Development of an index of physical functional health status in rehabilitation


      Hart DL, Wright BD. Development of an index of physical functional health status in rehabilitation. Arch Phys Med Rehabil 2002;83:655-65. Objective: To describe (1) the development of an index of physical functional health status (FHS) and (2) its hierarchical structure, unidimensionality, reproducibility of item calibrations, and practical application. Design: Rasch analysis of existing data sets. Setting: A total of 715 acute, orthopedic outpatient centers and 62 long-term care facilities in 41 states participating with Focus On Therapeutic Outcomes, Inc. Patients: A convenience sample of 92,343 patients (40% male; mean age ± standard deviation [SD], 48±17y; range, 14-99y) seeking rehabilitation between 1993 and 1999. Interventions: Not applicable. Main Outcome Measures: Patients completed self-report health status surveys at admission and discharge. The Medical Outcomes Study 36-Item Short-Form Health Survey's physical functioning scale (PF-10) is the foundation of the physical FHS. The Oswestry Low Back Pain Disability Questionnaire, Neck Disability Index, Lysholm Knee Questionnaire, items pertinent to patients with upper-extremity impairments, and items pertinent to patients with more involved neuromusculoskeletal impairments were cocalibrated into the PF-10. Results: The final FHS item bank contained 36 items (patient separation, 2.3; root mean square measurement error, 5.9; mean square ± SD infit, 0.9±0.5; outfit, 0.9±0.9). Analyses supported empirical item hierarchy, unidimensionality, reproducibility of item calibrations, and content and construct validity of the FHS-36. Conclusions: Results support the reliability and validity of FHS-36 measures in the present sample. Analyses show the potential for a dynamic, computer-controlled, adaptive survey for FHS assessment applicable for group analysis and clinical decision making for individual patients. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation


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        • Haley SM
        • McHorney CA
        • Ware JE.
        Evaluation of the MOS SF-36 physical functioning scale (PF-10): I. Unidimensionality and reproducibility of the Rasch item scale.
        J Clin Epidemiol. 1994; 47: 671-684
        • Hart DL.
        Assessment of unidimensionality of physical functioning in patients receiving therapy in acute, orthopedic outpatient centers.
        J Outcome Meas. 2000; 4: 413-430
        • McHorney CA
        • Haley SM
        • Ware JE.
        Evaluation of the MOS SF-36 physical functioning scale (PF-10): II. Comparison of relative precision using Likert and Rasch scoring methods.
        J Clin Epidemiol. 1997; 50: 451-461
        • Raczek AE
        • Ware JE
        • Bjorner JB
        • et al.
        Comparison of Rasch and summated rating scales constructed from SF-36 physical functioning items in seven countries: results from the IQOLA project.
        J Clin Epidemiol. 1998; 51: 1203-1214
        • Segal ME
        • Heinemann AW
        • Schall RR
        • Wright BD.
        Rasch analysis of a brief physical ability scale for long-term outcomes of stroke.
        Phys Med Rehabil State Art Rev. 1997; 11: 385-396
        • Ware JE
        • Sherbourne CD.
        The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • McHorney CA
        • Ware JE
        • Raczek AE.
        The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.
        Med Care. 1993; 31: 247-263
        • McHorney CA
        • Ware JE
        • Lu JF
        • Sherbourne CD.
        The MOS 36-Item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups.
        Med Care. 1994; 32: 40-66
        • Ware JE
        • Snow KK
        • Kosinski M
        • Gandek B
        SF-36 Health Survey manual and interpretation guide.
        : The Health Institute, N Engl Med Center, Boston1993
        • Binkley JM
        • Stratford PW
        • Lott SA
        • Riddle DL.
        The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application.
        Phys Ther. 1999; 79: 371-383
        • Hart DL.
        Orthotics and Prosthetics National Office Outcomes Tool (OPOT): initial reliability and validity assessment for lower extremity prosthetics.
        J Prosthet Orthot. 1999; 11: 101-111
        • Martin DP
        • Engelberg R
        • Agel J
        • Swiontkowski MF.
