control ov the amount of force applied. Although an orthosis ca substitute for the natural protective padding of the hand a degree, cushions or pads add bulk and may imped mobility. An orthosis can do virtually nothing to a sensibility and in fact often hinders it by covering sensa surfaces. Finally, an orthosis can rarely substitute for th
- 241. and functional hand,but during the treatment process, these desirable features may be compromised. The stated purpose of an orthosis must have a measur able outcome if one is to determine the effectiveness of the intervention. In determining purpose, assessments are suggested to clarify the pathology we seek to treat or alleviate. Many authors have described other categories for upper extremity orthotics (Brand, 1993; Fess & Philips, 1987; Redford, 1986; Rose, 1986). Although one could probably argue for the addition of several categories, four are identified here. Rest or Protection for PainReduction Orthoses that provide rest or protection to relieve or minimize pain are perhaps the most often prescribed upper extremity orthoses. A protective orthosis may be chosen in the event of an acute trauma such as a sprain or strain, for postoperative positioning, or in the presence of a long term pathology such as rheumatoid arthritis. Restore Joint Motion or Correct Deformity Several orthotic designs are available when restoration of joint ROM is desired. Dynamic orthoses can be fabri cated to restore motion through the use of resilient components, or a static progressive design may be indi cated. Dynamic orthoses utilize a variety of mechanisms with which to provide traction, including springs, rubber bands, and woven or knitted elastic threads or straps (Fig. 10-4). Static progressive designs use nonresilient straps or buckle designs to apply traction (Fig. 10-5). Serial static designs rely on remolding by the clinician to reposi tion a joint at end range to facilitate tissue expansion. Orthoses with resilient or dynamic components are con traindicated in the presence of involuntary muscle contrac tions. For such patients, static progressive components may be useful, as they are designed to apply an adjustable static force against which the patient cannot move. In FIGURE 10-4. This dynamic orthosis consists of a static base, outrigger, and traction supplied by steel springs. FIGURE 10-5. The nonelastic strapping employed here p static progressive stretch to the proximal and distal interphalange addition, this static force is not likely to facili involuntary contraction. A serial static orthosis su cylindrical cast is an example of an orthotic app often indicated to correct a long-standing contractur patient cooperation in an orthotics program is not f Restore or Augment Function Orthoses fabricated to substitute for lost or im function span the spectrum from simple hinged o that align or control motion to complex externally p orthoses. Function may be supplied by one o designs. First, the dynamic functional design uses e power or dynamic components to assist insuffic replace absent muscle innervation. The externally p orthosis is an example of this design. Second, an functional orthosis can be designed to mechanically fer power from one joint to another. A radial nerv WHO with static MP assist 2-5 is an example of th 10-6). Finally, a passive functional orthosis au function through the stabilization of unstable joints, positioning the hand to accomplish functional task Prevent Deformity or Cumulative Trauma Muscle contractures that occur due to the para paresis of the antagonist may be prevented by posi the muscle at its resting length to prevent shorteni reduction of muscle fibers. One example of a fun
- 242. 220 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-6. This orthosis, commonly used to substitute for loss of radial nerve function, employs tenodesis action to achieve finger exten sion on active wrist flexion. preventative orthosis is a figure-of-eight hand orthosis that positions the hand in an intrinsic minus position to overcome intrinsic paralysis and to maintain mobility at the MP joints (Fig. 10-7). An example of a nonfunctional orthosis is a functional position WHO (commonly known as a resting pan splint) used in the presence of flaccid hemiplegia, also to maintain mobility at the MP joints (Fig. 10-8). Orthoses are frequently being used in repetitive stress disorder prevention programs. The expanding field of ergonomics has brought a focus to positioning of the hand during the performance of voca.tional tasks. Advances in technology, particularly the proliferation of computers in the work place, have resulted in the development of semiflexible orthoses designed to limit specific ROMs, rather than to restrict all motion. Orthoses prescribed for prevention include those with gel cushions designed to absorb vibratory shock and orthoses fabricated from ure thane foams or rubber and elastic materials that retain warmth and act to limit end ROMs, particularly at final FIGURE 10-8. The functional position orthosis maintains the wrist an digits in midrange for rest and to prevent shortening of soft tissu structures follOWing trauma or neurologic impairment. ranges of wrist flexion and extension. This category o orthoses is not explored in depth here, as the prescriptio for an appropriate prevention program includes othe ergonomic considerations aside from positioning of th upper extremity. PURPOSE- PROSTHETICS The purpose of the upper extremity prosthesis is To replace not the lost hand but the grasping func tion of the hand • To extend the control of the residual limb through the prosthetiC components to the terminal device • To maintain or restore a positive body image • To restore independent ADL performance by re storing bimanual performance ability (Fig. 10-9). Like the upper extremity orthosis) the upper extremit prosthesis cannot provide dexterity. Each terminal devic can, for the most part, provide only one type of prehen FIGURE 10-9. This 12-year-old boy was able to master shoe tying wi the aid of his prosthesis with minimal training. FIGURE 10-7. A spring coil incorporated into a simple figure-of-eight design holds the MP joint in flexion to allow action of the lumbricals on the proximal and distal interphalangeal jOints to bring them into extension in the absence of ulnar nerve function.
- 243. the amputee adegree of control over the amount of force that is exerted through the termina'l device. The prosthesis at its current technical level of development does not allow sensory feedback. The prosthesis does not improve sensi bility, although some prosthetic wearers suggest that they are aware of sensory feedback through the prosthesis to the residual limb. The prosthesis rarely meets the cosmetic desires of the wearer. PATIENT VARIABLES The process of determining an optimal prosthetic or orthotic prescription must include assessment of patient variables. The ultimate outcome of this assessment process is the fitting of an external device. This device may have profound implications on a person's ability to perform those upper extremity tasks that help retain or restore functional independence. An orthosis or prosthesis is often accepted or rejected on the basis of its cosmesis. Upper extremity prostheses in particular may be viewed by the recipient as either completing their body image or so Significantly altering it as to be unacceptable. Of ultimate concern here are those factors that must be assessed to determine the likelihood of compliance versus noncompH ance with orthotic or prosthetic use. The time and expense required for the fabrication of an orthosis or prosthesis are significant, and the assessment process may be stopped here if it is determined that the recipient is not yet willing or able to accept the device. There is no tool, save the skill and intuition of the evaluator, that can measure the readiness of a person to accept an orthosis or prosthesis. The variables that follow are to be assessed both independently ·of one another and as a whole, as they create a total picture of the individuaL It is this total picture that determines the ultimate requirements of an orthosis or prosthesis for a given individual. Age Age influences ability to cooperate with the wearing schedule and the tolerance to the forces applied by an orthosis or prosthesis. Young children are likely to accept a prosthesis or an orthosis that allows them to participate in play, even if it is not aesthetically appealing. The older person whose diagnosis of arthritis makes functional tasks difficult may be less accepting of an orthosis that assists function but is cosmetically unappealing. A study at Shriner's Hospital, Philadelphia unit, found that adoles cents were more accepting of myoelectric prostheses that allowed them to look and feel more like other people than Wright and Johns (1961), in their study of five ty stiffness in subjects with connective tissue diseases, advancing age to be a Significant factor in increased joint stiffness. The results of this study are particula portant when consider1ing the alternatives in orthotic cation to restore motion in the hand of an older p Greater force may be required to achieve mobilizati the skin and soft tissues may be less tolerant of thi due to the loss of their ability to sustain stress. The normal protective mechanisms against ischemia a duced with age. Restricted capillary flow , inflamm diminished sensibility, and the reduction of the visco properties of the skin may all contribute to age-rela tolerance of stress app'lied by either orthoses or pros In the case of the child amputee, age may pr the fitting of an externally powered prosthesis beca the necessity of frequent replacement to accomm growth. In addition to potential financial constrain use of an externally powered prosthesis may p the child from participating in activities such a appropriate water play without special precauti prevent the destruction of the device. Like the chi older amputee may be less of a candidate for the h externally powered device due to decreased streng Sex ASlide from the societal differences that may acceptance of an orthosis or a prosthesis for a m woman, certain inherent biologic differences may al effectiveness of a chosen device. Wright and Johns cite a highly significant difference in normal joint st between men and women. Men were found to significantly greater joint stiffness than women. Al this may be viewed as a disadvantage to the cl seeking to restore joint motion in a male patien greater bone and muscle mass in males allows for areas of pressure distribution and tolerance of ext applied mechanical force. In the prescription of the upper extremity pros cosmesis is likely to be of greater concern to the than the male patient. Therefore, in addition to attem to meet the performance requirements of the patient's vocational and avocational roles, cosmesi be considered if the prosthesis is to be accepted female patient may be more likely to request, in addi a functional prosthesis. a passive or cosmetic prosthe social use. Cognition General orientation to time, place, and person m demonstrated if there is to be independent complian
- 244. 222 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT orthotic or prosthetic use. The cognitively impaired indi vidual requires the assistance of a competent and motivated caregiver to ensure carryover with a prescribed wearing program. If a dedicated caregiver is not available, the choice of no orthosis or prosthesis, as opposed to one improperly applied or unused, may be in the best interest of the patient. Socioeconomic Status The economics involved in the fabrication of an initial orthosis or prosthesis and the cost of maintenance must be considered. The clinician may eschew more expensive, "high-tech" components when these are not economically feasible. In an environment of ever-rising restraints on reimbursement, the economics of necessary rehabilitation technology may be borne more and more by the recipient. Clinicians must be sensitive to the financial resources of their patients. This again points to the situation of the child amputee who may do quite well with an externally powered pros thesis. Insurance may only pay for the initial fitting. The child will need adjustments on a yearly basis or perhaps even more frequently; therefore, unless the family can pay for the equipment or find another source to help, the child will not be kept in well-fitting devices. Another consideration is the amputee who lives in a remote area or whose home does not have electriCity. The battery-powered prosthesis requires access to electricity to charge the battery and to more regular maintenance to keep it in good working order. Where access to these services is questionable, body power is more reliable. Work History The motivation of a person wishing to return to gainful employment plays a major role in his or her acceptance or rejection of an orthosis or prosthesis. The clinician must not discount the possible societal or financial rewards for not returning to employment. The person motivated by the desire or the necessity of returning to work is likely to assist in the determination of which orthosis or prosthesis to fabricate. It is necessary to fully understand the demands of a person's job to choose the appropriate components that will ensure adequate force and maximal longevity for a given device. The component requirements for the carpen ter are different than those for the office administrator. The work history of the upper extremity amputee is important in making decisions related to prosthetic com ponents, harnessing, and suspension and is a strong determinant in the choice of a body- versus electrically powered prosthesis. Special terminal devices are available for specific occupations, especially in the Dorrance series (Dorrance Company, Campbell, California). The individual whose job has several facets may require different prosthe ses or at least different terminal devices to meet his or h job demands. Avocational History The upper extremity prosthesis should provide th amputee with the ability not only to return successfully employment but also, wherever possible, to return to his her avocational life. This may require consideration special terminal devices or other components to allow f task performance (Figure 10-10). Patient Expectations The traumatic amputee who has had no previo exposure to another amputee or to a prosthetic device likely to have unrealistic expectations. He or she may hav read about or seen a "bionic arm" and may expect receive a "replacement arm." He or she may be fearf about the course of life without an arm or part of an arm The sooner questions can be answered and correct info FIGURE 16-10. This patient with a below-elbow amputation is usi a prehensile hand terminal device for his woodworking project. He us a split hook for most activities.
