L H Daltroy

Brigham and Women's Hospital , Boston, MA, United States

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Publications (43)220.56 Total impact

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    ABSTRACT: The American Academy of Orthopaedic Surgeons (AAOS) has developed an array of outcomes assessment instruments designed for the efficient collection of outcomes data from patients of all ages with musculoskeletal conditions in all body regions. The Lower Limb Instruments were developed through a process of literature review, consensus-building, and field-testing. The instruments were distributed to a total of 290 subjects in twenty orthopaedic practices throughout the United States and Canada. Of the 290 patients, seventy each had a diagnosis in the categories of foot and ankle, sports/knee, and hip and knee and forty each had a diagnosis in the categories of trauma and rehabilitation. Retests to be taken twenty-four hours after the first test were distributed to subsamples of patients for each instrument. Seventy-one one-year follow-up questionnaires (twenty-five Sports/Knee, twenty-five Foot and Ankle, sixteen Hip and Knee, and five Lower Limb Core instruments) were returned. The Lower Limb Core Scale and the Hip and Knee Core Scale, each consisting of seven items addressing pain, stiffness and swelling, and function, performed at an acceptable level. Additional Sports/Knee and Foot and Ankle Modules proved to have internal and retest reliability of 0.80 or better, comparable with the values for well-established measures such as the Short Form-36 (SF-36). All of the new scales were moderately to strongly correlated with other measures of pain and function, such as physician ratings, the SF-36, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Seventy-one patients provided follow-up information for the analysis of sensitivity to change. The Lower Limb Core was found to contribute independently to the prediction of the transition score based on the patient and physician assessments of change. The AAOS Lower Limb Instruments for outcomes assessment are highly reliable and are correlated with other measures for similar constructs. They are also sensitive to change in patient status. The Lower Limb Core Scale may be used with attribution of pain either to the lower limb or to a specific joint or side without sacrificing reliability. Combined with the SF-36, the AAOS outcomes assessment instruments comprehensively and efficiently measure outcomes in orthopaedic patients with lower-limb conditions.
    The Journal of Bone and Joint Surgery 06/2004; 86-A(5):902-9. · 4.31 Impact Factor
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    ABSTRACT: The goal of this work was to develop an economical way of tracking disease activity for large groups of systemic lupus erythematosus (SLE) patients in clinical studies. A Systemic Lupus Activity Questionnaire (SLAQ) was developed to screen for possible disease activity using items from the Systemic Lupus Activity Measure (SLAM) and tested for its measurement properties. The SLAQ was completed by 93 SLE patients just prior to a scheduled visit. At the visit, a rheumatologist, blinded to SLAQ results, examined the subject and completed a SLAM. Associations among SLAQ, and SLAM (omitting laboratory items) and between individual items from each instrument were assessed with Pearson correlations. Correlations between pairs of instruments were compared using Student's t-tests. The mean score across all 24 SLAQ items was 11.5 (range 0-33); mean SLAM without labs was 3.0 (range 0-13). The SLAQ had a moderately high correlation with SLAM-nolab (r = 0.62, P < 0.0001). Correlations between patient-clinician matched pairs of items ranged from r = 0.06 to 0.71. Positive predictive values for the SLAQ ranged from 56 to 89% for detecting clinically significant disease activity. In studies of SLE, symptoms suggesting disease can be screened by self-report using the SLAQ and then verified by further evaluation.
    Lupus 01/2003; 12(4):280-6. · 2.48 Impact Factor
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    ABSTRACT: The measurement of the patient's experience with a condition or an illness is an important and quantifiable outcome and an example of action research. By making these concerns paramount, the goals and processes of health care can be redirected from anatomical and physiologic restoration to patient-oriented outcomes. At the same time, research can illuminate the complex mechanisms responsible. Critical, analytic synthesis and review of the research evaluating the ability of self-administered questionnaires to capture clinically meaningful changes. Responsiveness is differentiated from sensitivity, and statistical methods for evaluating sensitivity of instruments are referenced. Techniques for evaluating whether differences in instrument sensitivity could have occurred by chance are presented, and methods for assessing a clinically meaningful change are discussed. Responsiveness is the key psychometric property of an instrument if it is to be incorporated into daily practice. Improving responsiveness is a major research priority.
