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The effect of adding whole-body vibration exercises to home exercise program on muscle strength in patients with post-polio syndrome. Turk J Phys Med Rehabil 2022; 68:117-125. [PMID: 35949965 PMCID: PMC9305639 DOI: 10.5606/tftrd.2022.7063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/08/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives
This study aims to understand the effectiveness of whole-body vibration (WBV) exercises performed with home exercise program in patients with post-polio syndrome (PPS) in terms of muscle strength, fatigue, the quality of life, and laboratory parameters.
Patients and methods
Between October 2015 and March 2016, a total of 14 patients (7 males, 7 females; mean age: 45.1±6.6 years; range, 34 to 57 years) who were diagnosed with PPS were included in the study. The patients were randomized into two groups: the first group received WBV, home exercise program and patient education while the second (control) group received home exercise program and patient education. The patients were evaluated by knee isometric and isokinetic peak torque, Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS), Nottingham Health Profile (NHP), serum creatine kinase, aspartate aminotransferase, and alanine aminotransferase at baseline and at the end of the treatment.
Results
At the end of the treatment, the exercise program administered to the patients was found to be effective in increasing knee muscle strength in PPS patients (p<0.05). This difference was more apparent on the sequela side, isometric extension peak torque in the group with WBV. There was no significant change in the markers of muscle damage or NHP in both groups.
Conclusion
Inclusion of WBV in home exercise program in PPS patients does not seem to be superior, except for reducing the effect of fatigue on the patient's life.
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Wendebourg MJ, Weigel M, Richter L, Gocheva V, Hafner P, Orsini AL, Crepulja V, Schmidt S, Huck A, Oechtering J, Blatow M, Haas T, Granziera C, Kappos L, Cattin P, Bieri O, Fischer D, Schlaeger R. Spinal Cord Gray Matter Atrophy is associated with functional decline in Post-Polio Syndrome. Eur J Neurol 2022; 29:1435-1445. [PMID: 35102676 PMCID: PMC9310958 DOI: 10.1111/ene.15261] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/30/2021] [Accepted: 01/20/2022] [Indexed: 11/29/2022]
Abstract
Objective To determine if patients with post‐polio syndrome (PPS) show spinal cord gray matter (SCGM) atrophy and to assess associations between SCGM atrophy, muscle strength and patient‐reported functional decline. Methods Twenty patients diagnosed with PPS (March of Dimes criteria) and 20 age‐ and sex‐matched healthy controls (HC) underwent 3T axial 2D‐rAMIRA magnetic resonance imaging at the intervertebral disc levels C2/C3–C6/C7, T9/T10 and the lumbar enlargement level (Tmax) (0.5 × 0.5 mm2 in‐plane resolution). SCGM areas were segmented manually by two independent raters. Muscle strength, self‐reported fatigue, depression and pain measures were assessed. Results Post‐polio syndrome patients showed significantly and preferentially reduced SCGM areas at C2/C3 (p = 0.048), C3/C4 (p = 0.001), C4/C5 (p < 0.001), C5/C6 (p = 0.004) and Tmax (p = 0.041) compared to HC. SCGM areas were significantly associated with muscle strength in corresponding myotomes even after adjustment for fatigue, pain and depression. SCGM areaTmax together with age and sex explained 68% of ankle dorsiflexion strength variance. No associations were found with age at or time since infection. Patients reporting PPS‐related decline in arm function showed significant cervical SCGM atrophy compared to stable patients adjusted for initial disease severity. Conclusions Patients with PPS show significant SCGM atrophy that correlates with muscle strength and is associated with PPS‐related functional decline. Our findings suggest a secondary neurodegenerative process underlying SCGM atrophy in PPS that is not explained by aging or residua of the initial infection alone. Confirmation by longitudinal studies is needed. The described imaging methodology is promising for developing novel imaging surrogates for SCGM diseases.
