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New clinimetrics methods in physiotherapy


Intuition and clinimetrics, is it time to change the paradigm?
Rather not!

New clinimetrics methods in physiotherapy

New clinimetrics methods in physiotherapy

In medicine for a long time, perhaps even from its ancient beginnings, there have been co-existing two methods to assess the health status of the patient: “synthetic” and “analytical.”

Synthetic means comprehensive and the most subjective judgements based primarily on their own experience and their own choice of sources of knowledge. The criteria of judging are often not accurately described, and sometimes not fully realized by the evaluator.

This knowledge is a kind of intuition which for the talented and experi­enced people can be really effective, but hardly subjected to the description or comparative analysis. Moreover, such an assessment becomes possible only with a fairly large professional practice.

The analytical method is based on “spread” of disease, dysfunction or the health of the patient to several dozen or hundreds of components analysed separately. This analysis is based mostly on measuring and recording volume analysed as numbers. A classic example would be the temperature of the body (of course it is possible to distribute it over a number of measurements made at various locations such as the armpit and mouth). Febrile curve for centuries was an essential component of a hospital bed. This tradition was ended after introducing of personal data protection act.

In the second half of the twentieth century there were more courageous attempts to tackle what for centuries seemed to be immeasurable. These are such variables as well being of the patient, their performance, and mood. I am not sure, but it seems to me likely that this fashion has come to medicine from the side of psychology which is seeking for itself the status of genuine science.

This trend has formed part of a more general trend of a measure in science, measuring the effectiveness of science itself at the forefront. I think that nowa­days anyone who even brushed the study, knows indicators such as „impact factor”, citation index and knows what “Philadelphia List” is. At this point it should probably be noted that thoughtless applying the same measuring cup to the disciplines of a “fast market” science like pharmacology and slower like mathematics, could easily lead to a hasty conclusion about the intellectual superiority of pharmacologists over mathematicians.

Measuring the immeasurable was more difficult than expected and it was necessary to create a new discipline: the so-called “metrics”. Among them was the title character of this monograph clinimetrics, according to the profile of interests of our faculty, this time it focuses on the physiotherapy.

At this point it is worth noting that physiotherapy, although one of the oldest medical disciplines, is still struggling with the development of effec­tive methods to assess its effectiveness. Of course, the clinimetrics is still alive in the period of development, especially development and validation of scales, creating new standards and assessing their suitability. Therefore, we are observers of an extremely interesting period until the formation of a new discipline of science, where a lot can still change.

Clinimetrics should allow physiotherapy a greater involvement in the creation of evidence-based medicine., But at the same time it should allow also a critical analysis of drug based therapy.

The monograph, which we give into the hands of readers, is written by teams of authors from several centres and refers to a substantial part of the problem of clinimetrics in physiotherapy in significant part from Faculty of Physiotherapy and Pedagogy of Zamość University of Management and Administration. However, despite the effort and talent’s strengths, it is un­fortunately not possible to cover all of it. Nevertheless, we recommend it, not only to physiotherapists, but also to rheumatologists, neurologists, and endocrinologists, pulmonologists, family doctors and students of medical faculties, and of course to students of physiotherapy. Perhaps in the future clinimetrics will be once again the subject of subsequent symposia and the subject of publications also at our university.

Probably the method new today will be replaced tomorrow by a more recent and more accurate one.

I hope that somewhere along the way we will not get lost in the overall syn­thetic image of the sick man. In medicine, including one of its most important disciplines, physiotherapy, tomorrow there will also be space for a synthetic, holistic approach to the sick man
I also expect that there will be space for intuition which will allow us to im­mediately find the appropriate way to distinguish the important from unimportant. I would not be very much surprised if tomorrow scientiometrics also described precisely what intuition in medicine is. And, of course, how to measure it.

