Int . Disubil. Studies, 13, 9 - 11

Rehabilitation status - the relationship between the Edinburgh Rehabilitation Status Scale (ERSS), Bartbel Index, and PULSES profile

P.G. MATT IS ON,^ R.C.B. AITKEN,~ and R.J. PRESCOTT3

St. Hdens Hospital, Merseyside, Rehabilitation Studies Unit2 and Medical Statistics Unit, University of Edinb~rgh,~ UK

Accepted for publication: January 1991 Correspondence to:

Key words Assessment - Disability - Handicap - Rehabilitation - Scales

Summary A total of 364 patients attending day centres for the physically disabled had ERSS and Barthel scores recorded during the course of assegsment. In addition, 100 of the patients had PULSES profile scores recorded. Correlation of total scores for all three scales confirmed that all three succeeded in measuring disability and all three were significantly related. There were, however, weak correlations between some of the individual subscales of each score, indicating that each of the assessment tools was measuring some dimensions of disability not adequateIy considered by the other scales. The results suggest that while progress is being made towards better measurement of disability and handicap, further refinement of these particular measurement tools is required.

Dr. P.G. Mattison, Ayrshire Central Hospital, Irvine, Ayrshire KA12 8SS, UK

Introduction An increasing appreciation of the need to consider factors other than simple activities of daily living (ADL) functions in tho overall assessment of disability led to development of the Edinburgh Rehabilitation Status Scale (ERSS).' The original description of the ERSS included a comparison with both the Barthel Index and PULSES total scores in a small sample of patients, and produced a high degree of correla- tion between all three scales. No detailed examination was made, however, between the individual components of each of the scales.

Granger et al demonstrated that the combination of Bar- thel scores and PULSES profile was reliable and sensitive for describing functional abilities and change over a period of time in 307 severely physically disabled people.2 It was felt to be reasonable, therefore, to undertake a comparison between the ERSS and PULSES profile in a larger sample of patients than in Affleck et al's original report' and to exanline the relationship between the individual components of ewh subscale.

Traditionally, assessment of physical disability has been based on the capacity to perform various activities of daily living, and the Barthel Index is established in this respect. There have been suggestions that the Barthel Index be adopted as the standard measure of physical disability against which other measurement tools should be as~essed.~ It was against this background that comparisons of the two other scales were made with the Barthel Index.

Patients and methods A tatal of 364 patients attending five local authority day centdes for the physically disabled were included in the study. Age$ ranged from 16 to 76 years (median 43). The primary diasJloses causing disability in the attenders were overwhelm- ingly neurological, a pattern reflecting that of hospital-based rehabilitation services.

All 364 patients had Barthel scores recorded using the Granger-adapted three-level scale.4 Scores on this scale range from 0 to 1 0 0 , O indicating total dependence and 100 total independence in self-care and mobility. Similarly, all 364 patients had ERSS scores recorded following rigidly the guidelines set out in the manual produced by the devisers of the scale.

The above were recorded by one of a group of five in- vestigators, all of whom were experienced within the field of rehabilitation medicine and who were familiar with both of the assessment scales used. Inter-rater reliability for the use of both of the scales has been established and reported separately. l*5

The Granger-adapted PULSES profile was, in addition, recorded in 100 of the patients, 50 from each of two of the centres; the physical characteristics of this subgroup were similar to the total in age and diagnosis as well as duration of disabilities. All PULSES scores were recorded by the same investigator following the guidelines outlined by Gresham and Labi in their description of the scale.6 The investigator concerned was experienced in the use of this scale and had previously established reliability in application of the scale in terms of consistent reproducibility (data held on file).

Information was gained from interview of each patient, supplemented by examination of day centre and medical records, as well as by interview of relatives and carers if required. Statistical analysis was carried out utilizing non- parametric correlations to produce Spearman Rank correla- tion coefficients relating each of the individual subscales and totals for all three scales.

Results The results are summarized in Tables 1,2, and 3, expressed as Spearman Rank correlation coefficients.

There was a moderately strong correlation between total Barthel and total PULSES scores of -0.65, indicating that both scales were quantifying similar measures (Table 1). This correlation is in accordance with that reported by Granger and Greer who, in the same cohort of patients at different phases of their rehabilitation, reported total scores correla- tions for both scales varying from -0.61 to -0.80.4

The strongest correlations in subscales were between upper-limb function in PULSES and self-care in Barthel at -0.73, and lower-limb function in PULSES and mobility in Barthel at -0.79. Lower-limb function and total Bar- thel scores were also strongly correlated at - 0.78.