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Affiliation(s)
- Maria Janina Wendebourg
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,ThINK Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Matthias Weigel
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,ThINK Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland.,Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Basel, Switzerland.,MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Laura Richter
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Vanya Gocheva
- Division of Paediatric Neurology, University of Basel Children's Hospital, Basel, Switzerland
| | - Patricia Hafner
- Division of Paediatric Neurology, University of Basel Children's Hospital, Basel, Switzerland
| | - Anna-Lena Orsini
- Division of Paediatric Neurology, University of Basel Children's Hospital, Basel, Switzerland
| | - Valentina Crepulja
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,ThINK Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Simone Schmidt
- Division of Paediatric Neurology, University of Basel Children's Hospital, Basel, Switzerland
| | - Antal Huck
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Johanna Oechtering
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria Blatow
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tanja Haas
- Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Cristina Granziera
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,ThINK Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland.,MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,ThINK Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland.,MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe Cattin
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Dirk Fischer
- Division of Paediatric Neurology, University of Basel Children's Hospital, Basel, Switzerland
| | - Regina Schlaeger
- Neurology Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,ThINK Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland.,MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
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Grill B, Cole M. Approach to Fatigue and Energy Conservation. Phys Med Rehabil Clin N Am 2021; 32:493-507. [PMID: 34175009 DOI: 10.1016/j.pmr.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Fatigue, a common complaint in individuals with postpolio syndrome (PPS), is defined as an overwhelming sustained feeling of exhaustion and diminished capacity for physical and mental work. A comprehensive medical work-up is needed to rule out all other causes of fatigue. A sleep study should be considered for individuals with PPS who complain of fatigue. Self-reported outcome measures, such as the Fatigue Severity Scale, are reliable and valid tools to measure fatigue in this population. Fatigue management consists of individualized treatment of underlying medical conditions, energy conservation, pacing techniques, and lifestyle modifications.
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Affiliation(s)
- Beth Grill
- Spaulding Outpatient Center Framingham, 570 Worcester Road, Framingham, MA 01702, USA.
| | - Maria Cole
- Spaulding Outpatient Center Framingham, 570 Worcester Road, Framingham, MA 01702, USA
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Extra-motor manifestations in post-polio syndrome (PPS): fatigue, cognitive symptoms and radiological features. Neurol Sci 2021; 42:4569-4581. [PMID: 33635429 DOI: 10.1007/s10072-021-05130-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is a paucity of cerebral neuroimaging studies in post-polio syndrome (PPS), despite the severity of neurological and neuropsychological sequelae associated with the condition. Fatigue, poor concentration, limited exercise tolerance, paraesthesia and progressive weakness are frequently reported, but the radiological underpinnings of these symptoms are poorly characterised. OBJECTIVE The aim of this study is to evaluate cortical and subcortical alterations in a cohort of adult polio survivors to explore the anatomical substrate of extra-motor manifestations. METHODS Thirty-six patients with post-polio syndrome, a disease-control group with amyotrophic lateral sclerosis patients and a cohort of healthy individuals were included in a prospective neuroimaging study with a standardised clinical and radiological protocol. Validated clinical instruments were utilised to assess mood, cognitive and behavioural domains and specific aspects of fatigue. Cortical thickness analyses, subcortical volumetry, brainstem segmentation and region-of-interest (ROI) white matter analyses were undertaken to assess regional grey and white matter alterations. RESULTS A high proportion of PPS patients exhibited apathy, verbal fluency deficits and reported self-perceived fatigue. On ROI analyses, cortical atrophy was limited to the cingulate gyrus, and the temporal pole and subcortical atrophy were only detected in the left nucleus accumbens. No FA reductions were noted to indicate white matter degeneration in any of the lobes. CONCLUSIONS Despite the high incidence of extra-motor manifestations in PPS, only limited cortical, subcortical and white matter degeneration was identified. Our findings suggest that non-structural causes, such as polypharmacy and poor sleep, may contribute to the complex symptomatology of post-polio syndrome.
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Brehm MA, Ploeger HE, Nollet F. Self-reported functional ambulation is related to physical mobility status in polio survivors; a cross-sectional observational study. Ann Phys Rehabil Med 2020; 64:101428. [PMID: 32805457 DOI: 10.1016/j.rehab.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/23/2020] [Accepted: 06/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The condensed 3-level version of the self-reported ambulation classification by Perry is a validated, simple-to-use instrument in clinical practice to classify functional ambulation. OBJECTIVE To further validate the clinical meaning of the classification for polio survivors, we compared physical mobility status across 3 functional ambulation categories and investigated the relation between physical mobility and functional ambulation category. METHODS We investigated a convenience sample of 140 individuals with polio [mean (SD) age 59.4 (12.1) years; 74 men] who were able to walk at least indoors. For indicators of physical mobility status, we assessed the walked distance (m) and walking energy cost (Jkg-1m-1) during a 6-min walk test at a comfortable speed. Furthermore, self-reported physical functioning and fatigue were assessed with the 36-item Short Form Health Survey physical functioning scale (SF36-PF) and Fatigue Severity Scale (FSS), respectively. Self-reported functional ambulation was classified as household walker, limited community walker or full community walker. RESULTS The mean (SD) walked distance, energy cost, and SF36-PF and FSS scores significantly differed between household walkers (n=48) and limited community walkers (n=63) [275 (67) m; 6.35 (1.80) Jkg-1m-1; 27.7 (13.5), 5.53 (1.06), respectively, and 323 (73) m; 5.49 (1.50) Jkg-1m-1; 40.1 (15.1); 4.81 (1.38) (P<0.018)] and full community walkers (n=29) [383 (66) m; 4.68 (0.85) Jkg-1m-1; 63.9 (18.5), 3.85 (1.54) (P<0.001)], with significant differences also present between limited and full community walkers (P<0.05). Walked distance and SF36-PF score were significantly associated with functional ambulation level, determining 46% of the variance in ambulation level. CONCLUSION The simple, self-reported classification of functional ambulation in 3 levels is clinically meaningful for polio survivors because it consistently corresponds to differences in objective and self-reported indicators of physical mobility and, as such, can be used to better manage rehabilitation treatment.