- 245. Definitive orthoses, incontrast to prostheses, are gen erally fit farther along in the rehabilitation process. The patient may have already been fit with a temporary orthosis for the purpose of training as well as for determining the optimal functional position in which to fabricate the final orthosis. Generally, if an orthosis provides meaningful function-that is, meaningful to the recipient-it will be accepted. If the orthosis acts as a hindrance for those tasks the patient deems important, it will likely be rejected. ASSESSMENTS It is at this branch of the tree that the decision variables for orthotics and prosthetics diverge. It is the difference inherent in providing areplacement for a missing limb or in providing a support or assist for an existing part that necessitates this divergence. Although the ultimate objec tive may be the same-to restore function-the assess ments necessary to achieve this objective vary. For clarity and ease of following the decision process, the branches of the orthotics decision tree are presented first, followed by the branches of the prosthetic decision tree. The final branch converges to present materials common to both orthotics and prosthetics. ORTHOTICS Once it has been determined that an orthosis is appro priate, that the patient is accepting of the need for an orthosis, and what it is that the clinician wishes to accomplish, the true work of gathering data begins. Each clinician must have a basic set of evaluation tools and a thorough knowtedge base to use those tools properly. This text concerns itself with specific evaluation techniques, and the reader is referred to the appropriate chapters for greater detail and depth in technique. What is presented here is the rationale behind the use of a particular evaluation. The appropriate evaluation techniques and tools are discussed for each of the four defined orthotic purposes. Rest or Protection for Pain Reduction Range of Motion. Orthoses fabricated for the purpose of rest or protection, by their very definition, restrict motion. It is therefore necessary to determine precisely the degree and arc or motion one seeks to restrict. In the presence of acute trauma, it may not be possible to determine the origin of the pain or precisely which structures are involved. Careful recording of available ROM prior to providing initial visit. The clinician may simply establish a base'lin the jOints included in the orthosis by recording the po of the joints within the orthosis. One certain ma progress is the recovery of motion that allows for impr orthotic positioning, even as pain persists. Pain caused by inflammation secondary 10 overu more easily assessed, and only the arc of motion in w the patient experiences the pain need be restricted advent of semiflexible orthoses that allow for midr motion but increase their restriction as range incr requires that the clinician record two sets of measurem available active ROM and pain-free active ROM. Sensibility. In the presence of acute trauma, assess of pain may be solely via subjective report from the pa It is likely that in the most acute stages, the patie clinician is unable to distinguish between subjective and objective sensibility. If pain is secondary to a diag of nerve entrapment or localized inflammation, the cian needs to establish some baseline measure of sen ity. It is suggested that a brief evaluation of light to deep pressure responses be performed using mon ments. This assessment is suggested for the purpo comparison rather than as a basis for treatment plan Strength Testing. When a resting orthosis is prescrib reduce pain related to a chronic diagnosis, an abbrev assessment of functional strength patterns may b dicated. Volume. Volumetric assessment may be indicat either acute or subacute trauma, as well as in the pres of chronic inflammatory disease. It is essential to r vo~ume prior to the application of an orthOSiS, as any of immobilization may exacerbate edema due to decrease in active muscle function when the hand or is put at rest. Of particular interest to the treating clin should be the effect of volume on pain. A volum reduction that is not accompanied by an expressed r tion in pain and increase in ROM may indicate extensive tissue or skeletal involvement. Subjective Pain Assessment. Pain is a subjective s tion and should be recorded in a consistent manner use of scales on which the patient indicates a level of may be used and reassessed over time (Merskey, 197 pain scale developed for clinical use by this author measures how restrictive pain is in the performance of activities is suggested as one means of demonstr progress to the patient (see Appendix A at the end o chapter). The use of body charts may aid the clinici distinguishing the site of injury from areas of referred and help to define the appropriate intervention. assessment of pain should be independent of the pre one. The patient should be given a clean recording each time and not encouraged to compare levels from assessment to the next. This limits the ~ikelihood symptom exacerbation will influence the choice of vention.
- 246. 224 UNIT TWO-COMPONENTASSESSMENTS OF THE ADULT Functional ·Task Performance. By its very definition, a protective orthosis is meant to rest a part to relieve pain. In the case of an acute trauma, the patient's performance of tasks with the involved extremity is contraindicated. As sessment of functional skills is done only to assess the patient's ability to perform one-handed tasks. It is desirable that the dinician be schooled in the use of adaptive equipment and techniques needed to ensure that a patient will not be unduly burdened by an orthosis. If this is a subacute injury or chronic disease for which a semiflexible orthosis will be used during activity, the clinician needs to perform a simple task analysis to ensure that the patient can perform necessary tasks while wearing the orthosis without exacerbating symptoms. The danger in not ascertaining and limiting those activities that exac erbate pain is that the chosen intervention will fail. RestoreMotion or Correct Deformity Range of Motion. Perhaps no orthotic application re quires as careful and thorough a patient assessment as does the fitting of an orthosis designed to restore motion or correct deformity. This type of orthosis is meant to increase motion in one, or possibly several, planes. Therefore, it is necessary to have a precise recording not only of the degree of available ROM but also of the amount of torque required to achieve this motion. The techniques of torque ROM are well described in hand therapy literature (Bell-Krotoski et al. . 1990: Brand, 1993; F,Jowers & Pheasant, 1988). Torque ROM is useful in distinguishing tendon restriction from joint capsule restriction and in differentiating viscous restriction from elastic restraint. The torque angle curve (TAC) is a graphic representation of a series of torque angle measurements. The development of a TAC provides the information necessary to determine at what angle to apply traction, how much force to apply, and for how long. The TAC of a joint most likely to respond to orthotic application is a gradual or soft curve, demonstrating a slow progressive resistance to force. The indication of a soft end-feel or "give" as the TAC is developed bodes well for the success of orthotic treatment. The joint that produces an abrupt, sharp curve is likely to reqLlire a longer period of treatment, and the ultimate response may be less than optimal. The type and amount of leverage utilized, the wearing schedule, and the need for frequent readjustments and realignment are in great part determined by the informa tion gained from the TAC. The "giving" joint can be expected to respond more rapidly and require more frequent angle adjustments. The firmer, contracted joint may require longer wearing times and is likely to tolerate less force application due to the opposing reaction of firmly restricted structures. Sensibility. The skin's normal expected tolerance to force is given at a pressure of 50 g/cm2 and may be as high as 100 Kg/cm2 (Brand, 1993; Yamada, 1970). This presupposes normal function of the sympathetic nerv that supply vasomotor function (skin color and temper ture), sudomotor function (sweat), pilomotor functio (goose flesh response), and trophic function (skin textur soft-tissue atrophy, nail and hair changes, and rate healing) (Callahan, 1984). The reduction in or loss of an of these sympathetic nerve functions affects the plastic an viscoelastic properties of skin. Normal skin provides unparalleled cushion to protect the underlying skeleto maintains the flexibility needed to allow for motion, an responds to the stresses placed on it by creating callus distribute pressure. Sympathetic dysfunction impairs t plasticity and elasticity of the skin, contributing to ischem and eventual breakdown. If the presenting diagnosis or the patient's subjecti report indicates possible sensory involvement, a thoroug cutaneous sensibility evaluation is necessary before dete mining an orthotic prescription. The available battery cutaneous sensibility assessments does not include anyon conclusive assessment from which to determine the stat of a patient's sensation. From the available tests, an evaluation of light touc deep pressure response is suggested using the Semme Weinstein aesthesiometer monofilaments available fro North Coast Medical, San Jose, California (Bell-Krotoski al., 1990; Brand, 1993; Gelberman et al., 1983; vo Prince & Butler, 1967). This assessment is chosen for repeatability and standardization of the pressure applied each filament (Figure 10-11). The information gather aids the clinician in determining the areas of the hand extremity most likely to tolerate traction, determine a appropriate wearing schedule, and facilitate necessa precautions when it is not possible to avoid positioni traction over areas of skin that demonstrate impair cutaneous or sympathetic function. In the absence of a conclusive cutaneous sensory exam nation, the clinician should be careful not to discount t patient's subjective report. The patient may descri symptoms elicited only with evocative activity or positio FIGURE 10-11. Tests oj response to light touch-deep pressure usi monofilaments produce objective and repeatable data to be employed the decision process. (Courtesy of North Coast Medical, San Jo California.)
