The Italian version of the Lower Extremity Functional Scale was reliable, valid, and responsive

Validity and reliability of the Persian version of the STarT musculoskeletal tool

BACKGROUND

The Subgrouping for Targeted Treatment (STarT) musculoskeletal (MSK) tool stratifies patients with MSK disorders (MSDs) into prognostic categories based on poor outcomes.

PURPOSE

This study aimed at investigating the validity and reliability of the Persian STarT MSK tool in people suffering from painful MSDs in Iran.

METHODS

A total of 593 subjects with painful MSDs including neck, shoulder, low back, knee, and multisite pain received and completed the STarT MSK tool, visual analog scale (VAS), EuroQol five-dimensions three-levels questionnaire (EQ-5D-3 L), short form-36 health survey questionnaire (SF-36), and Örebro musculoskeletal pain screening questionnaire (ÖMPSQ) in the first visit. To examine test-retest reliability, 234 patients completed the STarT MSK tool 2 days after the initial visit.

RESULTS

In this study, 139 (23.5%), 266 (44.9%), and 188 (31.7%) participants were classified as low-, medium-, and high-risk groupings for poor outcomes, respectively. Spearman's correlation coefficient showed a strong relationship among Persian STarT MSK tool and EQ-5D-3 L (-0.78), SF-36 (-0.76), and OMPSQ (0.70). The results of known-group validity indicated that this tool could distinguish among the participants in different risk subgroups based on the scores of the ÖMPSQ, VAS, SF36, and EQ-5D-5 L (p < .001). No ceiling and floor effects were observed. Cronbach's alpha and intra-class correlation coefficient (ICC2,1) were acceptable (0.71) and excellent (0.98), respectively.

CONCLUSION

The Persian version of STarT MSK tool has shown to be a valid and reliable instrument to stratify people with painful MSDs into low-, medium-, and high-risk subgroups based on persistent pain disability.

Validation of the Polish versions of the Lower Limb Task Questionnaire, Lower Limb Functional Index, and Lower Limb Functional Index-10

BACKGROUND

Physicians who treat patients with lower limb diseases should pay attention not only to the patients' clinical condition but also to their individual needs and expectations. For this purpose, many different questionnaires can be employed. This study aimed to validate the Lower Limb Task Questionnaire (LLTQ), Lower Limb Functional Index (LLFI), and Lower Limb Functional Index-10 (LLFI-10) for their use in Polish conditions and to perform a mutual comparison and analysis of differences in subjective assessments by patients who undergo hip or knee arthroplasty.

METHODS

The LLTQ, LLFI, and LLFI-10 were translated into Polish. A total of 103 patients who qualified for hip or knee arthroplasty at a University Hospital in from 2019 to 2021 were included in this study. The patients were asked to complete the Polish versions of the LLTQ, LLFI, LLFI-10, Lower Extremity Functional Scale (LEFS), and Short Form-36 four times - twice before and twice after their surgeries.

RESULTS

The Polish versions of the LLTQ, LLFI, and LLFI-10 had good psychometric properties. One year after surgery, the Cohen's standard response mean revealed high improvement of limb functionality and thus quality of life among all patients. We observed better treatment outcomes among patients who had hip osteoarthritis.

CONCLUSIONS

The questionnaires were validated and can be used both in everyday health practice and in further research in Poland.

Rasch validation and refinement of the Lymphedema Life Impact Scale version 2 in an Italian cohort with secondary lymphedema

PURPOSE

To produce and validate an Italian version of the Lymphedema Life Impact Scale version 2 (LLISv2-It), a tool measuring the impact of lymphedema on health-related quality of life, and investigate its main psychometric characteristics.

METHODS

After translation and cross-cultural adaptation of the LLISv2, we administered it to 156 subjects with secondary lymphedema (upper or lower limb), together with (depending on the limb involved) either the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) or the Lower Extremity Functional Scale (LEFS). We analyzed the performance of LLISv2-It using Classical Test Theory and Rasch methods.

RESULTS

Cronbach alpha was 0.89. Item fit statistics indicated that item #12 was underfitting (Infit MnSQ = 1.56; Outfit MnSq = 1.75). Test-retest reliability of the 17-item version (without item #18, not scored, according to the original authors) and of a 16-item version (without #12 and #18-a unidimensional item set) were both excellent (ICC2.1 = 0.93; 95%). The minimum detectable change was 8.9 points. The correlation of LLISv2-It with DASH and LEFS was r = 0.81 and -0.57, respectively.

CONCLUSIONS

The Italian version of the LLISv2 is reliable and valid. To make the tool more psychometrically sound, we recommend to not calculate items #12 and #18 in the total score.

IMPLICATIONS FOR REHABILITATIONThe Lymphedema Life Impact Scale (LLISv2) is particularly useful as a validated condition-specific health-related quality of life measure for patients with chronic edema/lymphedema. We have validated its Italian version (LLISv2-It).We also examined the psychometric properties of the LLISv2 in individuals with secondary lymphedema of either upper or lower limb, using both classical test theory and Rasch techniques, to provide insights for further refinement of the questionnaire.Based on our results, we recommend not to count item #12 in the total score (besides #18, as already suggested by the original authors). Moreover, we determined that the minimum detectable change of the LLISv2 was 9 points. This information is helpful in clinical practice to understand if the change in score is not due to chance (measurement error).Although further research is warranted, the present validation study of the LLISv2 increases the confidence in the metric quality and clinical utility of the scale to assess lymphedema-specific health-related quality of life in individuals with secondary lymphedema of either upper or lower limb.

Efficacy and Safety of the Phytochemical Product Linfadren in the Management of Patients With Persistent Ankle Edema Following Trauma or Surgery: A Randomized Controlled Trial

BACKGROUND

Persistent posttraumatic/postsurgery ankle edema (PPAE) is edema that persists from 2 weeks to 3 months after injury or surgery. PPAE has negative effects on the healing process and quality of life. This study aimed to evaluate the efficacy of a phytochemical product containing diosmin, coumarin, and arbutin (Linfadren) in addition to the conventional treatment, in patients with PPAE.

METHODS

Between October 2018 and February 2020, 60 outpatients with PPAE (42 with ankle fractures and 18 with ankle sprains) were enrolled and randomized (1:1 ratio) to receive either 6-week conventional treatment plus Linfadren (study group) or conventional treatment alone (control group). Primary outcome was ankle edema as measured by the "figure-of-8-20" method. Secondary outcomes were ankle function measured by the Lower Extremity Functional Scale (LEFS), and patient's overall perceived treatment efficacy. Tolerability of Linfadren was also evaluated. Assessments were performed at baseline, at end of treatment (6 weeks after baseline), and 3 months after the end of treatment (follow-up). A subgroup analysis was also conducted for the injury type (fracture/sprain) to identify if this factor affected the results of the primary outcome measure.

RESULTS

At the end of treatment, the study group had a significantly greater improvement in ankle edema, improved ankle function, and more patients who considered this treatment effective compared with the control group. The measured difference in circumference by the figure-of-8-20 method averaged 4% at 6 weeks and 5% at 3 months. No difference between groups was seen in rescue medication. No adverse events were recorded. Subgroup analysis revealed no significant influence of the injury type on the primary outcome measure.

