Carrying Moving And Handling Objects - Mastectomy with Chemotherapy

Outpatient Therapy

Catherine Ricketson
Upper Limb Functional Index (ULFI)
• Title of the instrument: Upper Limb Functional Index
• Link to the instrument:
• Purpose of the tool: Assess any difficulties with the activities within the index because of an upper limb problem for
which a patient is seeking attention
• ICF domain: Body Function
• Time to administer the tool: minimal
• Number of items on the tool: 25
• Equipment required: paper/pencil
• Training required: no training
• Any costs associated with it: no cost
• Population you are applying it to: breast cancer survivors s/p mastectomy
• MDC90 and MDC95: 10.5% and 12.47% respectively
• Measurement Error: Determined by calculating the standard error the measurement (SEM) and MDC at the 90% and
95% CI: 4.5% and 10.5% respectively
• MCID: n/a
• Cut-off scores: n/a
• Criterion Validity: A high correlation between the ULFI and DASH with a Pearson coefficient of 0.87. See Appendix A
• Construct validity: ULFI exceeded the 0.95 level supporting its construct validity with a simple t-test
• Floor Effects: 4%
• Ceiling Effects: 23%
• Missed Responses: <0.5%
• Internal Consistency: satisfactory by the use of a CA coefficient with a value of 0.89.

The Upper Limb Functional Index has not been studied specifically in the post mastectomy and radiation breast cancer survivor population; however, many factors indicate that it might be a more appropriate outcome tool than DASH. In a direct comparison to DASH and the Upper Extremity Functional Scale (UEFS), the ULFI was the most practical tool. The practical component includes, brevity in length, short completion time, application across conditions, easy to understand and disease severity range. The ULFI improves clinical utility due to its speed and its score is easily calculated from a raw score of 25 converted to a 100-point scale. This leads to a reduced scoring time and minimal responses are missed. The ULFI asks multiple questions that relate lifting, carrying and handling objects of different weights, heights and sizes. The study by Gabel et al. demonstrated that the ULFI was approximate to or exceeded the reliability, validity, responsiveness, error measurement and internal consistency of the DASH and UEFS. The ease of scoring, rapidity of completion and inclusion of a VAS for functional status and a patient specific index (PSI) increase collected information diversity.

Gabel CP, Michener LA, Burkett B, Neller A. The upper limb functional index: Development and determination of reliability, validity, and responsiveness. J Hand Ther. 2006;19(3):328-48; quiz 349. doi: 10.1197/j.jht.2006.04.001.

Title: Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)
Description by: Theresa Horsch
Description: The DASH is an outcome measure designed by the Institute for Work and Health and the American Academy of Orthopedic Surgeons (AAOS).1,2 The DASH is a 30-item, self-questionnaire and is an appropriate tool to measure physical function and symptoms over time in people with any of several musculoskeletal disorders in the upper extremity. There is an optional section on the DASH which relates to performance in work, sports, and the performing arts.2

Justification for Use:
The DASH is a great tool to use as a functional outcome tool because the items on the DASH address function as it relates to the upper extremity. Many of the items relate to handing, carrying, or moving objects and would be appropriate to use for the post-mastectomy population (i.e. item 11- carry a heavy object or item-12 wash or blow-dry hair).2 It was found that 27 out of the 30 items specifically address the 3 constructs of the ICF model (activity limitations, impairments, or participation restrictions).3 This study by Dixon et al. provides an opportunity for clinicians to generate three distinct outcome measures (activity limitations, impairments, or participation restrictions) using the DASH for arm, shoulder and hand trauma.3 Because the DASH addresses the ICF model, it has been used as a benchmark for comparison in outcome measure studies related to breast cancer (BBAQ).4

The DASH has been accepted for use in many upper extremity disorders such as osteoarthritis in the shoulder, adhesive capsulitis, rotator cuff, rotator cuff repair, shoulder arthroplasty, and acrominoplasty.1 The DASH has high test/re-test reliability (0.96 and 0.94) showing that the test can be consistently completed by a patient before and after an intervention.2 Although the DASH has not been studied specifically in the breast cancer population for validity, reliability, or MDC; it has been used in this population to study functional mobility of the involved upper extremity. In addition, the DASH takes less than 30 minutes to administer and complete and requires only the questionnaire handout and a writing utensil. Based on previous studies and comparisons of the DASH with the ICF constructs, this outcome measure is efficient and adequately established to be used to assess handling, carrying, or moving objects in the post-mastectomy population.