    Medical Care 05/2002; 40(4 Suppl):II45-51. · 2.94 Impact Factor
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    ABSTRACT: Health status and disease activity in patients with systemic lupus erythematosus (SLE) and other chronic diseases are strongly associated with social support, which suggests that enhanced social support in medical care might improve SLE outcome. There has been little or no study on identifying patients for whom social support would be most beneficial. It would allow practitioners to enable social support more effectively as a complement to disease management. A retrospective cohort (200 patients with SLE from 5 centers), balanced by race and insurance status, was studied in a cross sectional design. Demographic, clinical, socioeconomic, and psychosocial factors and disease outcomes [Systemic Lupus Activity Measure (SLAM), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR), SF-36] were measured. Using multivariate linear regression and ANOVA (outcome = SF-36 physical function, mental health), we examined the interaction between social support and patients' characteristics, including race, age, income, occupation, insurance, employment, education, and social network, and characteristics of the disease itself such as disease activity (SLAM) at diagnosis, damage (SLICC/ACR) at diagnosis, and comorbidity. In multivariate models, higher social support was significantly associated (p < 0.05) with better physical function when respondents were white, had income above poverty level, had Medicare or private insurance (vs Medicaid or no insurance), and had low disease activity at diagnosis. Social support was associated with better mental health, although there was no significant interaction between social support and other predictors of mental health. The data suggest that social support is beneficial for mental health for all groups, but has the greatest opportunity for influence among those already possessing social, economic, and health advantages.
    The Journal of Rheumatology 06/2001; 28(6):1245-51. · 3.17 Impact Factor
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    M D Iversen, A H Fossel, L H Daltroy
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    ABSTRACT: Little is known about the features and role of exercise discussions between rheumatologists and patients. The goals of this study were to: 1) describe rheumatologists' and patients' attitudes and beliefs regarding exercise and physical therapy for rheumatoid arthritis (RA); 2) describe frequency and length of exercise discussions; 3) determine the accuracy of recall for exercise discussions; and 4) assess the influence of attitudes regarding exercise on communication about exercise. Goals 1-3 were addressed with analysis of baseline questionnaires and audiotaped encounters. The influence of attitudes and beliefs regarding exercise on the frequency and length of exercise discussions was assessed prospectively. Patients and rheumatologists were enrolled from a large tertiary care institution. Clinical encounters were audiotaped, transcribed, coded, and analyzed to identify specific characteristics of the exercise discussions. One hundred thirty-two patients and 25 rheumatologists participated in the study. Rheumatologists and patients discussed exercise in 53% of the encounters. Rheumatologists' beliefs regarding the usefulness of exercise for RA varied, with the least positive beliefs being reported for aerobic exercise. Exercise discussions were more likely to occur if the patient was currently exercising, odds ratio (OR) = 2.4; 95% confidence interval (CI) (1.2-4.9), and when the rheumatologist believed aerobic exercises were useful in managing RA, OR = 1.4; 95% CI (1.1-1.9). Current exercise behavior was associated with patients' positive attitude toward exercise (chi 2 1 = 8.4; P = 0.004) and perceived social support for exercise (chi 2 1 = 4.5; P = 0.04). When rheumatologists initiated exercise discussions, there was nearly twice as much discussion (beta = -8.4; P = 0.001). Exercise talk was influenced by patients' and rheumatologists' beliefs and attitudes regarding the effectiveness of exercise and physical therapy in managing RA, patient experience with exercise, and by characteristics of the rheumatologist.
    Arthritis care and research: the official journal of the Arthritis Health Professions Association 07/1999; 12(3):180-92.
  • Carolyn E Schwartz, Lawren H Daltroy
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    ABSTRACT: The role of response stability in the measurement of coping is examined with a focus on the unique information that can be gleaned from low test retest reliability ('inconsistency'). Data from two studies are presented in which a card sort measure of coping flexibility was used on people with three different chronic diseases and the elderly (n = 219). We begin by testing the hypothesis that the low stability reflects unreliability due to measurement artifacts, such as random error, low ecological validity, long test retest interval, surrogate assistance, or error due to completing the questionnaire in multiple sittings. Our findings suggest that surrogate assistance in completing questionnaires was the only measurement artifact associated with low stability. We then tested the proposition that low stability reflects a genuine behavior pattern (i.e. inconsistency). Hierarchical modeling revealed that measurement artifact accounted for less than one percent of the variance in inconsistency in reported coping behavior and that an additional 21% of the variance could be explained by the behavioral factors, including neuropsychological problems (9%), psychological morbidity (4%), locus of control (3%) and eudaimonistic well-being (5%). Thus inconsistency in reported coping behavior was better explained by behavioral and psychosocial factors than by the tested measurement artifacts. We conclude that inconsistency in reported coping behavior does indeed reflect a meaningful behavior pattern, rather than simply measurement artifact.
