Carpal tunnel syndrome (CTS) is a commonly diagnosed upper extremity neuropathy with a prevalence of 3.7% in the general population. The need to identify effective and economical conservative management strategies for the treatment of CTS is critical. The purpose of this randomized controlled clinical trial was to evaluate the effectiveness of a non-traditional wrist splint combined with tendon and nerve gliding exercises for the treatment of CTS. Sixty-one subjects diagnosed with mild to moderate CTS enrolled in the study. Fifty-one subjects completed the study. After completing the CTS history and demographic questionnaire, the CTS Symptom Severity and Functional Status Scale, the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire, and a physical examination subjects were randomly assigned to a group. The FAB-EX (n=13) and the FAB-NOEX (n=14) received the fabricated wrist splint, which supported the wrist and metacarpophalangeal (MCP) joints. The FAB-EX also received exercises. The OTS-EX (n=13) and the OTS-NOEX group (n=11) received an off the shelf wrist cock-up splint. The OTS-EX also received exercises. Subjects were instructed to wear either splint all night, for 4 weeks and if applicable, perform exercises 3 times a day. At 4 weeks subjects completed the same measures given at baseline. At 8 weeks, subjects were mailed the CTS Symptom Severity and Functional Status Scale, the DASH, and an exit survey. 2 x 2 x 3 mixed analysis of variances (ANOVA) were performed on the subjective measures and 2 x 2 x 2 mixed ANOVAs were performed on the objective measures. All groups, over time, demonstrated a significant improvement on the CTS Symptom Severity (p < .001) and Functional Status Scale (p < .001), DASH (p < .001), tip pinch (p < .008), and palmar pinch (p < .034). Subjects randomized to the non-traditional fabricated wrist/MCP splint demonstrated significant improvement on the CTS Symptom Severity (p < .014) and Functional Status Scale (p < .029). There were no significant findings between the groups who received exercises and the groups who did not receive exercises. The results of this study support the use of a fabricated wrist/MCP splint for the treatment of CTS.

Fibromyalgia (FM) is an elusive syndrome that affects 2% of the United States population, with health care costs exceeding $20 billion in 1998. FM alters lives with its symptoms and by interfering with everyday life. This dissertation explored the association between subgroups of women with FM and their functional status. The first study examined the effectiveness of an Internet-based health promotion intervention to improve the clinical outcomes for two subgroups of women with FM: those with high Fibromyalgia Impact Questionnaire (FIQ) scores (n = 5) and those with low FIQ scores (n = 5). Single subject design and grouped data revealed that the intervention had mixed results for the two subgroups. The clinical response to the intervention depended on the method of analysis (individual versus group) and the target behavior of interest. The second study examined the associations among objective and subjective measures, and two target outcomes: physical activity and functional status (FIQ total score), and then used the data to classify FM subgroups (n = 72). Using Exhaustive Chi-square Automatic Interaction Detector (Exhaustive CHAID), we developed two models. Model I, with the target outcome of physical activity, yielded 9 distinct subgroups, whose members had characteristics that were significantly associated with very unfavorable to very favorable physical activity outcomes. Model II, with the target outcome of the FIQ total score, yielded 5 distinct subgroups whose members had characteristics that were significantly associated with very unfavorable to very favorable functional status outcomes. The third study used qualitative and quantitative methods to identify clinically relevant triggers of FM flares, experienced by three subgroups women with low (n = 6), average (n = 5), and high (n = 4) FM impact, to explore the effect of triggers on their functional status. Using mixed methods, we were able to substantiate, quantify, and qualify the affects of FM on the lives of persons with FM and the direct consequences of those affects on activities. Overall activity, FM symptoms, and weather were the most prominent triggers. Findings from these studies suggest that the influence of FM on functional status affects women differently based on subgroup membership.