        Comparison of the musculoskeletal function assessment questionnaire with the Short Form-36, the Western Ontario and McMaster University's Osteoarthritis Index, and the Sickness Impact Profile health-status measures.
        J Bone Joint Surg Am. 1997; 79: 1323-1335
        • Hawker G
        • Melfi CA
        • Paul J
        • Green R
        • Bombardier C.
        Comparison of a generic (SF-36) and a disease-specific (WOMAC) instrument in the measurement of outcomes after knee replacement surgery.
        J Rheumatol. 1995; 22: 1193-1196
        • Jette DU
        • Jette AM.
        Physical therapy and health outcomes in patients with knee impairments.
        Phys Ther. 1996; 76: 1178-1187
        • Jette DU
        • Jette AM.
        Physical therapy and health outcomes in patients with spinal impairments.
        Phys Ther. 1996; 76: 930-945
        • Jette AM
        • Delitto A.
        Physical therapy treatment choices for musculoskeletal impairments.
        Phys Ther. 1997; 77: 145-154
        • Jette DU
        • Downing J.
        Health status of individuals entering a cardiac rehabilitation program as measured by the medical outcomes study 36-item short-form survey (SF-36).
        Phys Ther. 1994; 74: 521-527
        • Stratford PW
        • Binkley JM
        • Riddle DL
        • Guyatt GH.
        Sensitivity to change of the Roland-back pain questionnaire: Part 1.
        Phys Ther. 1998; 78: 1186-1196
        • Stratford PW
        • Binkley JM
        • Solomon P
        • Finch E
        • Gill C
        • Moreland J.
        Defining the minimum level of detectable change for the Roland-Morris Questionnaire.
        Phys Ther. 1996; 76 (discussion 366-8): 359-365
        • Deyo RA
        • Centor RM.
        Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance.
        J Chronic Dis. 1986; 39: 897-906
        • Kirshner B
        • Guyatt G.
        A methodological framework for assessing health indices.
        J Chronic Dis. 1985; 38: 27-36
        • Hart DL.
        The power of outcomes: FOTO Industrial Outcomes Tool—initial assessment.
        Work. 2001; 16: 39-51
        • Hart DL
        • Dobrzykowski EA.
        Impact of exercise history on health status outcomes in patients with musculoskeletal impairments.
        Orthop Phys Ther Clin North Am. 2000; 9: 1-16
        • Hart DL
        • Dobrzykowski EA.
        Influence of orthopaedic clinical specialist certification on clinical outcomes.
        J Orthop Sports Phys Ther. 2000; 30: 183-193
        • Patrick DL
        • Deyo RA
        • Atlas SJ
        • Singer DE
        • Chapin A
        • Keller RB.
        Assessing health-related quality of life in patients with sciatica.
        Spine. 1995; 20: 1899-1909
        • Hart DL
        • Tepper S
        • Lieberman D.
        Changes in health status for persons with wrist or hand impairments receiving occupational or physical therapy.
        Am J Occup Ther. 2001; 55: 68-74
        • Di Fabio RP.
        Physical therapy for patients with TMD: a descriptive study of treatment, disability, and health status.
        J Orofacial Pain. 1998; 12: 124-135
        • Di Fabio RP
        • Boissonnault W.
        Physical therapy and health-related outcomes for patients with common orthopaedic diagnoses.
        J Orthop Sports Phys Ther. 1998; 27: 219-230
        • Katz J
        • Harris TM
        • Larson MG
        • et al.
        Predictors of functional outcomes after arthroscopic partial meniscectomy.
        J Rheumatol. 1992; 19: 1938-1942
        • Wright JG
        • Young NL.
        A comparison of different indices of responsiveness.
        J Clin Epidemiol. 1997; 50: 239-246
        • Tugwell P
        • Bombardier C
        • Buchanan W
        • Goldsmith CH
        • Grace E
        • Hanna B.
        The MACTAR Patient Preference Disability Questionnaire—an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis.