- 247. Circulation. The vascularsupply of the hand should be assessed prior to the application of any orthosis, particu larly when the goal of the orthosis is to restore motion through the application of traction. The primary blood supply to the hand, through the radial and ulnar arteries, can be compromised through the fitting of an orthosis, especially in the presence of edema. A visual check of color and palpation of the radial and ulnar pulses at the wrist may be all that is required. However, if any sign of cyanosis is noted or pulses are felt to be diminished, the Allen's test for arterial patency may be performed (Ashbell et al., 1967). The test involves having the patient exsanguinate the hand through fisting while the clinician occludes the ulnar and radial arteries with pressure at the wrist. The patient then opens the hand while the examiner releases either the ulnar or radial artery and watches for revascularization. The procedure is re peated, and the opposite artery is evaluated. This test is dependent on the patient's ability to perform fisting, which is often not viable in the absence of full motion. A positive result, particularly if th.ere is involvement in both arteries, may preclude orthotic fitting. If an orthotic fitting is done, close and frequent inspection must be performed to monitor vascularity. strength. Assessment of strength may be indicated to determine the force available to counteract the reaction of the orthosis. If the patient can move against a resilient force to relieve pressure, an orthosis is likely to be tolerated for longer wearing periods. The performance of a targeted manual muscle test may indicate available sources of muscle power to be harnessed to augment the orthosis. If involuntary hypertonicity is present, this force may be sufficient to overcome static traction and result in areas of ischemia and skin breakdown. Although it is not possible to perform a manual muscle test in the presence of spasticity, an assessment and grading of the force required to overcome the spasticity should be noted. Tissue Extensibility. Much of the information on the extensibility of the involved tissues is gleaned from the performance of torque ROM. It is crucial to determine and grade the end-feel of the tissues around a chosen joint. To reiterate, tissues with a soft or spongy end-feel respond more rapidly to orthotic treatment and require more frequent realignment Those joints with a firm or hard end-feel respond more slowly and require longer wearing periods in the orthosis. Functional Task Performance. Orthoses with resilient components fit for the purpose of restoring motion or cor recting deformity are generally used intermittently. Of im port is the patient's ability to independently and properly don and doff the orthosis. Daily activities may be per formed with the orthosis removed so that the orthosis does not become a functional impediment. Serial static orthoses such as cylindriC casts are designed lor full-time wear and are not removed, even for hygiene. The patient or care- Restore or Augment Function Range of Motion. A primary consideration when mining the feasibility of fitting an orthosis design restore function is whether passive ROM is suffic achieve the desired outcome. If it is not, it will be nec to first fit an orthosis to restore motion. It is not desir all cases to achieve full passive or active ROM. limitation may be {unctional, as in the fitting of a driven tenodesis orthosis limitation in interphalange joint extension and metacarpophalangeal (MCP) flexion is desirable to achieve a stable pinch. Recording of total active motion (TAM) and total p motion (TPM) is recommended to assist in the deter tion of proper positioning. Total active motion and proVide a picture of functional, not necessarily full, Care should be taken when recording digital TAM and to note and be consistent in placement of the wri forearm when recording digital ROM . Sensibility. The greatest limitation of upper ext orthotics is that they can impede hand function presence of sensory impairment. An orthosis often h disadvantage of covering sensate areas of the ha extremity, thereby restricting fLUlctional use of thes faces. The cutaneoLls sensibility battery should lead development of a map of the hand that clearly defines and degrees of sensory impairmenL To that end suggested that an evaluation of light touch-cleep pr response be performed Llsing the Semmes-Weinstei thesiometer monofilaments, as described previously Tests that seek to define a level of functional sen include the Moberg pickup test, static and moving point discrimination, and using a sliding aesthesiom the Disk-Criminator' 1 (Figs. 10-12 and 10-13) (D 1981; Moberg, 1958). Functional testing reveals a tive patterns of function developed by the pati compensate for sensory deficits. An orthotic desig prohibits these compensatory patterns is likely rejected as too cLlmbersome or dysfunctional. Strength. Frequently, the indication for an ortho augment motion is insufficient strength or stabi perform fW1ctionai tasks. No published studies have presented that define the functional grip or pinch st necessary for the performance of self-care activities source cites 20 lb as minimum grip strength and 5 as minimum pinch strength necessary to perform daily activities (Nalebuff & Philips, 1984). In the abse speCific data, the clinician is left to correlate meas grip and pinch strength with observed performan functional tasks. Computer instrumentation for grasp and pinch st assessment is now availabJe and accessible to the cli One example is the Greenleaf SOLO system that in ..'-....._-;.- -..,-. :
- 248. 226 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-12. The aesthesiometer offers the clinician the conve nience of a sliding scale for distance between two points of stimulation. (Courtesy of Lafayette Instrument Lafayette, IN) a digitally self-calibrated dynamometer and pinch meter, raising the reliability and validity of strength testing (Fig. 10-14). Manual muscle tests are suggested to assess the appro priateness of an orthotic prescription. If a patient has a muscle power grade of 0 or 1, this will not be adequate to utilize a wrist-driven tenodesis orthosis without an external power source. Insufficient muscle strength in one position may be increased if tested with the muscle in its lengthened posture. Testing of incompletely innervated muscles may be performed in positions other than those described as FIGURE 10-13. The Disc-CriminatorsT.j employ a series of metal rods spaced from 2 mm to 25 mm apart for testing static and moving two-point discrimination. (Courtesy of Neuroregen, Lutherville, MD) FIGURE 10-14. The Greenleaf EVALn, SoloSystem™ includes com puterized instrumentation for evaluation of grasp and pinch strength a well as ROM of the upper extremity. All instruments are self-calibrating fo consistent, objective measures. (Courtesy of Greenleaf Medical System Palo Alto, California.) optimal in the literature (Kendall et aI., 1971). Inadequat finger flexion force may be increased as the wrist is ex tended, and this determines how the clinician is to positio adjacent joints in the orthosis to maximize function. TissueExtensibility. Soft tissue structures must be elasti enough to allow positioning without resistance. The neu rologically impaired hand tolerates less force due to sensor deficits and atrophy of soft tissues. If the orthosis is f against restricted tissues, the resultant forces may b intolerable. Proximal Stability. The successful use of an orthosis by person with neurologic impairment or spinal cord injury often dependent on sufficient proximal function and sta bility. The person with C3 or C4 quadriplegia may lack th upper extremity placement and trunk stability required t use an externally powered orthosis. In fitting a mobile arm support to a person with multiple sclerosis, trunk or hea and neck rigidity may preclude the motions necessary t ensure successful performance of activities. For the chil with cerebral palsy, the clinician must be aware of sittin postures and restrictive seating devices that may requir alternate setups for the successful completion of activities
- 249. functional orthosis iscontemplated. A baseline must be established for performance of daily tasks that includes not only a patient's ability to complete the tasks but also the time necessary to complete the tasks. The classic example is the patient with rheumatoid arthritis who, because of loss of pinch strength, can button a blouse but takes 30 minutes to do so. The fitting of a thumb IP extension blocker that serves to improve stability may reduce the time necessary to complete the task. Presenting Olihotic intervention as a means to perform tasks in a more time-efficient manner is more likely to be acceptable to the reluctant recipient. Prevention Range of Motion. The goal in preventative orthosing is to maintain ROM rather than to increase it. ROM assessment should include TAM and TPM. Hand and upper extremity orthoses should be directed at maintaining functional ROM. Functional ROM is considered to be midrange motion for each joint crossed. In the presence of hyperto nicity, it is necessary to assess and record at what degree and in what position muscle tone increases. Sensibility. Preventative orthoses are often fit for long wearing periods, and patients and caregivers must be cognizant of any areas of sensory deficit that require greater care and attention. In the upper extremity,it is important to test for response to light touch-cleep pressure over any areas the orthosis will cover. Strength. It may not be feasible or necessary to assess strength formally when fitting a preventative orthosis. Resisted strength assessment is contraindicated in the presence of hypertonicity. It is important, however, to assess and record the amount of force required and the length of time over which this force is applied to effect a reduction in tone. The result of this "strength of tone" assessment is necessary in determining optimal wearing schedules. Tissue Extensibility. It should be assumed that soft tissue is pliable and no absolute restriction yet exists if an orthosis is defined as preventative. If either condition exists, the orthosis would be corrective and not preventative. Of concern here is the assessment of whether the patient or caregivers can provide an appropriately prescribed regi men of ROM exercise to augment the orthotic positioning. Functioning Task Performance. We generally view pre ventative orthoses to be resting orthoses, which therefore act to impede rather than allow function. Of concern again is the ability of the patient or caregiver to properly don and doff the orthosis. In the case of nighttime positioning hand orthoses, the ability to manage night clothing and bedding should be assessed. Bilateral orthoses may make nighttime toileting impossible, and a schedule of alternating nights for each hand may be considered. Wound Healing Wound healing is the primary goal of early posta tation management. The postoperative dressing m soft, semirigid, or rigid. The type of postoperative dr chosen by the surgeon affects every other aspect patient's early postoperative management. The soft dressing provides a mechanical barrier be the wound and the environment. It is composed of a of sterile, nonadherent material and sterile gauze o held in place with a gauze wrap. This system of ma ment allows for frequent inspection of the postope wound site. The semirigid or rigid dressing prevents frequent w inspection. This dressing can be fabric ted from a nu of materials including Unna paste, plaster, or elastic p It is applied over a sterile dreSSing. The dreSSing c changed as needed to maintain gentle distal pressur good support of the limb. This dressing can serve socket base for the early- or immediate-fit pros discussed in the following section. Regardless of the type of postoperative dressing ch wound shear must e avoided. This is accomplish providing good,even compression with a firm fit in th and semirigid dressing. Applying a layer of nonadh gauze prior to application of the top dressing layers recommended. The soft dressing should be applied but not so tight as to cause vascular compromise. Immediate Postoperative Fit When feasible, an immediate postoperative fit (lPO early-fit prosthetiC device is used follOWing trau amputation. With lPOF, patient expectations are likely to be realistic, and the healing process m enhanced. The patient either wakes up from surger the immediate postoperative plaster socket in pla receive§ it shortly thereafter. The goals of early, i.e., the first 2 weeks follOWing amputation, or imm postoperative fittings are • To prevent the development of one-handed te niques for activity performance • To control edema To decrease or prevent problems associated w phantom pain To allow for experimentation with prosthetiCo tions prior to definitive prosthetiC fitting A plaster socket or rigid dressing is applied at the t surgery. After 1 to 3 days. the other componen the early-fit device are applied, including a harnes pension system, the wrist unit (or elbow unit in the of the above-elbow amputee), and the terminal d -.- ' ~. -::=--~
- 250. 228 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-15. A, The early-fit prosthesis is fabricated with layers of elastic plaster covered by regular plaster. B, Components such as the wrist un shown here are added to the plaster socket. (Fig. 10-15). The rigid plaster dressing provides compres sion to assist with edema con.trol. The compression provided by the dressing also helps with control of phan tom pain. Although the mechanism through which phan tom pain is reduced or relieved is not adequately under stood, it is possible to provide anecdotal evidence of its reduction (Jacobs & Brady, 1975). The patient who is fitted immediately after surgery does not have the opportunity to develop unilateral patterns of activity performance that the patient who has to wait several weeks or even months for a prosthesis to be fit is certain to develop. In addition, the patient has the op portunity to experiment with various terminal devices to familiarize himself or herself with what is available and to help in definitive terminal device selection. Edema Control Edema control is important in all postoperative manage ment, but especially so in the amputee, as it affects the timing for the patient's definitive prosthetic fitting . Edema control may be addressed by elevation, regardless of the type of postoperative dressing chosen. Where a soft dressing is chosen, the patient may also be instructed in the use of an elastic wrap or Compresso grip stockinette (Para Medical Distributors, Kansas City, Missouri) to provide assistance with edema control and with shaping of the residual limb. The elastic wrap is applied in a graded figure-of-eight fashion from distal to proximal (Fig. 10-16). If the limb is short, especially if it has been amputated at a short above-elbow level, it is very difficult to keep the wrap in place. Using a chest wrap with a figure-of-eigM over the shoulder can help to maintain the position of the wrap. The Compressogrip, while it decreases control of pressure application, is less likely to slip and may be very useful for the patient or family member who is having difficulty applying the elastic wrap correctly. The rigid or semirigid dressing itself serves as the mean of external compression. The dressing must be changed t accommodate decreases in edema. As mentioned prev ously, edema measurements help to determine the pa tien.t's readiness for definitive prosthetic fitting. Edem measurements must be taken regularly and documente FIGURE 10-16. The elastic wrap assists with edema control as well with shaping of the residual limb. The wrap is applied from distal proximal in a graded figure-oi-eight fashion.
