]GIF$DT)1_[(igure Research 79 Patients presenting to the emergency department in one year (n = 71 880) Patients managed by physiotherapists Patients managed by medical staff (n = 1320) (n = 70 560) Assessed for adverse events Patients with ineligible diagnostic codes (n = 62 772) Patients with ineligible diagnostic codes (n = 71) Patients with eligible diagnostic codes managed by medical staff (n = 7788) Patients with eligible diagnostic codes managed by physiotherapists (n = 1249) Patients who were managed by medical staff and who weren’t needed for the Patients with diagnostic codes that could matched cohort (n = 6621) not be matched to any patient in the cohort managed by medical staff (n = 82) Patients managed by physiotherapists Patients managed by medical staff and and with diagnostic codes matched to with diagnostic codes matched to patients patients managed by medical staff managed by physiotherapists (n = 1167) (n = 1167) Assessed for length of stay and medical Assessed for length of stay and medical imaging imaging Figure 1. Design and flow of patients through the study. with the primary-contact physiotherapy service. Therefore, the Did the matched cohorts differ in length of stay? estimated population proportion of adverse events among patients presenting to the emergency department who were managed by Patients in the physiotherapy cohort had a mean length of stay primary-contact physiotherapists was 0.0%. The sample size of of 103 minutes (SD 65). Patients in the medical cohort had a mean 1320 patients makes this a very precise estimate, with the 95% CI length of stay of 185 minutes (SD 128). The reduction in length of ranging from 0.0 to 0.3%. stay was statistically significant, with a mean difference of 83 minutes (95% CI 75 to 91). There were 33 re-presentations of patients within 28 days after being managed by the primary-contact physiotherapy service, Were imaging studies ordered more frequently in one of the none of which were due to an incorrect diagnosis or missed matched cohorts? fracture. Of the 33 re-presentations, five were for the same initial condition; however, they were all discharged with the same initial For each of the three types of imaging, the physiotherapists diagnosis. One patient with low back pain re-presented for ongoing ordered imaging studies for significantly fewer of their cohort than pain management, one patient with a patellar dislocation re- the medical staff ordered for their cohort (Table 1). presented with a recurrent dislocation, and the remaining 26 patients re-presented with unrelated conditions to those with Discussion which they initially presented. Providing safe patient care is one of the greatest single issues to Characteristics of the matched cohorts be addressed by the physiotherapy profession in order to practise in roles historically occupied by medical professionals.7 The Matching was achieved by seeking an ICD-matched patient main finding of this study was that the physiotherapy service among the medically-managed patients for each patient managed was able to identify appropriate patients and provide safe by the physiotherapy service. In total, 1167 pairs could be management without any identified adverse events or misdiag- identified, meaning 93% of the 1249 patients for whom matches noses. This is an encouraging outcome and provides support for the were sought were able to be matched (Figure 1). The mean age of safety of assigning appropriately experienced and qualified the patients was 33 years (SD 19) for the physiotherapy-managed physiotherapists into emergency departments. While the study cohort and 35 years (SD 23) for the medically-managed cohort, so utilised a robust process in order to identify any adverse events or the mean difference was 2 years (95% CI 0 to 4). Table 1 Number of patients (%) undergoing imaging in each cohort, absolute difference between cohorts in the percentage of patients undergoing imaging (95% CI), and the ‘number needed to treat’ to avoid one imaging study. Outcome Groups Absolute difference between groups in the percentage of Number needed to treata (95% CI) Physiotherapy (n = 1167) Medical (n = 1167) patients undergoing imaging (95% CI) Physiotherapy relative to medical Physiotherapy relative to medical X-ray 667 (57.2%) 809 (69.3%) –12.2% (–16.0 to –8.3) 8 (6 to 12) CT 6 (0.5%) 35 (3.0%) –2.5% (–3.7 to –1.5) 40 (27 to 69) Ultrasound 21 (1.8%) 38 (3.3%) –1.5% (–2.8 to –0.2) 69 (36 to 569) CT = computerised tomography. a Number needed to treat indicates the number of patients that would need to be managed by the physiotherapy service instead of medical staff to avoid one imaging study.