    Social Science [?] Medicine 04/1999; 48(5):619-31. · 2.56 Impact Factor
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    ABSTRACT: To review the published literature on interventions aimed at improving physicians' testing practices and propose methodologic standards for these studies and to review selected studies using the PRECEDE framework, a behavioral model that helps categorize interventions based on which behavioral factors are being affected. MEDLINE, EMBASE, and HEALTHStar databases were searched for the years 1966 to January 1, 1998, for English-language articles pertaining to diagnostic testing behavior; bibliographies were scanned to identify articles of potential interest; and researchers in health services, health behavior, and behavior modification were contacted for proprietary and other unpublished articles. A total of 102 articles were identified that described the results of interventions aimed at changing physicians' testing practices. We included the 49 studies that compared diagnostic testing practices in intervention and control groups. Two investigators independently reviewed each article in a blinded fashion using a standard data collection form to obtain a methodologic score and to abstract the key elements of each intervention. On a 38-point methodologic criteria scale, the mean +/- SD score was 13+/-4.4. The desired behavior change was reported in the intervention group in 37 (76%) of 49 studies. Twenty-four (86%) of 28 interventions targeted at many behavioral factors were successful, while 13 (62%) of 21 studies aimed at a single behavioral factor were successful (P=.12). A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results.
    JAMA The Journal of the American Medical Association 01/1999; 280(23):2020-7. · 30.39 Impact Factor
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    ABSTRACT: We discuss dilatonic gravity (bulk theory) from the point of view of (generalized) AdS/CFT correspondence. A self-consistent dilatonic background is considered. It may be understood as a two-boundary space where the AdS boundary appears as an infinite boundary and a new (singular) boundary occurs at short distances. The two-point correlation function and the conformal dimension for a minimal and dilaton coupled scalar are found. Even for a minimal scalar, the conformal dimension is found to be different on above two boundaries. Hence, a new CFT appears in AdS/CFT correspondence at short distances. The AdS/CFT correspondence may be understood as interpolating bulk theory between two different CFTs.
    Physics Letters B 01/1999; 449(1). · 6.02 Impact Factor
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    ABSTRACT: The influence of psychosocial variables in the outcome of surgery for lumbar stenosis (LSS) has not been evaluated. We studied 257 patients with LSS pre-operatively and at 6 months to: (a) relate patient expectations of surgery to baseline function and pain; and (b) determine how patient expectations and pre-operative function interact to predict post-operative outcomes. RESULTS: On average, patients experienced substantial pain relief, improved function and satisfaction. Patients with many pre-operative expectations, particularly patients with low baseline function, reported more improvement in post-operative function than patients with few expectations. More ambitious expectations for physical function were also associated with improved function and satisfaction at 6 months. Conversely, having more numerous pain relief expectations was associated with more pain and less satisfaction with pain relief. CONCLUSION: Patient expectations influence recovery from surgery at 6 months. To improve outcomes and satisfaction, clinicians should discuss expectations with patients pre-operatively.
    Patient Education and Counseling 07/1998; 34(2):169-78. · 2.60 Impact Factor
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    ABSTRACT: Patients with systemic lupus erythematosus (SLE) may have a variety of neuropsychiatric syndromes. Assessment of cognitive functioning for these patients is complicated by increased prevalence and disease severity among groups obtained lower scores on measures of cognitive functioning in normative national samples. Cognitive ability was quantified in a diverse cohort of patients with SLE and a demographically matched group of control participants. Hierarchical regression demonstrated a small increase (6%) in explained variation in cognitive functioning when presence of SLE was added to the equation derived from demographic variables. No significant interaction was found between race and disease. These results suggest that increased frequency of cognitive impairment in African Americans with SLE is due to the additive effects of psychosocial variables.