CONCLUSION

Linfadren in addition to conventional treatment was more effective than conventional treatment alone in patients with PPAE.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Italian version of the Cumberland Ankle Instability Tool (CAIT-I)

STUDY DESIGN

Evaluation of the psychometric properties of a translated, culturally adapted questionnaire.

OBJECTIVE

Translating, culturally adapting, and validating the Italian version of the Cumberland Ankle Instability Tool (CAIT-I).

SUMMARY OF BACKGROUND DATA

Ankle sprains are one of the most common musculoskeletal injuries and can lead to chronic ankle instability (CAI). The International Ankle Consortium recommends the Cumberland Ankle Instability Tool (CAIT) as a valid and reliable self-report questionnaire assessing the presence and severity of CAI. At this moment, there is no validated Italian version of CAIT.

METHODS

The Italian version of the CAIT (CAIT-I) was developed by an expert committee. Test-retest reliability of the CAIT-I was measured in 286 healthy and injured participants within a 4-9-day period, by using Intraclass Correlation Coefficients (ICC2,1). Construct validity, exploratory factor analysis, internal consistency and sensitivity were examined in a sample of 548 adults. Instrument responsiveness over 4 time points was determined in a subgroup of 37 participants.

RESULTS

The CAIT-I demonstrated excellent test-retest reliability (ICC≥0.92) and good internal consistency (α = .84). Construct validity was confirmed. Identified cut-off for the presence of CAI was 24.75, with sensitivity= 0.77 and specificity= 0.65. There were significant differences across time for CAIT-I scores (P < .001), demonstrating responsiveness to change, but no floor or ceiling effects.

CONCLUSION

The CAIT-I demonstrates acceptable psychometric performance as a screening and outcome measure. The CAIT-I is a useful tool to assess the presence and severity of CAI.

Shock Waves and Therapeutic Exercise in Greater Trochanteric Pain Syndrome: A Prospective Randomized Clinical Trial with Cross-Over

This study aimed to verify the comparative effectiveness of shock wave therapy versus therapeutic exercise, including the possibility of combining both therapies, in patients who did not respond to the first treatment. A prospective randomized clinical trial was carried out, predicting the possibility of a cross-over between the two treatment options, with patients who did not respond to either treatment. Treatments were, respectively, eccentric therapeutic exercise consisting of 30 min sessions of stretching and strengthening exercises, 5 days a week for 4 weeks (Groups A and D) and Extracorporeal Shock Waves Therapy (ESWT) according to a protocol of three sessions, one per week, each of 2000 pulses at a 4 Hz frequency and administering an energy flux density (EFD) varying between 0.03 mJ/mm² and 0.17 mJ/mm² (Groups B and C). Patients were evaluated at baseline (T0), 2 (T1), 4 (T2) and 6 months (T3) after the last session, using the Numeric Rating Scale (NRS), Low Extremity Functional Scale (LEFS) and Roles and Maudsley Scale (RMS). The whole study population demonstrated a progressive clinical reduction in pain according to NRS, a recovery from disability according to LEFS and a perception of recovery according to RMS within 6 months, with no significant differences between the four protocols (exercise; ESWT; exercise + ESWT; and ESWT + exercise). Both therapies are therefore valid options in patients with trochanteritis; the combination of the two therapies could be evaluated for those patients who do not respond to the single treatment.

Translation, cross-cultural adaptation and validation of the Italian version of the knee outcome survey - activities of daily living scale

PURPOSE

The Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS) is a joint-specific questionnaire measuring symptoms and functional limitations experienced by individuals with painful knee disorders. The original version of the KOS-ADLS has been shown to be reliable, valid and responsive to change. The purpose of this study was to perform a translation and cross-cultural adaptation of the KOS-ADLS into Italian and to assess its reliability and validity.

METHODS

In accordance with standard procedures, the original version of the KOS-ADLS was translated and cross-culturally adapted into Italian (KOS-ADLS-I). Then, the KOS-ADLS-I was administered to 150 patients with knee disorders. A subsample of patients compiled the KOS-ADLS-I again after five/seven days later to evaluate test-retest reliability. Symptoms and function-oriented questionnaires were also completed to evaluate construct validity. Structural validity (Explanatory Factor Analysis [EFA]), internal consistency (Cronbach's alpha), test-retest reliability (Intraclass Correlation Coefficient [ICC]), measurement error (Standard Error of the Measurement [SEM], Minimal Detectable Change [MDC]), and construct validity (hypothesis testing) were assessed.

RESULTS

The cross-cultural adaptation procedure revealed no major problems. EFA revealed a unidimensional structure. Internal consistency was high (Cronbach's alpha = 0.976) and the test-retest reliability was excellent (ICC = 0.990, 95%CI: 0.980-0.995) with low measurement error (SEM = 2.6 points; MDC = 7.1 points). The construct validity resulted to be satisfactory, as 100% a-priori hypothesis were met.

CONCLUSIONS

The KOS-ADLS-I is a reliable and valid questionnaire for the assessment of symptoms and functional limitations in individuals with musculoskeletal knee disorders and it can be used in clinical practice and research.

Participation in Low Back Pain Management: It Is Time for the To-Be Scenarios in Digital Public Health

Low back pain (LBP) carries a high risk of chronicization and disability, greatly impacting the overall demand for care and costs, and its treatment is at risk of scarce adherence. This work introduces a new scenario based on the use of a mobile health tool, the Dress-KINESIS, to support the traditional rehabilitation approach. The tool proposes targeted self-manageable exercise plans for improving pain and disability, but it also monitors their efficacy. Since LBP prevention is the key strategy, the tool also collects real-patient syndromic information, shares valid educational messages and fosters self-determined motivation to exercise. Our analysis is based on a comparison of the performance of the traditional rehabilitation process for non-specific LBP patients and some different scenarios, designed by including the Dress-KINESIS’s support in the original process. The results of the simulations show that the integrated approach leads to a better capacity for taking on patients while maintaining the same physiotherapists’ effort and costs, and it decreases healthcare costs during the two years following LBP onset. These findings suggest that the healthcare system should shift the paradigm towards citizens’ participation and the digital support, with the aim of improving its efficiency and citizens’ quality of life.

Systematic Review of Patient-Reported Outcome Measures for Patients with Exercise-Induced Leg Pain

Background and Objectives: To determine the most commonly used patient-reported outcome measures (PROMs) in exercise-induced leg pain (EILP) and to identify specific PROMs for EILP in order to evaluate their psychometric properties and methodological quality. Materials and Methods: A strategic search was performed in different databases to identify and extract the characteristics of studies based on the use of PROMs in patients with EILP. Specific PROMs were evaluated according to the Terwee et al. and COSMIN criteria. Results: Fifty-six studies were included in the review. The Medial Tibial Stress Syndrome Score (MTSSS), Lower Extremity Functional Scale (LEFS) and Exercise-Induced Leg Pain Questionnaire (EILP-Q) were identified as specific PROMs for EILP. The Visual Analog Scale (VAS) was the most widely used instrument in the assessment of EILP. The methodological quality assessment showed six positive values for the LEFS, four for the MTSSS and three for the EILP-Q for the eight psychometric properties analyzed according to the COSMIN criteria. The evaluation of the nine psychometric properties according to Terwee showed five positive values for the LEFS and MTSSS, and three for the EILP-Q. Conclusions: The overall methodological quality of the PROMs used was low. The VAS was the most widely used instrument in the assessment of EILP, and the LEFS was the highest quality PROM available for EILP, followed by the MTSSS and EILP-Q, respectively.