80 Sutton et al: Emergency department physiotherapists for minor trauma misdiagnoses, the possibility remains that an adverse event may must, however, be treated with caution due to the potential for still have occurred. For example, people may re-present to an confounding factors associated with the study design. Firstly, alternative care provider such as their general practitioner or an matching cohorts with ICD9 codes does not necessarily reflect alternative emergency department. In this situation, the adverse the severity or complexity of the presentation. Additionally, the event would not have been identified with the process used in this physiotherapy service was only available in daytime hours. This study. It is, however, likely that this would be an exceptional has the potential to influence length of stay due to a reduced circumstance. staffing profile after hours. It is also reasonable to consider whether people presenting during the night may be less likely to provide This study also showed a large reduction in length of stay with an accurate history due to, for example, being under the influence the physiotherapy service. The average reduction of 83 minutes in of alcohol. This would require the treating clinician to rely more managing a patient with minor trauma would provide short-term heavily on objective tests, such as imaging, to make an accurate clinical benefits such as earlier pain management and fracture diagnosis. Additionally, the study was unable to identify the immobilisation. As this potentially applies to 12.6% of the overall number of people who presented to the emergency department caseload, this would also assist with flow of patients through the with diagnostic imaging that had been performed elsewhere. emergency department. While it is unclear as to whether these factors would bias the results in one direction or the other overall, they remain potential The study also showed statistically significant reductions in confounders. requests for X-ray, CT and ultrasound imaging when the patients were managed by physiotherapists. These results are perhaps best In conclusion, the primary-contact physiotherapy service understood from the ‘number needed to treat’ statistic (Table 1). identified and managed a clinical caseload without any identified For example, the ‘number needed to treat’ result for X-ray is 8 (95% adverse events or misdiagnoses. This is a critical outcome to CI 6 to 12). This means that for every eight patients managed by support the safety of implementing such a service in the the physiotherapy service, we estimate that one X-ray will be emergency department. The study also suggests that for an ICD- avoided that would have been ordered if the eight patients had matched cohort, patients managed by the physiotherapy service been managed by the medical staff. There is some uncertainty had a reduced length of stay and fewer X-ray, CT and ultrasound associated with this estimate. The lower end of the 95% CI is 6, imaging requests than those managed by the medical staff. which means that the true effect of using physiotherapists instead of medical staff might be one X-ray avoided for as few as every What is already known on this topic: Primary-contact six patients, which would be a more worthwhile effect. However, physiotherapists working in the emergency department have even the higher end of the 95% CI (ie, one X-ray avoided for every demonstrated high patient satisfaction rates. 12 patients managed by physiotherapists instead of medical staff) What this study adds: Physiotherapists can safely manage a is arguably still worthwhile. For example, when applied to the minor trauma caseload in the emergency department. Phy- number of patients seen by the physiotherapy service and analysed siotherapists may also reduce length of stay and imaging in this study (n = 1167), this represents a likely saving of 146 X-ray requests for these patients. requests per year (with a minimum of 97 and maximum of 195 if the confidence limits are applied). The same analysis for the other eAddenda: Appendix 1 can be found online at doi:10.1016/j. imaging modalities shows that 29 CTs (95% CI 16 to 43) and jphys.2015.02.012. 16 ultrasounds (95% CI 2 to 32) would be prevented per year by using the physiotherapy service. Importantly, these reductions in Ethics approval: The Southern Adelaide Clinical Human the use of imaging were not at the compromise of patient safety. Research Ethics Committee approved this study ID number 379.12. Consent waiver was provided by the ethics committee. To date, there have been no studies comparing either length of stay or diagnostic imaging rates for primary-contact phy- Competing interests: Nil siotherapists with the rate of referral by doctors in the emergency Source(s) of support: Health Workforce Australia, SA Health. department. This study also identified that 12.6% of people Acknowledgements: This study was part of a national project to presenting to the emergency department had ICD9 diagnostic assess the effectiveness of primary-contact physiotherapy services codes suitable to be managed by a physiotherapist. This is in emergency departments across Australia, and funded by Health encouraging because this not only represents a substantial Workforce Australia (HWA). proportion of presentations to the emergency department, but is Corresponding author: Matthew Sutton, School of Health also very consistent with previously published data, which Sciences, Flinders University, Adelaide, Australia. Email matthew. reported 13.9% of presentations to the emergency department sutton@flinders.edu.au