Functional Assessment of Patients

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RENATA JABOSKA1, ROBERT LUSARZ1, JOANNA ROSICZUKTONDERYS2,WOJCIECH BEUTH3, WALDEMAR CIEMNOCZOOWSKI4

Functional Assessment of Patientswith Lumbar Discopathy

Czynnociowa ocena pacjentw z chorob dyskow krgosupa1

Department of Neurological and Neurosurgical Nursing, Collegium Medicum in Bydgoszcz,Toru in the GCM, Poland2 Department of Diseases of Nervous System, Wrocaw Medical Univeristy, Poland3 Department and Clinic of Neurosurgery and Neurotraumatology, Collegium Medicum GCM in Bydgoszcz,

Toru, Poland4 Department of Methodology Scientific Methodology Labor, Medical College in Bydgoszcz, NCU, Toru,

Poland

Adv Clin Exp Med 2009, 18, 4, 389399ISSN 1230025X

ORIGINAL PAPERS Copyright by Wroclaw Medical University

AbstractBackground. Disc disease is a complex of changes in the structures that make up the intervertebral disc and spinalcanal. Functional assessment is evaluation of the ability to cope with the activities of everyday life.Objectives. The aim was to functionally assess patients treated surgically for lumbar discopathy before and after

the intervention.Material and Methods. The study was conducted in a group of 46 patients qualified for surgery for lumbar discopathy. The Repty Functional Index (RFI, Polish: WFR) was used to gather data.Results. The respondents showed complete operational autonomy both before and after treatment. Scores rangedfrom 85105 points. RFI increased for sphincter control both in urinating (mean increase from 6.96 to 7.0 points)and defecating (6.91 to 7.0 points). The index also rose in the category of locomotion (going on foot from 6.61 to6.74 points). Decreases were noted in personal care and mobility.Conclusions. Patients with discopathy of the spine show complete independence in carrying out the activities ofeveryday life. The functional assessment was somewhat worse at the time of release from the neurosurgical ward(Adv Clin Exp Med 2009, 18, 4, 389399).

Key words: discopathy, spine, evaluation, functioning.

Streszczenie

Wprowadzenie. Choroba dyskowa jest zespoem zmian strukturalnych tworzcych krek midzykrgowy i kana krgowy. Ocena czynnociowa to umiejtno radzenia sobie z czynnociami dnia codziennego.Cel pracy. Ocena czynnociowa chorych leczonych operacyjnie z powodu dyskopatii ldwiowej krgosupaprzed i po zabiegu.Materia i metody. Badaniami objto grup 46 chorych przyjtych na oddzia z powodu dyskopatii ldwiowej,ktrzy zostali zakwalifikowani do leczenia operacyjnego. Do zbierania danych wykorzystano Wskanik Funkcjonalny Repty (WFR).Wyniki. Respondenci, zarwno przed, jak i po leczeniu operacyjnym wykazuj pen samodzielno; uzyskanapunktacja miecia si w przedziale 85105 pkt. WFR zwikszy si w kategorii kontrola zwieraczy, zarwno w oddawaniu moczu (rednio z 6,96 pkt. do 7,0 pkt.), jak i w oddawaniu stolca (rednio z 6,91 pkt. do 7,0 pkt.). Wskanik wzrs rwnie w kategorii lokomocja w chodzeniu pieszo: z 6,61 pkt. do 6,74 pkt. Spadek redniej punktowej odnotowano w samoobsudze i mobilnoci.Wnioski. Pacjenci z chorob dyskow krgosupa wykazuj pen samodzielno w wykonywaniu czynnoci dniacodziennego. Ocena czynnociowa badanych jest nieco gorsza po zastosowanym leczeniu operacyjnym, w dniu

wypisu z oddziau (Adv Clin Exp Med 2009, 18, 4, 389399).Sowa kluczowe: dyskopatia, krgosup, ocena, funkcjonowanie.