- 251. --- FIGURE 10-11. Circumferentialedema measurements are taken frequently, as they help to determine the patient's readiness for his or her definitive prosthesis. accurately to be meaningful (Fig. 10-17). The measure ments should be taken at easily duplicatable landmarks and at specified points along the residual limb. When measure ments have been stable for 2 weeks, it is generally safe to proceed with definitive conventional fitting. The myoelec tric prosthesis requires a more intimate fit between the residual limb and the prosthetic socket for reliable pros thetic function. For this reason, definitive fitting of the myoelectric prosthesis should be delayed until circumfer ential measurements have been stable for 4 to 6 weeks. Range of Motion Active and passive ROM are assessed goniometrically on a regular basis. These measurements are taken without and later with a definitive prosthesis. This is one method that is used to determine if the definitive prosthesis has achieved a good fit. GenHe active and passive ROM exercises are started as soon as possible following amputation surgery. Motion is much easier to maintain than ,it is to regain once it is lost. Pronation and supination are especia'lly difficult to regain. Patients have a habit of posturing their residual limb in pronation and allowing the interosseous membrane to con tract into a shortened position. As the level of amputation becomes higher, residual pronation and supination lessens. Effective elbow motion may also lessen at higher bdow elbow levels. As a general rule, everything that can move should move, to ensure maximum functional ability follow ing prosthetic fitting. Good shoulder and scapular motions are essential for operation of the body-powered prosthesis. Sensibility Most upper extremity sockets are fit as total-contact sockets; i.e., there is equal pressure distribution over creased or absent residual sensibility, as identified th sensibility evaluation as described earlier, must be special attention in terms of socket fit. Frequent insp to prevent the development of skin breakdown and w healing problems is recommended. These prob should they be allowed to develop, could result amputee's needing to go without the prosthesis healing is accomplished. Just as diminished sensibility can present problem the amputee, hypersensitivity or pain caused by a roma can present its own complications. A hypersen wound area or neuroma can prevent the amputee tolerating the pressure of the prosthesis and severel wearing tolerance. Appropriate intervention is ind in these cases. Muscle Control It is important to determine whether the patie volitional control of the musculature of the residual l the muscles are not under voluntary control, the p may not be a candidatefor a myoelectriC prosthesis. more sensitive devices can use very small amou muscle power at as few as one site to power a myoe prostheSiS, but the muscle function must be under vol control to allow the patient to open and close the ter device in a functional way. Strength The patient must have adequate strength in his residual musculature to support prosthetiC compo and to power them successfully. Manual muscle tes indicated to assess muscle strength. For example, case of the short below-elbow amputation, where a st hinge is needed to increase the effective range th which the patient is able to drive the prosthetic for use of this hinge requires greater strength on the part amputee to achieve the motion. Additional compon in the form of amplifiers may be needed to overcom problem DESIGN AND COMPONENTS ORTHOTICS Rest or Protection to Reduce Pain There are two design options for orthoses directed and protection. One is the fabrication or fitting Single-surface orthosis-one that covers only the pal - - • . L
- 252. 230 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-18. This outrigger is attached to the low-temperature thermoplastic base by the application of a second piece of thermoplastic heat bonded to the base. dorsal surface of the hand or extremity or the ulnar or radial surface. Single-surface orthoses require straps or wrap pings to create one or more three-point pressure systems to secure the orthosis in place. The second option is a circumferential design that wraps around the joint, creating equal pressure over all surfaces to limit motion. Strapping is needed only to maintain closure of the orthosis. Single-surface orthoses are effective for support and rest of joints surrounded by weak or flaccid muscles, such as found following a CVA or peripheraJ nerve injury. In the absence of active motion, a Single-surface design provides sufficient control and allows the clinician to readily adjust the force of the orthosis through adjustment or realignment of straps. Circumferential designs offer the choice of using Ughter weight or thinner materials. as the additional contours of the design add strength to the orthosis. Circumferential designs are particularly applicable when the patient has active motion and will be using the ortJ10sis during activity. The control that a circumferential orthosis provides helps to limit the shear forces that can be created when there is movement within or against the orthosis. These design qualities make the circumferential design most applicable in the presence of tendinitis or neuritis, as well as for the support or immobiUzation of unstable joints. Restore Motion or Correct Deformity The options for orthoses designed to restore motion fall into three categories: dynamic, serial static, and static progressive. The choice of design is again dependent on the results of assessments related to patient variables; to purpose of the orthosis; and now, more importantly, to information gathered from assessments of ROM, tissue extensibility, sensibility, and vascular status. By definition. a dynamic orthosis incorporates a resilien component (e.g., elastic, rubber bands, or springs) agains which the patient can move. Dynamic orthoses restore motion by assisting a Joint through its range and by ap plying traction force at the end of available range to promote tissue lengthening. This resilient component gen erally acts on the Joint through attachment to an outrigge to secure the line of pull. The outrigger, in turn, is attached to a static base fit securely to the hand or extremity (Fig 10-18). A serial static orthosis restores motion through the static application of end-range stretch. The serial stati orthosis relies on repeated remolding and repositioning to maintain the part at end range to achieve an increase in joint motion. This orthosis has no movable or resilien components. The classic example of a serial static orthosi is a serial plaster cast or circumferential thermoplastic orthosis fit to reduce a flexion contracture. Frequen remolding or replacement of the cast or orthosis place and holds the joint at its end range of motion to facilitate tissue lengthening (Fig. 10-19). FIGURE 10-19. Acircumferential wrap can be removed and remolded ,placing the proximal interphalangeal joint in progressively greater ex tension.
- 253. FIGURE 10-20. TheGyovai Finger Spring"" adjusts to provide force between 50 and 400 g. (Courtesy of North Coast Medical, San Jose, CA) Static progressive orthoses incorporate a static mecha nism to adjust the amount or angle of traction acting on the joint. This static mechanism is most often a loop or cloth strapping material, a turn buckle, or a nonresilient nylon line. The mechanism itself is adjusted to progressively change the angle and amount of force directed to the joint. The base orthosis remains unchanged (see Fig. 10-5). The resilient components used in dynamic orthoses are most commonly rubber bands or steel springs. The advan tages of rubber bands are their universal availability and low cost. The disadvantages include their lack of uniformity, limited and variable shelf life, and inconsistent quality. Mildenberger and colleagues (1986) have created a force enlongation values chart useful in helping to determine the spring constant for rubber bands. Spring constant is given by "the product of the cross-sectional area and the modulus of rubber band elasticity." Spring constant is defined as the "amount of force required to elongate the rubber band to twice its original length" (Mildenberger et aI., 1986, p. 242). The chart offers a systematic approach to the selection of rubber bands used to supply traction. An evaluation of commerCially available SCOMAC steel springs by Roberson and colleagues (1988) found them to be linear and consistent with negative creep and minimal hysteresis. The springs are supplied in kits and are color coded and graded for force from 50 to 2000 g. The authors concluded that the use of SCOMAC springs offers the advantage of greater consistency and predictability when applying force with a dynamic orthosis. They do, however, suggest that as with rubber bands, the springs be measured and adjusted accordingly once they are attached to an orthosis. SCOMAC springs are available from S.G.M. (Codim, St. Etienne, France). Graded springs are more readily available, the cost has diminished over time, and their design for convenient use outrigger line and loop tabs for attachment to the b an orthosis. The amount of force applied is a result distance the spring is stretched (Fig. 10-20). When fabricating orthoses with components desig restore motion, no other choice is as important choice of what force to use and how much force to Although the materials described here each have tions, it ,is the clinician's responsibility to obtain the reliable information by using the appropriate tools assessment of rubber bands or springs can be performed in the clinic. The results can be easily ch and confirmed by the use of a simple spring scale attaching components to an orthosis. The inform gathered during the performance of torque RO meaningful only when the clinician incorporates the mation appropriately and consistently to apply the termined degree of traction with the properly components. Fess and Philips (1987) give a "safe force magn table that suggests force parameters to be used applying dynamic traction to the digits. Although thi offers no absolute values, it does offer the clini formula for determining force parameters. Takin reading of the force gauge used in evaluating ROM mu'ltiplying this reading by the distance from the p traction to the axis of the joint gives a measureme torque (torque equals force times distance). This m must then be matched with the force and distance me of the chosen resilient component to provide a k degree of force . The two other components that make up a dyna static progressive orthosis are the outriggers emplo alignment of the force and hinges used to fa movement of the orthosis as it crosses a joint. The ou may be viewed as a nonmobile structural mechanis acts solely as a pivot point from which to establish an of pull. A high-profile outrigger is one that is set at suf height above the joint being acted on that it can exte resilient component to the length necessary to a predetermined measure of force (Fig. 10-21). A profile outrigger is one designed to act as a pivot po a static Hne. The static line, once it has passed thro FIGURE 10-21. The high-profile outrigger is set at a height tha the resilient component to apply its force in optimal midrange.