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Affiliation(s)
- Merel-Anne Brehm
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Hilde E Ploeger
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Frans Nollet
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Scharan KO, Bernardelli RS, Corrêa KP, Moser ADDL. Instrumentos da prática clínica com versão em português e a abrangência de seus conteúdos usando a CIF como referência: uma revisão sistemática. FISIOTERAPIA E PESQUISA 2020. [DOI: 10.1590/1809-2950/18032527032020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO A prática clínica tem sido subsidiada por instrumentos que permitem acessar e registrar informações de funcionalidade e saúde dos indivíduos. Uma forma de conhecer qual conteúdo da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) os instrumentos contemplam é usá-la como referência para auxiliar o profissional na escolha do mais adequado para acessar informações biopsicossociais. O objetivo foi identificar instrumentos da prática clínica em saúde que tiveram seu conteúdo ligado com a CIF e a existência de versão na língua portuguesa deles. Para tanto foi realizada uma revisão sistemática nas bases de dados SciELO Brasil, Lilacs e PubMed com os descritores “CIF”, “questionário” e “regra de ligação” em português e inglês. Três pesquisadores independentes realizaram a seleção, e o nível de concordância foi obtido pelo coeficiente Kappa. Os critérios de elegibilidade foram: estudos primários de ligação de conteúdo de questionários, escalas, índices e checklists com a CIF publicados após 2001 em língua portuguesa ou inglesa. Foram incluídos 61 artigos, sendo 19 de origem brasileira. Dos 250 instrumentos ligados à CIF, 158 (63,2%) apresentaram versão em português sendo que dos 37 que mais se repetiram nos estudos, dois não apresentam essa versão. O coeficiente Kappa mostrou concordância entre moderada e boa (p<0,001). Este estudo apresentou um panorama da ligação de conteúdo de instrumentos da prática clínica à CIF identificando quais têm versão em língua portuguesa, o que contribuirá para o potencial fortalecimento da abordagem biopsicossocial dos profissionais de saúde.
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The association between executive functioning, coping styles and depressive symptoms in patients with Multiple Sclerosis. Mult Scler Relat Disord 2019; 36:101392. [PMID: 31526983 DOI: 10.1016/j.msard.2019.101392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 08/24/2019] [Accepted: 09/07/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate the direct, mediated and moderated relationships between executive functioning, coping and depressive symptoms in patients with multiple sclerosis (MS). METHODS Cross-sectional cohort study of routine follow-up visits, including a standardized (neuro)psychological evaluation of 68 MS patients. Coping was measured with the Coping Inventory for Stressful Situations; Depressive symptoms with the subscale depression of the Hospital Anxiety and Depression Scale. Cognitive tests were reduced to a single 'executive function' factor by means of confirmatory factor analysis. Path analyses tested mediating and moderating effects of coping on the relation between executive functioning and depressive symptoms. RESULTS Consistently, the executive functioning factor was not related to task-oriented and emotion-oriented coping. Better executive functioning, however, and less reliance on avoidance coping, was related to more depressive symptoms. Testing of the mediating path showed that executive dysfunctioning was indeed significantly related to more depressive symptoms by less reliance on avoidance coping. There was no additional direct effect of executive functioning on depressive symptoms and also no moderating effect of any coping style on the association between cognition and depressive symptoms. CONCLUSION Our findings suggest that task-oriented and emotion-oriented coping do not influence the relationship between executive functioning and depression in MS patients, but their mental health might benefit from more reliance on avoidance coping.