The purpose of this project was to develop the Foot and Ankle Ability Measure (FAAM), a self-reported HRQL instrument specific to those with lower leg musculoskeletal disorders. The FAAM consists of the ADL and Sports subscales. Data analysis was done in two stages. Stage I consisted of item selection based on factor loading patterns, inter-item correlations, item to total score correlations, item characteristic curves and the test information functions. 914 subjects participated in the analyses for stage I. Stage II consisted of reliability and validity testing. The data analysis plan consisted of assessing internal consistency, test re-test reliability, responsiveness to change in status, responsiveness compared to general measures of function and validity based on the correlation to concurrent measures of physical and mental functioning. There were 164 subjects in a group expected to change and 79 subjects in a group expected to remain stable. Based on the analyses in state I, 4 items were omitted from the ADL subscale. These items were related to pain and sleeping. All items on the Sports subscale were retained. Based on the analyses in stage II, the errors associated with measurement at a single point of time were +/-6.9 and +/-10 points for the ADL and Sports subscales respectively. ICC for test re-test reliability were 0.89 and 0.87 for the ADL and Sports subscales respectively. The minimal detectable change was +/-5.7 and +/-12.3 points for the ADL and Sports subscales respectively. Two-way repeated measures ANOVA and ROC analysis found both the ADL and Sports subscales were responsive to changes in status. The minimal clinically important differences were 8 and 9 points for the ADL and Sports subscales respectively. Guyatts Responsiveness Index and ROC analysis found the ADL subscale was more responsive than general measures of function while the Sports subscale was not. The ADL and Sport subscales had high correlations to SF-36 physical function subscale, physical component summary score and global rating of function and low correlations with the SF-36 mental function subscale and mental component summary score. This study provides evidence of reliability, responsiveness and validity for the FAAM ADL and Sports subscales.

Purpose: The primary aim of this study was to validate a clinical prediction rule (CPR) to identify patients with low back pain (LBP) likely to benefit from spinal manipulation. Subjects: 131 consecutive patients referred for physical therapy. Patients with positive neurologic signs or other red flags for spinal manipulation were excluded. Method: A multicenter, randomized clinical trial. After completing a standardized history and physical examination, patients were randomly assigned to receive spinal manipulation (n=70) or a stabilization exercise intervention (n=61). Patients were seen in physical therapy twice the first week, then once a week for the next three weeks, for a total of five sessions. A single manipulative intervention was used for patients who received spinal manipulation during each of the first two sessions, who then completed the stabilization exercise intervention for the remaining three weeks. Patients who achieved at least a 50% improvement in their Oswestry Disability Questionnaire (ODQ) score were classified as a success. Patients who met at least 4/5 criteria in the CPR were classified as positive. Analyses: A 2*2*3 repeated measures multivariate analysis of variance (MANOVA) was performed, followed by a Bonferroni procedure for planned comparisons. Sensitivity, specificity, and positive and negative likelihood ratios (LR) with associated 95% confidence intervals were calculated. Results: There was a significant three-way CPR*Intervention*Time interaction for the overall repeated measures MANOVA (p<.001). Patients classified as positive on the CPR and received spinal manipulation achieved 2.5 times the minimum clinically important difference (MCID) on the ODQ compared to patients classified as negative on the CPR and received spinal manipulation and 3.4 times the MCID compared to patients classified as positive on the CPR but received the stabilization exercise intervention (p<.001). These results were maintained at the four-week follow-up (p<.003). With a positive LR of 13.2 (3.4, 52.1) and based on a pre-test probability of success of 44.3%, this translates into a post-test probability of success of 91.2%. Conclusions: The results of this study support the validity of the spinal manipulation CPR. Clinical Relevance: Clinicians can accurately identify patients with LBP likely to benefit from spinal manipulation.