        J Rheumatol. 1987; 14: 446-451
        • Patrick DL
        • Deyo RA.
        Generic and disease-specific measures in assessing health status and quality of life.
        Med Care. 1989; 27: S217-S232
        • Kaegi L.
        Medical Outcomes Trust conference presents dramatic advances in patient-based outcomes assessment and potential applications in accreditation.
        Jt Comm J Qual Improv. 1999; 25: 207-218
        • Rasch G.
        Probabilistic models for some intelligence and attainment tests.
        : MESA Pr, Chicago1980
        • Wright BD
        • Masters GN.
        Rating scale analysis.
        : MESA Pr, Chicago1982
        • Wright BD
        • Stone MH.
        Best test design.
        : MESA Pr, Chicago1979
        • Tennant A
        • Young C.
        Coma to community: continuity in measurement.
        in: Physical medicine and rehabilitation: state of the art reviews. : Hanley & Belfus, Philadelphia1997: 375-384
        • Likert R.
        A technique for the measurement of attitudes.
        Arch Psychol. 1932; 140: 5-55
        • Stucki G
        • Daltroy L
        • Katz JN
        • Johannesson M
        • Liang MH.
        Interpretation of change scores in ordinal clinical scales and health status measures: the whole may not equal the sum of the parts.
        J Clin Epidemiol. 1996; 49: 711-717
        • Merbitz C
        • Morris J
        • Gripp JC.
        Ordinal scales and foundations of misinference.
        Arch Phys Med Rehabil. 1989; 70: 308-312
        • Wright BD.
        Fundamental measurement for outcome evaluation.
        Phys Med Rehabil State Art Rev. 1997; 11: 261-287
        • Wright BD
        • Linacre JM.
        Observations are always ordinal; measurements, however, must be interval.
        Arch Phys Med Rehabil. 1989; 70: 857-860
        • Granger CV
        • Hamilton BB
        • Fiedler RC.
        Discharge outcome after stroke rehabilitation.
        Stroke. 1992; 23: 978-982
        • Jette DU
        • Jette AM.
        Professional uncertainty and treatment choices by physical therapists.
        Arch Phys Med Rehabil. 1997; 78: 1346-1351
        • Riddle DL
        • Stratford PW.
        Use of generic versus region-specific functional status measures on patients with cervical spine disorders.
        Phys Ther. 1998; 78: 951-963
        • Fairbank JC
        • Couper J
        • Davies JB
        • O'Brien JP.
        The Oswestry low back pain disability questionnaire.
        Physiotherapy. 1980; 66: 271-273
        • Vernon H
        • Mior S.
        The Neck Disability Index: a study of reliability and validity.
        J Manipulative Physiol Ther. 1991; 14: 409-415
        • Lysholm J
        • Gillquist J.
        Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.
        Am J Sports Med. 1982; 10: 150-154
        • Tegner Y
        • Lysholm J.
        Rating systems in the evaluation of knee ligament injuries.
        Clin Orthop. 1985; 190: 43-49
        • Keller SD
        • Bayliss MS
        • Ware JE
        • Hsu MA
        • Damiano AM
        • Goss TF.
        Comparison of responses to SF-36 Health Survey questions with one-week and four-week recall periods.
        Health Serv Res. 1997; 32: 367-384
        • Ware JE
        • Kosinski M
        • Keller SD.
        A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity.
        Med Care. 1996; 34: 220-233
        • Linacre JM
        • Wright BD.
        A user's guide to WINSTEPS.
        : MESA Pr, Chicago2000
        • Silverstein B
        • Fisher WP
        • Kilgore KM
        • Harley JP
        • Harvey RF.
        Applying psychometric criteria to functional assessment in medical rehabilitation: II. Defining interval measures.
        Arch Phys Med Rehabil. 1992; 73: 507-518
        • Westaway MD
        • Stratford PW
        • Binkley JM.
        The Patient-Specific Functional Scale: validation of its use in persons with neck dysfunction.
        J Orthop Sports Phys Ther. 1998; 27: 331-338