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8
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Li Hi Shing S, Chipika RH, Finegan E, Murray D, Hardiman O, Bede P. Post-polio Syndrome: More Than Just a Lower Motor Neuron Disease. Front Neurol 2019; 10:773. [PMID: 31379723 PMCID: PMC6646725 DOI: 10.3389/fneur.2019.00773] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/02/2019] [Indexed: 12/13/2022] Open
Abstract
Post-polio syndrome (PPS) is a neurological condition that affects polio survivors decades after their initial infection. Despite its high prevalence, the etiology of PPS remains elusive, mechanisms of progression are poorly understood, and the condition is notoriously under-researched. While motor dysfunction is a hallmark feature of the condition, generalized fatigue, sleep disturbance, decreased endurance, neuropsychological deficits, sensory symptoms, and chronic pain are also often reported and have considerable quality of life implications in PPS. The non-motor aspects of PPS are particularly challenging to evaluate, quantify, and treat. Generalized fatigue is one of the most distressing symptoms of PPS and is likely to be multifactorial due to weight-gain, respiratory compromise, poor sleep, and polypharmacy. No validated diagnostic, monitoring, or prognostic markers have been developed in PPS to date and the mainstay of therapy centers on symptomatic relief and individualized rehabilitation strategies such as energy conservation and muscle strengthening exercise regimes. Despite a number of large clinical trials in PPS, no effective disease-modifying pharmacological treatments are currently available.
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Affiliation(s)
- Stacey Li Hi Shing
- Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Rangariroyashe H Chipika
- Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Eoin Finegan
- Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Deirdre Murray
- Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Andersson N, Lexell J, Brogårdh C. Test-Retest Reliability of the Reintegration to Normal Living Index (RNL-I) to Assess Perceived Participation in Adults With Late Effects of Polio. PM R 2019; 12:147-153. [PMID: 30900809 DOI: 10.1002/pmrj.12162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/13/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many individuals with late effects of polio have difficulties participating in daily activities. The Reintegration to Normal Living Index (RNL-I) is a self-report questionnaire that evaluates perceived participation, but knowledge of the test-retest reliability and measurement errors in this population is lacking. OBJECTIVE To evaluate the test-retest reliability of the RNL-I in adults with late effects of polio. DESIGN A postal survey with a test-retest design. SETTING University hospital outpatient clinic. PARTICIPANTS Fifty-one adults (20 women and 31 men; mean age 72 years) with late effects of polio. MAIN OUTCOME MEASUREMENTS The Reintegration to Normal Living Index (RNL-I). METHODS The participants responded to the RNL-I twice, 3 weeks apart. Data were analyzed with the following statistical methods: percentage agreement (PA), quadratic kappa coefficients, the intraclass correlation coefficient (ICC), mean difference, standard error of measurement (SEM/SEM%), and the smallest real difference (SRD/SRD%). RESULTS The PA (ie, the same scoring at both test occasions) was >70% for 10 of 11 items. The kappa coefficients showed good test-retest agreement (>0.61) for 7 items. The ICC was 0.88 and the mean difference was -0.74. The SEM (SEM%) was 7.4 (9.7%) and the SRD (SRD%) was 20.5 (27.0%). CONCLUSION The RNL-I can be considered reliable for adults with mild to moderate late effects of polio. It can thereby be used to assess changes in perceived participation over time or after rehabilitation interventions, both for a group of individuals and a single individual. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nilla Andersson
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Jan Lexell
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Uppsala, Sweden
| | - Christina Brogårdh
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
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10
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Lexell J, Jonasson SB, Brogardh C. Psychometric Properties of Three Fatigue Rating Scales in Individuals With Late Effects of Polio. Ann Rehabil Med 2018; 42:702-712. [PMID: 30404419 PMCID: PMC6246856 DOI: 10.5535/arm.2018.42.5.702] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/05/2018] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the psychometric properties of the Fatigue Severity Scale (FSS), the Fatigue Impact Scale (FIS), and the Multidimensional Fatigue Inventory (MFI-20) in persons with late effects of polio (LEoP). More specifically, we explored the data completeness, scaling assumptions, targeting, reliability, and convergent validity. Methods A postal survey including FSS, FIS, and MFI-20 was administered to 77 persons with LEoP. Responders received a second survey after 3 weeks to enable test-retest reliability analyses. Results Sixty-one persons (mean age, 68 years; 54% women) responded to the survey (response rate 79%). Data quality of the rating scales was high (with 0%–0.5% missing item responses), the corrected item-total correlations exceeded 0.4 and the scales showed very little floor or ceiling effects (0%–6.6%). All scales had an acceptable reliability (Cronbach’s α ≥0.95) and test-retest reliability (intraclass correlation coefficient, ≥0.80). The standard error of measurement and the smallest detectable difference were 7%–10% and 20%–28% of the possible scoring range. All three scales were highly correlated (Spearman’s correlation coefficient rs=0.79–0.80; p<0.001). Conclusion The FSS, FIS, and MFI-20 exhibit sound psychometric properties in terms of data completeness, scaling assumptions, targeting, reliability, and convergent validity, suggesting that these three rating scales can be used to assess fatigue in persons with LEoP. As FSS has fewer items and therefore is less time consuming it may be the preferred scale. However, the choice of scale depends on the research question and the study design.