PURPOSE: The purposes of this study were to: 1) describe the magnitude and dimensions of self-reported fatigue in individuals with knee OA and 2) determine the influence of quadriceps fatigue and cardiorespiratory endurance on self-reported fatigue in individuals with knee OA, after accounting for potential confounders such as age, sex, pain, depression, and anxiety. SUBJECTS: The sample consisted of 44 adults (75% female) with radiographically confirmed knee OA. METHODS: All subjects participated in two testing sessions using a dynamometer with a software program developed specifically for this study. During the first session, subjects completed the Multidimensional Assessment of Fatigue Scale (MAF), the WOMAC Osteoarthritis Index, the Center for Epidemiologic Studies Depression Scale (CES-D), and the Beck Anxiety Inventory Scale (BAI). A burst superimposition maximum isometric quadriceps torque test was performed to determine maximum voluntary isometric contraction (MVIC) torque that was used in the quadriceps fatigue test. In the first testing session, subjects also performed a submaximal cycle ergometer test to estimate VO2 max as a measure of cardiorespiratory endurance. Within 1 week of the first session, subjects returned for the quadriceps fatigue test in which they performed repeated submaximal contractions equal to 50% of their MVIC isometric torque output for 6 seconds followed by a 4-second rest period (duty cycle 60%). The contractions were continued until the subject could no longer generate the torque target for 3 successive contractions. During the sixth contraction and every minute thereafter, subjects were instructed to push with a maximum effort and the train of electrical stimuli was superimposed upon the maximal effort quadriceps contraction. Quadriceps fatigue was measured as the rate of decline of the MVIC torque output over the course of the test. ANALYSIS: Descriptive statistics were used to describe the magnitude and dimensions of fatigue. An independent samples t-test was used to compare fatigue in individuals with knee OA to the levels of fatigue reported by normal controls and individuals with rheumatoid arthritis. Hierarchical regression analysis was used to determine the influence of quadriceps fatigue and cardiorespiratory endurance self-reported fatigue. RESULTS: The mean global fatigue index score was 23.6 (SD = 10.4, range 1-40). Individuals with knee OA reported significantly higher fatigue than controls and significantly lower fatigue than RA patients (p < 0.05). Fatigue was reported to occur every day by 25% of the sample. Fatigue most often affected walking, doing household chores, shopping, and exercise. Fatigue was significantly associated with sex (r = .52, greater fatigue in females), pain (r = .62), depression (r = .47), anxiety (r = .54), and cardiorespiratory endurance (r = -.55) but not to quadriceps fatigue (r= .01). Hierarchical regression analyses revealed that adding quadriceps fatigue or cardiorespiratory endurance to the model after controlling for age, sex, pain, depression, and anxiety did not explain any additional variance in fatigue, (ÄR2 =.00). CONCLUSION: Fatigue is common in individuals with knee OA. Quadriceps fatigue is not related to self-reported fatigue. Cardiorespiratory endurance is related to self-reported fatigue, but not after controlling for age, sex, pain, depression, and anxiety. CLINICAL RELEVANCE: Management of fatigue in individuals with knee OA may require interventions to address psychosocial issues and/or cardiorespiratory endurance.

The occurrence of a spinal cord injury (SCI) leads to an enormous change in an individual�s lifestyle. Limitation related to mobility can become critical affecting ability to participate in nearly all activities of daily living (ADL). People with SCI rely on assistive technology (AT), especially wheelchair to facilitate the return to as many pre-injury activities as possible and serve as a resource tool for community living and participation12. The purpose of this study was to investigate the wheelchair and related factors that affect the participation of individuals with SCI in activities performed in three settings including home, community and transportation. Seventy individuals with SCI who use wheelchairs for mobility participated in this study. A written survey, which recorded AT usage in daily activities, was distributed among individuals from Pittsburgh (Pitt) and Saint Louis (SL). The wheelchair was found to be the most limiting factor in activities performed in the home, community and transportation use. The second most limiting factor was physical impairment and environment. Significant differences were shown among individuals from Pitt and SL. A higher number of individuals from SL indicated pain, fatigue, wheelchair seating, social attitudes and self-concept as factors that limit their participation. In addition, significant differences were revealed in transportation use between individuals with paraplegia and tetraplegia. Pain was shown as a limiting factor for people with paraplegia, whereas, lack of equipment was indicated by people with tetraplegia. AT and related factors impact participation of individuals with SCI. The wheelchair was the most common limiting factor, followed by physical impairment and physical environment. The wheelchair is most likely their most important mobility device while also the one that is most associated with barriers.