- 254. 232 UNIT TVIJO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-22. The low-profile outrigger acts as a pivot point for the static component of the traction line. Once the pivot pOint is established at 90 degrees 1.0 the part being acted on. the angle of pull of the resilient component may be directed as needed. over the pivot point, is then attached to a resilient component for the application of force (Fig. 10-22). In assessing the orthosis to be constructed, the choice of high- versus low-profile outrigger is determined in part by the skill of the fabricator, the overall length of the orthosis, and patient tolerance and convenir::mce. The choice of outrigger height may be determined in great part by the size and length of the base orthosis. A finger-based or short hand-based orthosis may simply not have the length necessary to supply an attachment point and produce the optimal force range if a low-profile outrigger is used. A WHO or elbow wrist hand orthosis (EWHO) offers the clinician greater flexibility in establishing the necessary attachment sites for resiHent components. A variety of dynamic and static progressive designs rely on articulating hinged components to facilitate motion across a joint (Fig. 10- 23). Consideration must be given to the alignment of hinges with the anatomic joint. Many of the joints of the upper extremity are multiaxial with alignment that deviates from pure anatomic planes. The wrist joint is one example of a complex joint with two axes of motion-one for flexion and extension and one for radial and ulnar deviation. In addition to these two axes, conjunct motions occur tbat are not in alignment with anatomic planes. Wrist extension combines with radial deviation and a slight degree of forearm supination. Wrist flexion com bines with ulnar deviation and slight pronation. No manufactured hinge is now available that duplicates these conjunct motions. Therefore, any orthosis designed FIGURE 10-23. This elbow ROM hinge allows for free. limited, or blocked ROM at the elbow. FIGURE 10-2 4. This wrist-driven flexor tenodesis orthosis inclu locking ratchets for both the wrist and the digits to supply s prehension without sustained voluntary muscle contraction. (Courtes JAECO, Hot Springs, Arkansas.) to apply force across a hinge in the expectation of restor motion to a multiaxial joint must consider this limitati Binding and friction will be created, despite the great care in axial alignment. The clinician must constan reassess the alignment of any articular component and fit of the base orthosis to reduce the deleterious effects friction. Restore or Augment FUDction The broadest range of designs and components ex for this category of orthotic application. Designs ran from the simple static figure-of-eight HO that positi the MP joints in flexion to substitute for lost intrin function (see Fig. 10-7), to the highly complex externa powered WHOso As was mentioned earlier, the fitting of an orthosis on hand has the potential to limit, as well as to augme function. Of the orthoses cited in the previous paragra the figure-of-eight positions the hand to allow for full joint extension and improves grasp. It does so, however the expense of covering a portion of the palmar surface the hand. Care must be taken when fabricating this HO minimize the palmar surface covered, yet it must fit snu to overcome the strength of the extrinsic extensors. The wrist-driven tenodesis orthosis is commonly p scribed to augment function for the person with a spi cord injury at levels C5 through C7. It is at these levels t the extensor carpi radialis longus and brevis (C5-8) and extensor carpi ulnaris (C6-8) are innervated. This allo for active wrist extension and the accomplishment o weak tenodesis grasp. The wrist-driven orthosis augme the tenodesis action through the posting of the thumb a the attainment of sustained pinch. Orthoses with a lock ratchet at the wrist allow for passively sustained w extension (Fig. 10-24). This further augments function
- 255. - The static MPextension assist WHO designed for use in the presence of radial nerve dysfunction makes it possible to use the hand wilhout needing to use the substitute motions of forearm supination and pronation to facilitate grasp and release (see Fig. 10-6). The simple thumb IP extension blocker prevents IP joint hyperextension and can increase pinch strength by as much as 50 percent or more. For persons with severe arthritis in the thumb who may have a pinch measurement of only 2 to 3 lb, this increase is functionally significant. Prevention Orthoses designed to prevent deformity are often just one aspect of an ongoing program of prevention or maintenance, depending on the expectations for recovery of function. In the absence of motor function or in the presence of hypertoniCity, a static-design orthosis is sug gested. The choice of single-surface or circumferential orthosis is to be made by the clinician based on experience and preference. In general, the design choice will be that of a static orthosis without hinged or resilient components. In situa tions where there is unopposed innervation of muscle groups, an orthosis may be designed to supply, or simply allow for, the absent motion. A drop-out-style elbow orthosis allows for passive elbow extension when there is relaxation of spastic flexors and therelore prevents con tractures. Similarly, orthotic hinges are available that allow FIGURE 10-2 5. Hex screws are used to block motion in the elbow ROM hinge to allow for many combinations of free or limited elbow fleXion and extension. Orthoses used in the prevention of cumulative t are chosen for their ease of donning and doffing a their low-profile designs. Thin, lightweight circumfe designs are frequently the design of choice, as they interference with activity. Components may includ ible stays or foam pads that limit end ranges of m Hinges may be indicated to block motion in unde planes; e.g., an ulnar-based wrist hinge allows free f and extension but prevents ulnar deviation. To be ef in preventing trauma, an orthosis must be designed t only undesirable motion without transferring stres adjacent structures. DESIGN AND COMPONENTS PROSTHESES Upper extremity prosthetiC components are c primarily to meet the functional needs and dur requirements of the individual with emphasis on resto of prehension. The patient, surgeon, therapist, and thetist should work as a team to determine the o prosthesis based on the results of the assessment pr The three primary prosthetiC systems available to the extremity amputee are as follows: Body-powered or conventional systems body-powered or conventional prosthesis is con by motion from the amputee's body (Fig. 10-26 harness transmits power through the control st the cable and eventually to the terminal d Humeral flexion on the amputated side is the p motion utilized for terminal device operation below-elbow patient. External or myoelectric systems: Myoe prostheses are the popular version of the exte powered prosthesis. They rely on an external source, a battery, to convert the electric signal muscle to motion through an electric app (Fig. 10-27). The muscle acts as a signal sourc signal is passed through electrodes embedded socket to the control system, which translates t nal into the desired action, i.e., opening or clos the prosthetic appliance. Depolarization of th membrane of individual muscle fibers that occu ing muscle contraction is the origin of the myoe signal. Cosmetic or passive systems: While these d are most popular for the digital, partial hand, o amputee, endoskeletal designs may be fabricat patients with higher levels of loss. These system dedicated to improving the cosmetic appeara the amputated part and addreSSing the psycho needs of the person for whom a functional pros - - '."- ~...;:' ~' . . -
- 256. 234 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-26. This patient is wearing a conventional below-elbow system with mechanical hand. is not feasible (Fig. 10-28). A wide variety of cosmetic prostheses are available, from prefabricated gloves to those that are custom fit and custom colored. The price range is as varied as the options, and it often falls to the therapist to justify the cosmetic prosthesis to third-party payers. Patients are generally encouraged to look toward a functional prosthesis, either conven tional or myoelectric, before the notion of a cosmetic prosthesis is introduced, since restoring function is Ollr primary goal. In addition to the choices listed above, hybrids that combine aspects of several system types are also available. Terminal Device Every upper extremity prosthesis includes a terminal device. The terminal device may be either a hook or a hand that is either voluntary opening or voluntary closing. As the names imply. force is required either to open the terminal device to achieve prehension or to close the terminal device to maintain prehension. The terminal device may be man ual (Fig. 10-29) or electric in operation (Fig. 10-30), de pending on the type of prosthesis that has been selecte Decisions regarding the most appropriate or necessary te minal devices may be made during the early-fit period whe the patient may be expenimenting with various devices du ing training. Considerations in terminal device selectio include the patient's preinjury activity levell, both vocation ally and avocationally, residual limb length, residual lim strength, and general prosthetic choice. Wrist Units The wrist unit provides a point of attachment for th terminal device, allows for prepositioning of the termin device in either pronation or supination, and aillows for th exchange of terminal devices. Wrist units are available either friction or locking type. Quick-disconnect compo nents are available for rapid switching of terminal device A wrist flexion component is available for the amputee wh has a bilateral injury or is unable to operate close to th body with the opposite arm; e.g., an individual with a wri fusion on the opposite side (Fig. 10-31). Prosthetic Socket The prosthetic socket encases the residual limb. A extension is used to fill the space between the end of th socket and the wrist unit or between the end of the limb an the elbow unit in above-elbow patients. Socket design dependent on the level of amputation, residual functio and prosthetic choice. Special socket designs such as the split socket o Muenster socket may be necessary for individuals with ve short below-elbow amputations. The Muenster socket ha very high trim lines and encases the olecranon an condyles to provide additional stability. The disadvantag FIGURE 10-27. The below-elbow myoelectric system used by th patient has an electric hand.
- 257. FIGURE 10-28. A.The patient's residual limb prior to fitting with a cosmetic prosthesis. B, The same hand following prosthetic fitti of this socket is that elbow flexion is limited, usually to about 70 degrees, because of these trim lines. The split socket includes a socket that encases the residual limb and a separate forearm shell that includes the wrist unit and terminal device. This design may be used with step-up hinges discussed in the following section or with other modifications, such as an elbow lock. Hinges There are three primary types of hinges used with the below-elbow prosthesis. Flexible hinges fabricated from Dacron, leather, or other flexible material serve primarily a suspensory function. They are used mostly for wrist disarticulation and long below-elbow patients who retain pronation and supination. Step-up hinges are used in combination with a split FIGURE 10-29. One example of a conventional terminal device is the Dorrance 5X. (Courtesy of Dorrance Company, Campbell, California) socket, where residual elbow flexion is also limited step up the range of flexion through which the stump to drive the prosthetic forearm by either a 2: 1 or 3: 2 i.e., for every 1 degree of active elbow flexion, the fo will move 2 degrees. As mentioned earlier, the dis tage of using this device is that the strength requ achieve the same amount of flexion nearly doubles Elbow Units Elbow units prOVide elbow flexion and locking in v degrees of flexion. There are two basic types of elbow the external elbow, used for the elbow disartic patient and the internal elbow, used for above-elbo shoulder patients. Both are controlled by a separate lock mechanism and are available in manual and e versions (Fig. 10-32). Harness Systems The most frequently used harnessing system figure-of-eight (Fig. 10-33). The below-elbow h functions to suspend the prosthesis and to allow the to utilize body motions to operate the terminal devic harness works to hold the socket firmly against the r limb. The power of body motions is transmitted terminal device via the cable system. Other harn systems that are frequently used are the figure-of-ni the chest strap with shoulder saddle. The less-cumbe figure-of-nine harness is most appropriate for below-elbow amputations, as it provides a greater of freedom. In above-elbow harneSSing, the sys meant to provide power to flex the elbow and to lo unlock it. The chest strap and shoulder saddle harnessing ar ment may be used for individuals who do frequent
- 258. 236 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT FIGURE 10-30. The electric hand (A) and the Griffer (B) are the most frequently used myoelectric terminal devices. (B, Courtesy of Otto Bo Minneapolis, Minnesota.) lifting or for those who are unable to tolerate an axilla loop, system-the operation of the terminal device. In th perhaps due to nerve or skin irritation. system, the cable slides through a single length of housin to achieve this function. In the above-elbow prosthesis, th Control Systems cable system is required to perform two function The below-elbow cable system is the Bowden system. The cable produces only one function in the below-elbow FIGURE 10-31. A combination flexion wrist unit is often used with bilateral amputees to improve their ability to perform tasks close to midline. FIGURE 10-32. The above-elbow elbow lock mechanism runs fr the harness to the elbow unit. It locks the elbow in the desired degrees elbow flexion.