1. Rehab Institute of Chicago. Rehabilitation measures database. Rehabilitation Measures Database Web site. Published 2010. Updated 2010. Accessed 1-31-13.
2. The DASH Outcome Measure. Disabilities of arm, shoulder, and hand. The Dash Outcome Measure Web Site. Updated 2012. Accessed 1-31-13.
3. Dixon D, Johnston M, McQueen M, Court-Brown C. The disabilities of the arm, shoulder and hand questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the international classification of functioning, disability and health (ICF). BMC Musculoskelet Disord. 2008;9:114-2474-9-114. doi: 10.1186/1471-2474-9-114; 10.1186/1471-2474-9-114.
4. Yang EJ, Kim BR, Shin HI, Lim JY. Use of the international classification of functioning, disability and health as a functional assessment tool for breast cancer survivors. J Breast Cancer. 2012;15(1):43-50. doi: 10.4048/jbc.2012.15.1.43; 10.4048/jbc.2012.15.1.43.

Skilled Nursing Facility

Tara Ata SPT

According to the Middle Class Tax Relief Act of 2012, any patients going to physical therapy (along with other select healthcare services), and are insured under Medicare and Medicaid Services (CMS), are required to fill out functional limitation data on the day of an initial evaluation, and every 10th visit up until discharge. This data reporting is done through nonpayable G-codes, which are only viable if you are using an approved functional outcome measure tool. Recommended functional outcome measure tools can be found on the Functional Limitation Reporting webpage. However, not all tools listed in the database are applicable to certain special populations. In the case of patients who are post-mastectomy and going through chemo-radiation therapy, there are no tools that are listed for that specific population other than a balance scale. However, when reviewing the current research on patients with this condition who have a hard time carrying, moving, and handling objects, Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) was used frequently. This tool is a 30-item self-report questionnaire designed to assess upper extremity function. The DASH does not require any extra equipment, or training of staff, is very time efficient (5-30 minutes to administer), and is free.[1] According the DASH Rehab Measures Database, a minimal detectable change (MDC) has not been established, however a minimally clinically important difference (MCID) mean of 19 points (patient reports “much better” or “much worse”), 10 points (patient reports “somewhat better” or “somewhat worse”), and -3 points (patients report “no change”) has been established in patients pre-/post-upper extremity operations.[1] Although much of the reliability, internal consistency and validity have yet to be established, the DASH was found to have moderate correlation with other upper extremity function outcome measures.[1]

Compared to other nine outcome measure tools listed under “Upper Extremity Function,” the DASH seemed the most appropriate when trying to look at overall arm function for breast cancer patients within a skilled nursing facility environment. The other functions listed, such as the Box and Block Test, Jebsen Hand Function Test, and the Nine-Hole Peg test, looked more and hand and finger dexterity. While the ASIA Motor Sensory and Classification, Graded and Redefined Assessment of Strength, Sensibility, and Prehension, and Wolf Motor Function Test were geared more towards patients with spinal cord and traumatic brain injuries. However, according to the database, the DASH has only been tested for reliability and validity on patients with osteoarthritis, rheumatoid arthritis, and patients who had undergone shoulder surgery.[1] Currently there is very little evidence of reliability and validity of the DASH when used with the breast cancer population[2].

1. Smiley J. TA. Disability of the arm, shoulder, and hand questionnaire. Rehabilitations Measures Database Web site. Published 2010. Updated 2012. Accessed February 2, 2013.
2. Dawes DJ, Meterissian S, Goldberg M, Mayo NE. Impact of lymphoedema on arm function and health-related quality of life in women following breast cancer surgery. J Rehabil Med. 2008;40(8):651-658.

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