Upper-extremity Disability Research Articles

Les échelles d'incapacité fonctionnelle de l'épaule : revue systématique

Objectives. – To identify all available shoulder disability questionnaires designed to measure physical functioning and to examine those with satisfactory clinimetric quality. Methods. – We used the Medline database and the “ Guide des outils de mesure de l'évaluation en médecine physique et de réadaptation” textbook to search for questionnaires. Analysis took into account the development methodology, clinimetric quality of the instruments and frequency of their utilization. We classified the instruments according to the International Classification of Functioning, Disability and Health. Results. – Thirty-eight instruments have been developed to measure disease-, shoulder- or upper extremity-specific outcome. Four scales assess upper-extremity disability and 3 others shoulder disability. We found 6 scales evaluating disability and shoulder pain, 7 scales measuring the quality of life in patients with various conditions of the shoulder, 14 scales combining objective and subjective measures, 2 pain scales and 2 unclassified scales. Older instruments developed before the advent of modern measurement development methodology usually combine objective and subjective measures. Recent instruments were designed with appropriate methodology. Most are self-administered questionnaires. Conclusion. – Numerous shoulder outcome measure instruments are available. There is no “gold standard” for assessing shoulder function outcome in the general population.

Measures of Physical Performance and Risk for Progressive and Catastrophic Disability: Results From the Women's Health and Aging Study

Physical performance measures can predict incident disability, but little research has assessed and compared how these measures predict progressive and rapid-onset (catastrophic) disability. The authors evaluated the ability of upper and lower extremity performance measures to predict progressive and catastrophic disability in activities of daily living (ADL), mobility, and upper extremity function. The incidence of progressive and catastrophic disability was assessed semiannually during a 3-year period in 884 women participating in the Women's Health and Aging Study I. Four-meter walking speed, balance, and chair stands tests were used to evaluate lower extremity function. The putting-on-blouse test, the Purdue pegboard test, and grip strength were used to assess upper extremity function. Summary performance scores (SPS) for the lower and upper extremities were calculated. Among participants in whom disability developed, those who reported no difficulty in the previous year were defined as cases of catastrophic disability, and those who previously reported little or some difficulty were considered to be cases of progressive disability. Cox proportional hazard regression analyses were used to evaluate the association of performance measures and time to incident disability. The predictive ability of performance measures was compared using receiver-operator characteristic curves. All lower and upper extremity measures, with the exception of grip strength, significantly predicted the onset of progressive ADL disability, but only walking speed was significantly associated with the onset of catastrophic ADL disability. The chair stands test, walking speed, and the lower extremity SPS were significantly associated with the onset of both progressive and catastrophic mobility disability. Only lower extremity individual tests and SPS significantly predicted the onset of both progressive and catastrophic upper extremity disability. The receiver-operator characteristic curves for ADL and mobility disability showed that all performance measures evaluated had a greater predictive ability for progressive than for catastrophic incident disability. This finding was not consistent for upper extremity disability. The areas under the curve for walking speed and lower extremity SPS were very similar, ranging from 0.58 to 0.81 and from 0.57 to 0.85, and the predictive ability of these two measures was the greatest for all disability outcomes assessed. Physical performance measures of lower extremity and, in particular, walking speed and lower extremity SPS are valuable tools to predict different forms of disability, especially those with a progressive onset.

Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures

There have been few prospective studies of elderly patients with conservatively treated distal radius fractures and little is known about the relationship between acceptable radiographic reduction and functional outcomes in this population. We hypothesized that acceptable fracture reduction (according to standard radiographic dorsal/volar tilt criteria) would be associated with better functional outcomes and greater satisfaction. Seventy-four patients who were at least 50 years of age with conservatively managed distal radius fractures were recruited from 2 large urban emergency departments from January 2001 to December 2001. Patients with wrist fractures treated in the emergency department and discharged home were included; patients admitted to the hospital or who required surgical reduction were excluded. Standard lateral radiographs were taken after the final cast was removed. These were reviewed independently by a reference-standard musculoskeletal radiologist and the degree of dorsal/volar tilt was recorded. This value was dichotomized according to standard published dorsal/volar tilt criteria as acceptable (dorsal tilt <10 degrees or volar tilt <20 degrees ) or unacceptable (dorsal tilt >10 degrees or volar tilt >20 degrees ). The Medical Outcomes Study Short-Form 12 (SF-12); the Disabilities of the Arm, Shoulder, and Hand questionnaire; and a patient satisfaction survey were used to assess patient-reported outcomes 6 months after the injury. The average dorsal/volar tilt measured by the reference standard radiologist was 3.4 degrees (SD=13.6) dorsal; overall 47 patients (64%) were considered to have an acceptable radiographic reduction. Acceptable radiographic reduction was not associated with better generic physical or mental health status, lesser degrees of upper-extremity disability, or greater satisfaction with outcomes than was unacceptable reduction. Overall 44 of 74 patients (59%) reported being satisfied or very satisfied with their functional status at 6 months. Contrary to our hypotheses we found that acceptable radiographic reduction (according to dorsal/volar tilt criteria) was not associated with better self-reported functional outcomes or increased satisfaction at 6 months in elderly patients with conservatively treated distal radius fractures.