Krzysztof Marczewski
Dean of Faculty of Physiotherapy and Pedagogy
of Zamość University of Management and Administration


Waldemar Brola, Małgorzata Fudala, Józef Opara, Jan Czernicki, Waldemar Szwejkowski
New standards in the clinicometric evaluation of patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic disease resulting in a disability and worsening of the life quality. Due to the heterogeneity of the clinical symptoms, the evaluation of the nervous system becomes a very challenging task and some of the frequent MS symptoms (vision disorders, fatigue, pain and cognitive dysfunctions) are difficult to assess with typical clinical tests. The scale used commonly to measure the disorders of the nervous system (EDSS) failed to be a successful means for the evaluation. In response, the National MS Society in the USA created new tests for the objective evaluation of the patients, and these tests became the new standard. It was the consensus of the committee that the complex three-element test of the MSFC function (MS Functional Composite) should be introduced. The three elements of the test are: T25FW (Timed 25-Foot Walk) evaluating the time needed to walk 25 feet, 9HPT (9 – Hole Peg Test) measuring the time needed to insert 9 pegs into 9 appropriate holes, and PASAT (Paced Auditory Serial Addition Test) measuring the cognitive functions as well as calculating ability. It is also recommended to include the AI (Ambulation Index) into the test. The MSFC test concentrates on the abilities and coordination of the upper and lower extremities as well as the unilateral evaluation of cognitive disorders. None of the methods take into consideration the actual condition of the vision and that is why the Low-Contrast Sloan Letter Chart Testing is advised. To complete the evaluation, the SDMT (Symbol Digital Modalities Test) is conducted. In this test cerebral dysfunctions in patients are detected basing on the patients’ ability to pair symbols with numbers. All the new clinical methods serve the objective evaluation of MS and show a good correlation of the results in the EDSS scale and the NMRI. The fact that they can be conducted by the middle-level medical personnel is their great value, whereas EDSS needed the evaluation of an experienced physician.

Łukasz Oleksy, Renata Kielnar, Anna Mika, Anna Marchewka, Andrzej Kwolek
Complex evaluation of the masticatory system with optoelectronic motion analysis and surface electromyography

Background: Modern hardware can record movement with great accuracy which provides more capabilities, especially for small joint movements, where small trajectory deviations could be signs of dysfunction. An additional advantage is the ability to simultaneously record muscle’s bioelectrical activities.
Aim: To propose the application of optoelectronic motion analysis and surface electromyography as a comprehensive tool used for stomatognatic system evaluation and the assessment of the reliability of these devices.
Material and Method: 25 subjects aged 20-25 years without any masticatory system dysfunction participated in this study. Measurements of the mandible’s kinematics were assessed with motion capture system SMART (BTS) and the bioelectrical activity of the masseter and temporalis anterior muscles were measured with electromyography PocketEMG (BTS). These measurements were taken simultaneously. For the purpose of reliability, all measurements were taken twice: once during the initial assessment and again 3 days later. The intra-class correlation coefficient (ICC) between measurements and between subjects was calculated.
Results: The mandible kinematics ICC between measurements and days reached high repeatability for abduction, and for the rest of the tested movements ICC characterized good repeatability. For sEMG parameters the ICC between measurements and days for each measured movement reached moderate repeatability.
Conclusion: Complex evaluation of mandible kinematics assessment with motion analysis system and surface electromyography is a valuable and reliable device for such analysis.

Grzegorz Przysada, Mariusz Drużbicki, Andrzej Kwolek
Analysis of rehabilitation effects assessed by means of selected scales in a group of patients after cerebral stroke treated in rehabilitation ward

For a long time, cerebral stroke constitutes one of the most important interdisciplinary issues of modern medicine, because of its high frequency of occurrence, high mortality rate and, especially in the early period of the disease, seriousness and complexity of the related disability resulting in a long process of treatment and rehabilitation. The objective of this study is to determine to what degree different scales used to assess the patient’s state are correlated with each other and thus reliable and appropriate for the purpose of the rehabilitation effect assessment in this group of patients. Material and method. The study included all patients after cerebral stroke qualified for treatment in the rehabilitation ward in the years 2002–2005. A total number of 431 patients were admitted either directly from neurological wards, after qualification by medical rehabilitation physician, or from rehabilitation outpatient clinic. Patients with non-compensated cardiovascular and respiratory system insufficiency and patients who have been specifically qualified for medical care under conditions of long-term care ward were not qualified for the study. The concept of the so-called overall fitness, including communication with the people around the patient (communication ability), mental condition, sphincter function, cardiovascular system efficiency, and functional state was used in the assessment of patients’ conditions and rehabilitation progress. As another criterion of the assessment, the Brunnström test was adopted. The level of efficiency in scope of basic self-care activities was also assessed with Barthel index. Results. Patient condition assessment scales applied in this study to a group of patients after cerebral stroke turned out to be rather weakly inter-correlated, which means that they measure different aspects of human health. The conclusion speaks in favor of concurrent application of different methods that would enable an objective and comprehensive assessment of the obtained treatment results and changes occurring during the rehabilitation process. Conclusions. In patients after cerebral stroke, concurrent application of several different patient state assessment scales allows for proper qualification of subjects for rehabilitation, development of long term forecasting, estimation of required care resources, and improvement of analysis of the obtained results and changes occurring during rehabilitation process.