    Journal of Clinical and Experimental Neuropsychology 05/1998; 20(2):157-66. · 2.16 Impact Factor
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    ABSTRACT: Two explanations were tested for why patients who are less healthy tend to be less satisfied with their medical care than healthier patients. The explanations were (a) that poor health produces dissatisfaction directly and (b) that poor health produces dissatisfaction through the mediating effect of physicians' behavior. Two studies are presented that measured patients' health status, patients' satisfaction with care, and their physicians' communication as recorded on audiotape. In Study 1, 114 patients had first visits with rheumatologists; in Study 2, 649 patients had continuing-care visits with physicians in internal and family medicine. Causal modeling revealed that the first study supported the direct explanation. The second study also supported the direct explanation, as well as the mediation explanation with respect to the physician's use of social conversation.
    Health Psychology 02/1998; 17(1):70-5. · 3.95 Impact Factor
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    ABSTRACT: To study the risk factors for early work disability in systemic lupus erythematosus (SLE). A sample of 159 SLE patients who had been employed at some time since diagnosis was drawn from a multicenter study of outcome in SLE. Disease activity, organ damage, education, income, source of health insurance, and work-related factors were measured in a standardized interview. Work disability was defined by patient self-report of not working because of SLE. The outcome measure was current work status. Seven patients were excluded from the analysis because their choice not to work was unrelated to SLE. An average of 3.4 years after diagnosis, 40% had quit work completely, and job modification was substantial. Univariate analysis (chi-square and t-test) showed that significant predictors of early work disability included having a high school education or less, receiving Medicaid or having no health insurance, having a job which required more physical strength, having an income below poverty level, and having greater disease activity at diagnosis. In multivariate models, significant predictors were education level (P = 0.0004), higher physical demands of the job (P = 0.0028), and higher disease activity at diagnosis (P = 0.0078). Race, sex, cumulative organ damage at diagnosis, and disease duration were not significant. Early work disability in SLE is strongly associated with some sociodemographic factors that might be amenable to intervention.
    Arthritis & Rheumatology 01/1998; 40(12):2199-206. · 7.87 Impact Factor
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    ABSTRACT: The authors tested the hypothesis that individuals with a variety of severe chronic illnesses and the healthy elderly exhibit a loss of flexibility in their response to a variety of stressors, compared with healthy adults. A card sort game designed to assess self-reported coping behavior under different stressful life situations was used to compare healthy adults with individuals with multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and the elderly. The healthy adults were found to exhibit more variability than any of the illness groups or the elderly. Healthy function is marked by a complex type of variability.
    Behavioral Medicine 01/1998; 24(1):41-4. · 1.14 Impact Factor
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    ABSTRACT: To study gender-specific preferences regarding timing of elective total joint replacement (TJR) surgery in patients with moderately severe osteoarthritis (OA) of the hip or knee. Focus group discussions regarding TJR surgery were conducted among 18 women and among 12 men with moderately severe OA of the hip or knee. Discussions were tape recorded, transcribed, coded for themes, and evaluated semiquantitatively and qualitatively for gender differences. In general, men were more likely to choose surgery earlier in the disease than women and had higher expectations for surgical success. Women were more fearful of surgery. Women preferred to suffer arthritis pain rather than risk surgery, and indicated they would delay surgery to await better technology and to avoid disrupting caregiving roles for dependent spouses and others. Men and women differ in their willingness to accept continued functional decline, risks of surgery, and disruption of usual role. Gender differences may influence decisions regarding utilization of TJR.
