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OTD classic article review: Musculoskeletal Function Assessment

Instrument: Criterion and Construct Validity
Engelberg R, Martin DP, Agel J, et al (1996)
Musculoskeletal Function Assessment Instrument: Criterion and Construct Validity
Journal of Orthop Research; 14:182-192

Orthop. trauma dir. 2009; 03; 25-29

Authors’ summary/background
The Musculoskeletal function assessment (MFA) instrument is a 100-item, self-reported,
health status measure designed for use in a clinical setting on a broad range of patients
with musculoskeletal disorders of the extremities. This study sought to test both its
criterion and construct validity, an important aspect of creating a health status
instrument. The criterion validity was tested against physicians’ ratings of patient
function and against various clinical measures. Construct validity was evaluated using
medical records, demographic data, other standard health instruments, and by
comparing patients based on their various health issues. Both types of validity were
affirmed by significant correlations between the MFA scores and the criteria evaluated.

Objectives
To report on the construct and criterion validity of the MFA.
Measures used to assess validity
I. Criterion validity, which is established by showing correlations between tests scores
and one or more “gold standard” measure of the same variable, was assessed using the
following measures and methods:

a. Physicians’ ratings
 Three orthopedic surgeons reviewed and rated patients’ medical records and x-rays
on an 11-point scale ranging from “no dysfunction” to “maximum dysfunction”;
these scores were averaged to get a single score for each patient in each functional
area.
 Rated areas included upper and lower mobility, recreation and leisure activities,
activities of daily living, and emotional adjustment.
b. Clinical measures
 Upper extremity
 Grip strength: Jamar grip dynamometer test; averaged over three trials and
compared with normal values matched for age and sex.
 Elbow strength and endurance: concentric contractions; tested at 60°/seconds for
five repetitions and at 120°/seconds for 20 repetitions, respectively.
 Fine motor skills: Jebsen-Taylor set of seven standardized, timed tests
 Range of motion: goniometer
 Lower extremity
 Knee strength and endurance: concentric contractions; tested at 60°/seconds for
five repetitions and at 120°/seconds for 20 repetitions, respectively.
 Range of motion: goniometer
 Stair climb: average of two trials; a range of eight to eleven steps; climbing “at a
comfortable pace”.
 Walking speed: average of two trials; walking “at a comfortable speed” over a 20
meters timed course at Harborview Medical Center and a 10 meters timed course
at a private clinic site
II. Construct validity, which shows that a health measure relates to other measures (or
constructs) in a logical fashion, was assessed using the methods described below:

a. Medical records abstraction (medical records and x-rays)

 Medical records abstracted by a single investigator and x-rays reviewed by two
investigators
 Measures were also assigned assessing the severity of injury for trauma patients
(Injury severity score), severity of radiographic joint appearance for patients with
arthritis (Fairbanks four-point scale), and level of functional impairment for
patients with repetitive motion disorder (functional scale)
b. Demographic data from MFA interview (supplementary questions in the MFA
instrument)
 Included marital and living status, education, income, employment, race, health
insurance, and health habits.
c. Items from other health status instruments
 Included pain, upper and lower mobility activities, overall activity level, quality of
life, activity satisfaction, health status, social support, emotional functioning.
d. Comparison of MFA scores based on patients’ disease group
 Upper extremity involvement (injuries or repetitive motion disorders)
 Lower extremity involvement (injuries or repetitive motion disorders)
 Arthritis (osteoarthritis or rheumatoid arthritis)

Michael Suk / USA

Justin Kearse / USA
This study by Engelberg et al is a landmark article in the context of evidenced based
orthopedic trauma surgery. In establishing the construct and criterion validity of the
patient reported musculoskeletal function assessment (MFA) instrument, this article also
provided an important analytical framework for developing orthopedic outcomes
instruments. As a result of this article the process of determining validity became
concrete and foundational for later orthopedic manuscripts and projects.
A musculoskeletal outcomes instrument is only valid when it measures what it was
intended to measure. This article was written at a time when the process used to
determine an orthopedic assessment’s validity was rarely found in the literature.
Engelberg et al provided a concrete, systematic method that determined the validity of
the MFA instrument as one that reliably provides valuable information for the treating
physician regarding a patient’s condition.