Muscle cell-mediated gene delivery to the rotator cuff.

Rotator cuff lesions are one of the most common causes of upper extremity disability. Surgical therapy addresses mostly the extrinsic etiology, but not intrinsic factors such as aging, structural changes, low vascularity, and inflammatory processes. In this study, genetically engineered, highly purified muscle-derived cells (MDCs) were characterized and injected into the supraspinatus tendons of nude rats. The injected cells were monitored for 3 weeks. In vitro, the engineered, highly purified MDCs do not express vimentin; 98% of them are positive for the beta-galactosidase marker gene, and 99% hybridize with the specific pancentromeric mouse probe. beta-Galactosidase marker gene expression of the injected cells was detected up to 21 days. From day 7 after injection, the cell nuclei became spindle shaped, cells were integrated into the tendon collagen bundles, and the cells showed differentiation into vimentin-expressing fibroblastic cells. The results indicate that the rotator cuff tendon matrix and its original cellular components modulated the injected MDCs toward a fibroblastic phenotype. The compatibility and ability of MDCs to differentiate into other cell lineages, such as fibroblasts, might have high potential utility in tissue-engineering applications for tendon healing. This approach facilitates the application of muscle-derived progenitor cells and ex vivo gene therapy for the treatment of rotator cuff lesions.

Assessing the Motor Status Score: A Scale for the Evaluation of Upper Limb Motor Outcomes in Patients after Stroke

The Motor Status Scale (MSS) measures shoulder, elbow (maximum score = 40), wrist, hand, and finger movements (maximum score = 42), and expands the measurement of upper extremity impairment and disability provided by the Fugl-Meyer (FM) score. This work examines the interrater reliability and criterion validity of the MSS performed in patients admitted to a rehabilitation hospital 21 ± 4 days after stroke. Using the MSS and the FM, 7 occupational therapists masked to each other’s judgments, evaluated 12 consecutive patients with stroke. Two therapists evaluated 6 additional patients on consecutive days. Intraclass correlation coefficients were significant for each group of raters for the shoulder/elbow and for the wrist/hand (P < 0.0001); test-retest measures were also significant for the shoulder/elbow (Pearson correlation coefficient r = 0.99, P < 0.004) and for the wrist/hand (Pearson correlation coefficient r = 0.99, P < 0.003). The internal item consistency for the overall MSS was significant (Cronbach alpha = 0.98, P < 0.0001). Finally the correlation between the MSS and the FM (R 2 = 0.964) was significant (P < 0.0001). The MSS affords a reliable and valid assessment of upper limb impairment and disability following stroke.

Functional outcome after centralization for radius dysplasia.

Centralization for radius dysplasia purportedly offers a more normal appearance, provides length to a shortened forearm, and improves upper-extremity function. Limited objective outcome data, however, exist to substantiate its use. To better define functional status after centralization, the Jebsen-Taylor hand test and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) were administered to 21 patients (25 wrists) at an average of 20 years after surgery. Jebsen-Taylor scores, a measure of hand function, were significantly altered with an average total score of 48 seconds compared with an average normal score of 30 seconds (62% increase). The DASH questionnaire, a measure of upper-extremity function, showed only a mild disability of 18%. These long-term follow-up data show that hand function remains markedly abnormal while upper-extremity disability is mild. Improved wrist alignment and increased ulna length did not correlate with improved upper-extremity function.

Transitions in self-reported musculoskeletal pain and interference with activities among newspaper workers.

