Simple Clinical Measures

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Simple C linical Me asu res

RICHARD W. BOHANNON

The purpose of this article is to present for physical therapists a broad array ofsubjective and objective options for simple clinical measures. These measuresare relatively inexpensive, easy to apply, technologically simple, and useful ineveryday patient assessment. Clinical considerations for applying the measuresare given.

Key Words: Physical therapy; Tests a n d measurements, general.

This article is concerned with measures used by physicaltherapists in a clinical setting, that is, with measures that tellclinicians something of value regarding a patient or the treatment being applied to the patient. Whether such measuresare simple is, of course, a matter of judgment. Nevertheless,in this article, I will use the term "simple" relative to cost,technological sophistication, and ease of application. Thus,the text will be confined to measures that can be performedeither without equipment or with equipment that costs lessthan $1,000, is not computerized, and is not confined toapplication in limited settings. By this definition, manualmuscle testing1 and hand-held dynamometry are simple,2,3

but isokinetic dynamom etry is not.4 Similarly, observation ofa patient's capacity to balance with his feet together for 30seconds is simple,5 but force-plate stabiliometry is not.6 Determining a patient's speed during gait over an 8-m expanseof floor using a stopwatch also is simple,7 whereas using acomputerized gait mat to determine the patient's speedis not.8

Clinical measures that can be obtained easily and rapidlyare necessary components of the initial assessment of a patient, treatment planning, and patient program monitoring.The application of clinical measures is not limited, however,to what the patient is doing or capable of doing. If theappropriateness of an intervention is to be known, cliniciansalso must have measures of the interventions they are applying. For example, they must know n ot only whether a patienthas become stronger, concurrent with a muscle strengtheningregimen, but also the frequency, intensity, and duration withwhich the patient has been trained. Because the literatureprovides direction as to appropriate frequencies, intensities,and durations of training,9 a failure to control these measurable variables may result in a less-than-optimal outcome.

For the sake of clarity, the simple clinical measures discussed will be divided in to those that are subjective and thosethat are objective. Of course, like a measure's simplicity, itssubjectiveness or objectiveness may be debatable. Many subjective measures mus t rely ultimately on objective criteria fortheir limits.

The measures discussed in this article are not all inclusivebut, nonetheless, range from nominal dichotomous subjectivetypes,which can be coun ted, through those that are subjective

and ordinal (eg, MMT), to those that are objective, usinginterval or ratio scales. Some objective measures(eg, distance,time,weight) are pure, whereas others are derivations. Velocity (distance time) is an example of such a derivation.Although all ofthe measures discussed are not for functionaltasks, I believe that their importance is in their relationshipto or in their determination of function.

Regardless of the specifics of the simple measures discussed ,my intent is to advocate them so that clinicians will bestimulated to use them because I believe that the applicationof simple clinical measures is critical to the future of ourprofession. Expensive, technologically complex, and institutionally bound measures may be of growing importance, butthey probably will never be used by most clinicians. Furthermore, the results of research incorporating such measuresmay be difficult for clinicians to interpret and apply (R. W.Bohannon, unpublished research, 1986). The goal of thisarticle is to serve as an impetus to committed clinicians tomore effectively validate their physical therapy practice.

SUBJECTIVE MEASURES

Numerous measures that are available to clinicians aredependent largely on a clinician's judgment. These measuresusually are performed without the use of instrumentation.When instrumentation (eg, a stethoscope) is used, however,its purpose is to increase the clinician's sensitivity to thevariable being measured. Subjective measures are, at thesimplest level, a way of naming the variable that is beingobserved. Most fundamentally, that variable can be reducedto a dichotomous condition. A condition or situation eitherexists, or it does not. The classification of a patient's condition

into dichotomous options can be im portant in the predictionof outcome. The possibilities for such classifications are limitless: A wound is either infected or uninfected10; a joint iseither painful, or it is not painful11; a patient either canmaintain sitting or standing balance, or he cannot12; a patientis either dependent (assisted) or independent (unassisted) in afunctional activity such as rolling or attaining standing; anextremity may or may not be edematous; a muscle group iseither spastic or nonspastic; muscle force production is eithernormal or abnormal; a patient may have normal endurance,or he may be fatigued easily13; an activity is either active orpassive; crepitus is either noted, or it is not; a m uscle may ormay not respond to tetanizing current14; a patient demonstrates either normal or abnormal lumbar extension15; and apatient can be categorized either as cooperative or compliantor as uncooperative or noncompliant.

Mr. Bohannon is Associate Professor, Program in Physical Therapy, University of Connecticut, School of Allied Health Professions, PO Box U-101, 358

Mansfield Rd, Storrs, CT 06268 (USA). He was Chief, Department of PhysicalTherapy, Southeastern Regional Rehabilitation Center, Cape Fear Valley Medical Center, PO Box 200 0, Fayetteville, N Y 2 830 2, when this article was written.