were due to symptoms referable to the musculoskeletal system.8 The similarity of these findings suggests that other emergency References departments could confidently expect to have a similar proportion of people present with minor trauma suitable for management 1. Lebec MT, Jogodka CE. The physical therapist as a musculoskeletal specialist in the by a physiotherapist. emergency department. J Orthop Sports Phys Ther. 2009;39(3):221–229. These outcomes have potentially important implications, 2. Nall C. Primary care physiotherapy in the Emergency Department. Aust J Physiother. particularly in the context of increasing pressures on emergency 2009;55:70. departments across Australia. The improvement in average length of stay would help ease overcrowding in the emergency department. 3. Jibuike O, Paul-Taylor G, Maulvi S, Richmond P, Fairclough J. Management of soft The reduction in length of stay is likely to be at least in part explained tissue knee injuries in an accident and emergency department: the effect of the by the reduction in X-ray and CT referral rates, because these introduction of a physiotherapy practitioner. Emerg Med J. 2003;20(1):37–39. investigations require a number of personnel and processes to complete. For example, a typical X-ray will require the input of a 4. Kilner E. What evidence is there that a physiotherapy service in the emergency radiographer, a radiology registrar and a specialist, as well as a department improves health outcomes? A systematic review J Health Serv Res Policy. specialist in Emergency Medicine to cross-check all imaging findings 2011;16(1):51–58. with discharge diagnoses retrospectively to identify any possible misdiagnoses. Additionally, a reduction in imaging rates has the 5. Yoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the benefit of reducing exposure to harmful ionising radiation. emergency department. CJEM. 2003;5(3):155–161. The findings of reduced length of stay and reduced referral for 6. Herring A, Wilper A, Himmelstein DU, Woolhandler S, Espinola JA, Brown DF, et al. X-ray, CT and ultrasound imaging for the physiotherapy service Increasing Length of Stay Among Adult Visits to U.S. Emergency Departments, 2001–2005. Acad Emerg Med. 2009;16(7):609–616. 7. Farrell SF. Can physiotherapists contribute to care in the emergency department? Australas Med J. 2014;7(7):315–317. 8. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance data from vital and health statistics; no. 386. Hyattsville, MD: National Center for Health Statistics; 2007.
Journal of Physiotherapy 61 (2015) 51–52 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Editorial Reflections on the career of Janet Carr – a physiotherapy trailblazer§ Colleen G Canning a, Catherine M Dean b, Louise Ada a a Faculty of Health Sciences, The University of Sydney; b Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia Janet Carr was one of the profession’s leading lights and she had a leadership. This scholarship is evidenced in the progression of life-long passion for advancing physiotherapy. Following her death their writing over time, which is mirrored in the scientific in 2014, it is timely to reflect not only on her life and contribution evolution of our profession. A marker of the early stage of their to physiotherapy, but also on our profession’s origins, directions influence was the publication of their first internationally available and future. textbook in 1980 – Physiotherapy in Disorders of the Brain1 – a book that was specifically published to clarify the changing role of During the last 50 years – the period in which Janet treated, physiotherapy in the treatment of adults with brain damage. taught, thought and wrote – the physiotherapy profession has Unlike previous physiotherapy texts, this book was extensively faced significant challenges, which have resulted in unprecedented referenced to support their arguments, a feature that was changes in our professional role. In particular, these years have particularly unusual at that time. By providing detailed reference encompassed the period when physiotherapists developed inde- lists and giving, where possible, reasons for the treatments pendence, both in reasoning and professional practice. For the first described, they provided a basis for further investigation into time, physiotherapists were developing career paths in scholarship treatment effectiveness. The three main themes of this early text and learning, as well as in the clinical setting. Entry programs were illustrate the beginning of the paradigm shift towards the need for: increasingly located in universities, such that academic pathways a problem-oriented approach to assessment and treatment, an became possible, leading to the growth of higher degrees and understanding of the processes involved in motor skill relearning, research within the profession. The move from hospital-based to andTFD2_I]$[ an understanding the pathological and psychological reasons university-based education coincided with a shift in the profession underlying the problem. towards scientific rigour. There was strong recognition of the