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Disc disease, also called discopathy or damageto the disc, is a group of structural changes as anaftereffect of disorders of mutually arranged elements creating the intervertebral disc and spinalcanal [13]. Discopathy is a degenerative diseaseof the organ of movement and consists of three

pathogenic factors which can be analyzed in termsof biomechanics (overload), pathobiology (inflammation), and neurophysiology (nociception) [2].Everyday mechanical wear and the aging processcontinuously influence the destruction of intervertebral discs. The process lies in the biomechanicaland tissue decomposition of a disc caused by theburden of the spine, inborn defects, as well asspinal damage caused by past disease and injury[4, 5]. Thus the height of the intervertebral discdrops, which destabilizes the whole motive segment and leads to damage of the remaining ele

ments. Its functional abilities worsen in visiblysignificant ways, i.e. elasticity, carrying capacity,and ability to regenerate [4, 6, 7]. Stimuli thatdamage tissues in turn cause inflammation, whichis a complex defensive reactive of the organism.The hernial process of discopathy causes vertebralcanal invasion and reduces its lumen to variousdegrees, particularly on the lateral sides in whichnerve roots run. Roots damaged in this way generateneuropathic pain, as opposed to receptor pain [8].

Although most people complaining of spinalpain are successfully cured by conservative meth

ods, some require surgery; however there is noconsensus regarding treatment [7, 9, 10]. Theassessment of neurological status is fundamentalin deciding the choice of treatment and also themain criterion defining its effectiveness. Despitemany clinical observations, great advances inmedicine, and experience, spinal pain is common,persistent, and chronic and tends to recur withoutany perceptible cause. It results in a total inabilityof the afflicted to perform at work and is also oftenthe cause of total loss of working ability [11].According to statistics, 90% of the population of

the USA experience discopathy sometime duringtheir life. One can assume that the data in otherdeveloped countries are similar [10].

Functional assessment is an evaluation of theability to perform the activities of everyday life.These include the ability to be independent ofother persons in satisfying basic life necessities,such as moving, nourishing, controlling physiological functions of the organism, and carrying ourhygienic activities [12]. Although they are physical processes, they also have a psychologicaldimension because a deficit of physical efficiency

has an unfavorable impact on mood and quality oflife. Efficient and independent functioning has sig

nificant practical and emotional meaning for thepatient and is conducive to a feeling of independence [11].

The aim of this study was to conduct functional assessments of patients treated surgically forlumbar discopathy before and after the interven

tion, i.e. on the day of leaving the hospital ward.

Material and Methods

The examinations were conducted at theDepartment of Neurosurgery and Neurotraumatology in the Efficient Therapy Division of J. BizielRegional Hospital in Bydgoszcz, Poland. Theexaminations were conducted on 46 patients qualified for surgery for lumbar discopathy. Approvalof the Bioethics Committee of the Collegium

Medicum in Bydgoszcz to conduct this study wasobtained.The subjects were characterized regarding

age, sex, place of residence, education, professional status, and the kind of job they were currentlydoing. Table 1 presents these data. In the examinations, the Repty Functional Index (RFI, in Polish:WFR) was used. The RFI/WFR was introduced byJ. Opara et al. [13] at the Repty SilesianRehabilitation Center in the TarnowskieMountains in 1998. It was created as a modification of American FIM (Functional Independence

Measure) scale. The RFI, in contrast to the FIM,does not cover items connected with socialawareness (interpersonal contacts, problem solving, memory) because they do not subject to pointopinion and belong more to the sphere of specialpsychological and sociological tests [12].

The RFI is a universal tool which can be successfully applied in assessing independence in various neurological diseases as well as illnesses ofthe organ of movement, especially after cerebralinjury or damage to the peripheral nervous system,diseases of the extrapyramidal system, muscle dis

eases, spinal pain, arthrosis, and after limb amputation [1315]. The examinations were carried outon the same patient twice: on the day before theiroperation as well as on leaving the ward, usuallyon the seventh day after surgery.

The arithmetic means of the patients RFIscores were compared as a measure of the centraltendency of the studied feature in the wholepatient population. Investigation of changes in features and possible correlations was conducted onthe basis of the nonparametric Spearman correlation with the use of the Statistica computer pro

gram. A level ofp 0.05 was accepted as significant.

R. JABOSKA et al.390


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Results

The examinations showed that the respondentswere able to perform independently both beforeand after surgery. Their RFI scores ranged from

85105 points (Table 2, Fig. 1). The mean SDscore before intervention was 101.3 4.713 andafter intervention 100.43 5.868, which meansthat the functional assessment after the operationwas a little worse, by 0.9 points (Table 3).

The different categories of the RFI scale werethen subjected to analysis. For personal care, thefirst group of functional assessment, the valuesdecreased from 40.43 to 39.52 points (Table 4,Fig. 2). This drop was visible in every determinantof the criterion, although it was most visible for

care of appearance and personal hygiene (from6.83 points before the operation to 6.57 pointsafter). Consuming meals caused the least problem(drop of 0.05 points).