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Other nominal terms, not necessarily dichotomous, alsocan be of importance in describing patient status. For example, several descriptions of normal and abnormal breathsounds (eg, rhonchi) exist, which can be used to monitorpatient response to treatment.16 Rather than just describinggait as abnorm al, specific abnormalities can be described (eg,circumduction).17,18 Because the device and gait pattern usedby a patient may affect gait performance, they should benamed (eg, rolling platform walker or three-pointgait).19 Evenfloor surfaces can influence step length and gait speed and

may be worthy of documentation.20

To increase precision, the clinician can go beyond namingan observation by ranking it. Ranking scales are commonand are used to grade numerous variables, both specific andgeneral. All clinicians probably are familiar with ordinalscales, designed specifically to assess muscle strength. Although differing slightly from one another, all ordinal scalesrate strength according to the range of motion through whicha muscle can move a limb and the force against which themuscle can maintain resistance1,21,22 Pain also frequently isgraded ordinally. Among these methods are those for rankingpain on 5-point (0-5)23 or 10-point (0-10)24 scales or along anunsealed line.25 Such methods usually describe the perceivedlevel of sensation at the bottom of the scale as "no pain" andthat at the top of the scale as "maximum tolerable pain" or"unbearable pain." An interesting alternative for ranking painin joints is the Ritchie Articular Index.11 In this scale, grade 0indicates "no tenderness"; grade1 indicates that the "patientcomplains of pain"; grade 2 indicates that the "patient complains of pain and winces"; and grade 3 indicates that the"patient complains of pain, winces, and withdraws."A specificapplication of the Ritchie scale is to the shoulders of patientswho are hemiplegic after a stroke. Bohannon and LeFortshowed the Ritchie scale to be reliable when used for thispurpose.26

Another characteristic of importance to physical therapiststhat has been ranked is perceived exertion. The Borg scaleranks perceived exertion on a 15-point scale (6-20), withdescriptors ranging from "very, very light" to "very, veryhard."27 Perceived exertion ratings have been shown to havehigh validity and reliability,28 leading Morgan to suggest thatup to 90% of adu lts could have exercise intensities prescribedpartially on the basis of such ratings.29 Muscle spasticity ortone (resistance to passive stretch) has been graded ordinallyusing four- to six-category scales.30-32 Chan has recommendedordinal scales for grading both clonus and hyperreflexia (tendon reflexes).33 Gabell and Simons have coded static balanceon a six-point scale (0-6).34 Ambulation performance has beenranked on a n ine-point scale (0-9) by Hauser and associates.35

Simple ordinal measures of overall performance of functional capacityalso are available and usually encompass measures of specific behaviors or capacities, in add ition to summ edestimates of status. Among these measures are the BarthelIndex,36 Kenny Self-Care E valuation,37 Katz Index,38 Donaldson Unified Activities of Daily Living Evaluation,39 PatientEvaluation Conference System,40 and the Pulses Profile.41

Whether nominal or ordinal, subjective measures shouldfulfill certain criteria. According to MacKenzie and Charlson,they should be "clearly defined and mutually exclusive."42

Ordinal scales, they suggest, should be arranged in a hierarchical progression.42 The scales should be sensitive to bothprogression and regression. Prerequisite to such sensitivity isa distribution of patients on whom the measures are usedthroughout the range of the scale.

Because subjective measures intrinsically are imprecise,they often must be defined elaborately to fulfill the specifiedcriteria. Their bounds must be delineated ifone state is to bedifferentiated clearly from another, sometimes by objectivecriteria. Consider, for example, a dichotomous descriptor ofsitting balanceindependent versus dependent. Are patientsindependen t if they are able to sit without the help of another,but require the use of one or both upper extremities? Are theyindependen t if they can perform the task for only10 seconds?To circumvent interclinician differences in rating the inde

pendence of sitting balance,independent sitting balance hasbeen described in our clinic as the capacity to main tain staticsitting balance for 30 seconds or longer without the use of theupper extremities, lower extremities, back support, or the helpof another person.12 Therapists have eliminated, as a rule, theuse of the term "independence" in lieu of phrases such as"without supervision" or "without physical assistance of another person."

That subjective measures lack precision is a major limitation. The ability to document patient progress is critical topatients, physical therapists, physicians, and third-party payers, all of whom are concerned about improvement in patientstatus. Unfortunately, subjective m easures sometimes are no t

sensitive enough to assess inpatient status precisely. Beasley,for example, found that 20% to 25% differences in strengthwere not determined by MMT in the range of 30 to 50lb.*43

Bohannon and Smith found that the Patient Evaluation Conference System also was insensitive to significant changes inthe muscle strength of patients with hemiplegia secondary tostroke.44 Koller and Kase reported that MMT classified 21patients with parkinsonism as "normal," even though 17complained of weakness and had significant decreases inmaximal torque in the wrist, arm, and knee compared withcontrols.45 A risk of unreliability accompanies subjectivemeasures. The measures sometimes are unreliable becauseevaluators have not first come to an agreement on terms10,46

or because the human capacity to observe accurately thephenomenon of interest is limited.Subjective measures lack specificity. They may not identify

adequately the problem on which intervention should focus.For example, a subjective test for muscle tone may identify amuscle's increased resistance to passive stretch while a patientlies supine ,32 but m ay not identify the source of that resistanceas reflexive muscle contraction or the muscle's altered mechanical characteristics.47 Moreover, the test may yield different results depending on whether it is performed during gaitor while the patient is resting in a supine position.