Active surveillance of symptoms and disability due to musculoskeletal disorders (MSD) in working populations can map individual transitions in symptom intensity or disability level. Using repeat surveys, this study examined if aetiological risk factors for new symptoms or disability, measured by interference with activities, were similar to prognostic risk factors for subsequent outcomes of symptoms and disability. This paper reports on 379 Toronto newspaper workers who completed questionnaires in 1996 and 1997. Questions on pain/discomfort during the last year, episode frequency and duration formed the basis for constructing three mutually exclusive symptom levels: noncases (Level 1); mild cases (Level 2); and more severe or frequent pain cases (Level 3). A similar construction of overall interference levels was based on the frequency with which musculoskeletal pain/discomfort interfered with daily, recreational, social and family activities, or ability to do one's job during the previous 12 months. The last was also examined as work interference alone. Levels of symptoms were cross-tabulated by overall and work interference at the two time points and Markov models of transitions between states were formulated. Results indicate that period prevalence of symptoms and overall interference increased between phases, though only significantly for symptoms (Levels 2 and 3, 65.7-70.7%, p = 0.04), while work interference was unchanged (17.9-17.0%). Equivalent proportions of workers improved as worsened in symptoms (21.1 and 22.4%, respectively), overall interference (16.7 and 17.8%), and work interference (7.4 and 6.6%). The only significant predictor for those without work interference at time one was job tenure, which was protective against work interference (Odds Ratio (OR) 1.06, 95% Confidence Interval (CI) 1.01-1.12). Among those who had more severe/frequent symptoms at time one, lack of improvement over time was predicted by longer job tenure (OR = 0.92 per year, CI: 0.87-0.97), greater psychological demands of work (OR = 0.65 per point, CI: 0.51-0.84) and marginally by greater upper extremity disability score. At time one, women with work interference were more likely to have persistent interference at time two (OR = 7.22, CI: 1.57-33.20). Suggestive findings included opposite effects of social support at work: reduced risk of development of new symptoms but increased risk of persistence at the highest symptom level.

VALIDITY OF PULP-TO-PALM DISTANCE AS A MEASURE OF FINGER FLEXION

This study investigated the validity of pulp-to-palm distance measures as clinical indicators of finger flexion capacity. Pulp-to-palm distance and goniometry of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints were measured by a single tester in 50 patients with abnormal digital flexion using a computerized hand assessment system. The correlation between pulp-to-palm distance measurements and total finger flexion measures obtained by goniometry, was moderate (r=−0.46 and −0.51). This indicates that the measures are not interchangeable. The relationship between an upper extremity disability score (DASH) and restricted motion was stronger for the goniometric measurements (r=0.45, P<0.01) than for the pulp-to-palm distance measurements (r<0.30,P >0.01). Both types of range of motion measurements were able to discriminate between minimal and substantial upper extremity disability. Further methodological evaluation is required to support the use of pulp-to-palm distance measures as an outcome indicator.

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients.

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed to measure upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale. We performed cross-cultural adaptation of the DASH to Swedish, using a process that included double forward and backward translations, expert and lay review, as well as field-testing to achieve linguistic and conceptual equivalence. The Swedish version's reliability and validity were then evaluated in 176 patients with upper-extremity conditions. The patients completed the DASH and SF-12 generic health questionnaire before elective surgery or physical therapy. Internal consistency of the DASH was high (Cronbach alpha 0.96). Test-retest reliability, evaluated in a subgroup of 67 patients who completed the DASH on two occasions, with a median interval of 7 days, was excellent (intraclass correlation coefficient 0.92). Construct validity was shown by a positive correlation of DASH scores with the SF-12 scores (worse upper-extremity disability correlating with worse general health), stronger correlation with the SF-12 physical than with the mental health component, correlation of worse DASH scores with worse self-rated global health, and ability to discriminate among conditions known to differ in severity. The Swedish version of the DASH is a reliable and valid instrument that can provide a standardized measure of patient-centered outcomes in upper-extremity musculoskeletal conditions.