importance of deriving clinical implications from the literature, The next textbook – The Motor Relearning Programme for Stroke2 particularly the related sciences, and of conducting research on – was published in 1982. It also illustrates the change from human function. In addition, there was a rapid development of inductive thinking to scientific rigour. In it, Janet and Roberta interventions that were based on a wider and sounder theoretical wrote: basis, the development of reliable measurement tools, and the vigorous testing of outcomes. D[_T‘]FI$1 We are aware of the need to research thoroughly the effectiveness of any new developments in physiotherapy, particularly since the Over the decades, Janet Carr and her close colleague Roberta therapeutic measures at present employed in stroke rehabilitation Shepherd have been at the forefront of many of these changes. The are carried out despite there having been little or no investigation drive for change in the conceptual basis for professional practice is of their effectiveness’. particularly evident in their scholarly work and academic They emphasised the need to describe physiotherapy interven- § This editorial is being co-published in the New Zealand Journal of Physiotherapy. tion in detail and to develop the tools with which to measure outcomes, so that the effect of intervention could be tested. These ideas, which are taken for granted now, were advanced for that time. By 1998, in their text Neurological Rehabilitation: Optimizing Motor Performance,3 Janet and Roberta were aiming to: . . . assist clinicians to become more informed and effective practitioners and to stimulate clinical and laboratory research which will in turn lead to dynamic and effective methodologies. Throughout the book, we have provided references in order to illustrate the process of utilizing theoretical and data-based information in clinical practice. Where these are available, we have included reference to outcomes studies because it is such evidence-based material which is a powerful determinator of theory and direction, enabling the development and testing of protocols (or strictly observed guidelines) as a means of establish- ing best practice. This quote illustrates that the profession had by then advanced to the stage of testing interventions, and coincides with the http://dx.doi.org/10.1016/j.jphys.2015.02.006 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
52 Editorial exponential increase in randomised, controlled trials in physio- a lasting one. She cared about patients’ outcomes before therapy.4 patient-centred care was articulated. Her contribution was ahead of its time, in that it was in line with the contemporary In the preface of the second edition of Neurological Rehabilita- view of healthcare systems, which are now best conceptualised as tion: Optimizing Motor Performance,5 published in 2010, Janet and learning systems where healthcare delivery, education and Roberta reflect on the progress of the profession and their research coexist to improve patient outcomes at individual and optimism for the future: societal levels. Physiotherapists are making a major change away from method- Janet entered the physiotherapy profession in 1954, at a time ologies developed in an earlier time for which there is no when the average working life of a physiotherapist was 5 years – evidenciary support, and increasingly using methods that are she went on to devote close to 60 highly productive years to congruent with current knowledge and for which there is her profession. Janet never retired; until her death she held an encouraging evidence. The results of suitably rigorous clinical honorary position of Associate Professor in the Faculty of trials eventually contribute to evidence-based practice. The current Health Sciences, The University of Sydney. On hearing of Janet’s interest in rehabilitation research and the quality of that research illness, the physiotherapy staff at the F]uTDI_3[$ niversity sent Janet are grounds for optimism. flowers and promptly received a response from her: ‘I have fond memories of working at the School of Physiotherapy, The Janet felt that bridging the gap between science and practice University of Sydney in its golden years – we thought we could was an overwhelming task for the clinician and was, therefore, change the world’. a critical driver in writing textbooks throughout her career. Collaboratively with Roberta, Janet authored/edited 13 books from Janet did change the world, she made it a better place, and she 1976 to 2010, which have inspired generations of physiotherapists. will be greatly missed. She inspired and empowered generations of These books have been translated into most European languages physiotherapists. and many Asian languages including Korean, Chinese, Japanese, Arabic and Farsi. The books have stimulated many passionate Ethics approval: Not applicable. Health debates and the development of ideas within the broad physiother- Competing interests: Nil. apy community, and between physiotherapy and other professions. Source(s) of support: Nil. To engage in these debates, Janet