Having a patient involved in their treatment is very important, and patient-reported

subjective input is one way of garnering involvement. Engelberg et al further
demonstrated that the MFA (a “patient-reported” outcomes instrument), correlated with
multiple “clinicianbased” factors including physician ratings, various clinical measures,
certain demographic data, and associated medical co-morbidities. By comparing each
aspect in relation to the MFA, the authors provided a sound methodology of validation
that provides valuable information in the treatment and prognosis of a broad range of
patients manifesting various musculoskeletal disorders.

Today, the MFA is not only known to be a valid assessment tool, it is also regarded as a
logical framework to establish the validity of many later outcomes instruments. As
mentioned in the article, however, once an assessment tool is considered valid, the
process does not end. Determining validity is an ongoing process - refinement to
refinement, validity is a continuum.

A patient’s outcome is not one dimensional. They are more than the arc of their motion,
more than their demographic, more than their co-morbid conditions, more than their
ability to perform a task- they are a mosaic. All of these factors together determine the
success or demise of a patient’s ability to live life after encountering a disease or
traumatic event, and this article reminds us of the importance of valid assessment
instruments in providing our patients with the best care.

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD008130.pub2/abstract

Background
A fall on the outstretched arm can result in an elbow fracture. Loss of elbow function is a
common problem with these fractures and can have major implications for functional
capabilities. It is unknown whether early mobilisation can improve functional outcome
without increasing complications.
Objectives
To compare the effects (benefits and harms) of early mobilisation versus delayed
mobilisation of the elbow after elbow fractures in adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register
(August 2010), the Cochrane Central Register of Controlled Trials (The Cochrane
Library 2010, Issue 2), MEDLINE (1950 to August 2010), EMBASE (1980 to August 2010),
CINAHL (1982 to June 2010), PEDro (31 May 2010), and ongoing trials registers (April
2010).
Selection criteria
We included randomised and quasi-randomised controlled trials evaluating early mobilisation
of the elbow joint after elbow fracture in adults.
Data collection and analysis
Two authors independently selected trials, assessed risk of bias and extracted data. There was
no pooling of data.
Main results
We included one trial reporting outcome at follow-up times ranging between two and 47
months for 81 participants with Mason type 1 and 2 radial head fractures. This poorly-
reported trial was at particular high risk of detection and reporting biases. The trial found no
significant differences between early and delayed mobilisation in the numbers of participants
with pain or limitations in their range of elbow motion. All participants were reported as
being able to use their arms for full activities of daily living and none had changed their
occupation or lifestyle. There was no mention of fracture complications.
Authors' conclusions
There is a lack of robust evidence to inform on the timing of mobilisation, and specifically on
the use of early mobilisation, after non-surgical or surgical treatment for adults with elbow
fractures.

There is a need for high quality, well-reported, adequately powered, randomised controlled
trials that compare early versus delayed mobilisation in people with commonly-occurring
elbow fractures, treated with or without surgery. Trials should use validated upper limb
 function scales, and assessment should be both short-term (to monitor recovery and early
complications) and long-term (at least one year).
 English
 Spanish; Castilian
 French
 Tamil
Plain language summary
Early elbow movement compared to delayed elbow movement after a broken elbow in
adults
The elbow plays an important role in any arm movement such as reaching or lifting. A
broken bone, commonly referred to as a fracture, in the elbow can result from a simple fall
onto an outstretched arm. A fracture may occur in one or more of parts of the three bones that
form the elbow joint. These parts are the upper sections of the two forearm bones (the radius
and the ulna) and the lower section of the upper arm bone (the humerus). A well-documented
problem after an injury to the elbow is elbow stiffness and loss of normal movement. After
initial treatment, which may involve surgery for more serious fractures, treatment may
involve immediate gentle movement of the elbow, using a sling for support only, or it may
involve a period of time resting still in a sling or plaster cast. It is not known which approach
results in better movement and function of the elbow after the fracture has healed.

We searched for randomised controlled trials that compared early movement with delayed
movement of the elbow after elbow fracture. We included one trial reporting results at times
ranging from two to 47 months for 81 people who had had an elbow fracture that involved
the head of the radius. The evidence from this trial is of very low quality. The trial found no
important differences between early and delayed mobilisation in the numbers of participants
with pain or limitations in their range of elbow motion. All participants were reported as
being able to use their arms for full activities of daily living and none had changed their
occupation or lifestyle. There was no mention of fracture complications.

We concluded that there was a lack of reliable evidence to answer the question of whether
early mobilisation improved function without increasing complications in adults with elbow
fractures.

https://www.cancertherapyadvisor.com/shoulder-and-elbow/treatment-of-distal-humerus-
fractures/article/627359/

Post–operative Rehabilitation
 The elbow is splinted in full extension and elevated on pillows for the first 24-48 hours.