OBJECTIVE MEASURES

Simple objective measures are available for most variablesin which the clinician has an interest. At the simplest levelare counts, followed by unit measures such as distance andtime. O ther m easures that also are of value (eg, velocity) canbe derived from two or more of these single-unit measures.The objective measures described in this article are not exhaustive, but have been selected because of their potentialclinical usefulness.

The simplest objective measure of clinical value and applicable to the individual is probably that of counts or repetitions. How many steps can a patient ambulate? How manysteps can a patient climb? Either of these measures could

* 1 lb = 0.4536 kg.

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mean the difference between functioning with or without theassistance of another person at home. How many beats of theheart did the patient have? How man y breaths did the patienttake? How many repetitions of exercise did the patient perform? These questions all relate to counts of activities,whether measured by observation, by contact switches, or ona strip chart recorder. Instruments ranging from simple mechanical pedometers to electronic devices can be used tomeasure motion or activity, freeing the clinician of the needto observe continually. 48,49

Distance is another simple measure. Whether linear, circumferential, or angular, distance is frequently an importantmeasure. Linear distances can be measured with tapes, rules,or calipers. The clinician should be interested in how far apatient can walk or propel h is wheelchair. Such d istances, likesteps, can mean the difference between independent andassisted living or activity completion. 50 Gait step or stridelength can be measured from gait trials on a premarked gridpattern, 51 on a section of floor marked by ink patches on apatient's shoes, 52 or by a felt-tip marker taped to the heel ofthe patient's shoes. 53 The chair seat height from which apatient can rise and the stair height that a patient can negotiateare important to independent functioning. 54 Leg-lengthdiscrepancies 55 and lateral trunk flexion, 56 which can be measured with a measuring tape, may be important predictors oflow back dysfunction. Linear measurements of wound dimensions have been used to document wound healing. 57

Circumferential measures can be taken easily with a tapeand used to give an indication of muscle atrophy, edema, orchest expansion. Because many anatomical structures may beinvolved in contributing to the circumference measured, clinicians should be careful not to overinterpret the meaning ofthe measurements. Single measurements may not be particularly useful for some tasks, such as predicting musclestrength, but changes in muscle circumference documented

by serial measu reme nts may reflect chan ges in other variables,such as muscle strength. 58

Angular distance in degrees typically is measured when theclinician is interested in assessing joint ROM. Because goni-ometry is the subject of another article in this issue (see thearticle by Gajdosik and Bohannon), it will not be discussedin this article. Angular measures are important, however,outside the context of joint m otion . The clinician may w antto know the incline of a hill or ramp. Because the stability ofconventional and lightweight wheelchairs on inclines variesand because the stability of lightweight wheelchairs varieswith wheel position, the angle of such inclines can be animportant safety factor. 59 The angle of a chair seat back or a

tilt table or the angle at which a force is applied also may beimportant. Such angles can be measured with a goniometeror an inclinometer 60 or by trigonom etry from linear measures.

Another unit of measure of considerable importance toclinicians is time. We consider it to be so important that, inour clinic, all clinicians are provided with digital stopw atches.Some tests (eg, 2-, 6-, and 12-minute walking tests for respiratory disease) are performed for specific time periods. 61 Timecan be a component of many skill or activity-of-daily-livingtests. A watch is used to determine how long it takes for anindividual to complete a task, such as walking 10 or 100m. 62,63 Time is important, not only in a patient assessment,but in the effective provision of patient care. The duration ofmany treatments, such as ROM exercises, 64,65 is critical tosuccessful patient outcomes.

Although many of the instruments used to measure forceare quite expensive or comp lex, others such as spring scales, 66

strain gauges, 67 and cable tensiometers 68 are relatively inexpensive and sim ple to use. Force m easures are used frequentlyby physical therapists. Examples of such measures are bodyor limb-segment weight, muscle strength, passive resistance,and the force applied during treatment. The importance ofbody weight cannot be overestimated. With muscle strengtha function of body weight 69 and with functional capacityrelated to body weight in patients with certain disabilities, 70,71

clinicians should be aware of their patients' body weights.Simple bathroom scales can be used to measure body weightor weight-bearing. 72 Spring scales can be used to measurebody weight underwater for calculating percentage of bodyfat. Although not without problems, hydrotherapy tanks canbe used for this purpose. 73

Other basic measures are available that may be of use tophysical therapists. Temperature of a body part or of the waterin which a body part is to be submerged may be important inevaluation of treatment. V arious electrical m easures also m aybe important in the application of therapeutic currents (eg,measures of current, intensity, or resistance).