Measurement properties of Patient-Reported Outcome Measures in patients with a tibial shaft fracture; validation study alongside the multicenter TRAVEL study

The aim of this study was to evaluate the measurement properties of the Short Musculoskeletal Function Assessment (SMFA) and Lower Extremity Functional Scale (LEFS) in patients who sustained a tibial shaft fracture, by comparing them with the scores of a general health-related quality of life instrument scale (i.e., EuroQoL-5D). Data of 136 patients participating in a multicenter randomized controlled trial comparing incisions for intramedullary nail entry in adults with a tibial shaft fracture were used. Patients completed the SMFA, LEFS, EQ-5D and an anchor question at 2 and 6 weeks, and at 3, 6 and 12 months. Reliability (internal consistency), construct validity, responsiveness (longitudinal validity), floor and ceiling effects, minimal important change (MIC), and smallest detectable change (SDC) were determined. The SMFA and LEFS (sub)scales showed adequate internal consistency (0.84<α<0.94). Construct and longitudinal validity were also adequate (correctly predicted hypotheses between 83%-100%). Floor effects were not present. Ceiling effects were present at 12 months for the SMFA lower extremity dysfunction and bother subscales (22% and 19%, respectively) and the LEFS (19%). MICs could not be determined with the available data. The SDC was 13.84 points for the SMFA and 38.74 points for the LEFS. This study confirms that the SMFA and LEFS are reliable, valid, and responsive instruments for monitoring functional limitation in patients after sustaining a tibia shaft fracture during at least the first six months post-injury. An anchor-based MIC for the SMFA remains to be determined.

A Prospective Observational Study of Multivisceral Resection for Retroperitoneal Sarcoma: Clinical and Patient-Reported Outcomes 1 Year After Surgery

BACKGROUND

Primary retroperitoneal sarcoma (RPS) may require multivisceral resection (MVR). Clinical outcome (morbidity and renal function) and quality of life (QoL) are not as well reported as the oncologic outcome.

METHODS

Patients with primary RPS who underwent surgery between 2014 and 2016 were prospectively enrolled in an observational longitudinal study. At baseline, then at 4 and 12 months, the study measured Clavien-Dindo morbidity, estimated glomerular filtration rate (EGFR), EORTC QLQ-C30, QLQ-CR29, DN4 (neuropathic pain [NP]), lower-extremity functional scale (LEFS), and the brief pain inventory. The primary end point was the difference in global health status (GHS/QoL). The secondary end points were EGFR changes, difference in other QLQ-C30 scales, pain intensity, NP, and LEFS. The study is registered at ClinTrials.gov (NCT03480399).

RESULTS

Of 74 patients, 58 were evaluable. Morbidity grade 3 or higher was 24.1%, and mortality was 1.3%. After nephrectomy, the mean 1-year EGFR change was -33.9%. The GHS/QoL at baseline was 58.6 and had increased of 6.9 points at 1 year, comparable with that of the general population. A transient worsening in pain and diarrhea had recovered at 12 months. Average pain was mild and did not differ at 12 months. However, NP was found in 41.4% of the patients and was significantly associated with resection of the psoas muscle. At baseline, LEFS was already lower than the normative value, and worsening after surgery was not clinically relevant.

CONCLUSION

A QoL measure after MVR in primary RPS is complex and requires multiple tools. Whereas overall MVR is safe and associated with an improvement in GHS/QoL, chronic NP is frequent and deserves specific attention. Pre-surgery rehabilitation tracks may help to prevent or reduce chronic NP.

Focused Shockwave Treatment for Greater Trochanteric Pain Syndrome: A Multicenter, Randomized, Controlled Clinical Trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a condition of lateral hip pain. Its physiopathology remains unknown, and there is no consensus on optimal management. The aim of this study was to assess the effectiveness of electromagnetic-focused extracorporeal shockwave treatment (F-ESWT) in patients with GTPS.

METHODS

This multicenter clinical trial included 103 patients with chronic GTPS randomly assigned to the treatment group, consisting of electromagnetic F-ESWT and a specific exercise protocol, or the control group, receiving sham F-ESWT and the same exercise protocol. Both groups were treated with 3 weekly sessions; the F-ESWT group received an energy flux density of 0.20 mJ/mm, whereas the control group received 0.01 mJ/mm. Patients were assessed at baseline and 1, 2, 3, and 6 months after treatment. A visual analogue scale (VAS) score for pain at 2 months was the primary outcome. The Harris hip score (HHS), Lower Extremity Functional Scale (LEFS), EuroQoL-5 Dimensions Questionnaire (EQ-5D), and Roles and Maudsley score were used as secondary outcomes. Complications were recorded.

RESULTS

The mean VAS score decreased from 6.3 at baseline in both groups to 2.0 in the F-ESWT group versus 4.7 in the control group at 2 months; the 2-month score differed significantly between groups (p < 0.001). All secondary outcomes at all follow-up intervals were significantly better in the F-ESWT group, except for the LEFS score at 1 month after treatment (p = 0.25). No complications were observed.

CONCLUSIONS

F-ESWT in association with a specific exercise program is safe and effective for GTPS, with a success rate of 86.8% at 2 months after treatment, which was maintained until the end of follow-up.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cross-cultural adaption and validation of simplified Chinese version of the lower extremity function scale in patients with knee osteoarthritis

INTRODUCTION

The lower extremity function scale (LEFS) is widely used to investigate patients' functional status due to musculoskeletal dysfunction of the lower extremity. The aims of this study were to translate and cross-culturally adapt the LEFS into simplified Chinese (SC-LEFS) and evaluate the psychometric properties in patients with knee osteoarthritis (OA).

METHODS

The SC-LEFS was translated and cross-culturally adapted on the basis of guideline. Patients scheduled for knee arthroplasty (108) were invited in this study. The Cronbach's alpha coefficient was employed to assess the internal consistency. The test-retest reliability was determined by intra-class correlation coefficient (ICC). Pearson's correlation coefficient was detected to evaluate the criterion validity between the SC-LEFS and WOMAC/SF-36/range of motion (ROM). Construct validity was assessed by exploratory factorial analysis. Additionally, responsiveness analysis was conducted with effect size (ES) and standardized response mean (SRM).

RESULTS

The results revealed good internal consistency (Cronbach's alpha = 0.975) and good test-retest reliability (ICC = 0.937). Strong correlations were observed between the SC-LEFS and WOMAC pain/function/total, physical component summary of SF-36, and ROM. We confirmed the SC-LEFS as a two-factor structure with factor 1 and factor 2 explaining 73.781% and 5.546% of the variance, respectively. The ES (1.74) and SRM (1.95) indicated a good responsiveness.

CONCLUSIONS

The SC-LEFS has been nicely adapted into simplified Chinese. It was proved to be reliable and valid for knee OA patients from China mainland who are undergoing arthroplasty. Furthermore, additional research should be conducted to assess these findings in other dysfunctions of lower extremity in a larger sample size. Key Points • The present study firstly cross-culturally adapted the lower extremity function scale (LEFS) into simplified Chinese and applied for patients with knee osteoarthritis in China mainland. • The psychometric properties including reliability, validity, and responsiveness were evaluated in SC-LEFS. • The SC-LEFS turned out to be a reliable and valid tool for clinical physicians and researchers assessing patients with knee osteoarthritis.