travelled, collaborated with Acknowledgements: Nil. international scientists, taught and presented conference papers in Correspondence: _[]CFD$I4T olleen DF[IC_T$5] anning, Faculty of over 30 different countries. Janet and Roberta worked, discussed, Sciences, The University ofI[$T]_DF6 Sydney, Sydney, Australia. argued and conducted their own research and scholarly work, while Email: F$DcIT_7[] olleen.FcI[8_]TD$ [email protected] encouraging and mentoring young researchers and clinicians. Although Janet’s major contribution was in neurological rehabilita- References tion, the way she conceptualised the profession and moved it forward applied to other areas of rehabilitation. The breadth of her 1. Carr JH, Shepherd R. Physiotherapy in Disorders of the Brain. London: Heinemann; influence and mentorship is exemplified by the Foundations for 1980. Physiotherapy Practice Series, commissioned by Janet and Roberta, and published in the early 1990s: Key Issues in Cardiopulmonary 2. Carr JH, Shepherd R. The Motor Relearning Programme for Stroke. 1st ed. London: Physiotherapy,6 edited by Elizabeth Ellis and Jenny Alison; Key Issues Heinemann; 1982. in Musculoskeletal Physiotherapy,7 edited by Jack Crosbie and Jenny McConnell; and Key Issues in Neurological Physiotherapy,8 edited by 3. Carr JH, Shepherd R. Neurological Rehabilitation: Optimizing Motor Performance. Louise Ada and Colleen Canning. The editors of each of these volumes 1st ed. Oxford: Butterworth Heinemann; 1998. were, at the time, all Janet’s junior colleagues who were inspired by her mentorship and guidance. 4. http://www.pedro.org.au/english/downloads/pedro-statistics/. Accessed February 3, 2015. It is important for us to acknowledge our debt to those who inspire and lead us. Janet will be remembered as a tirelessly 5. Carr JH, Shepherd R. Neurological Rehabilitation: Optimizing Motor Performance. inquiring academic who was a trailblazer, and her legacy will be 2nd ed. London: Churchill Livingstone Elsevier; 2010. 6. Ellis E, Alison J. Key Issues in Cardiopulmonary Physiotherapy. Oxford: Butterworth Heinemann; 1992. 7. Crosbie J, McConnell J. Key Issues in Musculoskeletal Physiotherapy. Oxford: Butter- worth Heinemann; 1993. 8. Ada L, Canning C. Key Issues in Neurological Physiotherapy. Oxford: Butterworth Heinemann; 1990. Papers of the Year 2014 The Editorial Board is pleased to announce the 2014 Paper of the exacerbating lymphoedema.2–4 This may have contributed to the Year Award. The winning paper is judged by a panel of members of reduced physical function – particularly upper limb strength – in the International Advisory Board who do not have a conflict of women during and after treatment for breast cancer.5 The interest with any of the papers under consideration. They vote for systematic review by Paramanandam and Roberts1 demonstrated the paper published in the 2014 calendar year which, in their with meta-analyses that weight training does not increase the opinion, has the best combination of scientific merit and onset or severity of lymphoedema in women after breast cancer. application to the clinical practice of physiotherapy. This process Weight training also improves upper and lower limb strength and resulted in a tied vote. improves aspects of quality of life related to physical function. The first winning paper is Weight training is not harmful for The second winning paper is Treadmill training provides women with breast cancer-related lymphoedema: a systematic greater benefit to the subgroup of community-dwelling people review by Vincent Paramanandam from Tata Memorial Hospital in after stroke who walk faster than 0.4 m/s: a randomised trial by India and Dave Roberts from Oxford Brookes University in the Catherine Dean from Macquarie University and Louise Ada and United Kingdom.1 In the past, clinical practice guidelines for breast Richard Lindley from the University of Sydney, Australia.6 Despite cancer have advised against strenuous activity or exercises with regaining the ability to walk, many survivors of stroke do not the arm on the affected side in order to reduce the risk of causing or regain their original walking speed or distance. Overall, treadmill
Journal of Physiotherapy 61 (2015) 98 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics The Pad Test for urinary incontinence in women Summary Reliability and validity: The short-term Pad Test has low Description: James et al. first described the Pad Test in 1971.1 It reliability, with a mean difference of 9.7 g (SD 29.7) between is a standardised method for quantifying urine loss that can be 1-week test-retest and wide limits of agreement (46 to 66 g).2 Low performed at work or home. There are two versions: the short- reproducibility has been found in other studies.1 The use of a term Pad Test and the long-term Pad Test. In the literature, the duration of the test varies widely. The most commonly used short- standardised bladder volume increases the reliability of the short- term Pad Test is performed in the clinic over 1 hour and the long- term Pad Test is usually performed at home over 24 hours. term Pad Test, but there