Assessment of Patients with Lumbar Discopathy 391

Examined feature Number of people examined %(Badana cecha) (Liczba zbadanych pacjentw)

Age years 40 18 39.1(Wiek lata) 4150 16 34.8

> 50 12 26.1total 46 100.00

Sex women 18 39.1(Pe) men 28 60.9

total 46 100.0

Education basic 0 0.0(Wyksztacenie) vocational 23 50.0

average 16 34.8high 7 15.2total 46 100.0

Place of residence no. inhabitants village 14 30.4(Miejsce zamieszkania liczba town: 25,000 6 13.0mieszkacw) town: 26,000100,000 10 21.7

city: > 100,000 16 34.8total 46 100.0

Job status student 0 0.0(Status zawodowy) active professionally 32 69.6

pension/annuity 7 15.2pension/annuity + active 2 4.3unemployed 5 10.9total 46 100.0

Kind of work physical labor 26 73.9(Rodzaj pracy) mental labor 12 26.1

total 46 100.0

Table 1. Characteristics of the examined population

Tabela 1. Charakterystyka badanej populacji

RFI/WFR Score Before operation After operation(Ocena RFI/WFR) (Przed operacj) (Po operacji)

n % n %

85 0 0 2 4.387 1 2.2 0 089 2 4.3 1 2.291 0 0 2 4.393 1 2.2 3 6.595 2 4.3 4 8.797 3 6.5 0 0.099 3 6.5 4 8.7101 7 15.2 4 8.7103 9 19.6 5 10.9

105 18 39.1 21 45.7Total 46 100.0 46 100.0(Razem)

Table 2. Assessment of functional capacity according tothe RFI scale

Tabela 2. Ocena wydolnoci funkcjonalnej badanych wgskali WFR

N Mean SD Min Max(rednia) (Min.) (Maks.)

Before operation 46 101.30 4.713 87 105(Przed operacj)

After operation 46 100.43 5.868 85 105(Po operacji)

Table 3. Average total scores according to the RFI scale

Tabela 3. rednia uzyskanych punktw wg skali WFR


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RFI/WF

R

Beforeoperation

Afteroperation

(Przedoperacj)

(Pooperacji)

full

m

edium

help

total

aver

full

medium

help

tota

l

aver

independence

independence

needed

depen

dence

age

independence

independence

needed

dep

endence

age

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Havingmeals

45

97.8

1

2.2

6.96

44

95.7

2

4.3

6.91

(Przyrz

dzanieposikw)

Careof

onesappearance

42

91.3

4

8.7

6.83

37

80.4

8

17.4

1

2.2

6.57

andhygiene

(Dbaoowygldihigien)

Bath

39

84.8

5

10.9

2

4.3

6.61

32

69.6

12

26.1

2

4.3

6.30

(Kpiel)

Getting

dressed

40

87.0

5

10.9

1

2.2

6.70

38

82.6

7

15.2

1

2.2

6.61

upper

partsofthebody

(Ubieraniegrne

czciciaa)

Getting

dressed

36

78.3

7

15.2

3

6.5

6.43

33

71.7

11

23.9

2

4.3

6.35

lower

partsofthebody

(Ubieranie

dolne

czciciaa)

Hygiene

44

95.7

2

4.3

6.91

41

89.1

5

10.9

6.78

(Toaleta

)

Table4.

Assessmentoffunctionalcapacityaccord

ingtotheRFIscale:personalcare

Tabela4

.OcenawydolnocifunkcjonalnejbadanychwgWFRsamoobsuga


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Sphincter control is another category of functional assessment. In this criterion, urinating anddefecating are taken into account. There was some

improvement in both: urinating increased from6.96 to 7.0 points and defecating from 6.91 to 7.0points (Table 5, Fig. 3).

The third category of functional assessmentwas mobility. Here one can observe a generaldecrease from 20.43 points to 20.26 (Table 6, Fig. 4).The most frequent problem patients had in thisregard was going under a shower or into a bathtub;one respondent (2.2%) required help in this actionbefore intervention and two respondents (4.3%)after intervention.

The results concerning locomotion show that

the mean value for this category rose slightly aftersurgery, from 12.65 to 12.78 points (Table 7, Fig. 5).This category consists of two determinants: walk

ing and using stairs. The first remained at anapproximately steady level (6.61 points beforesurgery and 6.74 after) and the second stayed at

the same level of 6.04 points. In fact, the numberof people with full independence in walking stairsincreased (from 26 to 30) and the number of people with moderate independence dropped (from 18to 11), while two needed help before the operationand four afterwards. One person was classified asentirely dependent in this regard after the operation.