Marta Topolska, Rafał Sapuła, Marek Maciejewski, Krzysztof Marczewski
The simple anthropometric methods to assess obesity – author’s own observations

Background: Measurement of fat meter allows us to specify the thickness of the fold of skin – the fatty, obesity and subcutaneous fat distribution type. Based on the distribution of body fat in different parts of the body it is possible to evaluate health risks, implement preventive measures and implement effective treatment.
Goals: The aim of this study is to analyze the distribution and changes in body fat for men and women aged 18-87 years.
Material and methods: The study was conducted from May 2009 to July 2010 in Rehabilitation Clinic of Zamość University of Management and Administration on a random group of 677 people. The survey was conducted on people aged 18 to 87 years. Age ranged from 47.2 years for men and 43.7 years for women. In order to determine the thickness of subcutaneous fat tissue there was used electronic fat meter PF – 4 connected to the computer system.
Results: The highest total thickness of the fold of skin – fatty acids found in women aged 60-69 years and amounted to 144.84 mm. The highest total thickness of the fold of skin – the fatty reached the men aged 18-29 years and amounted to 115.67 mm. The average thickness of all the folds of skin – for women in the study group was 126.06 mm, 105.12 mm in the case of men.
Conclusions: As results from studies younger women have a greater accumulation of subcutaneous fat on limbs and type of gynoidal obesity, whereas older women have a greater accumulation of subcutaneous fat on the body and androidal type of obesity. Regardless of age, males have a greater accumulation of subcutaneous fat on the body and androidal type of obesity. Normal BMI was found among only 43.36% of people and others had problems with overweight and obesity. The percentage of women with a coefficient of WHR > 0.8 increases with age. Measurement by fat meter is a method that allows you to quickly diagnose the type of obesity.

Rafał Sapuła, Piotr Dropek, Andrzej Lesiak, Marta Topolska
Functional analysis of hand in children with cerebral palsy

Introduction. Professor Andreas Peto, the inventor of the Conductive Learning system and the founder of the Peto Institute, once said: „If I was to start my life all over again, I would only work on hand”. Anyone who considers improving the mobility of hand, as one of the first objectives to be accomplished in the rehabilitaion process will soon realize the wisdom of those words. What makes the human hand unique is the development of cerebral cortex, and cortex control of the movements. When we look at the hand, we can see perfection in the layout of bones, muscles and tendons, but it is the neural mechanism that initiates, coordinates and controls movement and makes the hand perfect and special. It is what allows the hand to organize life around us.
Aim of the study. The aim of the study was to evaluate the function of hand in children with cerebral palsy based on objective and subjective tests.
Material and methods. The study was conducted on 41 subjects with cerebral palsy aged between 6 and 23 years. The control group consisted of 39 people, in similar age range. The study was divided in two parts – subjective and objective. The subjective part comprised: Zancolli classification, Haus classification, and MACS functional scale, the objective part consisted of measurement of grip force and range of movement in cylindrical grip on the DIAGREH device.
Results and conclusions. Muscular strength, range of movement and function of the hand of a child with cerebral palsy is worse than in healthy children. Higher functional level coexists with higher muscular strength of hand. Flexion contracture of fingers doesn’t affect the range of movement in cylindrical grip. Extent of finger contracture is bigger in children with more severe brain damage. Higher functional level is seen in children with less pronounced flexion contracture of fingers. Flexion contracture of II-V fingers usually coexists with contracture of the thumb. Contracture of the thumb doesn’t affect the range of hand movement in cylindrical grip.