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Affiliation(s)
- Jan Lexell
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Uppsala, Sweden.,Department of Health Science, Lulea University of Technology, Lulea, Sweden.,Department of Neurology and Rehabilitation Medicine, Skane University Hospital, Lund, Sweden
| | - Stina B Jonasson
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Skane University Hospital, Lund, Sweden
| | - Christina Brogardh
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Skane University Hospital, Lund, Sweden
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11
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Plewa J, Surampalli A, Wencel M, Milad M, Donkervoort S, Caiozzo VJ, Goyal N, Mozaffar T, Kimonis V. A cross-sectional analysis of clinical evaluation in 35 individuals with mutations of the valosin-containing protein gene. Neuromuscul Disord 2018; 28:778-786. [PMID: 30097247 PMCID: PMC6490182 DOI: 10.1016/j.nmd.2018.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/26/2018] [Accepted: 06/19/2018] [Indexed: 12/12/2022]
Abstract
Inclusion body myopathy (IBM) associated with Paget disease of the bone and frontotemporal dementia or IBMPFD is an autosomal dominant degenerative disorder caused by mutations in the valosin-containing protein (VCP) gene. We aim to establish a detailed clinical phenotype of VCP disease amongst 35 (28 affected individuals, 7 presymptomatic gene carriers) individuals versus 14 unaffected first-degree relatives in 14 families to establish useful biomarkers for IBMPFD and identify the most meaningful tests for monitoring disease progression in future clinical trials. Comprehensive studies included the Inclusion Body Myositis Functional Rating Scale (IBMFRS) and fatigue severity scale questionairres, strength measurements using the Manual Muscle Test with Medical Research Council (MRC) scales, hand-held dynamometry using the microFET and Biodex dynamometers, 6 minute walk test (6MWT), and pulmonary function studies. Strong correlation was observed between the IBMFRS and measurements of muscle strength with dynamometry and the other functional tests, indicating that it may be utilized in long-term follow-up assessments due to its relative simplicity. This cross-section study represents the most comprehensive evaluation of individuals with VCP disease to date and provides a useful guide for evaluating and possible monitoring of muscle weakness and pulmonary function progression in this unique cohort of individuals.
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Affiliation(s)
- Jake Plewa
- Division of Genetics and Genomic Medicine, Department of Pediatrics, University of California, Irvine Medical Center, 101 The City Drive South, ZC4482, Orange, CA 92868, United States
| | - Abhilasha Surampalli
- Division of Genetics and Genomic Medicine, Department of Pediatrics, University of California, Irvine Medical Center, 101 The City Drive South, ZC4482, Orange, CA 92868, United States
| | - Marie Wencel
- Division of Genetics and Genomic Medicine, Department of Pediatrics, University of California, Irvine Medical Center, 101 The City Drive South, ZC4482, Orange, CA 92868, United States
| | - Merit Milad
- Division of Genetics and Genomic Medicine, Department of Pediatrics, University of California, Irvine Medical Center, 101 The City Drive South, ZC4482, Orange, CA 92868, United States
| | - Sandra Donkervoort
- Division of Genetics and Genomic Medicine, Department of Pediatrics, University of California, Irvine Medical Center, 101 The City Drive South, ZC4482, Orange, CA 92868, United States; National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Vincent J Caiozzo
- Department of Orthopedics and Physiology & Biophysics, University of California, Irvine, CA, United States
| | - Namita Goyal
- ALS and Neuromuscular Center, Department of Neurology, University of California, Irvine, CA, United States
| | - Tahseen Mozaffar
- ALS and Neuromuscular Center, Department of Neurology, University of California, Irvine, CA, United States
| | - Virginia Kimonis
- Division of Genetics and Genomic Medicine, Department of Pediatrics, University of California, Irvine Medical Center, 101 The City Drive South, ZC4482, Orange, CA 92868, United States.