Cross-Cultural Adaptation and Validation of the Simplified Chinese Version of the Lower Extremity Functional Scale

Purpose

The purpose of this study was to cross-culturally adapt and validate the Simplified Chinese version of the Lower Extremity Functional Scale (SC-LEFS).

Methods

The original English version of the Lower Extremity Functional Scale was translated and cross-culturally adapted into Simplified Chinese according to international guidelines. The SC-LEFS and 36-Item Short-Form Health Survey were administered to 213 patients with lower extremity musculoskeletal disorders. Psychometric properties including internal consistency, test-retest reliability, content validity, and construct validity were tested.

Results

There were no floor or ceiling effects for the SC-LEFS. The scale had high values for internal consistency (Cronbach α = 0.97) and test-retest reliability (intraclass correlation coefficient = 0.97). Corrected item-total correlations for every item ranged from 0.67 to 0.89. And the item-level content validity index (I-CVI) for each item ranged from 0.78 to 1.00. Principal component analysis revealed a one-factor structure. Nine of ten prior hypotheses were confirmed, which further supports good construct validity within the SC-LEFS.

Conclusion

The SC-LEFS has high internal consistency, good test-retest reliability and content validity, convergent construct validity, and a one-factor structure. Thus, it could be regarded as a reliable and valid tool to assess activity limitations in Chinese patients with lower extremity musculoskeletal disorders.

Application of the Lower Extremity Functional Scale and Its Correlation with Lymphedema Health-Related Quality of Life on Lower Limb Filarial Lymphedema Patients

Introduction: This study carried out as a part of the lymphedema (LE)—osteoarthritis project to know the feasibility and applicability of lower extremity functional scale (LEFS) and LE health-related quality of life (LEHRQoL) among filarial LE patients of the lower extremity.

Materials and Methods: Following inclusion and exclusion criteria 30 LE patients and 30 controls were recruited in the study. After obtaining informed written consent, Tamil version of the two “self-reporting assessment tools” LEFS and LEHRQoL were applied to all the participants by two examiners independently. Feasibility was assessed by the time schedule. Internal consistency and the correlation between two examiners was assessed by calculating Cronbach's alpha and Karl Pearson correlation coefficient and Spearman rank correlation respectively.

Results: The mean time taken for completing the LEFS and LEHRQoL questionnaire was 5 minutes and 2 seconds and 12 minutes and 8 seconds respectively. Internal consistency reliability assessment showed good internal consistency for both the examiners (Cronbach's alpha 0.816 and 0.812). There was a strong positive correlation for the cases (r = 0.956, p < 0.001; r = 0.908, p < 0.001) and controls (r = 0.992, p < 0.001; r = 0.985, p < 0.001) between the two examiners.

Conclusions: LEFS and LEHRQoL were well accepted among filarial LE patients and the patients with low literacy were able to respond without any difficulty to both assessment tools. LEFS was found suitable for the assessment of lower extremity functions of the LE patients as in other diseases affecting the lower limb and it also indirectly brought out the impact on the QoL.

Reliability and validity of the Turkish version of the Lower Extremity Functional Scale in patients with different lower limb musculoskeletal dysfunctions

Background/Aims

Lower extremity functional scales in Turkish are limited in number and generalisability. The aims of this study were to translate the Lower Extremity Functional Scale into Turkish, and to investigate its reliability and validity in patients with different musculoskeletal conditions in their lower extremities.

Methods

The Turkish Lower Extremity Functional Scale, Visual Analogue Scale and Timed Up and Go test were administered in 256 outpatients with a re-test after 24–48 hours. Internal consistency, test–retest reliability, construct validity, factor structure and floor-ceiling effects were investigated.

Findings

The Scale has good reliability and validity. The Spearman correlation coefficient was 0.91 and intraclass correlation coefficient was 0.923. The standard error of measurement value was 4.015 and internal consistency coefficient was 0.92. Item-total correlation values were 0.46–0.74. It had a 3-factor structure, explaining 58.51% of the total variance and the eigenvalues were 1.04–8.26. It had no floor and ceiling effects, and was negatively correlated with the Visual Analogue Scale and Timed Up and Go test (P=0.000).

Conclusions

The Turkish Lower Extremity Functional Scale is a reliable and valid tool to be used in participants with lower extremity musculoskeletal dysfunctions. Evaluation of its responsiveness and minimal clinically important difference in future studies would have a great value.

Translation into modern standard Arabic, cross-cultural adaptation and psychometric properties' evaluation of the Lower Extremity Functional Scale (LEFS) in Arabic-speaking athletes with Anterior Cruciate Ligament (ACL) injury

BACKGROUND

The Lower Extremity Functional Scale evaluates the functional status of patients that have lower extremity conditions of musculoskeletal origin. Regional Arabic dialects often create barriers to clear communication and comparative research. We aimed to cross-culturally adapt the Lower Extremity Functional Scale in modern standard Arabic that is widely used and understood in the Middle East and North Africa region, and assess its psychometric properties.

METHODS

Cross-cultural adaptation followed a combination of recommended guidelines. For psychometric evaluation 150 patients with anterior cruciate ligament injury and 65 asymptomatic individuals were recruited. All measurement properties as indicated by the Consensus-based Standards for the selection of health status Measurement Instruments recommendations were evaluated, including content-relevance analysis, structural validity, longitudinal reproducibility, anchor- and distribution-based methods of responsiveness, as well as the longitudinal pattern of change of Lower Extremity Functional Scale in anterior cruciate ligament injured patients' functional status.

RESULTS

The questionnaire presented excellent internal consistency (α = 0.96), reliability (0.80-0.98), and good convergent validity (ρ = 0.85). For reproducibility testing: minimal detectable change was 9.26 points; for responsiveness assessment: minimal clinically important difference was 9 points and presented moderate effect sizes (Glass'Δ = 0.71, Cohen's d = 0.81). Its unidimensionality was not confirmed and an exploratory factor analysis indicated a 2-factor solution explaining 78.1% of the variance.

CONCLUSION

The Arabic Lower Extremity Functional Scale presented acceptable psychometric properties comparable to the original version. The Arabic version of Lower Extremity Functional Scale can be used in research and clinical practice to assess the functional status of Arabic-patients suffering an anterior cruciate ligament injury.

Responsiveness of the modified lower extremity functional scale in patients with low back pain and sciatica: A comparison with pain intensity and the modified Roland-Morris Disability Scale

We tested the responsiveness of the modified Lower Extremity Functional Scale (LEFS) for patients with low back pain (LBP) and sciatica and made a comparison with the modified Roland-Morris Disability Scale for sciatica (RMS-L) and self-reported pain intensity measured by visual analogue scale (VAS).One hundred and forty-eight participants were recruited from 2 university hospitals. The evaluation included demographic data, LBP history, and the modified LEFS, RMS-L, and VAS, with a follow-up one month later. Several responsiveness statistics were calculated.The study followed 132 participants, approximately 25% reported improvement. Guyatt responsiveness index (GRI) was 0.8 or higher for 3 measures, while standardized response means were 0.8 or higher for the RMS-L and VAS, but only 0.6 for the modified LEFS among improved group. According to ROC analysis, the modified LEFS had an area under curve (AUC) similar to that of the modified RMS-L, but significantly smaller than that of the VAS.The responsiveness of the modified LEFS was moderate but not superior to the VAS or RMS-L. Although, the modified LEFS could not replace the RMS-L or VAS, it could still be used as a complementary measure since these three measurements covered different body function, activity and participation domains.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Focused extracorporeal shock wave therapy for greater trochanteric pain syndrome with gluteal tendinopathy: a randomized controlled trial

OBJECTIVES:

To investigate if focused extracorporeal shock wave therapy (f-ESWT) is an effective treatment in a population affected by greater trochanteric pain syndrome (GTPS).