Numerous derivations of these single-unit measures alsoare available to the clinician. Measurem ents of area (distancesquared) are useful in documenting muscle function 74 andwound size.75 Because mu scles and woun ds usually are shapedirregularly, simply multiplying length by width will not givean accurate indication of area. Graph paper counting, w eighing, and planimeter techniques can be u sed to determine areaaccurately. 75 Measurements of volume (distance cubed) alsocan be useful to the clinician. These measurements can givean indication of limb edema and can be obtained by volumetric displacement o f water in specially designed tanks. 76,77

Rate measurements, which are derivations of single-unitmeasures, are valuable clinical measures. Probably more important than the single-unit measures, they p rovide indispensable measures of patient status and of treatment variables.For example, heart rate has a linear relationship with oxygenconsumption 78 and can be used to indicate energy expenditureduring walking under different condition s (eg, with orthoses 79

or with different gait patterns or assistive devices. 80,81) Heartrate can be monitored by palpation of a patient's pulse or byinstrumentation (electronic heart-rate monitors or electrocardiograms). Zinkgraf et al concluded that because the carotidartery pulse reveals a similar rate to an electronic device, the"benefit gained by purchasing a relatively expensive heart ratemonitor is minimal." 82(p212) A rate measurement of potentialimportance to patient treatment w ith electrical stimulation isthat of impulse frequency (pulses per second). Although thisvariable may not be measured easily, the frequency of electrical stimulators usually is either stipulated or adjustable. Because the muscular strengthening resulting from an electricalstimulation program can vary, depending on impulse frequency, 83 this variable should be known and documented.Velocity and cadence (steps time) are particularly usefulmeasures that can be obtained reliably. 52 Because gait velocityis probably the best indicator of gait progress in patients withstroke 84,85 and because it can be used to characterize diseaseprogression in muscular dystrophy, 86 its measurement is particularly important in these groups.

Work (force X distance) and power (work time) are twoother derivations of clinical worth. Although some of theinstrumentation for making such measurements is complexaccording to the definition given previously, many mechani-

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cally braked ergometers are not. Whether used for the moretraditional leg cranking or for arm cranking, ergometers provide objective docum entation of work capacity, which can berevealing abou t a patien t's fitness level.87 For exam ple, testingof disabled me n, of various ages, demonstrated that the poweroutput required for some common wheelchair propulsionsituations (eg, across level low-pile carpet) exceeded the subjects' maximum power output.88

The precision and judgment-free nature of objective measures establishes their value. They allow exacting assessment

of the patient's status and progress. Inherent in these characteristics is a foundation for validity and reliability. Afterdeciding the variable to be measured, the clinician need onlyto select an appropriate objective means of measurement, anda numerical expression of the measured variable can beobtained to represent it. Reliability beyond mere agreementcan be determined for objective measurements. By takingmultiple m easurem ents, the variability associated with the testprocedure can be determined. This process allows the establishment of critical values, which, if exceeded, are indicativeof potentially real differences rather than measurement variability.

The very strengths of objective measures also are their

downfall. Because they tend to be equipment-dependent, theclinician is subject to that equipment. Even if clinicians canafford the equ ipment, they m ay not always have it with themduring a patient assessment. Even more importantly, theclinician may not require the precision afforded by the instrumentation. For example, although elderly individuals mayhave a high incidence of minimal joint limitations that canbe documented by goniometry, the decreased ROM rarelyresults in any significant problems.89 In a study of patientswith osteoarthritis of the knee, Lankhorst et al concludedthat, because static and dynamic torque measurements explained only 23% to 35% of the variation in functionalcapacity, outcome measurements should be directly problem

oriented.90

More specifically, they recommended "subjectivescorings of functional capacity and p ain. . .and semi-objectivevariables such as a walking test.90(171)

CLINICAL CONSIDERATIONS

The value of simple clinical measures is their applicability.Applicability, notwithstanding, other issues are important tothe appropriate use of clinical measures. The measures mustbe part of a planned approach to patient assessment andtreatment. In such an approach, data should be gatheredselectively and should serve as a basis for problem identification, goal establishment, further examination, treatment planning and implementation, and decision making regardingconsultation with or referral to others.91,92

Clinicians' knowledge of simple clinical measures, theirability to select measures rapidly and appropriately, and theircapacity to apply measures skillfully are prerequisites to themeasures having clinical value. Academic and clinical facultycan help to develop these prerequisites. Important to thisdevelopment are meaningful learning experiences and studentsupervision. Feinstein makes this point very clearly withregard to medical students:

A medical student seldom watches his teachers take a history.His teachers also seldom watch him. They often check that hehas acquired salient information; they checkhis ability to reasonwith the information, but they almost never check his competence in the act of getting the primary data at bedside. A fewhours of direct supervision and enlightened criticism early in hiscareer as a history-taker could greatly improve a student's subsequent attitudes and abilitiesas a clinician.93

Supervision also is important to staff members who arenew to a practice setting if they are to be able to practiceconsistently with others in that setting. A good place to startwith new staff members is with an orientation that includesan introduction to operational definitions. Clinicians mustknow what they are measuring before they measure it. Handouts of comm on measurement scales and procedures can beprovided so that new clinicians will have a source to whichthey can refer when in doubt. New clinicians should beobserved to determine whether they demonstrate m ethods forapplying clinical measures that are similar to those used byothers in the clinic. All clinicians should test their own test-retest reliability, at least informally, by taking repeated "blind"measurements. Reliability checks against measurements byknown skilled practitioners also are in order. Even after suchreliability is established, self-appraisal should continue. Suchsteps must be taken if we are to develop a critical mass ofcompetent clinicians in our profession and in our individualclinical settings. Unless clinicians know when and how toapply valid measures and can do so reliably with their peers,the data they gather will be useless for either research or

patient care.