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Unger J, Jervis Rademeyer H, Furlan JC, Pujol C, Dawe J, Musselman KE. Personalized adapted locomotor training for an individual with sequelae of West Nile virus infection: a mixed-method case report. Physiother Theory Pract 2018; 36:844-854. [PMID: 30136877 DOI: 10.1080/09593985.2018.1510450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND West Nile virus (WNV) can have severe consequences, including encephalitis and paralysis. Purpose: To describe the benefits of intensive locomotor training (LT) for an individual with a previous WNV infection resulting in chronic paraplegia. Case Description: The patient, who became a wheelchair user following standard rehabilitation, began LT 3 years post infection. Her goals included standing and walking with an assistive device and transferring independently. The intervention consisted of bodyweight-supported treadmill training and overground training, which involved walking, balancing, strengthening, and transferring activities. Outcomes: Following 5 months of LT, the patient ambulated independently with a walker at a speed = 0.34m/s. She walked 110.1 metres in 6 minutes and increased her Berg Balance Scale score by 17 points. These improvements were either maintained or further increased 3 months post LT. The patient's perspectives on LT were collected through a semi-structured interview. A conventional content analysis, which uses data to drive themes, revealed three themes: (1) recalibrating goals, (2) outcomes (i.e. physical and psychological benefits, such as a sense of accomplishment), and (3) challenges of LT and effective coping strategies. Conclusions: The patient demonstrated improved balance and walking abilities. Intensive LT was feasible and effective for this individual with chronic paraplegia due to WNV infection.
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Affiliation(s)
- Janelle Unger
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto , Toronto, ON, Canada
| | - Hope Jervis Rademeyer
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada.,School of Physical Therapy, College of Medicine, University of Saskatchewan , Saskatoon, SK, Canada
| | - Julio C Furlan
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto , Toronto, ON, Canada
| | - Clara Pujol
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada
| | - Jaclyn Dawe
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto , Toronto, ON, Canada
| | - Kristin E Musselman
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto , Toronto, ON, Canada.,School of Physical Therapy, College of Medicine, University of Saskatchewan , Saskatoon, SK, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto , Toronto, ON, Canada
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13
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Hoofs H, Jansen N, Jansen M, Kant IJ. Monitoring of need for recovery and prolonged fatigue within the working population: Evaluation of reliability and agreement over time. Work 2017; 58:399-412. [DOI: 10.3233/wor-172624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- H. Hoofs
- Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Academic Collaborative Centre for Public Health Limburg, Public Health Service Southern Limburg, Geleen, The Netherlands
| | - N.W.H. Jansen
- Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - M.W.J. Jansen
- Academic Collaborative Centre for Public Health Limburg, Public Health Service Southern Limburg, Geleen, The Netherlands
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - IJ. Kant
- Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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14
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Measuring Physical and Cognitive Fatigue in People With Post-Polio Syndrome: Development of the Neurological Fatigue Index for Post-Polio Syndrome (NFI-PP). PM R 2017; 10:129-136. [DOI: 10.1016/j.pmrj.2017.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 06/07/2017] [Accepted: 06/17/2017] [Indexed: 11/24/2022]
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15
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Bertolasi L, Danese A, Monaco S, Turri M, Borg K, Werhagen L. Polio Patients in Northern Italy, a 50 Year Follow-up. Open Neurol J 2016; 10:77-82. [PMID: 27651845 PMCID: PMC5012079 DOI: 10.2174/1874205x01610010077] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 05/24/2016] [Accepted: 06/09/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Poliomyelitis was before the immunization an important medical problem. Nowadays polio prior patients (PP) suffer from polio sequelae or have developed post-polio-syndrome (PPS) with increasing paresis, pain and fatigue. OBJECTIVES To analyze the medical situation 50 years after acute polio. The degree of paresis was compared between the recovery 1952-1961 and 2012.The prevalence of patients fulfilling the criteria for PPS was estimated. METHOD The study was performed in Italy. Included were PP with rehabilitation after acute polio 1952-1961 and in 2012. During the years PP underwent yearly evaluation. A thorough neurological examination was performed in 2012. A telephone interview with questions concerning pain, paresis, fatigue, walking aids and concomitant diseases was performed in 2012. The patients were divided in two groups, if they fulfilled the criteria for PPS or not. RESULTS Included were 67(94%) patients receiving rehabilitation after acute poliomyelitis and 2012. 78% were walkers, half of the PPS used wheelchair. Eight out of ten suffered from pain. Four out of ten fulfilled the PPS criteria. Pain was slightly more common in PPS. CONCLUSION Female gender, fatigue and wheelchair dependency were significantly more common in PPS while pain was common in both groups.