    The American Journal of Medicine 07/1997; 102(6):524-30. · 5.30 Impact Factor
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    ABSTRACT: Tick bite control is an important initiative to prevent Lyme disease and other tickborne infections. While several studies have demonstrated that knowledge and awareness of Lyme disease in endemic areas are good, none has evaluated the relative importance of knowledge with other attitudinal and health belief variables to determine motivators of preventive behavior. We conducted a cross-sectional analysis of 304 commuter ferry passengers departing Martha's Vineyard Island, Massachusetts, in August 1992, to ascertain the prevalence of tick-avoidance behaviors among individuals from an endemic area of Lyme disease and to identify the knowledge, behavioral, and demographic variables that best determine precautionary behavior. Overall, survey respondents (n = 304) had very good knowledge of Lyme disease (73% items correct on a knowledge test), but only 59% of respondents reported limiting time in tick areas, 58% usually wore protective clothing, 40% wore tick repellent, and 66% usually performed tick checks. By stepwise linear regression analysis, determinants of tick-avoidance behaviors included perceiving the behavior's benefits as outweighing its inconvenience (P < .0001), having confidence in recognizing Lyme disease symptoms (P < .0004), believing that Lyme disease is a serious illness (P < .0009), and believing that the avoidance behavior is effective in reducing the risk of Lyme disease (P < .01). Younger respondents (P < .05) performed fewer avoidance behaviors. Visitors (P < .0001) performed fewer tick checks than residents. Having confidence that one could find a tick on oneself with a tick check also predicted performance (P < .008). Increased general knowledge about Lyme disease did not predict any protective behaviors. Precautionary behaviors were underperformed in an at-risk population despite good knowledge of Lyme disease symptoms and transmission. Instead, performance was related to confidence in finding a tick on oneself and a perception that a precaution's benefit outweighed its inconvenience and would adequately reduce risk for Lyme disease. These data have implications for Lyme disease prevention programs, which typically focus on enhancing general knowledge as a means toward disease reduction.
    American Journal of Preventive Medicine 01/1997; 13(4):265-70. · 4.28 Impact Factor
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    ABSTRACT: To study the relationship of race, socioeconomic status (SES), clinical factors, and psychosocial factors to outcomes in patients with systemic lupus erythematosus (SLE). A retrospective cohort was assembled, comprising 200 patients with SLE from 5 centers. This cohort was balanced in terms of race and SES. Patients provided information on socioeconomic factors, access to health care, nutrition, self-efficacy for disease management, health locus of control, social support, compliance, knowledge about SLE, and satisfaction with medical care. Outcome measures included disease activity (measured by the Systemic Lupus Activity Measure), damage (measured by the SLICC/ACR damage index), and health status (measured by the SF-36). In multivariate models that were controlled for race, SES, center, psychosocial factors, and clinical factors, lower self-efficacy for disease management (P < or = 0.0001), less social support (P < 0.005), and younger age at diagnosis (P < 0.007) were associated with greater disease activity. Older age at diagnosis (P < or = 0.0001), longer duration of SLE (P < or = 0.0001), poor nutrition (P < 0.002), and higher disease activity at diagnosis (P < 0.007) were associated with more damage. Lower self-efficacy for disease management was associated with worse physical function (P < or = 0.0001) and worse mental health status (P < or = 0.0001). Disease activity and health status were most strongly associated with potentially modifiable psychosocial factors such as self-efficacy for disease management. Cumulative organ damage was most highly associated with clinical factors such as age and duration of disease. None of the outcomes measured were associated with race. These results suggest that education and counseling, coordinated with medical care, might improve outcomes in patients with SLE.
    Arthritis & Rheumatology 01/1997; 40(1):47-56. · 7.87 Impact Factor
  • J A Hall, D L Roter, M A Milburn, L H Daltroy
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    ABSTRACT: Although some patient characteristics are known to be related to physician and patient communication in medical encounters, very little is known about the impact of patients' health status on communication processes. The authors assess relations of patients' physical and emotional health status to verbal and nonverbal communication between physicians and patients in four original studies, and combine results across the four studies using meta-analytic procedures. In four original studies of routine outpatient visits (consisting of more than 250 physicians and more than 1,300 patients), health status was measured and audiotape or videotape records were coded for verbal content and nonverbal cues indicating task-related behavior and affective reactions on the part of both the physician and the patient. Both physical and mental health data were obtained, using physicians and/or patients as sources; in two studies, physicians' satisfaction with the visit also was measured. All available background characteristics for both physicians and patients were controlled via partial correlations. The meta-analytic procedures used were the unweighted and weighted (by sample size) average partial correlations, the combined P across studies (Stouffer method), and the test of effect size heterogeneity. Physicians showed signs of negative response to sicker or more emotionally distressed patients, both in their behavior and in their ratings of satisfaction with the visit. Sicker patients also behaved more negatively than healthier patients. However, physicians also engaged in a variety of positive and professionally appropriate behaviors with the sicker or more distressed patients. This mixed pattern of responses is discussed in terms of alternative frameworks: the physician's goals, reciprocation of affect, and ambivalence on the part of the physician. The patient's health status appears to influence physician-patient communication. In clinical practice, increased attention by physicians to their own and their patients' behavior may enhance diagnosis and prevent misunderstandings.