is no consensus on ideal volume and the For the 1-hour Pad Test, women are asked to wear pre-weighed short-term Pad Test may not reflect the problems of urinary pads and drink 500 ml of sodium-free liquid in < 15 minutes. After incontinence in daily activities.1,3 A number of studies have rest, they are instructed to exercise for 30 minutes, including: walking, climbing up and down one flight of stairs, standing-up concluded that the long-term Pad Test has adequate repeatabili- from sitting (10 x), coughing vigorously (10 x), running on the spot ty.1,4 Studies comparing the short-term and long-term Pad Tests for 1 minute, bending to pick up an object from the floor (5 x) and washing hands for 1 minute in running water. Before and after the have shown better reproducibility for the long-term Pad Test than test, the weight of the pad is measured with a high-precision the short-term Pad Test.5 Groutz et al6 reported a satisfactory balance in order to determine the amount of leakage. The short- term Pad Test may be performed with a fixed bladder volume of repeatability for the long-term Pad Test of 0.721 (Lin’s concordance 150 to 300 ml, or with 50 to 75% of the functional bladder capacity.1 For the 1-hour Pad Test, an increase of 1 to 10 g correlation coefficient). They found that longer tests (ie, 48 and represents mild incontinence, 11 to 50 g represents moderate incontinence and > 50 g represents severe incontinence. 72 hours) result in better reproducibility than the standard The long-term Pad Test does not require women to perform set 24-hour Pad Test, but the adherence is lower. The correlation activities. Women are, however, asked to perform their usual physical activities. They start the test with an empty bladder and between Pad Test results and the severity of incontinence is better wear a pre-weighed pad inside waterproof underwear. They are in long-term Pad Tests.7 However, a number of variables can affect asked to change the pad every 4 to 6 hours. The test pads need to be weighed immediately, or stored in an airtight bag for weighing the validity of the 24-hour Pad Test such as hormonal status, in a laboratory. For the 24-hour Pad Test, 4 to 20 g represents mild incontinence, 21 to 74 g represents moderate incontinence and environmental conditions, physical activity level and the type > 75 g represents severe incontinence. of pads used.1 The short-term Pad Test has shown a good correlation (r = 0.88) with a self-assessment questionnaire.3 The long-term Pad Test does not differentiate between continent and incontinent women when using a subjective self-assessment.7 However, a good correlation has been found with the International Consultation on Incontinence Questionnaire-Short Form.8 The sensitivity of the short-term Pad Test for predicting urinary incontinence varies between 34 and 83%, and the specificity varies between 65 and 89%.1 There are no equivalent data for the long- term Pad Test.1 Commentary Cristine Homsi Jorge Ferreiraa and Kari Bøb aRibeira˜o Preto Medical School, University of Sa˜o Paulo, Sa˜o Paulo, Brazil The fourth International Consultation on Incontinence recom- mends Pad Tests as an adjunctive measure on outcome measures bDepartment of Sports Medicine, Norwegian School of for urinary incontinence.9 A recent review, which was prepared by Sport Sciences, Oslo, Norway a working group of the International Continence Society Urody- namics Committee, concluded that Pad Tests are underutilised and, References although they have some limitations, they provide an easy, inexpensive and objective assessment of urine loss.1 Pad tests 1. Krhut J, et al. Neurourol Urodyn. 2014;33(5):507–510. should, however, be supplemented by other assessment tools such 2. Simons AM, et al. BJOG. 2001;108(3):315–319. as questionnaires. The selection of motivated women and 3. Lose G, et al. Urology. 1988;32(1):78–80. provision of detailed instructions from the physiotherapist are 4. Versi E, et al. Br J Obstet Gynaecol. 1996;103(2):162–167. important to improve adherence and reliability of the tests. The 5. Lose G, et al. Acta Obstet Gynecol Scand. 1989;68(3):211–215. level of physical activity should be recorded and a voiding diary 6. Groutz A, et al. J Urol. 2000;164(3 Pt 1):698–701. should be kept and replicated in reassessments when using the 7. Matharu GS, et al. Eur Urol. 2004;45(2):208–212. 24-hour Pad Test. 8. Karantanis E, et al. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15(2):111–116. discussion 116. 9. Abrams P, et al. Neurourol Urodyn. 