 When the fixation is secure, the gravity-assisted active range-of-motion exercise should
be initiated within 24-48 hours postoperatively. In the supine position, the patient holds
the arm vertical and then actively flexes the elbow with the gravity assist. For extension,
position the arm at side of the body and allow the gravity to extend the elbow.
 Gradual increasing of the motion is anticipated within 4-6 weeks post surgery. Static
progressive splint and night extension splint can be used if the range-of-motion is not
appreciated.

 Resistive exercise begins after radiographic healing is seen, at approximately 12 weeks.

https://www.ncbi.nlm.nih.gov/pubmed/23115603

https://clinicalgate.com/rehabilitation-of-the-elbow/

https://www.verywell.com/physical-therapy-after-a-broken-elbow-2696016

https://www.livestrong.com/article/264321-range-of-motion-exercises-for-fractured-elbow/

https://clinicalgate.com/rehabilitation-of-the-elbow/

Stiffness
The treatment of the stiff elbow continues to pose a challenge and has been the source of much
controversy. However, it is clear that clinicians are well placed to employ preventative strategies in at-
risk groups post trauma and surgery. There is a dearth of evidence regarding effective manual therapy
techniques and optimal exercise approaches in management of the stiff elbow, and so evidence
regarding patho-physiology and expert opinion guide intervention. Prevention of stiffness is clearly
preferable and techniques such as the cervical lateral glide previously described have a role in
modulating neural sensitivity, which has been identified as a risk factor in the development of stiffness.
Equally, early mobilization, as soon as pain and stability allow, performed frequently during the day will
help prevent oedema and the increase in viscosity of inflammatory exudate, which may predispose to
adhesion formation.

Rehabilitation of stiffness: exercise

Current evidence regarding the activation patterns of the musculature in stiff elbows challenge the use of
commonly utilized techniques such as sustained stretching. The biceps is highly responsive post injury to the
11
elbow, often resulting in muscle spasm and sustained contraction of the elbow flexor musculature. Consequently
the loss of motion in some patients has an active muscle co-contraction component in addition to passive
restrictions such as the capsule. This helps to elucidate why elbow flexion contracture is the most common
11
reported restriction post trauma. Page et al demonstrated that sustained extension stretching and loaded
stretching (both techniques employed for increasing extension range) result in increased activity in the elbow
flexors. This suggests that these techniques are, in fact, counterproductive. It would appear that the triceps is
relatively inhibited in the presence of elbow flexor dominance and difficult to isolate; exercise prescription must
reflect this.
In an effort to improve extension range, patients should lie in supine with the shoulder flexed at 90°. This
is the optimal position to isolate the triceps and reduce flexor dominance. Patients are instructed to take their hand
to their forehead, nose and ear and return to the start position. This works the triceps both concentrically and
eccentrically and so this exercise should be started immediately post surgery (as long as any incision does not
involve the triceps insertion) or post injury. The findings regarding elbow flexor dominance also suggest that
contract relax techniques should be directed at the triceps rather than the elbow flexors.

Rehabilitation of stiffness: manual therapy

Manual therapy techniques can be employed to improve range of movement and expert opinion currently proposes
28
mobilization with movement as an effective treatment choice. This technique can be employed to optimize the
effects of the extension exercises described. The patient lies in a supine position with the shoulder flexed at 90°.
A mobilization belt is wrapped around the therapist’s hips and the patients forearm so the proximal edge is level
with the elbow joint. The therapist stabilizes the lower end of the humerus with one hand and supports the forearm
with the other. The therapist can then glide the ulna laterally with the belt by moving their hips away. This
technique must be pain-free. The patient is then asked to actively extend their elbow while the therapist maintains
the lateral glide. As the patient extends it is important to remember that due to the carrying angle (as the patient
extends) the treatment plane will alter slightly, and so the direction of glide must be adapted accordingly. This
technique can be done without a belt if the therapist fixes the lower end of the humerus with one hand and applies
the glide with the other hand (Fig. 34.5
https://www.cancertherapyadvisor.com/shoulder-and-elbow/treatment-of-distal-humerus-
fractures/article/627359/
McRae [11] has reported that the normal elbow joint allows flexion and extension from 0° to 140° and
the functional range of motion to perform activities of daily living is described by Morrey., et al. [15] to
be in the 30° to 130° range. It has been shown that elbow flexion and extension occurs around an
‘instant center of rotation involving an area of 2-3 mm in diameter at the trochlea’ [1]. Morrey., et
al. [31] has shown that the ulnohumeral joint also has 6° axial rotation due to the obliquity of the
trochlea groove. These findings are important in consideration for designing elbow implants to try to
restore anatomy and biomechanical properties as close as possible to the original joint.