CONCLUSION

Numerous subjective and objective measures that are inexpensive and easy to apply in the field of physical therapyare available to the clinician. One factor to consider in selecting appropriate measures is the ability of the measures todescribe clearly the behavior or condition of interest. Anotherimportant factor is the actual predictive value of the information obtained. Before the full value of clinical measurescan be realized, clinicians must develop skills in selecting andapplying the measures. Such skills can be developed best inthe context of appropriate clinical supervision.

R E F E R E N C E S

1. Janda V: Muscle Function Testing. Boston, MA, Butterworth Publishers,1983

2. Wiles C M , Karni Y: The measu rement of mu scle strength in pa tients withperipheral neuromuscular disorders. J Neurol Neurosurg Psychiatry46:1006-1013,1983

3. Bohannon RW: Test-retest reliability of hand-held dynam ometry during asingle session of strength asse ssm ent. Phys Ther 66:206-20 9, 1986

4. Griffin JW, M cC lure M H, Bertorini TE: Seque ntial isokinetic and man ualmu scle testing in patients with neuromu scular disease: A pilot study. PhysTher 66:32-35, 1986

5. Bohannon RW, Larkin PA, Cook AC, etal : Decrease in timed balance testscores with aging. Phys Ther 64:1067-10 70, 1984

6. Mu rray MP, Seireg AA, SepicS B: Normal postural stability an d steadines s:Quantitative ass essm ent. J Bone Joint Surg [Am] 57:510-516 , 1975

7. Bohannon RW : Strength of lower limb related to gait velocity a nd caden cein stroke patients. Physiotherapy Canada 38:204-206, 1986

8. Nayak USL, Gabell A, Simons M A, etal : Mea surem ent of gait and balancein the elderly. J Am Geriatr Soc 30 :516-520, 1982

9. Hislop HJ: Quantitative changes in hum an m uscular s trength during isometric exercise. J Am er Phys Ther Assoc 43:21-38 , 1963

10. Holm J: Wound and graft infection: Clinical aspects and prophylaxis. ActaChir Scand [Suppl] 529:87-89, 1983

11 . Hart LE, Tugwell P, Buchanan WW, et al: Grading of tenderness as asource of interrater error in the Ritchie Articular Index. J Rheumatol

12:716-717, 198512. Bohannon RW , Sm ith M B, Larkin PA: Relationship be tween indepe ndent

sitting balance and side of hemiparesis. Phys Ther 66:944-945, 1986



5/6

13 . Lieberman JS, Corkill G, Taylor RG: Fatiguing weakness: An initial symptom in cervical compressive radiculopathy. Surg Neurol 19:354-357 , 1983

14. Oester YT, Licht S: Routine electrodiagnosis. In Licht S (ed): Electrodi-agnosis and Electromyography, ed 3. New Haven, CT, Elizabeth LichtPublisher, 1971 , pp 201-2 17

15 . Kopp JR, AlexanderAH , Turocy RH, etal : The use of lumbar extension inthe evaluation and treatment of patients with acute herniated nucleuspulposus. Clin Orthop 202 :211-218, 1986

16 . Murphy R: Auscultation of the lung: Past lessons, future possibilities.Thorax 36:99-107, 1981

17. Goodkin R, Diller L: Reliability am ong p hysical therapis ts in diagnosis andtreatment of gait deviations in hemiplegics. Percept Mot Skills 37:727-734, 1973

18 . Krebs DE, Edelstein JE, Fishman S: Reliability of observational kinematicgait analysis. Phys Ther 6 5:1027-10 33, 1985

19 . Smidt GL, Momm ens M A: Systems of reporting and comparing influenceof ambulatory aids on gait. Phys Ther 60:551-558 , 1980

20 . Willmott M: The effect of a vinyl floor surface and a carpeted floor surfaceupon walking in elderly hospital in-patients. Age Ageing 15:119-120, 1986

21. Daniels L, Worthingham C: M uscle Tes ting: Techniques of M anual Examination, ed 4. Philadelphia, PA, W B Saunders Co, 1980

22 . Medical Research Council: Aids to the Investigation of Peripheral NerveInjuries, ed 2. London, England, Her Majesty's Stationery Office, 1943

23 . Bini G, Cruccu G, Hagbarth K-E, et al: Analgesic effect of vibration andcooling on pain induced by intraneural electrical stimulation. Pain 18:239-248 ,1984

24. M offett JAK, Chase SM , Portek I, etal : A controlled, prospective study toevaluate the effectiveness of a back schoolin the relief of chronic low backpain. Spine 11:120-122, 1986

25. Price DD, McGrath PA, Rafii A, et al: The validation of visual analoguescales as ratio scale measures for chronic and experimental pain. Pain