Although participation in continuing education activities is the most widely accepted method of upgrading professional training in the area of seating and mobility, the impact of these educational experiences has yet to be documented. Specifically, reliable and valid measures of the outcomes of educational experiences or clinical practice on the ability to make specialized clinical decisions are needed. This dissertation is comprised of a series of three, inter-related studies, which, develop and validate the Seating and Mobility Script Concordance Test (SMSCT); a performance-based measure intended for use with professionals that recommend seating and mobility devices to individuals with spinal cord injuries. The SMSCT is designed to assess clinicians by examining the organization of their knowledge, associations between items of their knowledge, and adequacy of their clinical decisions compared to expert consensus. The first study presents the conceptual foundation, item generation process, and content validity evidence leading to the final version of the SMSCT. Results indicate that the 67-item SMSCT adequately represents the dimensions of assessment and intervention knowledge for seating and mobility for spinal cord injury. In the second study, 15 spinal cord injury experts assisted with the development of the scoring system, and 100 physical and occupational therapists were used for obtaining internal and external validity evidence. Appraisal of the technical quality of the test showed reasonable item performance, with some items performing better than others. Other evidence showed the SMSCT distinguished between intervention subscores for two groups of known differences. Proxy measures of clinical expertise on the whole did not prove to be strong predictors of SMSCT scores for a population of clinicians with varying amounts of seating and mobility experience. The third study, comprised of 50 seating and mobility clinicians, further explored the validity of the SMSCT as a measure of educational effectiveness. No one proxy measure of clinical expertise accounted for a considerable change in posttest scores following an educational program. Changes in SMSCT scores were detected following an educational program. Initial psychometric testing maintains that the SMSCT is a promising measure of seating and mobility clinical expertise. Further SMSCT development, revision and validation are needed.

Wheelchair seating discomfort is an important but poorly understood negative outcome for long duration wheelchair users. A major impediment to the study of this problem is the lack of a validated tool for quantification of wheelchair seating discomfort. The goal of this dissertation research was to develop and validate an assessment tool appropriate for the quantification of wheelchair seating discomfort among long duration (more than 8 hours per day) wheelchair users. This was accomplished through the completion of three research phases, each described within the body of this dissertation. Phase I consisted of a qualitative research study involving in-depth interviews with experienced wheelchair users. Data from these interviews resulted in the development of the Wheelchair Seating Discomfort Assessment Tool (WcS-DAT), a three-part tool to allow wheelchair users to quantify their level of seating discomfort. Phase II of the research assessed the reliability and concurrent validity of this assessment tool through a test/re-test reliability study. Intra class correlation (ICC) coefficient scores ranged from 0.83 to 0.97, indicating adequate reliability of the two discomfort scores in the WcS-DAT. Internal item consistency, assessed using Cronbachs alpha, indicated that all items were consistent and not redundant, with scores ranging from 0.82 to 0.92. Pearson product-moment correlations were used to assess the concurrent validity of the WcS-DAT and all of these correlations were significant at a minimum of p less than 0.05, with many significant results at the 0.01 and 0.001 levels. These results indicated good concurrent validity of the WcS-DAT. In Phase III, the WcS-DAT was evaluated for its ability to show changes in discomfort over time and with the introduction of novel, user adjustable wheelchair seating. Both the General Discomfort Assessment score (GDA) and the Discomfort Intensity Score (DIS) were sensitive to changes in seating discomfort level and were adequate for use in detecting differences associated with changes in duration of sitting as well as those associated with use of different seating equipment. Results of this final phase indicated that the WcS-DAT is a useful tool for evaluation of wheelchair seating discomfort in a research or clinical environment.