DESIGN:

Randomized controlled trial, with blind outcome assessors.

SETTING:

Outpatients, University Hospital.

SUBJECTS:

A total of 50 patients affected by GTPS with gluteal tendinopathy.

INTERVENTIONS:

The study group was assigned to receive f-ESWT, the control group received ultrasound therapy (UST).

MAIN MEASURES:

We assessed hip pain and lower limb function by means of a numeric rating scale (p-NRS) and the Lower Extremity Functional Scale (LEFS scale), respectively. The first follow-up evaluation (2M-FUP) was performed two months after the first treatment session, the second (6M-FUP) was carried out six months later.

RESULTS:

The mean age of the population was 61.24 (9.26) years. A marked prevalence of the female sex was recorded (44 subjects, 86%). The statistical analysis showed a significant pain reduction over time for the study group and the control group, the f-ESWT proving to be significantly more effective than UST ( P < 0.05) at the 2M-FUP (2.08 vs 3.36) and at the 6M-FUP (0.79 vs 2.03). A marked improvement of the LEFS total score was observed in both groups as well, but we found no statistical differences in the comparisons between groups.

CONCLUSION:

Our findings support the hypothesis that f-ESWT is effective in reducing pain, both in the short-term and in the mid-term perspective. We also observed a functional improvement in the affected lower limb, but, in this case, f-ESWT showed not to be superior to UST.

Cross-cultural adaptation and multi-centric validation of the Italian version of the Achilles tendon Total Rupture Score (ATRS)

PURPOSE

The purpose of this study was to translate the Achilles tendon Total Rupture Score (ATRS) into Italian and establish its cultural adaptiveness and validity.

METHODS

The original version of the ATRS was translated into Italian in accordance with the stages recommended by Guillemin. A web-based survey was developed to test the construct validity of the Italian ATRS. Eighty patients with an average age of 45.5 years (SD 11) were included in the study. The ATRS was completed twice at 5 days intervals for test-retest reliability. The intraclass correlation coefficient was used to calculate the test-retest reliability, and Cronbach's α coefficient was used for internal consistency. Validity was evaluated by external correlation (Spearman's rank correlation coefficient, r) of the ATRS with the Italian versions of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the 17-Italian Foot Function Index (17-FFI), the Lower Extremity Functional Scale (LEFS), and the Short-Form 36 (SF-36).

RESULTS

The internal consistency (α = 0.97) and the test-retest reliability (ICC = 0.96) were excellent. The correlation coefficient showed strong correlation of the Italian ATRS with the VISA-A and the LEFS (r = 0.72 and r = 0.70, respectively, p < 0.0001), a weak correlation with the 17-FFI (r = -0.30, p = 0.007), and high-to-moderate correlation with the physical functioning, bodily pain, physical role functioning, social functioning, role emotional, and vitality of the SF-36 (r = 0.75, r = 0.61, r = 0.52, r = 0.49, r = 0.40 and r = 0.34, respectively, p < 0.0001).

CONCLUSION

The Italian version of the ATRS is a valid instrumentation to assess the functional limitations of Italian patients after Achilles tendon rupture.

LEVEL OF EVIDENCE

III.

Construct and criterion validity of the Malaysia version of Lower Extremity Functional Scale (LEFS)

Objective

The objective of this study is to translate the Lower Extremity Functional Scale (LEFS) into the Malay language and to validate the resulting version.

Methods

A two-stage observational study was conducted. The LEFS was initially cross-culturally adapted to Malay language through double forward and backward translation. The finalized version of Malay LEFS (M-LEFS) was subsequently validated for both construct validity and criterion validity. Participants (n = 208) with normal lower limb condition and various lower limb conditions completed the M-LEFS.

Results

Reliability of M-LEFS revealed excellent Cronbach's alpha value of 0.98. Construct validity, evaluated using exploratory factor analysis, exhibited good factor loadings (>0.6) of all 20 items. Interestingly, we extracted 2 components which was not reported elsewhere. With a cut-off point of 60, the sensitivity of the scale was 99% and the specificity was 81%.

Conclusions

The M-LEFS had very good psychometric properties among the studied population. Further studies are needed to enhance these preliminary outcomes in Malaysia.

Measurement Properties of the Lower Extremity Functional Scale: A Systematic Review

STUDY DESIGN

Systematic review of measurement properties.

BACKGROUND

Many primary studies have examined the measurement properties, such as reliability, validity, and sensitivity to change, of the Lower Extremity Functional Scale (LEFS) in different clinical populations. A systematic review summarizing these properties for the LEFS may provide an important resource.

OBJECTIVE

To locate and synthesize evidence on the measurement properties of the LEFS and to discuss the clinical implications of the evidence.

METHODS

A literature search was conducted in 4 databases (PubMed, MEDLINE, Embase, and CINAHL), using predefined search terms. Two reviewers performed a critical appraisal of the included studies using a standardized assessment form.

RESULTS

A total of 27 studies were included in the review, of which 18 achieved a very good to excellent methodological quality level. The LEFS scores demonstrated excellent test-retest reliability (intraclass correlation coefficients ranging between 0.85 and 0.99) and demonstrated the expected relationships with measures assessing similar constructs (Pearson correlation coefficient values of greater than 0.7). The responsiveness of the LEFS scores was excellent, as suggested by consistently high effect sizes (greater than 0.8) in patients with different lower extremity conditions. Minimal detectable change at the 90% confidence level (MDC90) for the LEFS scores varied between 8.1 and 15.3 across different reassessment intervals in a wide range of patient populations. The pooled estimate of the MDC90 was 6 points and the minimal clinically important difference was 9 points in patients with lower extremity musculoskeletal conditions, which are indicative of true change and clinically meaningful change, respectively.

CONCLUSION

The results of this review support the reliability, validity, and responsiveness of the LEFS scores for assessing functional impairment in a wide array of patient groups with lower extremity musculoskeletal conditions.

Translation, cross-cultural adaptation and validation of the Turkish version of the Lower Extremity Functional Scale on patients with knee injuries

INTRODUCTION

The Lower Extremity Functional Scale is a widely used questionnaire to evaluate the functional impairment in lower extremities. To date, the Lower Extremity Functional Scale has not been translated into Turkish. The aim of this study is to translate and culturally adapt the Lower Extremity Functional Scale into a Turkish version, and evaluate the psychometric properties of this version in patients with knee injuries.