Willing., et al. [32] described the use of computational models to predict the range of elbow motion
calculated from computed tomography image data. This data could be useful in assisting surgeons in
improving the outcomes of surgical treatment of patients with elbow contractures.
Allied to this, is the physiotherapy side of rehabilitation and the knowledge of the extremes of movement,
while aware of the degree of motion required nominally may improve outcome further down the line of
recovery [33,34].
Pronation and Supination

Pronation and supination of the elbow also needs to be considered. The axis of movement for pronation
and supination is a longitudinal axis from the centre of the radial head to the centre of the ulna head
[35]. According to Naig [36], the radius and ulna lie in parallel, but in supination, the radius crosses over
the ulna and during pronation, its head does move distally and dorsally. There is movement of the ulna
proximally and medially and of the radius proximally in pronation and distally in supination [37].
It is reported that [38], with an approximate degree of pronation of 80 to 90 degrees and approximate
supination of 90 degrees, the average rotation is 180 degrees [39]. Supination is an elbow driven
movement, and the substitution allowed through shoulder abduction in pronation does not exist for
supination [40].
Ibanez-Gabeno., et al. [41], looking at the role of pronator teres and the forces through it, found that the
maximal efficiency is the highest in full elbow flexion and close to forearm neutral position for each
elbow angle. The vertical component of pronator teres is the highest among all components and is
greater in pronation and elbow extension, as well as there being effects from movement further down
the forearm to wrist [42].
According to Laksanachareon and Wongsiri [43] we find that the average torque created at the elbow
joint is 7 kg-m in male and 3.5 kg-m in female with the elbow at 90 degrees flexion. However, in
extension, the torque is less and noted to be 800-900 g-m in male, 350-500 g-m in females.
Measurement of torque is changing with assessment of the analysis processes [44]. Morrey., et al. [45]
describes that at 0° to 30° flexion the forces through the radial head were of greatest magnitude and
much greater in pronation (Figure 3). This occurs because the direction of the joint reaction force
changes with the angle of flexion, becoming more posterior with elbow flexion and anterior with elbow
extension [1]. Figure 4 demonstrates that force vectors acting at the elbow change with flexion angle.
Pain Management
Most fractures hurt moderately for a few days to a couple of weeks. Many patients
find that using ice, elevation (holding their arm up above their heart), and simple,
non-prescription medications for pain relief are all that are needed to relieve pain.

If your pain is severe, your doctor may suggest a prescription-strength medication,

such as an opioid, for a few days.

Be aware that although opioids help relieve pain after surgery, opioid dependency
and overdose has become a critical public health issue. For this reason, opioids are
typically prescribed for a short period of time. It is important to use opioids only as
directed by your doctor. As soon as your pain begins to improve, stop taking opioids.

Rehabilitation
Whether your treatment is surgical or nonsurgical, full recovery from an olecranon
fracture requires a good effort at rehabilitation.
Nonsurgical Treatment
Because nonsurgical treatment can sometimes require long periods of splinting or
casting, your elbow may become very stiff. For this reason, you may need a longer
period of physical therapy to regain motion.

During rehabilitation, your doctor or a physical therapist will provide you with
exercises to help:

 Improve range of motion

 Decrease stiffness
 Strengthen the muscles within the elbow

You will not be allowed to lift, push, or pull anything with your injured arm for a few
weeks. Your doctor will talk with you about specific restrictions.
Surgical Treatment
Depending on the complexity of the fracture and the stability of the repair, your
elbow may be splinted or casted for a short period of time after surgery.

Physical therapy. Patients will usually begin exercises to improve motion in the
elbow and forearm shortly after surgery, sometimes as early as the next day. It is
extremely important to perform the exercises as often as directed. The exercises will
only make a difference if they are done regularly.

Restrictions. You will not be allowed to lift heavy objects with your injured arm for at
least 6 weeks. You will also be restricted from pushing and pulling activities, such as
opening doors or pushing up while rising from a chair. You may be allowed to use
your arm for bathing, dressing, and feeding activities. Your doctor will give you
specific instructions. He or she will also let you know when it is safe to drive a car.