Krzysztof Mataczyński, Mieczysław Kowerski, Paweł Kalinowski, Mateusz Pelc
The rehabilitation results of patients hospitalized due to serious damages of central nervous system

Background: Damages of central nervous system (CNS) against the background of vascular system but also injuries are the examples of main problems of contemporary medicine. Beyond these enumerated reasons, more and more often rehabilitated are patients with a developing cancer process – primary or secondary within CNS, causing very serious repercussions and somatic and psychic dysfunctions. Early rehabilitation of serious damages of central nervous system should be multidirectional, focused on treatment and restitution of lost motor functions, acting against coexisting depression and nervous breakdown.
Aim of work: Presentation of rehabilitation results of patients hospitalized due to serious damages of central nervous system, results of this hospitalization, the most frequent coexisting diseases. Material and method: The retrospective analysis of medical documentation of 111 hospitalized patients was made. The patients were hospitalized on Rehabilitation Ward of Pope John Paul II Regional Public Hospital in Zamość from December 2008 to January 2010. They were admitted to so called Rehabilitation of Serious Damages CNS, with number of points – 5, in Rankin’s scale. Results at the beginning and at the end of treatment were compared with the use of Barthel Index, everyday clinical observation, and medical documentation of hospitalized patients made by doctors and nurses. Coexisting diseases were also taken into consideration. For statistic calculations the paired two sample for means t-test, correlation analysis and linear regression model were used. The level of significance is p= 0,05.
Results: Within the researched group there were 111 people with average hospitalization time – 40 days. The reasons for hospitalization were: cerebral infraction concerning 68 people, hemorrhagic – 22 people, brain and core injuries – 14 people and cancer disease of CNS – 7 people. The average number of Barthel Index increased from 15,7 points at the beginning of treatment to 40,3 points after the end of treatment. Significant improvement (at the level 0,00004) affected average values of all elements of Barthel Index. Evaluations of Barthel Index before and after the therapy are remarkably higher (appropriately at the level of significance 0,0327 and 0,0266) in the case of city citizens. As a result of the therapy the average result among women increased from 14,6 to 32,4 points, however, among men it raised much more – from 16,8 to 47,7 points. As the consequence, after the end of therapy, the average value among men was significantly higher than among women, which means that the therapy used was more successful in the case of men than women. The best, in the sense of criteria of quality used (the significance of parameters at the level at least 0,05 and maximum value of determination coefficient) was the regression model of Barthel Index after the therapy, where explanatory variable was the value of Barthel Index before the therapy, hospitalization type, patient’s age and sex. What is more, lengthening of hospitalization time conduced the improvement of therapy results. On the other hand, the older the patient was, the worse the results of therapy were. In the case of male patients – better by 10,2 points according to female patients of the same age, hospitalized through the same period of time and having the same Barthel Index at the beginning of therapy, was the value of Barthel Index at the end of treatment.
At Rehabilitation Ward hospitalizations caused by serious damages of central nervous system were mostly caused by vascular brain damages, out of 111 hospitalizations 90 were strokes. In this case intensive hospitalization is compulsory. In the case of all patients there appeared diseases, which hindered and lengthened the rehabilitation process, especially against the background of hypertension, sclerosis and diabetes. These diseases had negative influence on the result of the therapy, however, it was not statistically important. The final results of the therapy depended especially on: the patient’s health state at the beginning of the therapy, time of hospitalization, age and sex of the patient. The coexisting diseases had negative but not significant impact on the effects of therapy.

Monika Bal-Bocheńska, Adrian Kużdżał
The importance of evaluating the level of anxiety and life quality of people suffering from bronchial asthma and undergoing respiratory rehabilitation

no abstract

Adrian Kużdżał, Grzegorz Magoń, Ewa Szeliga, Filip Georgiew
Evaluation of dysfunctions of sacroiliac joint in intellectually disabled girls and boys in comparison to the control group