Multicomponent Intervention for Work-Related Upper Extremity Disorders

Although several multidimensional models have emerged to explain the development, exacerbation and maintenance of work-related upper extremity disorders and disability, there is a paucity of data on the application of these models for the development of worksite-based prevention and management programs. Sign language interpreting is an occupation associated with increased risk for upper extremity symptoms. Ergonomic, work organization, work style, and work-related and individual psychosocial factors have been demonstrated to play a role in the exacerbation of symptoms and lost time in this group. Therefore, it was hypothesized that an intervention directed at reducing the impact of these factors would be associated with reductions in the number of upper extremity cases/year and associated lost time and health care costs in a group of full-time sign language interpreters. Subjects included 53 symptomatic and asymptomatic interpreters working at the National Technical Institute for the Deaf. The intervention (eleven 1.5-hr group sessions) was designed to 1) reduce musculoskeletal overexertion by reducing workload and biomechanical strain, while increasing flexibility and endurance through tailored exercise and preinterpreting “warm ups,” 2) improve the ability of workers to manage job stress and musculoskeletal pain, 3) reduce biomechanical exposure through work organization and work style changes, 4) alter organizational sources of stress by improving supervisor's managerial skills to address work related upper extremity problems and provide increased supervisor support, and 5) educate workers and supervisors regarding the optimal utilization of health care resources, given the present state of the art in terms of clinical evaluation and management. Results indicated a 69% reduction in the number of cases reporting upper extremity problems in the 3 years following the intervention. Indemnity costs were reduced by 64% and were maintained over the next 2 years. Health care costs followed a similar, although smaller magnitude, change. Despite this reduction, a partial rebound in all outcome measures was observed in Year 3 postintervention. This rebound followed a progressive increase in workload over the 3-year follow-up period.

A case report on employment of persons with disability of upper extremity to supermarkets and stores

A case report on employment of persons with disability of upper extremity to supermarkets and stores

Measuring disability of the upper extremity: A rationale supporting the use of a regional outcome measure

Objective: Many existing upper extremity outcome measures have been designed for a specific anatomic site (e.g., shoulder) or a specific disease entity (e.g., carpal tunnel syndrome). The purpose of this paper is to examine whether questionnaire items taken from very specific measures are considered relevant only to that specific region or are applicable to the whole extremity. Methods: Fifteen practicing clinicians categorized a sample of 132 items from existing questionnaires according to whether the items reflected disability specific to an anatomic site or were relevant to the whole extremity. Results: Seventy-two percent of the items were categorized as relevant to the extremity as a whole, while only 21% of the items were categorized as specific to an anatomic site. Conclusion: Items in existing specific upper extremity questionnaires are also relevant to other regions and conditions. This finding is in agreement with kinesiologic and biomechanical theories that the upper extremity acts as a single functional unit. Questionnaires designed for the whole extremity could provide a more practical and still valid measure of upper extremity disability.

Midlife hand grip strength as a predictor of old age disability.

Poor muscle strength, functional limitations, and disability often coexist, but whether muscle strength during midlife predicts old age functional ability is not known. To determine whether hand grip strength measured during midlife predicts old age functional limitations and disability in initially healthy men. A 25-year prospective cohort study, the Honolulu Heart Program, which began in 1965 among Japanese-American men living on Oahu, Hawaii. A total of 608945- to 68-year-old men who were healthy at baseline and whose maximal hand grip strength was measured from 1965 through 1970. Altogether, 2259 men died over the follow-up period and 3218 survivors participated in the disability assessment in 1991 through 1993. Functional limitations including slow customary walking speed (< or =0.4 m/s) and inability to rise from a seated position without using the arms, and multiple self-reported upper extremity, mobility, and self-care disability outcomes. After adjustment for multiple potential confounders, risk of functional limitations and disability 25 years later increased as baseline hand grip strength, divided into tertiles, declined. The odds ratio (OR) of walking speed of 0.4 m/s or slower was 2.87 (95% confidence interval [CI], 1.76-4.67) in those in the lowest third and 1.79 (95% CI, 1.14-2.81) in the middle third of grip strength vs those in the highest third. The risk of self-care disability was more than 2 times greater in the lowest vs the highest grip strength tertile. Adding chronic conditions identified at follow-up to the models predicting disability reduced the ORs related to grip strength only minimally. Among healthy 45- to 68-year-old men, hand grip strength was highly predictive of functional limitations and disability 25 years later. Good muscle strength in midlife may protect people from old age disability by providing a greater safety margin above the threshold of disability.