Communication was the last analyzed category of functional assessment. The results showsmall differences: 97.8% of the respondentsshowed independent verbal speech as well as aural

and visual understanding (Table 8, Fig. 6).The statistical analysis demonstrated that the

functional assessments before and after the applied


Fig. 1. General level of functional capacity according to the RFI scale

Ryc. 1. Poziom oglny wydolnoci funkcjonalnej badanych wg skali WFR

30

32

34

36

38

40

42

44

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

before treatment after treatmentlog (before treatment) log (after treatment)

Fig. 2. Level of functional capacity according to the RFI scale: personal care

Ryc. 2. Poziom wydolnoci funkcjonalnej badanych wg skali WFR samoobsuga

30

32

34

36

38

40

42

44

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

before treatment after treatmentlog (before treatment ) log (after treatment)


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RFI/WF

R

Beforeoperation

Afteroperation

(Przedoperacj)

(Pooperacji)

full

m

edium

help

total

aver

full

medium

help

tota

l

aver

independence

independence

needed

depen

dence

age

independence

independence

needed

dep

endence

age

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Urinatin

g

45

97.8

1

2.2

6.96

46

100.0

7.00

(Oddawaniemoczu)

Defecating

44

95.7

2

4.3

6.91

46

100.0

7.00

(Oddawaniestolca)

Table5.


ingtotheRFIscale:sphinctercontrol

Tabela5

.OcenawydolnocifunkcjonalnejbadanychwgskaliWFRkontrolazwieraczy

RFI/WF

R

Beforeoperation

Afteroperation

(Przedoperacj)

(Pooperacji)

full

m

edium

help

total

aver

full

medium

help

tota

l

aver

independence

independence

needed

depen

dence

age

independence

independence

needed

dep

endence

age

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Getting

upfrombedonto

45

97.8

1

2.2

6.96

43

93.5

3

6.5

6.87

awheelchair

(Wstawaniezka

nawze

k)

Sittingo

natoiletbowl

43

93.5

3

6.5

6.87

43

93.5

3

6.5

6.87

(Siadanienamuszli

klozetow

ej)

Goingu

ndertheshower

38

82.6

7

15.2

1

2.2

6.61

37

80.4

7

15.2

2

4.3

6.52

orintoa

bathtub

(Wejciepodprysznic

albodo

wanny)

Table6.


ingtoscaletheRFI:mobility

Tabela6

.OcenawydolnocifunkcjonalnejbadanychwgskaliWFRmobilno


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RFI/WF

R

Beforeoperation

Afteroperation

(Przedoperacj)

(Pooperacji)

full

m

edium

help

total

aver

full

medium

help

tota

l

aver

independence

independence

needed

depen

dence

age

independence

independence

needed

dep

endence

age

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Walking

37

80.4

9

19.6

6.61

40

87.0

6

13.0

6.74

(Chodze

nie)

Stairs

26

56.5

1

8

39.1

2

4.3

6.04

30

65.2

11

23.9

4

8.7

1

2.2

6.04

(Chodze

nieposchodach)

Table7.


ingtotheRFIscale:locomotion

Tabela7

.OcenawydolnocifunkcjonalnejbadanychwgskaliWFRlokomocja

RFI/WF

R

Beforeoperation

Afteroperation

(Przedoperacj)

(Pooperacji)

full

m

edium

help

total

aver

full

medium

help

tota

l

aver

independence

independence

needed

depen

dence

age

independence

independence

needed

dep

endence

age

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Listenin

gorVisual

45

97.8

1

2.2

6.96

45

97.8

1

2.2

6.96

comprehensive

(Rozumieniezesuchu)

Verbals

peech

45

97.8

1

2.2

6.96

45

97.8

1

2.2

6.91

(Mowa)

Table8.


ingtotheRFIscale:communication

Tabela8

.OcenawydolnocifunkcjonalnejbadanychwgskaliWFRkomunikacja


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treatment were on the same level. This differencewas not statistically significant (p > 0.05). Thiswas related to the fact that some of the mean val

ues of the individual categories of the RFIincreased while others decreased. However, theaverage assessments of the whole group beforeand after treatment were quite similar.