17:45-56, 198326 . Bohannon RW, LeFort A: Hemiplegic shoulder pain measured with theRitchie Articular Index: Brief research report. IntJ Rehabil Res 9:379-381,1986

27 . O'Sullivan S B: Perceived Exertion: A review. Phys Ther 64:343-346, 198428 . Stamford BA: Validity and reliability of subjective ratings or perceived

exertion during work. Ergonomics 19:53-60, 197629 . M organ WP: Psychophysiology or self-awarene ss during vigorous physical

activity. Research Quarterly for Exercise and Sport 52:385-427, 198130 . Booth BJ, Doyle M, MontgomeryJ: Serial casting for the m anagement of

spasticity in the head-injured adult. Phys Ther 63:1960-1966, 198331. Ashworth B: Preliminary trial of carisoprodai in multiple sclerosis. Practi

tioner 192:540-542, 196432 . Bohannon RW , Sm ith MB: Interrater reliability of a modified Ashworth

scale of muscle spasticity. Phys Ther 67:206-20 7, 198733 . Chan CWY: Motor and sensory deficits following a stroke: Relevance to a

comprehensive e valuation. Physiotherapy C anada 38:29-34, 198634. Gabell A, Simons M A: Balance coding. Physiotherapy 68:286-288 , 198235 . Hauser SL, Dawson DM , Lehrich JR, et al: Intensive immunosuppression

in progressive m ultiple sc lerosis: A ran domized, three-arm study of highdose intravenous cyclophosphamide, plasma exchange and ACTH. N EnglJ M ed 308:173-180, 1983

36 . Mahoney Fl, Barthel DW: Functional evaluation: Barthel Index. Md StateMe d J 14:61-65, 1965

37 . Schoening HA, Iversen IA: Numerical scoring of self-care status: A studyof the Kenny Self-Care Evaluation. Arch Phys Med Rehabil 49:221-229,1968

38 . Katz S, Ford AB, Moxkowitz RW, etal : Studies of illness in theaged: Theindex of ADL, a standardized measure of biological and psychosocialfunction. JAMA 185:914-919 , 1963

39 . Donaldson SW, Wagner C C, Gresham C E: A unified ADL evaluation form.Arch Phys Me d Rehabil 54:175-179 , 1973

40 . Harvey R F, Jellinck HM : Functional performance assessm ent: A programapproach. Arch Phys M ed Rehabil62:456-461, 1981

41. M uzzio TC , Burris CT: Fun ctional Lim itations: A State-of-the Art Review.

Falls Church, VA, Indices, 197842 . MacKenzie CR, Charlson ME: Standards for the use of ordinal scales inclinical trials. Br Me d J [Clin Res] 292 :40-43, 1986

43 . Beasley W C: Influence of method on estimates of normal knee extensorforce among normal and postpolio children. Phys Ther Rev36:21-41,1956

44. Bohannon RW, S mith MB : Assess m ent of strength deficits in eight pareticupper extremity muscle groups of stroke patients with hemiplegia. PhysTher 67:522-525, 1987

45. Koller W, Kase S: Muscle strength testing in Parkinson's disease. EurNeurol 25:130-136, 1986

46 . Garraway W M , AkhtarAJ, Gore SM , etal : Observer variation in the clinicalassessm ent of stroke. Age Ageing 5:233-240, 1976

47 . Dietz V, Berger W: Normal and impaired regulation of muscle stiffness ingait: A new hypothesis about muscle hypertonia. Exp Neurol 79:680-68 7,1983

48 . Dearwater SR, Laporte RE, Cauley JA, et al: Assessment of physicalactivity in active populations. Med Sci Sp orts Exerc 17:651-655 , 1985

49 . Kashiwazaki H, Inaoka T, Suzuki T, et al: Correlations of pedometerreadings with energy expe nditure in workers during free-living daily activities. Eur J Appl Physiol 54:585-590 , 1986

50 . Melamed S, Ring H, Najenson T: Prediction of functional outcome inhemiplegic patients. Scand J Rehabil Med [Suppl] 12:129-133, 1985

51 . Robinson JL, Smidt GL: Quantitative gait evaluation in the clinic. PhysTher 61:35 1-353, 1981

52. Holden MK, Gill KM, Magliozzi MR, et al: Clinical gait assessment in theneurologically impaired: Reliability and meaningfulness. Phys Ther 64:35-40 , 1984

53 . Cerny K: A clinical method of quantitative gait analysis: Suggestion fromthe field. Phys Ther 63:1125-1126, 1983

54. Lundgren-Lindquist B, Aniansson A, Rundgren A: Functional studies in 79year olds: III. Walking performanc e a nd climbing capacity. Sca nd J RehabilM ed 15:125-131, 1983

55. Gofton JP: Persistent low back pain an d leg length disparity. J Rheum atol12:747-750, 1985

56 . Mellin GP: Accuracy of measuring lateral flexion of the spine with a tape.Clinical Biomechanics 1:85-89, 1986

57 . Mc Culloch JM : Interm ittent compres sion for the treatme nt of a chronicstasis ulceration: A case report. Phys Ther 61:1452-1453, 1981