Web content accessibility is to which degree a site is accessible to the largest possible range of people, especially for persons with disabilities. The current study comprises four interrelated parts revolving around evaluating and enhancing Web content accessibility. First, a novel measurement metrics called Web Accessibility Barriers (WAB) score is constructed based on published Web accessibility design guidelines. The performance of the measurement metrics is assessed using a Web accessibility gold standard. The Receiver Operating Characteristic (ROC) curve shows that WAB score separate inaccessible Web pages well from accessible ones with Area Under the Curve (AUC) value of 0.917. Second, using the WAB score, I evaluate the degree of Web accessibility of consumer health information websites. Mean of WAB score of the 108 selected websites is 9.31 with standard deviation of 6.29. Among those websites, government and education websites have lower WAB score 0.39 and 1.16 respectively. ANalysis Of VAriance (ANOVA) test shows statistical significances across different functional categories of the websites (F=9.705, p < 0.001). In addition, this study shows that WAB score correlated with traffic rank of the websites with (r = 0.32, p < 0.01). Third, a usability study is conducted to examine the performance of a Web Transcoder Gateway (WTG) server for blind Web users to access online information. The WTG server removes Web accessibility barriers in real time based on Web accessibility design guidelines. The study design is a within-subject cross-over design. A mixed model analysis is employed to examine the effect of the WTG server on time, success, errors, and subjective measurement. Sixteen blind Web users took part in the study. Results show that participants spent less time, make few errors, and succeed more on the tasks via WTG server. Participants also feel more satisfactory, less frustrated, and more confident when access online information via WTG server. Observational and anecdotal findings imply that only removing accessibility barriers may not be sufficient to achieve the best usability for blind Web users. Finally, a usability study is conducted to examine the performance of a Web Transcoder Gateway (WTG) server for PDA users to access Web sites. The study design is also a within-subject cross-over design. A mixed model analysis is employed to examine the effect of WTG server on time, success, and subjective measurements. Twenty subjects took part in the study. Results show that participants spend less time on each task via WTG server. Each participant can finish the tasks successfully via either WTG server or non WTG server. This implies that the WTG server can serve as Electronic Curb Cut for Web users under constraints. However, the participants show no statistically significant preference to WTG server.

Cognitive and Physical Performance in Patients with Asymptomatic Carotid Artery Stenosis and Occlusion. This dissertation project presents a review of the anatomy and functional relationships of the circulatory territory of the internal carotid artery, and considers the functional changes that can occur when there is disease within this system. The project has two specific aims which are addressed in two articles. The first specific aim is to determine if persons with asymptomatic carotid artery disease (high moderate stenosis through occlusion) demonstrate deficits in cognition and on physical performance measures. The second specific aim is to determine if there is a correlation between the cognitive measures and the instrumental activities of daily living in these asymptomatic patients. In the first article, the purpose of the study was to determine if patients with asymptomatic carotid artery stenosis and occlusion demonstrate deficits in cognitive and physical performance. The relationship between cognitive measures and performance of instrumental activities of daily living was examined. Thirty-nine patients with asymptomatic carotid artery stenosis of moderate and severe degrees, or occlusion were tested. Cognition was assessed via the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Executive Interview (EXIT). Physical performance was assessed via the Physical Performance Test (PPT), and the Lawton Instrumental Activities of Daily Living. Deficits in cognitive function were found on the RBANS for all levels of stenosis and occluded subgroups in the domains of visuospatial/constructional and delayed memory, in the moderate stenosis subgroup in immediate memory, attention and visuospatial/constructional, and in the severe subgroup in all domains except language. There were no significant findings on the EXIT. Decreased performance on the PPT was identified in all 3 subgroups. The Lawton IADL did not identify any decrease in IADL performance. The second article included a more definitive examination of physical performance. Physical performance was assessed via the 9-item and 7-item Physical Performance Test (PPT). Individual tasks were also timed. Patients with asymptomatic carotid artery stenosis and occlusion demonstrated less than optimal performance on the PPT ( 9-item, 27/36; 7-item 21/28). Simulated eating was the slowest task to perform for the patients with moderate stenosis. Deficits in cognitive function were found in this observational study of patients with asymptomatic carotid artery stenosis and occlusion. Additionally, patients exhibited changes in function as indicated by their performance on the PPT. This may be indicative of preclinical disability, and a potential symptomatic status of the patient. Both articles demonstrate that asymptomatic patients may not be truly asymptomatic. This potential change in status needs to be considered as patients are being evaluated for interventions to manage their carotid artery disease.