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Affiliation(s)
- L. Bertolasi
- Section of Neurology, Department of Neurological, Neurophysiological, Morphological and Motor Sciences, University of Verona, Verona, Italy
| | - A Danese
- Section of Neurology, Department of Neurological, Neurophysiological, Morphological and Motor Sciences, University of Verona, Verona, Italy
| | - S Monaco
- Section of Neurology, Department of Neurological, Neurophysiological, Morphological and Motor Sciences, University of Verona, Verona, Italy
| | - M Turri
- Section of Neurology, Department of Neurological, Neurophysiological, Morphological and Motor Sciences, University of Verona, Verona, Italy
| | - K Borg
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institut at Danderyds Hospital, Stockholm, Sweden
| | - L Werhagen
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institut at Danderyds Hospital, Stockholm, Sweden
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16
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van der Borg WE, Schipper K, Abma TA. Protocol of a mixed method, randomized controlled study to assess the efficacy of a psychosocial intervention to reduce fatigue in patients with End-Stage Renal Disease (ESRD). BMC Nephrol 2016; 17:73. [PMID: 27391406 PMCID: PMC4939050 DOI: 10.1186/s12882-016-0277-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 06/14/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) commonly suffer from severe fatigue, which strongly impacts their quality of life (QoL). Although fatigue is often attributed to disease- and treatment characteristics, research also shows that behavioural, psychological and social factors affect perceived fatigue in dialysis patients. Whereas studies on fatigue in other chronic patient groups suggest that psychological or psychosocial interventions are effective in reducing fatigue, such interventions are not yet available for ESRD patients on dialysis treatment. The objective of this study is to examine the efficacy of a psychosocial intervention for dialysis patients aimed at reducing fatigue (primary outcome) and improving QoL (secondary outcome). The intervention consists of counselling sessions led by a social worker. The implementation process and patients' and social workers' expectations and experiences with the intervention will also be evaluated. METHODS/DESIGN This study follows a mixed-methods design in which both quantitative and qualitative data will be collected. A multi-centre, randomised controlled trial (RCT) with repeated measures will be conducted to quantitatively assess the efficacy of the psychosocial intervention in reducing fatigue and improving QoL in ESRD patients. Additional secondary outcomes and medical parameters will be assessed. Outcomes will be compared to patients receiving usual care. A sample of 74 severely fatigued dialysis patients will be recruited from 10 dialysis centres. Patients will be randomly assigned to the intervention or control group. Outcomes will be assessed at baseline, post intervention/16 weeks, and at three and six-month follow-ups. A qualitative process evaluation will be conducted parallel to/following the effectiveness RCT. Interviews and focus groups will be conducted to gain insight into patients' and social workers' perspectives on outcomes and implementation procedures. Implementation fidelity will be assessed by audio-taped and written registrations. Participatory methods ensure the continuous input of experiential knowledge, improving the quality of study procedures and the applicability of outcomes. DISCUSSION This is the first mixed method study (including an RCT and qualitative process evaluation) to examine the effect and implementation process of a psychosocial intervention on reducing fatigue and improving QoL in ESRD patients on dialysis treatment. TRIAL REGISTRATION NTR5366 , The Netherlands National Trial Register (NTR), registered August 26, 2015.
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Affiliation(s)
- Wieke E van der Borg
- Department of Medical Humanities, VU University Medical Center/EMGO+, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
| | - Karen Schipper
- Department of Medical Humanities, VU University Medical Center/EMGO+, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
| | - Tineke A Abma
- Department of Medical Humanities, VU University Medical Center/EMGO+, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
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17
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Brogårdh C, Lexell J. Test-Retest Reliability of the Self-Reported Impairments in Persons With Late Effects of Polio (SIPP) Rating Scale. PM R 2016; 8:399-404. [DOI: 10.1016/j.pmrj.2015.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 07/31/2015] [Accepted: 09/25/2015] [Indexed: 10/22/2022]
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18
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Peel MM, Cooke M, Lewis-Peel HJ, Lea RA, Moyle W. A randomized controlled trial of coenzyme Q10 for fatigue in the late-onset sequelae of poliomyelitis. Complement Ther Med 2015; 23:789-93. [PMID: 26645517 DOI: 10.1016/j.ctim.2015.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 07/15/2015] [Accepted: 09/06/2015] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine if coenzyme Q(10) alleviates fatigue in the late-onset sequelae of poliomyelitis. DESIGN Parallel-group, randomized, placebo-controlled trial. BACKGROUND SETTING Coenzyme Q(10) has been shown to boost muscle energy metabolism in post-polio subjects but it does not promote muscle strength, endurance or function in polio survivors with post-poliomyelitis syndrome. However, the collective increased energy metabolism might contribute to a reduction in post-polio fatigue. PARTICIPANTS Polio survivors from the Australian post-polio networks in Queensland and New South Wales who attribute a moderate to high level of fatigue to their diagnosed late-onset sequelae of poliomyelitis. Those with fatigue-associated comorbidities of diabetes, anaemia, hypothyroidism and fibromyalgia were excluded. METHOD Participants were assigned (1:1), with stratification of those who use energy-saving mobility aids, to receive 100 mg coenzyme Q(10) or matching placebo daily for 60 days. Participants and investigators were blinded to group allocation. Fatigue was assessed by the Multidimensional Assessment of Fatigue as the primary outcome and the Fatigue Severity Scale as secondary outcome. RESULTS Of 103 participants, 54 were assigned to receive coenzyme Q(10) and 49 to receive the placebo. The difference in the mean score reductions between the two groups was not statistically significant for either fatigue measure. Oral supplementation with coenzyme Q(10) was safe and well-tolerated. CONCLUSION A daily dose of 100 mg coenzyme Q(10) for 60 days does not alleviate the fatigue of the late-onset sequelae of poliomyelitis. The registration number for the clinical trial is ACTRN 12612000552886.