Discussion

Of the great number of spine ailments, thebroadest and most known group constitutes discogenic pain caused by pathology in the area of anintervertebral disc [16]. The pain, together with

neurological disorders and loss of dexterity, is onlya consequence. Spinal pain caused by a degenerative disease of an intervertebral disc is often found

in young and middleaged people, who are themost agile and professionally active. It is a causeof decreased work efficiency, absence due to sick

leave, and resignation from jobs which requirephysical involvement or extensive physical effort.It is also the reason for early retirement in manycases or for applying for a disability pension. Itmight result in discouragement, apathy, depression, and even a nervous breakdown [9, 17, 18].

Surgery provides the possibility of treatingspinal pain caused by degenerative disc disease: itinterrupts the cascade of degenerative changes inthe spine, reproduces the correct anatomical relationships, and retains ability of movement [19, 20].Current reports indicate significant improvement

in health status after such intervention in 7596%of cases, depending on the author [1, 9, 21, 22]. Anessential problem is the quality of functioning with


Fig. 3. Level of functional capacity according to the RFI scale: sphincter control

Ryc. 3. Poziom wydolnoci funkcjonalnej badanych wg skali WFR kontrola zwieraczy

10

10,5

11

11,5

12

12,5

13

13,5

14

14,5

15

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46


Fig. 4. Level of functional capacity according to the RFI scale: mobility

Ryc. 4. Poziom wydolnoci funkcjonalnej badanych wg skali WFR mobilno

15

16

17

18

19

20

21

22

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46



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disc disease, as the restrictions imposed by the disease relate to professional, social, cultural, as well

as family life [3].It seems that only surgery is an essential cor

relate of better functioning in those who underwent this sort of treatment. The complex andchangeable clinical picture of those suffering fromdiscopathy makes it difficult to form an objectiveand unambiguous opinion of the results of treatment. Patients referred for surgery show morepathological neurological symptoms than thosewho continue conservative treatment. The indicators of improvement directly after surgery aregreater than in a corresponding period of conserv

ative treatment. Total retreat of neurologicaldeficits more often involves patients who havebeen operated [9, 23]. Of the factors which influ

ence the functional assessment of patients withdiscopathy, one should mention at least three main

components of the disease: the pain, the degree ofdisability, and the deficiency symptoms.

The above examinations showed that thepatients generally demonstrated full independenceboth before and after intervention, but that afterthe neurosurgical operation this independence wasslightly less. After intervention, improvement inefficiency was observed in sphincter control andwalking ability. However, there were decreases inthe indicators of personal care activities andmobility, although these differences were not statistically significant. On the other hand, according

to Frost [24], the index of functional efficiencyafter surgery, i.e. on leaving the hospital, obtainedusing the same examination tool, improved from


Fig. 5. Level of functional capacity according to the RFI scale: locomotion

Ryc. 5. Poziom wydolnoci funkcjonalnej badanych wg skali WFR lokomocja

7

8

9

10

11

12

13

14

15

1 2 3 4 5 6 7 8 9 1011 121314 151617 181920 212223 242526 272829 303132 3334 353637 383940 414243 444546

before treatment after treatmentlog (before treatment) log(after treatment)

Fig. 6. Level of functional capacity according to the RFI scale: communication

Ryc. 6. Poziom wydolnoci funkcjonalnej badanych wg skali WFR komunikacja

8

9

10

11

12

13

14

15

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46



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80.9 points (partial dependence before surgery) to95.2 points (independence after surgery). Differentauthors case studies [25, 26] also show thatpatients who underwent a neurosurgical operationrevealed improvement in functional efficiency onleaving the hospital ward. A review of the litera

ture also permits the conclusion that most patientspresent a very high degree of functional inefficiency before surgery [26, 27].

The assessment of patients functional efficiency with disc disease is one of the criteriaapplied in evaluating treatment results. It is essen

tial mainly because it adequately predicts thechances of returning to work; a limitation ofones own activity is a factor in ones inability towork [11]. Last but not least, it seems one is ableto conduct the assessment after treatment.

The authors concluded that patients with lum

bar discopathy show full independence in terms ofexecuting the activities of everyday day. The functional assessment of those who were examinedwas a little worse after surgery, i.e. on leaving thehospital ward.


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Address for correspondence:Renata JaboskaDepartment of Neurological and Neurosurgical NursingTechnikw 385801 BydgoszczPolandTel.: +48 52 585 21 93Email: [email protected]

Conflict of interest: None declared

Received: 25.05.2009Revised: 27.07.2009Accepted: 20.08.2009


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Functional Assessment of Patients