Clinimetric and Psychometric Strategies for Development of a Health Measurement Scale

Clinimetrics and psychometrics, two accepted methods for developing multiitem health measurement scales, have fundamentally different aims and methods that have seldom been compared and never prospectively. The purpose of this study was to determine whether these two methodologies provided comparable scales in the development of an upper extremity disability measure. Psychometric analysis involved field testing a 70-item questionnaire on 407 patients. Equidiscriminatory item total correlation (EITC) was used to select the top 30 items. Clinimetric testing used the mean importance and severity ratings of the 70 items by 76 patients to select the top 30 items. Clinimetric and psychometric analyses were performed independently. Cronbach’s alpha was 0.97 for the top 30 items selected by EITC and 0.96 for the items selected based on patient’s ratings. The two scales (after clinician modification to improve face validity) shared 16 items in common (P = 0.10). The intraclass correlation coefficient of the patient scores on the two 30-item scales was 0.93 before clinician input and 0.97 after. The mean (and standard deviation) difference between scales was 9.1 (8.8) before and 1.7 (5.2) after clinician input. A scale developed with a clinimetric strategy can measure a complex (so-called heterogeneous) clinical phenomenon (thought to be composed of several patient attributes) but still fulfill psychometric criteria for “homogeneity.” Thus, these strategies for the development of health measurement scales, which have been considered potentially opposite or conflicting, may be complementary.

Psychosocial factors and the rehabilitation of patients with chronic work-related upper extremity disorders

This prospective cohort study investigated the effects of psychosocial factors on long-term employment outcome of a sample of chronic work-related upper-extremity pain disorder patients who had completed an interdisciplinary functional restoration program. Factors examined included the following: DSM-III-R Axis I and Axis II diagnoses, derived from the Structured Clinical Interview for DSM-III-R (SCID); history of childhood abuse experienced as elicited by the SCID; the Quantitated Pain Drawing, which evaluated perceived pain intensity; Million Visual Analog Scale, which measures perceived level of disability; and the Beck Depression Inventory, which assessed the level of depression. Results from univariate analyses demonstrated that return-to-work status 1 year following rehabilitation was predicted by the following psychosocial variables: The number of Axis I disorders, a past diagnosis of substance abuse, a past and/or current diagnosis of an anxiety disorder, a diagnosis of borderline personality disorder, a history of childhood abuse, self-report of depressed mood, and a moderate to high level of perceived disability. Additionally, age, race, length of disability, and prior surgical treatment predicted return-to-work rates. A multiple logistic regression further revealed that upper extremity patients who were older, Caucasian, had a current diagnosis of an anxiety disorder, and whose perception of their disability deteriorated from pre- to post-program were significantly less likely to return to work at one-year follow-up. Overall, the findings indicate that psychosocial variables influence the successful rehabilitation of patients with upper extremity disability, suggesting that these patients should be assessed and treated for psychosocial dysfunctions in conjunction with their rehabilitation so as to optimize favorable outcomes after treatment.

Biomechanical and computer analysis of radial head prostheses

Radial head fractures can lead to significant upper extremity disability. A comminuted radial head fracture with a medial collateral ligament tear presents a clinical conundrum. The radiocapitellar (RC) joint should be maintained, yet the head frequently cannot be reduced and stabilized. The silicone rubber implant currently available is not biomechanically or clinically satisfactory, and thus there is a need for a more suitable prosthetic replacement for the radial head. We have attempted to design such a prosthesis and have examined prosthetic design with various materials that would best transmit force at the RC joint. Design configurations based on our cadaveric and radiographic measurements were tested with structural finite element method computer analyses. Materials examined included titanium alloy, cobalt-chrome alloy, alumina ceramic, and ultrahigh molecular weight polyethylene (UHMWPE). Metals and ceramic transmitted force at the distal bone and implant interface and strain shielded the proximal radial cortex while UHMWPE distributed load uniformly through the cortex and along the entire bone and implant interface. In addition, load transmission comparisons were made with the intact radial head, with a silicone prosthesis, and with 6 and 10 mm thick UHMWPE prostheses in cadaveric specimens. UHMWPE prostheses transmit more force to the RC joint than the silicone prosthesis and with loads closer to physiologic levels at all flexion angles. UHMWPE prostheses not only transmit much more force than silicone, but because of substantially less deformation under load, also provide more stability to the joint.

Arthroscopic Anterior Shoulder Capsulorrhaphy

Shoulder dislocation is a common cause of upper extremity disability. The recurrence rate is inversely proportional to the patient's age at the initial dislocation. There are several pathologic variations of anterior/inferior glenohumeral ligament laxity. The indications, contraindications, as well as the surgical procedure are reviewed in the following text. The postoperative rehabilitation program is briefly described.

Upper extremity disability due to lower extremity paralysis in paraplegia

Upper extremity disability due to lower extremity paralysis in paraplegia

Devices to assist early ambulation for lower-extremity fractures with upper-extremity disability.

Devices to assist early ambulation for lower-extremity fractures with upper-extremity disability.