    Medical Care 01/1997; 34(12):1205-18. · 2.94 Impact Factor
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    ABSTRACT: The objective of this study was to analyze the problem of interpreting change scores of ordinal health status measures for clinical research or practice. Methods used included exploration of the generation of change scores in the physical ability scale of the SF-36, one of the most widely used generic health status instruments. Resulting data are presented as the ranking of items according to baseline score; a percentage of patients with severe difficulty and Rasch analysis provided the same rank order of item difficulty. On the interval scale provided by the Rasch model a concentration of items reflecting moderate difficulty occurred. This "inflates" numerical gains for patients with moderate disability compared to patients with very severe or minor physical disability. Calibration of change scores using patient perception of the level of change in function showed important variation of numerical gains with baseline. We conclude that numerically equal gains may differ in their meaning depending on baseline health status. It is recommended that distribution of baseline health status measures and distribution of responders by baseline status be reported in evaluative studies.
    Journal of Clinical Epidemiology 08/1996; 49(7):711-7. · 5.48 Impact Factor
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    ABSTRACT: The measurement properties and validity of a newly developed patient questionnaire for the assessment of patients with lumbar spinal stenosis was tested in an ongoing prospective multicenter observational study of patients undergoing decompressive surgery in three teaching hospitals. The goal of the study was to develop a short, self-administered questionnaire on symptom severity, physical functional status, and patient satisfaction. The measure is intended to complement existing generic measures of spinal-related disability and health status. The questionnaire includes three scales with seven questions on symptom severity, five on physical function, and six on satisfaction. The internal consistency of the scales was assessed with Cronbach's coefficient alpha on cross-sectional data from 193 patients before surgery. The test-retest reliability was assessed on data from a random sample of 23 patients using Spearman's rank correlation coefficient. The responsiveness was assessed on 130 patients with 6-month follow-up data using the standardized response mean. The test-retest reliability of the scales ranged from 0.82 to 0.96, the internal consistency from 0.64 to 0.92, and the responsiveness from 0.96 to 1.07. The direction, statistical significance, and strength of hypothesized relationships with external criteria were as expected. This short self-administered spinal stenosis measure is reproducible, internally consistent, valid, and highly responsive. It can be used to complement generic instruments in outcome assessment of patients with lumbar spinal stenosis.
    Spine 05/1996; 21(7):796-803. · 2.45 Impact Factor
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    ABSTRACT: A cross-sectional study of a convenience sample of lumbar spine patients, with a subsample followed for retest reliability. To assess the instrument's reliability, validity, and acceptability to patients. Patients with eight diagnoses, four before surgery and four after surgery, were recruited from six orthopedic practices to test the questionnaire. One hundred sixty-seven patients were approached through the physician's office, yielding 136 usable questionnaires (84%) and 24-hour retests on 64 patients. The questionnaire took about 20 minutes to administer and was acceptable to patients. The lumbar spine pain and disability and neurogenic symptoms subscales discriminated among patient groups as hypothesized and showed significantly better scores for patients independently judged successful by their physicians after surgery. Test-retest reliability and internal reliability were high (range, 0.85-0.97). Sample sizes of 20-37 would be needed to detect a 20% difference between two groups (alpha, 0.05; beta, 0.20). The questionnaire should be considered for monitoring of individual patient's progress in treatment and for clinical trials.
    Spine 04/1996; 21(6):741-9. · 2.45 Impact Factor

Publication Stats

2k Citations
220.56 Total Impact Points


  • 1988–2002
    • Brigham and Women's Hospital
      • • Department of Medicine
      • • Center for Brain Mind Medicine
      Boston, MA, United States
  • 1988–2001
    • Harvard Medical School
      • Department of Medicine
      Boston, MA, United States
  • 1999
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1997–1998
    • Northeastern University
      • Department of Psychology
      Boston, MA, United States
  • 1996
    • University of Zurich
      Zürich, Zurich, Switzerland
  • 1991
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States