MATERIALS AND METHODS

The translation of the English version of the Lower Extremity Functional Scale into a Turkish version was performed using standard guidelines. Validity and reliability of Turkish version were tested in 134 patients with knee injuries. Association level between other outcomes measures (Kujala Patellofemoral Score, the Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale and a Visual Analog Scale) and Turkish version of the Lower Extremity Functional Scale was analyzed to assess validation. Participants completed the questionnaire at baseline and after 2 days to test reliability.

RESULTS

The Turkish version of the Lower Extremity Functional Scale was showed a high degree of internal consistency (Cronbach α = 0.93). ICCs were 0.96 and no floor or ceiling effects. The Lower Extremity Functional Scale had a high level of association with the Kujala Patellofemoral Score (r = 0.82), Lysholm Knee Scoring Scale (r = 0.80) and the Western Ontario and McMaster Universities Osteoarthritis Index scores (r = 0.69) (all, p < 0.05).

CONCLUSION

The Turkish version of the Lower Extremity Functional Scale is a valid and reliable questionnaire that can be used to evaluate functional status in Turkish speaking patients with different knee disorders.

LEVEL OF EVIDENCE

III.

Cross-cultural adaptation, validity and reliability of the Arabic version of the Lower Extremity Functional Scale

PURPOSE

The aim was to translate and cross-culturally adapt the Lower Extremity Functional Scale (LEFS) into Arabic language and to examine its measurement properties in patients with musculoskeletal disorders of the lower extremity.

METHODS

Standard forward and backward translation followed by expert committee review, then preliminary testing was carried out to produce the final Arabic version of LEFS (LEFS-Ar). The test-retest reliability, measurement error, internal consistency and construct validity of the LEFS-Ar were examined in patients with musculoskeletal disorders of the lower extremity (N = 116).

RESULTS

The LEFS-Ar had excellent test-retest reliability (ICC2,1 = 0.96). LEFS-Ar standard error of measurement was 3.5 points while the minimal detectable change MDC95 was 9.8 points. LEFS-Ar showed excellent internal consistency with Cronbach's alpha of 0.95. Parallel analysis and factor analysis showed that LEFS-Ar measures one underlying factor with all items loading heavily on this single factor. LEFS-Ar showed significant positive correlation with patient's global assessment of function (r = 0.59) and that patients recovering from surgery reported lower LEFS-Ar score compared to patients with no surgery further supporting the construct validity of the LEFS-Ar.

CONCLUSION

LEFS-Ar has excellent internal consistency, test-retest reliability with relatively small measurement error and is a valid measure of activity limitation due to lower extremity musculoskeletal disorders. All these measurement properties of the LEFS-Ar suggest the clinical usefulness of this measure.

IMPLICATIONS FOR REHABILITATION

The Arabic Lower Extremity Functional Scale (LEFS-Ar) is a reliable and valid measure of activity limitation due to lower extremity musculoskeletal disorders with relatively small measurement error. LEFS-Ar can be used in daily clinical practice and for research purposes to quantify activity limitation in Arabic-speaking individuals with lower extremity musculoskeletal disorders.

Long-term morbidity after multivisceral resection for retroperitoneal sarcoma

Background

More than 60 per cent of patients treated surgically for primary retroperitoneal sarcoma survive for at least 5 years. Extended surgical resection has been proposed for primary disease, but long-term morbidity data are lacking. A cross-sectional study was conducted to assess the long-term morbidity of patients undergoing surgery for retroperitoneal sarcoma.

Methods

Patients operated on between January 2002 and December 2011 were eligible for the study. Long-term morbidity was evaluated based on a semistructured clinical interview. Lower limb function was assessed by means of the Lower Extremity Functional Scale (LEFS), a self-report questionnaire with a total score ranging from 0 (low functioning) to 80 (high functioning). Pain was investigated by means of the Brief Pain Inventory – Short Form, with pain intensity scores reported on a scale from 0 (no pain) to 10 (worst pain).

Results

Some 243 patients underwent surgery, and 101 of 160 patients who were alive at the time of the investigation responded to the study invitation letter. Finally, 95 patients were enrolled in the study. Sensory impairment of the limbs was reported in 72 patients (76 per cent). The median LEFS score was 60 (i.q.r. 43–73). Mean scores for the pain intensity items varied from 1·23 to 2·68. In multivariable analysis, there was no difference in median levels of creatinine at survey between patients who did or did not undergo nephrectomy (difference between median values 13 (95 per cent c.i. −4 to 30) µmol/l; P = 0·170).

Conclusion

Severe chronic pain and lower limb motor impairment after multivisceral resection for retroperitoneal sarcomas are rare. Long-term renal function is not significantly impaired when nephrectomy is performed.

17-Italian Foot Function Index with numerical rating scale: development, reliability, and validity of a modified version of the original Foot Function Index

BACKGROUND

Clinical research quantifies symptoms and signs of pain.

OBJECTIVE

To develop a brief outcome measure to assess foot and ankle conditions, the psychometric properties of a modified version of the original Foot Function Index (FFI) were examined.

METHODS

Eighty-six subjects with musculoskeletal foot and ankle disorders were enrolled. The internal consistency and test-retest reliability were evaluated by using Cronbach's α and intraclass correlation coefficient (ICC). Criterion validity was tested by Pearson's correlation coefficient between 17 items of the Italian FFI (17-IFFI) and the Lower Extremity Functional Scale (LEFS). The responsiveness was calculated using the receiver operating characteristic curve (ROC).

RESULTS

Cronbach's Alpha was 0.95 (95% CI: 0.92, 0.99). The intra-interviewer and inter-interviewer ICC values were, respectively, 0.92 (95% CI: 0.88-10 0.96) and 0.90 (95% CI: 0.89-0.94). Correlations between the 17-IFFI scores and the LEFS scores were -0.564 and -0.456 at the initial and at the end of the treatment, respectively. The ROC analysis revealed an area under the curve of 0.732 (95% CI: 0.61-0.82) for the 17-IFFI and 0.633 (95% CI: 0.52-0.71) for the LEFS score.

CONCLUSIONS

The 17-IFFI is a reliable and valid scale and we recommend its application to evaluate the effectiveness of a treatment in patients with musculoskeletal foot and ankle disorders.

Responsiveness of SF-36 and Lower Extremity Functional Scale for assessing outcomes in traumatic injuries of lower extremities

OBJECTIVE

To assess the responsiveness of one generic questionnaire, Medical Outcomes Study Short Form-36 (SF-36), and one region-specific outcome measure, Lower Extremity Functional Scale (LEFS), in patients with traumatic injuries of lower extremities.

DESIGN

A prospective and observational study of patients after traumatic injuries of lower extremities. Assessments were performed at baseline and 3 months later.

SETTING

In-patients and out-patients in two university hospitals in Taiwan.

PARTICIPANTS

A convenience sample of 109 subjects were evaluated and 94 (86%) were followed.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Assessments of responsiveness with distribution-based approach (effect size, standardized response mean [SRM], minimal detectable change) and anchor-based approach (receiver's operating curve analysis, ROC analysis).

RESULTS

LEFS and physical component score (PCS) of SF-36 were all responsive to global improvement, with fair-to-good accuracy in discriminating between participants with and without improvement. The area under curve gained by ROC analysis for LEFS and SF-36 PCS was similar (0.65 vs. 0.70, p=0.26).