- 259. FIGURE 10-33. Themost frequently used below-elbow harnessing is the figure-ol-eight (A), which includes an axilla loop on the uninvolved side, a Sllspensor strap, and controlstrClP that qttaches to the controlcable on the involved side. terminal device operation and elbow flexion. The above elbow cable system is known as the fair lead or dual-cable system. It uses two lengths of cable housing to accomplish the two functions of elbow flexion and terminal device operation (Fig. 10-34). MATERIALS The materials used in orthotic and prosthetic fabrication span a broad spectrum from low-cost, readily available plaster-of-Paris bandage to expensive Kevlar ', Kingsley Manufacturing Company, Costa Mesa, California, and FIGURE 10-34. The above-elbow lair lead cable system has two lengths 01cable housing. As the cable slides through the first, the elbow is brought into position. Once the elbow is locked, the cable is Iree to operate the terminaJ device. The terminal device cannot be operated without first locking the elbow. to make appropriate choices for a given prescriptio It is ever more important in an era of cost contai that clinicians choose those materials that will serv for short- or long-term use of an orthosis. Orthoses cated to augment function for the spinal cord-injur tient are considered permanent and must be fabr from long-lasting materials. Orthoses expected to b intermittently or for a short time frame may be app ately fabricated from lower-cost materials that h known limited shelf life. To facilitate the assessment process along the de tree, at this point we present an explanation of ma and their properties and then offer suggestions for rials for each orthotic or prosthetic application. Plaster-of-Paris The ready availability, low cost, and ease of plaster-of-Paris continues to make it an appropriate rial for many orthotic and prosthetic applications. P of-Paris is manufactured from calcium sulfate, more monly known as gypsum. Plaster-of-Paris band commercially available in loose dry plaster bandag hard-coated bandages, and in elastic fabric impreg with plaster (Prosthetic Orthotic Center). Setting time can be manipulated by increasing creasing the water temperature. Water temperature not be set above 150°F (65.5°C), as excessive tempe actually prevents rather than hastens setting time. working with plaster bandage, the clinician should be that setting time and drying time are not equivalent. S is a relatively short process, while drying takes signif longer and is not complete until the excess wate evaporated from the plaster. Drying may take any from 8 hours to several days, depending on the siz thickness of the apphed bandage. Plaster-of-Paris is highly moldable, has excellent ri can be used circumferentially or for Single-surface ap tions, and is comparatively low in cost. This conve and low cost continue to make plaster-of-Paris band frequent choice for postsurgical positioning. Plaster as the initial model of the residual limb and as the ba fabrication of the check socket in prosthetics. It is al rigid component of the early-fit prosthesiS. Leather Animal skins and hides are composed mainly of m intricately interlaced protein fibers. Tanned leath tensile properties unmatched by any other material o weight. It can retain a molded shape permanently maintaining flexibility and strength. Leather is highly ture resistant yet maintains excellent porosity for v
- 260. 238 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT tion. Leather can be cut, perforated, sewn, molded with water, laminated, and riveted. Most of the leathers used in orthotic and prosthetic applications are vegetable tanned for a smooth texture and to prevent skin irritation. CaHskin and cleer skin are used in upper extremity orthotic applications due to their light to medium weight. Weight is expressed in the number of ounces per square foot with light weight being 2 to 3 oz per square foot, and medium weight being 3 .5 to 4 oz per square foot (Redford, 1986). When wet, leather can be readily stretched and molded over a plaster or wood mold. Once dry, leather holds its molded shape permanently and continues to contour and mold to a body part over time. In upper extremity prosthetics, leather is frequently used in the fabrication of shoulder saddles and as portions of the harnessing system. For these applications, heavier horsehide and stretchable cowhide are used for their durability and strength. Rubber and Silicone Elastomers Natural and synthetic rubber is available in a variety of forms, all of which have the common characteristic of elasticity. Rubber and rubberlike compounds are highly resilient to pressure deformation and so have excellent shock-absorbing qualities. Silicone elastomers are now available for use in both orthotic and prosthetic fabrication (Haberman, 1995). Their use is suggested relative to the use of rubber due to their ease of application and ready availability. Natural rubber is a highly elastic material with good tear and abrasion resistance. The disadvantage of the use of natural rubber in orthotic and prosthetic applications is its Ilow resistance and tendency to degrade with exposure to sunlight, water, skin oils, and most solvents. Of the commonly used synthetic rubbers, Butyl rubber has greater resistance to heat, sunlight, and water but is not as resilient or elastic as natural rubber. Neoprene is one of the synthetic rubbers commonly used for orthotics today. Neoprene combines excellent resistance to water, aging, and heat with good resistance to oil and solvents. Neoprene lacks the extreme resistance of rubber to deformation and requires the addition of plastic or metal stays to provide any Significant degree of joint restriction (Redford, 1986). Silicone elastomers are available in a variety of forms for the fabrication of flexible orthoses. Open-weave fab rics or bandages can be incorporated into the mold for greater strength and longevity. Silicone elastomers retain their flexibility and elastic qualities when molded and are often recommended when an orthosis is required during sporting events. Unlike rubber, silicone is stable in heat and in oxidizing environments and does not yellow with time. The elasticity and elongation of silicone are not equivalent to those of rubber, but silicone is a highly accept able substitute. Low-Temperature Thermoplastics Low-temperature thermoplastics include synthetic r ber sheets, such as Orthoplasf" (Johnson and Johnso Piscataway, New Jersey), and polyester polycaprolacto sheets, such as NCM Clinic'" (North Coast Medical, In San Jose, California) and Polyform~ (Smith & Neph Rolyan, Germantown, Wisconsin). By definition, the thermoplastics require no more than 180°F (80°C) or wet heat to become moldable, and they may be shap directly on the body part. Their principle use is in upp extremity orthotics, where rapid fabrication and frequ remo'lding for positioning are essential. The array of available low-temperature thermop'lastic ever expanding. The clinician is referred to the therm plastic charts available from distributors for specific ch acteristics of each material. Basic characteristics of lo temperature thermoplastics are given in Appendix B at end of the chapter to assist the clinician in choosing thermoplastic most appropriate for a given applicati Low-temperature plastics are susceptible to oxidat and crystallization that cause breakdown of the polym structure over time. The level of resistance to crystallizat varies among low-temperature plastics, and therefore shelf life of plastics varies. Those thermoplastics t contain isoprene are known to be more susceptible oxidation and experience yellowing and structural deg dation more quickly. Polyethylene Foams and Cellular Rubbers The two basic classes of foams and cellular rubbers open-cell and closed-cell structures. In open-cell foams a rubbers, fluids can flow through the holes. The holes i closed-cell structure are separately sealed, preventing fl transfer. Foam denSity is dependent on the size of individ cells, the ratio of cell space to volume, and the continuity discontinuity of the cells (Redford, 1986). Open-cell foams are softer and spongelike and allow varying degrees of ventilation. Their use in orthotics primarily as lining materials to assist in the distribution shear stress and to act as a moisture wick. Closed-cell foa are firmer and nonabsorbent and can often be heat-mold to create a semiflexible orthosis. Plastizote (Kewell Co verters Limited, Surrey, England) is a commonly us closed-cell polyethylene foam that is moldable when hea at 230°F to 285°F (110°C to 140°C). Plastizote can used as a liner or incorporated with thermoplastic leather to form a semiflexible orthosis. Polyethylene foams have the disadvantage of ra loss of their density and absorption capacity under pr sure. This limits their usefulness to non-weight-bear orthoses. Their lack of fluid absorption may also be seen
- 261. - - - frequentchanges of cotton lining, and heat may be somewhat dissipated by perforating the foam. Woven and Knit Materials Cotton duck, polyester and cotton woven with elastic threads, and a variety of vinyl-impregnated materials are in common use for upper extremity orthotics. Woven or knit materials are readily available, cost effective, and easily modified for custom fitting. The use of such materials for orthotic application is generally limited to short-term use due to the limited durability of these materials. High-Temperature Thermoplastic The deSignation of high temperature when applied to thermoplastics denotes materials that become moldable at 350°F to 450°F (176°C-232°C) and can only be molded over a model. High-temperature thermoplastics are highly resistant to stress and heat and are ideal for long-term use and for weight-bearing applications. Corrective forces can be incorporated into the model prior to vacuum forming the materials over the model for an exact fit. Of the high-temperature plastics used in orthotics, polyethylene has the most application in upper extremity orthotics. Polyethylene is available in low-, medium-, or high-density formulas, each having a specific gravity and tensile strength. Low-density polyethylene is most com monly used in upper extremity orthotics and prosthetics due to its toughness and flexibility. Low-density polyeth ylene can be heated in a convection oven and then vacuum formed or hand formed on a plaster model. With care, polyethylene may be molded over a foam base directly on the patient. Polyethylene is used also in upper extremity prosthetics to make molded shoulder saddles and triceps cuffs. The high-temperature thermoplastics are susceptible to both oxidation and crystallization that, over time, lead to structural failure. These plastics, however, have a signifi cantly greater life span than the low-temperature plastics and are likely to last for up to 10 years. Laminating Resins A variety of polyester, acrylic, and epoxy resins are available for creating thin shell laminates for use in upper extremity orthotics and particularly for prosthetics. These shells are formed over plaster models, and some materials can then be heated, sanded, and reshaped as needed. Color can be added to certain resins to simulate skin tones. The addition of nylon or carbon graphite into the resins of components significantly, but it does so at an incre cost. The choice of laminates is dependent in good p the stress tolerances needed, on funding availability, a the experience of the prosthetist or orthotist. Metals The metals most commonly used in orthotics are less steel and aluminum. Metal alloys such as those titanium or magnesium offer some distinct advantag terms of decreased weight and density and incr tensile .strength. Their disadvantage is high cost, limits their use to small component parts. The metals are chosen for their properties of stre weight; resistance to deformation, fatigue, and corro ease of fabrication; and cost. Aluminum is commonly in upper extremity orthotics due to its high streng weight ratio and its corrosion resistance. Alumin approximately one third the weight of steel, and its str can be enhanced by heat treatment, the addition of amounts of alloy metals, or by cold working to increa tensile strength. Pure aluminum is a relatively soft that can be hammered and thinned to accomm complex shapes without loss of strength or increa brittleness (Redford, 1986). Although resistant to corrosion, aluminum can be aged by alkalis and acids.To counteract this, aluminu be coated by anodizing or by exposing it to electr action. This has the added advantage of giving alum parts a more attractive finish and allows the metal colored for a cosmetically pleasing appearance. Materials Application Although many materials may be useful for one cation, and one material may be useful for many ap tions, there are choices to be made to choose the appropriate material for a given application. Appendi the end of the chapter gives suggestions for material for the described orthotic and prosthetic applica Durability, cost, availability, and fabrication experien factor into the decision. Prosthetic Checkout Prosthetic checkout is performed to ensure tha completed device is fitting and operating well and t adheres to clinic prescription. A few of the items eval at checkout include length, efficiency in various plan motion, control system efficiency, ROM with and w the prosthesis, and suspension. .'