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Affiliation(s)
- Margaret M Peel
- NHMRC Centre for Research Excellence in Nursing Interventions, Menzies Health Institute Queensland, Centre for Health Practice Innovation, Griffith University, Queensland, Australia
| | - Marie Cooke
- NHMRC Centre for Research Excellence in Nursing Interventions, Menzies Health Institute Queensland, Centre for Health Practice Innovation, Griffith University, Queensland, Australia.
| | - Helen J Lewis-Peel
- NHMRC Centre for Research Excellence in Nursing Interventions, Menzies Health Institute Queensland, Centre for Health Practice Innovation, Griffith University, Queensland, Australia
| | - Rodney A Lea
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia
| | - Wendy Moyle
- NHMRC Centre for Research Excellence in Nursing Interventions, Menzies Health Institute Queensland, Centre for Health Practice Innovation, Griffith University, Queensland, Australia
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Chuang LL, Lin KC, Hsu AL, Wu CY, Chang KC, Li YC, Chen YL. Reliability and validity of a vertical numerical rating scale supplemented with a faces rating scale in measuring fatigue after stroke. Health Qual Life Outcomes 2015; 13:91. [PMID: 26122080 PMCID: PMC4486436 DOI: 10.1186/s12955-015-0290-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 06/18/2015] [Indexed: 01/17/2023] Open
Abstract
Background Poststroke fatigue is a persistent and distressing symptom among stroke survivors. In this study, we investigated the reliability and validity of a vertical numerical rating scale supplemented with a faces rating scale (NRS-FRS) in measuring poststroke fatigue. Methods The fatigue intensity of 106 individuals with stroke was measured twice, 1 week apart, using a vertical NRS-FRS to measure test-retest reliability. The intraclass correlation coefficient, a relative reliability index, was calculated to examine the degree of consistency and agreement between the two test occasions. Absolute reliability indices, including the standard error of measurement, minimal detectable change, and Bland-Altman limits of agreement, were used to quantify measurement errors and determine systematic biases of the two test occasions. We also administered the vertical NRS concurrently as a comparator measure for assessing fatigue in 50 consecutive patients with stroke who were recruited later in the study period. The Spearman rank correlation coefficient (ρ) was used to examine the concurrent validity of the NRS-FRS. Discriminant validity was assessed by means of receiver operating characteristic curves, sensitivity, and specificity. Results The intraclass correlation coefficient was 0.95 for the NRS-FRS. The standard error of measurement and the minimal detectable change at the 95 % confidence interval of the NRS-FRS were 0.50 and 1.39, respectively. The Bland-Altman analyses showed no significant systematic bias between the repeated measurements. A narrow range of the limits of agreement was shown on the Bland-Altman plot, indicating the NRS-FRS had high stability and low variation between the two test occasions. The correlations between the NRS-FRS and NRS were good at test (ρ = 0.85) and retest (ρ = 0.84). Compared with the NRS cutoff value of ≥1, sensitivity with the NRS-FRS at test and retest was 94 and 92 % and specificity was 79 and 90 %, respectively. Conclusions This study provides further evidence of the reliability and validity of the NRS-FRS in measuring fatigue intensity in patients with stroke. The NRS-FRS had high sensitivity and specificity. The NRS-FRS may be a reliable and valid measure for clinicians and researchers to assess fatigue and determine whether a real change has occurred in groups and at the individual level of patients with stroke.
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Affiliation(s)
- Li-Ling Chuang
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Healthy Ageing Research Center, Chang Gung University, 259 Wen-hua 1st Rd., Guishan, Taoyuan, Taiwan.
| | - Keh-Chung Lin
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan. .,Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan.
| | - An-Lun Hsu
- Department of Physical Therapy, Mackay Memorial Hospital, Taipei, Taiwan.
| | - Ching-Yi Wu
- Healthy Ageing Research Center, Chang Gung University, 259 Wen-hua 1st Rd., Guishan, Taoyuan, Taiwan. .,Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ku-Chou Chang
- Department of Neurology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Yen-Chen Li
- Department of Physical Medicine and Rehabilitation, Physical Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - You-Lin Chen
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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