CONCLUSIONS

Our findings revealed comparable responsiveness of LEFS and PCS of SF-36 in a sample of subjects with traumatic injuries of lower limbs. Either type of functional measure would be suitable for use in clinical trials where improvement in function was an endpoint of interest.

The German Lower Extremity Functional Scale (LEFS) is reliable, valid and responsive in patients undergoing hip or knee replacement

PURPOSE

To determine the measurement properties of a German version of the Lower Extremity Functional Scale (LEFS) in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR).

METHODS

This prospective cohort study included 486 consecutive patients. The LEFS and other self-reported outcome measures were administered at different time points and several classical measurement properties were determined.

RESULTS

The German LEFS was highly reliable (ICC 0.98) and internally consistent (CA 0.95). Construct validity was proven by large to very large correlations (r = 0.52-0.91) with all other instruments in the expected directions. Factor analysis using a polychoric correlation matrix revealed two factors at baseline and 6 months explaining about 70% of the total variance. There were no floor or ceiling effects for the total score, but significant floor effects for the single items 16-19 at baseline. The LEFS was highly responsive at 6 months.

CONCLUSIONS

The German LEFS proved to be a reliable, valid and responsive tool for the self-assessment of patients undergoing total hip or knee replacement. Nevertheless, the questionnaire seems to summarize more than one construct as highlighted by the factor analysis. Further research seems therefore warranted.

The reliability of the modified lower extremity functional scale among adults living with HIV on antiretroviral therapy, in Rwanda, Africa

Peripheral neuropathy (PN) is common among people living with HIV (PLHIV) on antiretroviral therapy (ART), and affects their daily functional ability and quality of life. Lower extremity functional ability, which is most commonly compromised in patients with PN, has not been clearly evaluated in an African setting, with regard to functional limitations. The lower extremity functional scale (LEFS) was originally developed and validated among elderly people in the USA, where the environment and activities of daily life are very different from those in Rwanda. The purpose of this study was to adapt and establish the reliability of LEFS, among adults living with HIV on ART, in a Rwandan environment. The study translated LEFS from English to Kinyarwanda, the local language spoken in Rwanda, the LEFS was then modified accordingly, and tested for test-retest reliability among 50 adult PLHIV on ART. An average Spearman rank order correlation coefficient, ρ ≥ 0.7, was considered optimal for reliability. Prior to the modification of the LEFS and in the initial testing of the translated LEFS, none of the activities was strongly correlated (ρ ≥ 0.8); most of the activities (90%, 18/20) were moderately correlated (ρ ≥ 0.5) and 10% (2/20) were weakly correlated (ρ ≤ 0.5). The ρ of most of the functional activities improved after modification by an expert group to ρ ≥ 0.7, establishing reliability and validity of LEFS among PLHIV on ART with lower extremity functional limitations, in this environment. In conclusion, this study demonstrated the importance of modifying and establishing test - retest reliability of tools derived from developed world contexts to local conditions in developing countries, such as in Rwanda. The modified LEFS in this study can be used in Rwanda by clinicians, specifically at ART clinics to screen and identify people with functional limitations at an early stage of the limitations, for treatment, rehabilitation and/or referral to appropriate health care services.

Translation and cultural adaptation of the Turkish Lysholm knee scale: ease of use, validity, and reliability

BACKGROUND

The Lysholm knee scale, first published in 1982, is an eight-item questionnaire designed to evaluate patients after knee ligament injury. However, as a tool developed in English, its use as a validated instrument has been limited to English-language populations.

QUESTIONS/PURPOSES

The objectives of this study were to test the ease of use, reliability, and validity of a Turkish-language, culturally adapted version of the Lysholm knee scale.

METHODS

The Lysholm knee scale was translated into Turkish according to Guillemin's recommendations. Seventy patients (mean age, 36 years; range, 17-72 years) with different knee complaints were included, and the scale was completed twice by each participant at 3- to 14-day intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbach's alpha evaluated internal consistency. External validity was evaluated with correlations between the Lysholm knee scale, Kujala Anterior Knee Pain Scale, and SF-36. The distribution of floor and ceiling effects was determined.

RESULTS

Patients completed the Turkish-language Lysholm questionnaire in approximately 3 minutes. The test-retest reliability was 0.82, with a Cronbach's alpha coefficient of 0.68. The Lysholm knee score was strongly correlated with the Kujala Anterior Knee Pain Scale (r = 0.78). The Turkish Lysholm knee scale showed high correlations with the SF-36 physical component score (r = 0.61) and a low association with the mental component domain (r = 0.14).

CONCLUSIONS

The Turkish version of the Lysholm knee scale is quickly administered, valid, and reliable, and can be used for patients with various knee disorders.

Translation and cross-cultural adaptation of the lower extremity functional scale into a Brazilian Portuguese version and validation on patients with knee injuries

STUDY DESIGN

Clinical measurement.

OBJECTIVE

To translate and culturally adapt the Lower Extremity Functional Scale (LEFS) into a Brazilian Portuguese version, and to test the construct and content validity and reliability of this version in patients with knee injuries.

BACKGROUND

There is no Brazilian Portuguese version of an instrument to assess the function of the lower extremity after orthopaedic injury.

METHODS

The translation of the original English version of the LEFS into a Brazilian Portuguese version was accomplished using standard guidelines and tested in 31 patients with knee injuries. Subsequently, 87 patients with a variety of knee disorders completed the Brazilian Portuguese LEFS, the Medical Outcomes Study 36-Item Short-Form Health Survey, the Western Ontario and McMaster Universities Osteoarthritis Index, and the International Knee Documentation Committee Subjective Knee Evaluation Form and a visual analog scale for pain. All patients were retested within 2 days to determine reliability of these measures. Validation was assessed by determining the level of association between the Brazilian Portuguese LEFS and the other outcome measures. Reliability was documented by calculating internal consistency, test-retest reliability, and standard error of measurement.

RESULTS

The Brazilian Portuguese LEFS had a high level of association with the physical component of the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.82), the Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.87), the International Knee Documentation Committee Subjective Knee Evaluation Form (r = 0.82), and the pain visual analog scale (r = -0.60) (all, P<.05). The Brazilian Portuguese LEFS had a low level of association with the mental component of the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.38, P<.05). The internal consistency (Cronbach α = .952) and test-retest reliability (intraclass correlation coefficient = 0.957) of the Brazilian Portuguese version of the LEFS were high. The standard error of measurement was low (3.6) and the agreement was considered high, demonstrated by the small differences between test and retest and the narrow limit of agreement, as observed in Bland-Altman and survival-agreement plots.

CONCLUSION

The translation of the LEFS into a Brazilian Portuguese version was successful in preserving the semantic and measurement properties of the original version and was shown to be valid and reliable in a Brazilian population with knee injuries.