58 . Cooper H, Dodds WN, Adams ID, et al: Use and misuse of the tapemeasure as a mean s of assessing mu scle strength and power. Rheum atolRehabil 20:211-218, 1981

59 . Loane TD, Kirby L: Static rear stability of conventional and lightweightvariable-axle-position wheelchairs. Arch Phys Med Rehabil 66:174-176,1985

60 . Pearcy M : Me asurem ent of back and spinal mobility.Clinical Biomechanics1:44-51,1984

61 . Butland RJA, Pang J, Gross ER, et al: Two, six, and 12-minute walkingtests in respiratory disease. Br Me d J [Clin Re s] 284:1607 -1608, 1982

62 . Wade DT, Wood VA, Heller A, et al: Walking after stroke: Measurementand recovery over the first 3 months. Scand J Rehabil Med 19:25-30,1987

63 . Morice A, SmithiesT: The 100-m walk: A simple an d reproducible e xercisetest. Br J Dis Chest 78 :392-394, 1984

64. Rizk TE, Christopher RP, Pinals RS, et al: Adhesive capsulitis (frozenshoulder): A new approach to its management. Arch Phys Med Rehabil64:29-33, 1983

65 . Riddle D: Case study: A treatment approach for a resistant knee extensioncontracture. Journal of Orthopaedic and Sports Physical Therapy 7:159-162, 1986

66 . Bohannon RW: Upper extrem ity strength and strength relationships a mongyoung wome n. Journal of Orthopaedicand Sports Physical Therapy 8:128-133, 1986

67 . Andres PL, Hedlund W, Finison L, etal : Quantitative motor assessment inamy otrophic lateral sc lerosis. Neurology36:937-941, 1986

68 . Clarke HH: Comparison of instruments for recording muscle strength.Research Quarterly25:398-411, 1954

69 . Thomas LE: Isokinetic torque levels for adult females: Effects of age andbody size. Journal of Orthopaedic and Sports Physical Therapy 6:21-24,1984

70 . Edwards RHT, Round JM , Jackson M J, et al: Weight reduction in boyswith muscular dystrophy. Dev Med Child Neurol 26:384-390, 198471 . Bergstrom EM , Frankel HL, Galer ARA: Physical ability in relation to

anthropometric measurements in persons with complete spinal cord lesionbelow the sixth cervical segment. Int Rehabil Med 7:51-55, 1985

72 . Bohannon RW, Larkin PA: Lower extremity weight bearing under variousconditions in independently ambulatory patients with hemiparesis. PhysTher 65:1323-132 5, 1985

73 . Williams D, Anderson T, C urrierD: Underwaterweighing using the Hubbardtank vs the standard tank. Phys Ther 64 :658-663, 1984

74. WilkersonJD, Morrow JR, DischJG: The reliability and validity of the handheld dynamometer for determining kinetic curve parameters. ResearchQuarterly for Exercise and Sp ort 53:18 0-183 ,1982

75. Bohannon RW, Pfaller BA: Documentation of wound surface area fromtracings of wound perimeters: Clinical report on three techniques. PhysTher 63:1622-1624, 1983

76 . Quillen WS, Rouillier LH: Initial management of acute ankle sprains withrapid pulsed pneumatic compression andcold. Journal of Orthopaedic a nd

Sports Physical Therapy 4:39-43, 198277 . Swedborg I: Voluminometric estimation of the degree of lymphedema andits therapy by pneum atic compression. Scand J Rehabil Me d 9:13 1-135,1977

78 . Burger GC: Heart rate and the concept of circulatory load. Ergonomics12:857-864, 1969

79 . Davies JB: Use of heart rate in assessment of orthoses. Physiotherapy63:112-115,1977

80 . Patterson R, Fisher SV: Cardiovascular stress of crutch walking. ArchPhys M ed Rehabil 62:257-26 0, 1981

81 . Lough LK, Nielsen DH: Ambulation of children with myelomeningocele:Parapodium versus p arapodium with orlan swivel modification. Dev M edChild Neurol 28:489-497, 1986

82 . Zinkgraf S, Squires WG, Maneval M: On measuring heart rate duringexercise. J Sports M ed Phys Fitness 23:210-212 , 1983

83 . Stefanovska A, Vodovnik L: Change in muscle force following electricalstimulation: Dependence on stimulation waveform and frequency. S candJ Rehabil Med 17:141-146, 1985

84 . Mizraki J, Susak Z, HellerL, et al : Objective expression of gait improvementof hemiplegics during rehabilitation by time-distance parameters of thestride. Med Biol Eng Comp ut 20:628-634, 1982

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85 . Brandstater M E, Bruin H, Gowlan d C, et a l: Hemiplegic gait: Analysis oftemporal variables. Arch Phys M ed Rehabil 64:583-587, 1983

86 . Cohen L, M organ J , Babbs R Jr, etal : Fast walking velocity in health andDuchenne muscular dystrophy: A statistical analysis. Arch Phys MedRehabil 65:573-578, 1984

87 . M ellerowicz H, Sm odlaka VN (eds): Ergometry: Basics of Medical ExerciseTesting (transla ted from Germ an by A. L. Rice). Baltimore, M D, Urban &Schwarzenberg Inc, 1981 , pp 1-61