- 262. 240 UNIT 1WO-COMPONENTASSESSMENTS OF THE ADULT The length of the completed prosthesis should be close to that of the uninvolved arm. This becomes a problem in fitting a myoelectric prosthesis in the wrist disarticulation patient where limited space is available for componentry. The patient should be able to move through space to complete a task without the terminal device opening and closing involuntarily. The patient should be able to achieve maximum opening or closing of the terminal device with the forearm in 90 degrees of flexion at waist and at mouth levels. For the conventional prosthesis, efficiency is evaluated with the elbow in 90 degrees of flexion . A small spring scale that registers up to 50 lb in l-lb increments is required with adaptors to attach the scale to a hand, hook, or hanger. The control cable is disconnected from the terminal device, and the scale with appropriate adaptor is attached. A 0.5-inch thick wood block is placed in the terminal device. The amount of force required to open the terminal device is recorded. The cable is reattached. Next, the scale with adaptor is attached at the hanger, the proximal end of the cable assembly through which the cable assembly attaches to the harness. Again, the evaluator pulls on the scale, and the amount of force required to open the terminal device is recorded. Efficiency is determined by multiplying force at the terminal device by 100 and dividing it by the force at the hanger. The prosthesis should be at least 80 percent efficient. The patient should be able to achieve at least 50 percent of full available pronation and supination with the prosthe sis in place. In a standard below-elbow socket, active elbow flexion with the prosthesis in place should be within 10 degrees of full available ROM. The prosthesis should n slip distally by more than 1 inch when a heavy axial loa 50 lb, is applied at the terminal device. Orthotic Checkout All custom-fit and custom-fabricated orthoses shou be checked for fit and function. The wearer shou be instructed in recommended wearing schedules and the performance of regular skin checks. Orthoses fa ricated from both high- and low-temperature therm plastics should be checked regularly for signs of we particularly for any signs of potential fracture sites. If an orthosis is fit to restore or augment motion, ongoi documentation should be performed to ensure that th purpose is in fact being met. Once the wearer has ceas to make gains, it must be determined whether an adju ment or realignment is necessary or if no further progre is possible. At that point, the orthosis should be disconti ued, a retaining orthosis fabricated to consolidate the gai made, or an alternative intervention considered. Any wearer of a long-term orthosis should arrange f follow-up with a therapist or orthotist for regular maint nance and reassessment of the continuing necessity of t orthosis. Patients will and do accommodate to the use of orthosis that has long since ceased to bring them a benefit beyond that of a placebo. It is the health profe sional's responsibility to educate patients in the prop usage, including expected outcomes from use, of eve orthosis he or she fits.
- 263. APPENDIX A ANALOGPAIN SCALE Pain levels are marked on a linear pain scale and compared over time. No pain Unbearable pain Patients are given a clean, unmarked form to indicated their subjective pain level each time it is assessed in the FUNCTIONAL PAIN SCALE The focus is on how pain affects performance of functional tasks rather than on the severity or location of pain. Indicate the statement that most accurately reflects how the pain you are experiencing affects you on a daily bas ___ I cannot accomplish any of my daily activities, even with medication. ___ I require rest breaks at least every hour and regular medication to accomplish my daily activities. ___ I can perform activities for 2 to 3 hours before pain interferes and I must rest or take medication. ___ I can usually accomplish all my activities but I am aware of the pain several times a day and take medica least once a day. ___ Iam aware of the pain occasionally but it does not stop my performance of daily activities. I do not requir medication. A clean, unmarked form is used with each assessment of pain levels.
- 264. A P,t~1?,-' ENDI X B bow-Temperature Thermoplastic Characteristics The low-temperature thermoplastics currently available are frequently described by their handling characteristics their handling when warm-and their finished charac teristics-their qualities when cold. Given here is a brief explanation of the terms used to describe these character istics, followed by a description of categories of available materials. CHARACTERISTICS OF WARM OR MOLDABLE MATERIAL Resistance to Stretch. This refers to the tendency of a material to stretch and thin with only the force of gravity pulling on it. Materials with low resistance to stretch tend to conform easily with only minimal effort on the clinician's part. Those materials that resist stretch even with manual force require and tolerate more aggressive handling to achieve conformability. Conformability or Drape. Conformability has a direct correlation with resistance to stretch. If a material has low resistance to stretch, it will have a high degree of conform ability. When laid on the body part, the material will conform intimately around the angles and configurations of that part. Materials with high resistance to stretch have a low degree of conformability and require handling on the clinician's part to achieve good conformability and fit, especially around small parts and bony prominences. Memory. Memory is the ability or tendency for molded material to return to its original cut shape and thickness when reheated. Materials are available with varying de grees of memory, from 100 percent to very slight memo or ability to regain size and thickness if stretched. Self·Sealing Edges. This refers to the tendency of the c edges of material to round and seal together when cut whi warm. Scissors crimp warm material as they cut. Gene ally, materials that have little or no memory seal togeth and stay sealed even when reheated. Materials with hig degrees of memory do not seal as firmly when cut an unseal if reheated. CHARACTERISTICS OF COLD OR MOLDED MATERIAL Rigidity Versus Flexibility. These terms describe th degree to which a molded material will resist deformatio when force is applied. Materials with a high degree resistance to deformation are considered to be rigid. Mat rials that give or deform with force are flexible. Low temperature thermoplastics range from very flexibl highly perforated 1/16 inch (1.6 mm) thick materials, to ve rigid 1/s inch (3.2 mm) or 1/ 16 inch (4.2 mm) materials. Self·Adherence or Bonding. This describes the strength the bond between two pieces of material pressed togeth when warm and cooled. The majority of materials ava able today are coated to resist accidental bonding an require a solvent to remove the coating to allow bondin The strength of the bond varies between materials an is in part dependent on how hot the materials are whe pressed together and whether a wet or dry heat band w used. 242
- 265. - - - THERMOPLASTIC Thelow-temperature thermoplastics currently available fall generally into one of four categories of material depending on their chemical formulas . The materials said to be plastic/ike generally have excellent conformity and drape. When warm they stretch with only the force of gravity, which allows them to conform intimately over body parts with minimal effort on the clinician's part. When cold, plasticlike materials are very rigid and withstand the forces applied by outriggers and resilient components. The rubberlike materials tend to resist stretch and have a low degree of conformability and drape. The resistance to stretch of the rubberlike materials allows them to be like materials generally are flexible and give when pr is applied. Combination plastic and rubberlike materials are able that have midrange characteristics. They d stretch as readily as do the plasticlike materials, bu offer greater ease of conformability than do the rubb materials. Their resistance to deformation when cold than that of the plasticlike and greater than that rubberlike materials. The fourth category of materials is the elastics, have unique handling characteristics because of memory. These materials can be handled and stre aggressively to form circumferential orthoses, and the be readily re-formed by reheating. When cold, materials may be quite rigid if full thickness (l/s in [3.2 or flexible if thin (1/16 in [1 .6 mm]) and highly perfo ---~ t _ - - -
- 266.
- 267. Low 16gb Silicone! TemperatureTemperature Plaster leather Rubber Plastic: Foam Fabric Plastic LamiDat_ Metal Ortllotic. REST AND Short-term, PROTECTION posttrauma, postsurgical RESTORE Serial static MOTION, designs CORRECT DEFORMIlY RESTORE OR AUGMENT MOTION PREVENTION Postoperative use Pro.tllet'c. !POF [POF sockets HARNESS SOCKET Check sockets Long-term use only Excellent for heavy use for cuffs Good durability for long- term use For harness Elk. horsehide. russet Cushioning Good for small protective orthoses Uners to assist with scar management Protection over atrophied parts Protect incision, scar management Uner sleeve for suspension Short-term use, good adjustability Excellent due to easy remolding Attachments easy to add Use for less than 1 y, use when functional return expected Short-term use, trial positioning May use for molding socket Uners for prefabricated or molded orthosis Relieve or distribute pressure Une cuffs for pressure distribution and comfort For safety and comfort, prevent self- injury Cushion and help achieve contact Sleeve liners For short-term or intermittent use Functional activities Semiflexible orthoses Dacron or nylon for harness Long-term use only Polyethylene, long-term use For hand and forearm shells Long-term positioning, polyethylene, polypropylene Shoulder saddles, triceps cuffs Acrylic. epoxy polyester resins Outriggers Aluminum, composits outriggers For dynamic componen Cable system
- 268. 246 UNIT lWO-COMPONENTASSESSMENTS OF THE ADULT Creep--The phenomenon of tissue degradation over time with constant application of pressure. Dynamic spUnt-A molded or contoured body support employing resilient components to produce motion. Force-Any action of one object on another that results in a measurable effect on either or both objects. Hysteresis-The lag or difference between the reaction of a resilient material being stretched or compressed as compared with the same material's response as it relaxes. The variance in response can be displayed graphically as a hystereSiS loop. Moberg pick.up test-Timed test of functional sensi bility involving picking up and placing nine objects with and without visual assist. Moment, or torque-A measurement of the effect of force given by multiplying force times the distance from the axis of a lever where that lever is capable of rotating at its axis. Serial static spUnt-A molded or contoured body support that employs an adjustable static component to produce motion. Static progressive spUnt-An adjustable molded support fabricated for the purpose of increasing joint ROM through frequent remolding and repositioning. Thermoplastics-A group of polymer-based materials that become moldable with heat and that retain a molded shape when cooled. REFERENCES American Academy of Orthopaedic Surgeons. (1975). Atlas of orthot ics. St. Louis, MO C. V Mosby Company. American Society of Hand Therapists. (1992). Splint classification system. Chicago: American Society of Hand Therapists. Ashbell, T., Kutz, J., & Kleinert, H. (1967). The digital Allen test. Plastic and Reconstructive Surgery, 39, 31l. Bell-Krotoski, J. A, Breger, D. E., & Beach, R. B. (1990). Application of biomechanics for evaluation of the hand. In Rehabilitation of the hand: Surgery and therapy (3rd ed.). St. Louis, MO: C. V Mosby Company. Bell-Krotoski, J. A (1990). Light touch-deep pressure testing using Semmes-Weinstein monofilament. In Rehabilitation of the hand: Surgery and therapy (3rd ed.). St. Louis, MO C. V Mosby Company. Brand, P. W. (1993). Clinical mechanics of the hand (2nd ed) St. Louis, MO: C. V Mosby Company. Callahan, A D. (1984). Sensibility testing: Clinical methods. In Rehabili tation oj the hand (2nd ed.). St. Louis, MO: C. V Mosby Company. Dellon, A L. (1981). Evaluation of sensibility and reeducation of sensation in the hand. Baltimore: Williams & Wilkins. Fess, E. E., & Philips, C. A (1987). Appendixes In Hand splinting principles and methods. St. Louis, MO: C. V Mosby Company. Fess, E. E., & Philips, C. A (1987). Hand splinting principles and methods. St. Louis, MO: C. V Mosby Company. Flowers, K R., & Pheasant, S. D. (1988). The use of torque angle curves in the assessment of digital joint stiffness. Journal of Hand Therapy, 1(2),69. Gelberman, R. H., et al. (1983). Sensibility testing in peripheral nerve compression syndromes: An experimental study in humans. Journal of Bone and Joint Surgery, 65A, 632. Guilford, A. , & Perry, J. (1975) Orthotic components and systems Atlas of orthotics: Biomechanical principles and applicat St. Louis, MO: C. V Mosby Company. Haberman, L. J. (1995). Silicone-only suspension with socket-lock the ring for the lower limb.Journal of Prosthetics and Orthotics, 7 Jacobs, R. R., Brady, W. M. (1975). Early post-surgical fitting in up extremity amputations. Journal of Trauma, 15(22), 966-968. Kendall, H . 