Cross-cultural adaptation and validation of the Spanish version of the Cumberland Ankle Instability Tool (CAIT): an instrument to assess unilateral chronic ankle instability

The Cumberland Ankle Instability Tool (CAIT) is a valid instrument to determine the presence of chronic ankle instability (CAI) and to assess its severity. Self-report test is very useful for researchers and clinical practice, and CAI is a widespread tool. Nevertheless, there is lack of measurement instruments validated into Spanish, which represents a major difficulty for research dealing with a Spanish-speaking population. The questionnaire was cross-culturally adapted into Spanish. The psychometric properties tested in the Spanish version of the CAIT were measured for internal consistency, test-retest reliability, construct validity, criterion validity, and responsiveness in 108 participants who were recruited from several fitness centers. The Spanish version of the CAIT had high internal consistency (Cronbach's α = 0.766) and reliability (intraclass correlation coefficient = 0.979, 95 % confidence interval (CI) = 0.958-0.990). Correlation with the 36-item Short-Form Health Survey (SF-36) physical component summary score (rho = 0.241, p = 0.012) was greater than the SF-36 mental component summary score (rho = -0.162, p = 0.094). The construct validity shows three different factors in the questionnaire and good responsiveness with a mean change of -2.43 (95 % CI = -3.12 to 1.73, p < 0.0001) and a size effect of Cohen's d = 1.07. The Spanish version of the CAIT has been shown to be a valid and reliable instrument for measuring chronic ankle instability and constitutes a useful instrument for the measurement of CAI in the clinical setting in Spain.

The Dutch Lower Extremity Functional Scale was highly reliable, valid and responsive in individuals with hip/knee osteoarthritis: a validation study

Background

The WOMAC is the most widely used self-report measure to evaluate physical functioning in hip or knee osteoarthritis, however its ability to discriminate pain and physical functioning (i.e. discriminate validity) has repeatedly been questioned. Little to no data is available on the discriminant validity of alternative questionnaires that measure the same construct, for instance the Hip and Knee Osteoarthritis Outcome Score (HOOS and KOOS, respectively) and the Lower Extremity Function Scale (LEFS). Therefore, we translated the LEFS to Dutch and studied its psychometric properties (i.e. validity, reliability and responsiveness). In addition, we assessed the discriminate validity of the LEFS, HOOS and KOOS.

Methods

After translation with a forward/backward protocol, 401 individuals with hip or knee osteoarthritis completed the LEFS, HOOS/KOOS, SF-36, Hospital Anxiety and Depression Scale and Checklist Individual Strength questionnaires. To assess reliability and responsiveness, a sample of 106 and 108 patients completed a comparable set of questionnaires within 3 weeks and 3 months, respectively. Feasibility, validity, reliability and responsiveness were evaluated. Discriminant validity of the LEFS, HOOS and KOOS was examined by contrasting the scales’ correlations with the physical functioning subscale of the SF-36 with the scales’ correlations with the bodily pain subscale of the SF-36.

Results

The Dutch version of the LEFS was feasible, had good internal consistency (0.96), good reliability (ICC = 0.86), good construct and discriminant validity, and showed no floor or ceiling effects. The minimal detectable change (MDC₉₀) was ten points. Area under the receiver operating characteristic curve (AUC) analyses revealed good (AUC = 0.76) and fair (AUC = 0.63) responsiveness for the LEFS in improved and worsened patients, respectively. Discriminant validity for pain was apparent for the LEFS (p < 0.01), but not for the HOOS and KOOS (p = 0.21 and p = 0.20, respectively).

Conclusions

Considering the LEFS’ good psychometric qualities and ability to discriminate between pain and functioning, we recommend the LEFS as the outcome measure of choice to assess self-reported physical functioning in individuals with hip or knee osteoarthritis.

Lower limb functional index: development and clinimetric properties

BACKGROUND

Existing lower-limb, region-specific, patient-reported outcome measures have clinimetric limitations, including limitations in psychometric characteristics (eg, lack of internal consistency, lack of responsiveness, measurement error) and the lack of reported practical and general characteristics. A new patient-reported outcome measure, the Lower Limb Functional Index (LLFI), was developed to address these limitations.

OBJECTIVE

The purpose of this study was to overcome recognized deficiencies in existing lower-limb, region-specific, patient-reported outcome measures through: (1) development of a new lower-extremity outcome scale (ie, the LLFI) and (2) evaluation of the clinimetric properties of the LLFI using the Lower Extremity Functional Scale (LEFS) as a criterion measure.

DESIGN

This was a prospective observational study.

METHODS

The LLFI was developed in a 3-stage process of: (1) item generation, (2) item reduction with an expert panel, and (3) pilot field testing (n=18) for reliability, responsiveness, and sample size requirements for a larger study. The main study used a convenience sample (n=127) from 10 physical therapy clinics. Participants completed the LLFI and LEFS every 2 weeks for 6 weeks and then every 4 weeks until discharge. Data were used to assess the psychometric, practical, and general characteristics of the LLFI and the LEFS. The characteristics also were evaluated for overall performance using the Measurement of Outcome Measures and Bot clinimetric assessment scales.

RESULTS

The LLFI and LEFS demonstrated a single-factor structure, comparable reliability (intraclass correlation coefficient [2,1]=.97), scale width, and high criterion validity (Pearson r=.88, with 95% confidence interval [CI]). Clinimetric performance was higher for the LLFI compared with the LEFS on the Measurement of Outcome Measures scale (96% and 95%, respectively) and the Bot scale (100% and 83%, respectively). The LLFI, compared with the LEFS, had improved responsiveness (standardized response mean=1.75 and 1.64, respectively), minimal detectable change with 90% CI (6.6% and 8.1%, respectively), and internal consistency (α=.91 and .95, respectively), as well as readability with reduced user error and completion and scoring times.

LIMITATIONS

Limitations of the study were that only participants recruited from outpatient physical therapy clinics were included and that no specific conditions or diagnostic subgroups were investigated.

CONCLUSION

The LLFI demonstrated sound clinimetric properties. There was lower response error, efficient completion and scoring, and improved responsiveness and overall performance compared with the LEFS. The LLFI is suitable for assessment of lower-limb function.

Baseline dependency of minimal clinically important improvement

BACKGROUND

Minimal clinically important improvement (MCII) is the smallest outcome measure change important to patients. Research suggests that MCII is dependent on patients' baseline functional status measures.

OBJECTIVE

The purposes of this study were: (1) to confirm whether MCII is dependent on patients' admission scores and (2) to test whether MCII is dependent on selected demographic characteristics.

STUDY DESIGN AND SETTING

This was a prospective, longitudinal, observational cohort study of 6,651 patients with orthopedic knee impairments treated in 332 outpatient rehabilitation clinics in 27 states in the United States.

OUTCOME MEASURES

Patient self-reports of functional status (FS) from the Lower Extremity Functional Scale were assessed using a computerized adaptive testing application (0-100 scale).

METHODS

An anchored-based longitudinal method, with a 15-point Likert-type scale (-7 to +7), was used to provide a global rating of change (GROC). The MCII threshold for the GROC was defined at a cut-score of +3 or greater and was determined using nonparametric receiver operating characteristic curve analysis for each of the following variables: sex, symptom acuity, age group, and quartile of baseline FS scores.

RESULTS

The results showed that MCII was dependent on patient baseline and demographic characteristics. Patients who were male, were younger, had more-acute symptoms, or had lower FS scores at admission required more FS change to report meaningful change.

LIMITATIONS

As this study was a secondary analysis, how the length of treatment mediated the relationship between the independent and dependent variables was unclear.

CONCLUSIONS

Although a single MCII index may provide a standard cut-score defining the smallest FS change that is meaningful to patients, researchers and clinicians should be aware that MCII is context specific and not a fixed attribute. Current results may help researchers, clinicians, and policy makers to interpret FS change related to the importance of the change to the patient.