88 . Sawka M N,Glasor RM ,Laulach LL, etal : Wheelchair exercise performanceof the young, middle-aged, and elderly. J Appl Physiol: Respirat EnvironExercise Physiol 50:824-828, 1981

89 . Bergstrom G, Bjelle A, Sorensen LR, et al: Prevalence of symp toms andsigns of joint impairment at age 79. Scand J Rehabil Med 17:173-182,1985

90 . Lankhorst GJ, Van de Stadt RJ, Van der Korst JK: The relationships offunctional capacity, pain, and isometric and isokinetic torque in osteoarthrosis of the knee. Scand J Rehabil Med 17:167-172, 1985

91 . Sac kett DL, Haynes RB, Tugwell P: Clinical Epidemiology: A Basic Scien cefor Clinical Medicine. Boston, MA, Little, Brown & Co, 1985, pp 5-158,245-269

92 . Rothstein JM , Echtemac k JL: Hypothesis-oriented algorithm for clinicians:A method for evaluation an d treatm ent p lanning.Phys Ther 66:1388-1394,1986

93 . Feinstein AR: Clinical Judgment. Melbourne, FL, R E Krieger PublishingColn c, 1967, p 341

Manuscript Reviewers

The Associate Editors and the Editor of PHYSICAL THERAPYwish to thank the followingindividuals for their dedicated and valuable services as manuscript reviewers during 1987.

Diane L. AitkenLouis R. Amundsen, PhDJoseph Asturias

Jean S. Barr, PhDJohn Ban-Paul BeattieSusan A. BemisDonna B. BernhardtBarbara M. Bourbon, PhDJeri Boyd-WaltonGerard P. Brennan, PhDDavid A. BrownSusan Marie ButlerSuzann Campbell, PhDPatrick J. CarleyJanet M. CastonDonna J. CechKay CernyCatherine M. E. CertoEmily Louise Christian,

PhDNancy CieslaShelby ClaysonMeryl CohenBarbara H. Connolly, EdDThomas M. Cook, PhDJanet CooksonMark W . Cornwall, PhDJane Coryell, PhDLinda CraneJohn P. Cummings, PhDDean P. Currier, PhD

Jerome V. Danoff, PhDCarol M. Davis, EdDJody DelehantyRichard P. Di Fabio, PhDNora DonohueRichard L. D onTignyJohn L. Echternach, EdDJoan E. EdelsteinDonna J. El-Din, PhDMary L. EnglesLinda Fetters, PhDDale R. Fish, PhDJoan FlynnRichard L. GajdosikSusan L. Garritan

Meryl Roth GershJoan GertzCarol A. Giuliani, PhD

Diana N. GoldsteinMarilyn Gossman, PhDLTC David G. Greathouse,

PhDMaureen V. GribbenAndrew A. GuccioneSusan HaberkornStephen M. Haley, PhDSusan Harris, PhDJean M. Held, EdDJane Hill, PhDHelen Z. HillegassFaye B. Horak, PhDDamien HowellD. LaVonne JaegerGail M. Jensen, PhDGeneva R. Johnson, PhDColleen M. KiginKaren KirkmanLuther KlothJoan M. KnappRhonda K. KotarinosDavid E. Krebs, PhDCarl G. Kukulka, PhDPatricia Ann LarkinMichelle A. Larson, PhDCarol I. LeiperBarney F. LeVeau, PhDSandra B. Levine, PhDElizabeth H. Littell, PhDRosalie B. LopopoloJoyce MacKinnonWinifred W. MauserBella J. May, EdDDawn A. McNultySue MichlovitzScott D. Minor, PhDRuth U. Mitchell, PhDPatricia Montgomery, PhDChristine A. MoranMichael MuellerRose Myers, PhDRoger M. Nelson, PhDRoberta A. Newton, PhD

Garvice N icholsonDavid H. Nielsen, PhDArthur J. Nitz, PhD

Michael F. Nolan, PhDCarol A. Oatis, PhDLinda O'ConnorJohn J. PalazzoRobert J. Palisano, ScDNancy Patton, PhDLeslie G ross PortneyLCDR William QuillenBrian V. Reed, PhDAndrew J. Robinson, PhDMary M. Rodgers, PhDSteven J. Rose, PhDJules M. Rothstein, PhDAnn Gaither RussellH. Steven SadowskyEmily K. SavinarBeverly J. Schmoll, PhDKay Shepard, PhDAnn Shumway-Cook, PhDDavid S. Sims, JrGary L. Smidt, PhDLaura K. Smith, PhDRichard L. SmithSusan S. SmithMAJ Michael A. SmutokLynn Snyder-MacklerSandra StuckeyPaul SurburgJan Stephen Tecklin

A. Joe Threlkeld, PhDJo Ann TomberlinJanice TomsDarcy A. Umphred, PhDJessie Van SwearingenAnn F. VanSant, PhDJoan M. Walker, PhDJane W alterMary WatkinsLydia Wingate, PhDPatricia WinklerSteven L. Wolf, PhDCynthia Zadai


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