0., Kendall, F. P., & Wadsworth, G. E. (1971). Mus testing and function . Baltimore: Williams & Wilkins. Merskey, H . (1973). The perception and measurement of pain. Jour of Psychosomatic Research, 17, 251-255. Mildenberger, L. A , Amadio, P. c., An, K N. (1986). Dynamic splint A systematic approach to the selection of elastic traction. Archive Physical Medicine and Rehabilitation, 67, 241-244. Moberg, E. (1958). Objective methods for determining the functio value of sensibility in the hand. Journal of Bone and Joint Surg 40B, 454 . Nalebuff, E. A , Philips, C. A (1984). The rheumatoid thumb Rehabilitation of the hand (2nd ed .). St. Louis, MO: C. V Mo Company. Prosthetic Orthotic Center. (Undated). Upper limb orthotics for orthot Manual for orthotics 721 . Chicago: Northwestern University Med School. Redford, J. B. (1986) Materials for orthotics. In Orthotics etc. (3rd Baltimore: Williams & Wilkins. Roberson, L., Breger, D. , Buford, w., & Freeman, M. J. (1988). Anal of physical properties of SCOMAC springs and their potential us dynamic splinting. Journal of Hand Therapy, April-June 1(2). Rose, G. K (1986). Orthotics: Principles and practice. London: Wil Heinemann Medical Books. vonPrince, K, & Butler, B. (1967). Measuring sensory function of hand in peripheral nerve injury. American Journal of Occupatio Therapy, 21, 385. Weaver, S. A , Lange, L. R. , & Vogts, V M. (1986). Comparison myoelectric and conventional prosthesis in adolescent amput Philadelphia: Hospitals for Crippled Children. Wright, V , & Johns, R. J. (1961). Quantitative and qualitative analys joint stiffness in normal subjects and in patients with connective tis disease. Annals of the Rheumatic Diseases, 20, 36. Yamada, H. (1970) In F. G. Evans (Ed.), Strength of biolog materials. Baltimore: Williams & Wilkins. BIBLIOGRAPHY Burkhalter, W E., Mayfield, G, & Carmona, L. S. (1976) The up extremity amputee: Early and immediate post-surgical prosth fitting. Journal of Bone and Joint Surgery, 58A (1) . Childress, D. S. (1981). External power in upper limb prosthetics American Academy of Orthopaedic Surgeons, Atlas of limb prost ics, surgical and prosthetic principles. St. Louis, MO: C. V Mo Company. Day, H . J. (1981). The assessment and description of amputee acti Prosthetics and Orthotics International, 5(1), 23-28. Fryer, C. M. (1981). Upper limb prosthetic components. In Amer Academy of Orthopaedic Surgeons, Atlas of limb prosthetics, su cal and prosthetic principles. St. Louis, MO: C. V Mosby Compa Jacobsen, S c., & Knutt, D. (1973). A preliminary report on the U arm . Salt Lake City, UT: University of Utah. Lamb, D. W (1993). State of the art in upper-limb prosthetics. Jour of Hand Therapy 6(1), 1- 8. Maiorano, L. M. , & Byron, P. M. (1990). Fabrication of an ear prosthesis In J. M. Hunter, L. H. Schneider, E. J. Mackin, & A Callahan (Eds.), Rehabilitation oj the hand. Philadelphia : C. V Mo Company. New York University, Post Graduate Medical School. (1982). Prosthe and orthotics, upper limb prosthetics. New York: New York Uni sity. Olivett, B. L. (1990). Adult amputee management and conventi prosthetic training. In J. M. Hunter, L. H. Schneider, E. J. Mackin A D. Callahan (Eds.), Rehabilitation of the hand. Philadelp C. V Mosby Company. Sanderson, E. R., & Scott, R. N. (1985). UNB Test oj Prosth Function: A test Jor unilateral upper extremity amputees. N Brunswick, NJ: Bio-engineering Institute, University of New B swick.
- 269. UNIT THREE Assessmentof Central Nervous System Function of the Adult
- 271. C HAP TE R 1 1 Motor Recovery After Stroke Joyce Shapero Sabari, PhD, OTR SUMMARY Stroke survivors cope with a variety of motor, sensory, cognitive, per ceptual, psychological, social, and functional disabilities. This chapter focuses on the motor impairments associated with cerebrovascular accident and examines standardized assessments that evaluate motor performance after stroke. Problems of motor performance in individuals with stroke are complex and varied. Reha bilitation specialists have not yet reached consensus about the sequence of recovery or the preferred intervention strategies for improving motor performance in this population. Therefore, many therapists still use nonstandardized, qualitative evalua tion tools that reflect their unique clinical philosophies. This chapter reviews the major therapeutic approaches to treating motor dys function in individuals with hemiplegia due to stroke and describes the major as sessment tools that reflect each of these approaches. Research data to support the reliability and validity of these tools are provided. HISTORY AND THEORY OF THERAPEUTIC APPROACHES TO ENHANCE MOTOR RECOVERY AFTERSTROKE Hemiplegia, or paralysis of one side of a person's body, has long been a recognized residual of cerebrovascu lar accident. However, early rehabilitative efforts with hemiplegic individuals focused only on teaching functional strategies to compensate for motor deficits or attempted to improve muscle strength and range of motion using treatments designed for patients with orthopedic or pe ripheral nervous system disorders (Gordon, 1987). It wa not until the latter half of this century that physicians and therapists began to search for unique descriptions and explanations of the motor behaviors demonstrated by stroke survivors. Twitchell's Findings Twitchell's (1951) study of the sequence of moto recovery of 121 patients with hemiplegia generated find ings that continue to influence the evaluation and treatmen ...:::..=-:,:..~-- ==-~ ,. :.- ..- ~ 249
- 272. 250 UNIT THREE-ASSESSMENTOF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT of persons with stroke. This descriptive, longitudinal study of individuals with occlusive cerebrovascular accidents observed motor recovery of both upper and lower limbs but focused on function in the arm and hand. Twitchell noted that the patients studied progressed uniformly through a series of recovery stages. All patients began with total, flaccid paralysis of limb muscles. This was followed by the demonstration of positive stretch reflexes in selected muscles, and the influence of tonic neck reflexes on active movement and muscle tone in the arm and leg. Patients whose recovery was not arrested at one of these early stages progressed to demonstrate active perfor mance of gross, stereotypic movement patterns. Twitchell termed these gross patterns the flexor and extensor limb synergies. Patients who continued to progress eventually performed voluntary hand movements, as well as active arm and leg movements that deviated from the limb synergies. Of the 121 patients in Twitchell's study, 25 were observed until a comparatively stable condition had been reached. After 3 months, five patients demonstrated full recovery. The remaining participants varied in the levels of recovery they achieved. The Brunnstrom Approach Signe Brunnstrom (1970) applied Twitchell's findings and her own clinical experience to develop a program that would gUide persons with hemiplegia through the following six stages toward motor recovery: Stage 1: flaccidity Stage 2: associated reactions/developing spasticity 'lAI3LI' ] ] - ] SYNERGIES OF DIE UPPER AND LOWER UMBS Flexor Synergy: Extensor Synergy: Uppel'Umb Uppel'Umb Elbow flexion Elbow extension Forearm supination Forearm pronation Shoulder abduction (to 90 Shoulder adduction (front of degrees) body) Shoulder external rotation Shoulder internal rotation Shoulder girdle retraction Shoulder girdle protraction Shoulder girdle elevation Flexor Synergy: Extensor Synergy: Lower Limb Lower Limb Toe dorsiflexion Toe plantarflexion Ankle dorsinexion and Ankle plantarflexion and inversion inversion Knee flexion Knee extension Hip flexion, abduction, and ex Hip extension, adduction, and ternal rotation internal rotation Data from Brunnstrom, S. (1970). Movement therapy in hemiplegia: A neurophysiological approach. New York: Harper & Row. TABLE ]] -2 HANDFUNCTION-SEQUENCE OF RECOVERY Mass grasp Hook grasp Lateral prehension Palmar prehension CylindriC grasp Sphericgrasp Release of grasp Individual finger movements Manipulative tasks Affected hand as an assist Affected hand as dominant Data from Brunnstrom, S. (1970). Movement therapy in hemiplegia: A neurophysiological approach. New York: Harper & Row. Stage 3: severe spastiCity/active movement in synergy patterns Stage 4: some movements deviating from synergy patterns Stage 5: active movements isolated from synergy pat terns Stage 6: isolated active movement with near normal speed and coordination Brunnstrom clearly categorized the flexor and extensor synergies of the hemiparetic arm and leg (Table 11-1). Other contributions included a postulated sequence of recovery in hand function (Table 11-2) and a clearly defined sequence of movement patterns hemiparetic indi viduals are expected to achieve as they recover the ability to perform movements that deviate from the gross limb synergies. In addition, Brunnstrom (1970) superficially introduced the concept that balance and postural abnormalities are common motor residuals of stroke. Brunnstrom proposed that therapists evaluate balance impairments by (1) assess ing patients' tendencies to list toward the affected side when sitting unsupported, and (2) observing patients' responses to forceful manual disturbance of their unsup ported sitting posture. Neurodevelopmental Treatment While Brunnstrom's program sought to facilitate motor recovery by encouraging the development of primitive reflexes and active movement in synergy patterns, Berta Bobath's (1970, 1978) approach followed an opposite course. Neurodevelopmental treatment (NOT) for adults with hemiplegia was designed to minimize the develop ment of spasticity and to prevent the learning of stereotypic patterns of movement. Neurodevelopmental treatment viewed the motor im pairments of stroke survivors from a broader perspective than Brunnstrom and Twitchell. In addition to limb paraly sis, descriptions of hemiplegia were expanded to include
- 273. (1970, 1978) introducedtherapists to the roles of righting and equilibrium reactions for maintaining balance in up right positions. Furthermore, training in performance of gross transitional movements from one posture to another was included in the restorative treatment protocol. Previ ously, individuals with hemiplegia were taught only com pensatory strategies for achieving mobility in rolling, achieving sitting, and rising to stand. The NDT approach considered improvements in the procedures used to per form such tasks to be indicative of motor recovery. Finally, NDT emphasized the interrelationships between position ing of specific body segments and motor control at other regions. For example, control of shoulder and elbow movements is facilitated by assumption of the supine position, as well as by enhanced mobility at the pelvis. Bobath's (1970, 1978, 1990) treatment program for adults with hemiplegia differed Significantly from Brunnstrom's approach in its use of closed kinematic chain movements, or weight bearing, in the therapeutic se quence toward motor recovery. Like the Rood (1954, 1956) and proprioceptive neuromuscular facilitation (PNF) (Knott and Voss, 1956) interventions, NDT recognized that activities in which the limbs served as distal supports for proximal movement (or weight shift) played an important developmental role in the acquisition of motor control. Bobath's treatment attempted to bypass movement in synergy patterns by teaching patients to exercise muscles in closed, rather than open, kinematic chains. Neurodevelopmental treatment recognizes the need for mobility, or disassociation, between adjacent body seg ments, su