2010;29(1):213–240. http://dx.doi.org/10.1016/j.jphys.2014.12.001 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 99 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics The Spinal Cord Independence Measure Description The Spinal Cord Independence Measure (SCIM) captures the There are many reports on the reliability, validity and sensitivity ability of a person with spinal cord injury (SCI) to complete of the three versions of the SCIM (see Anderson et al6 for a good activities of daily living (ADL).1,2 It assesses independence in 19 key areas, including: self-care (six items), respiration and sphincter summary). Inter-rater reliability for the first and third versions of the management (four items), and mobility (nine items). Each item is SCIM ranges between 0.64 and 0.98.1,7–9 The SCIM has face validity, scored and weighted slightly differently, but all are summed to a total possible score of 100, with a high score indicating with a sensible hierarchical ordering of categories. Construct validity independence in most ADL. The original 1997 version of the SCIM was modified in 20013 and then again in 2007 (SCIM III).4 It was has also been demonstrated in a number of studies, including three originally designed to be completed through observation from a clinician, but in recent years a self-report version has been that have correlated SCIM and Functional Independence Measure developed, which enables people with SCI to complete it through (FIM) scores (r = 0.79 to 0.80).4,8,9 The SCIM demonstrates the type of interview or over the telephone.5 changes that would be expected, based on neurological change and time since injury; however, it does have ceiling and floor effects that are yet to be fully examined.8–10 Also, the respiration item does not contribute to the total score in its current format because most individuals score at either the top or bottom of the scale on this item.8 Commentary The SCIM has been largely adopted and endorsed by the dependent) and those who only require supervision (but are not international SCI community as the most appropriate measure of fully independent). It also seems unfortunate that the scoring for independence for people with SCI.6 Consequently, it is widely bladder management is linked to residual urine volume. This is not advocated for both clinical and research use. The SCIM is logical something that can be easily measured in a community setting, and probably reflects what most clinicians and people with SCI particularly in some countries, and it begs the question of how this would expect to see in a measure of ADL and independence. For is being ascertained in studies utilising the SCIM. example, mobility is scored on a 9-point scale, with the lowest score reflecting the inability to mobilise independently in an Despite its limitations, there is no doubt that the SCIM is electric wheelchair and the top score reflecting the ability to walk currently the most appropriate generic measure of independence without aids. The original authors of the SCIM weighted the items and ADL following SCI. It is therefore appropriate that it is widely in terms of their assumed clinical relevance. It is, however, advocated and used. It is unfortunate that in some countries, like interesting how the different items are weighted in the scoring Australia, the government insists that clinicians use the Functional system, with a heavy weighting on mobility. This may not reflect Independence Measure (FIM). It makes it very time-consuming for the priorities of people with SCI who may, for example, prefer to clinicians to collect both the FIM and SCIM, which are different but see more weighting on aspects of independence related to bladder perhaps not different enough to justify the additional time and bowel function. required to collect data using both. The SCIM would benefit from a detailed manual to better Lisa A Harveya and Kim D Andersonb explain the scoring of some items. This is particularly required for aSydney Medical School/Northern, University of Sydney, Sydney, the two dressing items, where the scoring is linked to three variables, namely: the use of ‘specific settings’, independence with Australia ‘buttons, zippers and laces’, and use of ‘adaptive devices’. bDepartment of Neurological Surgery, University of Miami, Miami, Occasionally, it is difficult to score these items because people do not perfectly satisfy any one score. More importantly, however, USA it is unclear as to what is meant by a ‘specific setting’. For example, does the need to put your socks on while seated in a wheelchair References equate to a ‘specific setting’? The original author of the SCIM would say not, because some able-bodied people would sit down to put 1. Catz A, et al. Spinal Cord. 1997;35:850–856. their socks on and the wheelchair is irrelevant. However, it is 2. Catz A, et al. Spinal Cord. 2001;39:97–100. unclear as to whether this is being interpreted in the same way 3. Catz A, et al. Disabil Rehabil. 2001;23:263–268. around the world. In addition, some of the definitions of scores are 4. Itzkovich M, et al. Disabil Rehabil. 2007;29:1926–1933. broad and lack sensitivity. For example, ‘requires partial assistance’ 5. Fekete C, et al. Spinal Cord. 2013;51:40–47. includes those who require a lot of assistance (but are not fully 6. Anderson K, et al. J Spinal Cord Med. 2008;31:133–144. 7. Catz A, et al. Spinal Cord. 2007;45:275–291. 8. Anderson KD, et al. Spinal Cord. 2011;49:880–885. 9. Glass CA, et al. J Rehabil Med. 2009;41:723–728. 10. Ackerman P, et al. Spinal Cord. 2010;48:380–387. http://dx.doi.org/10.1016/j.jphys.2015.02.013 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
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