Background The weight of almost whole body is supported on the sacral bone that is pressed between pelvic bones – and created this way sacroiliac joints. Porous surfaces of these joints allow small movements but very important because of amortization and balance functions. Clinical evaluation of sacroiliac joint is an important part of preventive clinical examination of body posture in children and youth. The aim of this study was to assess the dysfunctions of sacroiliac joints in groups of girls and boys with intellectual disability.
Material and Method The subjects were 204 girls and boys aged 11-13 with intellectual disability. 209 healthy boys and girls constituted the control group. The following features were assessed: personal and clinical data, morphological parameters: body height, body mass, BMI. Biomechanical parameters of the pelvic region were assessed using the device to three-dimensional anthropometric analysis, as well as by orthopaedic manual examination and additional clinical tests: Derbolowski and Thomas. To examine pain of the joints provocative tests of distraction, compression, rotation, springing and Patrick’s test were used. Intergroup differences were statistically analyzed.
Results Painful sacroiliac joint in analyzed groups were more frequent in intellectually disabled group in comparison to the control group consisting of mentally fit coevals. The pain of sacroiliac joint was detected in 46% of research group. Asymmetry and block of SI joint were detected in 44% of research group – the most often in children with severe intellectual disability. Asymmetry and block of SI joint were more frequent in intellectually disabled subjects. Functional shortening of leg length in analyzed groups were more frequent in intellectually disabled subjects. All intergroup differences were statistically significant.
Conclusions Asymmetry and block of sacroiliac joints are frequent in children with intellectual disability. As frequent as asymmetry is the pain of this region of the body. The more intellectual disability the more frequently dysfunctions of sacroiliac joint appear. The diagnosis of body posture in intellectually handicapped children should include also a diagnosis of sacroiliac joint. In medical rehabilitation of intellectually retarded children there should be used more appropriate methods of rehabilitation and corrective therapy of spinal dysfunctions that would account also for the level of severity of mental deficiency. Key words: intellectual disability, sacroiliac joint, diagnosis, dysfunction.

Mariusz Drużbicki, Grzegorz Przysada, Agnieszka Klus
Clinical Methods of Gait Assessment in Patients with Post-stroke Hemiplegia

Gait assessment is a component of overall functional examination with special importance in patients with neurological diseases, including those with post-stroke hemiplegia. The assessment of efficiency in the area of gait is a sensitive measure of patient’s efficiency and progress achieved in rehabilitation. The contemporary medicine, and rehabilitation science in particular, needs reliable and tangible evidence in support of effectiveness of the therapeutic process. Methods of gait assessment include laboratory procedures providing detailed space-time, kinetic and kinematic data, as well as visual observation methods, gait assessment scales among them. The aim of this paper consists in presentation of selected point-scoring scales applicable to assessment of gait in patients with hemiplegia after cerebral stroke. Gait assessment scales can be divided into two groups. The first group comprises functional assessment scales, injury scales, and quality of life scales, where the gait assessment represents one of scale components, in most cases concerning gait ability and realization of tasks in various conditions. Scales of the second group are oriented on gait assessment from qualitative and quantitative perspective and include: Wisconsin Gait Scale, Dynamic Gait Scale, Gait Assessment Rating Scale, Rancho Los Amigos Gait Analysis Form — Observational Gait Analysis. A single, clinical observational scale that could be used for gait assessment and be commonly adopted as the best one still awaits creation. However, although the use of the existing scales is inevitably associated with subjectivity related to knowledge and experience of the rater, on the other hand, they constitute simple tools that can be utilized in everyday clinical practice.

Agnieszka Bejer
Validation analysis of Polish version of the Stroke-Specific Quality of Life Scale

The author has made a linguistic adaptation of the Stroke-Specific Quality of Life scale (SSQoL) written by Linda Williams et al. As a result she has obtained a Polish version of the scale, which takes into consideration a wide range of functional, emotional and social problems that are typical of stroke patients. The aim of the research is the evaluation of some psychometric properties of the Stroke-Specific Quality of Life scale.
Materials and methods: The research was conducted among patients treated in 2007 and 2008 at two rehabilitation units. One hundred patients aged 41-80 were qualified for the study. In the validity process of SSQoL the following were used: Barthel Index, Scandinavian Stroke Scale, Beck Depression Inventory and the SF-36.
Results: A high degree of internal consistency has been acknowledged for most SSQOL subscales (a >0.80). The scale is characterized by good stability assessed with the use of „test-retest” method (for r=0.74 – 0.93 subscales). Both the general result and the nine subscales have an excellent or moderate convergent validity (r>0.30). The SSQOL also indicates a satisfactory theoretical validity assessed by analyzing the internal structure and with the use of external criterion. Most SSQOL subscales show either a satisfactory or excellent responsiveness to changes in the condition of the examined (r=0.30-0.72).
Conclusion: High reliability of the SSQoL scale, good convergent validity and construct validity, as well responsiveness to changes makes the scale a reliable tool to assess the quality of life of people after stroke.


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