Correlations were weak between the support factors subscale of PULSES and all components of the Barthel, and between the physical condition subscale of PULSES and the Barthel components. The excretory functions component of

0379-0797/91 $3.00 Q 1991 Taylor & Francis Ltd. 9

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Inl. Disabit. Studies, 1991; vol. 13, no. 1

Table 1 PULSES - Barthel Spearman Rank correlation coefficients ( n = 100)

P U L S E S Total

Barthel Self-care - 0.44 -0.73 - 0.60 -0.15 - 0.54 -0.29 - 0.67

Mobility -0.32 -0.45 -0.79 -0.06 -0.39 - 0.29 -0.54

Total -0.37 -0.59 - 0.78 -0.04 - 0.49 -0.34 -0.65

scores P = O.Oo0 O.Oo0 O*OOO 0.062 O-OOO 0.001 O.Oo0

P = 0.001 0.OOO O.Oo0 0.262 O.Oo0 0.001 O.Oo0

D = O.Oo0 O*OOO O.Oo0 0.336 O.Oo0 O.Oo0 O*OOO

Table 2 ERSS - Barthel Spearman Rank correlation coefficients In = 364)

ERSS scores Support Inactivity Isolation Symptoms Total

Barthel Self-care -0.68 -0.65 -0.51 -0.67 -0.71

Mobility -0.54 -0.52 -0.41 -0.61 -0.58 scores p = 0 . m 0.m o.OO0 0 - m 0 . m

P = 0 . m o*OOo 0 . m 0.OOO 0 . m

P= 0 . m 0.m 0 . m 0.m 0 . m Total -0.65 -0.63 -0.49 -0.71 -0.69

Table 3 PULSES - ERSS Spearman Rank correlation coefficients (n = 100)

P U L S E S Total

ERSS Support scores P =

Inactivity P'

Isolation P =

Symptoms P'

Total P =

0.44 O.Oo0 0.33 O-OOO 0.27 0.003 0.36 O.Oo0 0-39 O*OOO

0.61 0.OOO 0.40 O-OOO 0.32 0.001 0.53 O*OOO 0.52 O*OOO

0.46 O.Oo0 0.42 O-OOO 0.34 O.Oo0 0.49 O.Oo0 0.49 0.OOO

0.30 0.001 0.24 0.007 0.29 0.001 0.22 0.013 0-30 0.001

0.37 0-OOO 0.33 0-OOO 0.18 0-036 0.36 O.Oo0 0.35 O.Oo0

0.46 O.Oo0 0.39 O*ooO 0.30 0.001 0.29 0.002 0.41 O.Oo0

0.64 0.0oO 0.49 O~OOO 0.41 0.OOO 0.53 O*OOO 0.59 O.Oo0

PULSES was moderately strongly correlated with the self- care component of the Barthel score, but not particularly strongly correlated with the mobility section of that scale. There was no significant correlation between the sensory components subscale of PULSES and any of the Barthel variables; clearly, this subscale of the PULSES is measur- ing a dimension not addressed within the Barthel Index.

Correlations between ERSS and Barthel total scores was high, -0.69 (Table 2), and slightly higher than the correla- tion between PULSES and Barthel totals although somewhat lower than that reported by Affleck and his colleagues.'

The support, inactivity, and symptoms scales of the ERSS, plus the total score, all showed similar fairly strong correla- tions with the Barthel self-care score (and the total score), and similar but weaker correlations with the Barthel mobility score. The high correlation between the ERSS symptdms score and the Barthel self-care score suggests a significant association between somatic symptoms and patient performance.

The correlation of the ERSS isolation score with the Bar- thel subscales was appreciably lower than for the ERSS subscales, the relatively low correlation between social isola- tion measured by the ERSS and the Barthel mobility score indicating that components of disability other than simple lack of mobility are important in bringing about social isolation.

The correlation of 0.59 between the total scores of ERSS and PULSES scales (Table 3) was somewhat lower than that reported by Affleck et a1 on the ERSS,' and lower than that found between the ERSS and the Barthel and between PULSES and Barthel in the present study. The implication is that both scales are measuring similar parameters overall,

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but that individually the components making up the total may be measuring different things. The highest correlations were between the ERSS support scale and the upper-limb functions component of PULSES as well as the total PULSES score.

In general terms, correlation was poor between the social isolation component of the ERSS and all components of PULSES, indicating that this particular parameter is not really addressed adequately in the PULSES profile. Simi- larly, the sensory components scale of PULSES was poorly correlated with all components of the ERSS, indicating that communication and sensory difficulties are not adequately considered within the ERSS.

Discussion The relatively strong correlations between the total scores for all three scales indicate that, in general terms, they are measuring a single common entity - disability. The Bar- thel Index, with its emphasis on self-care and mobility related to ability to carry out daily living activities, is primarily a disability scale and the high correlations between the PULSES and ERSS subscales most closely dealing with ADL activities and the Barthel scores bear out that these more global scales are also successful in measuring this parameter.

The PULSES profile and the ERSS, however, purport to be measures of wider aspects of disability than simple ADL measures and to be more measures of handicap, i.e. the social consequences of the underlying disability. Only one subscale of PULSES directly considers social and support factors, and this scale is only moderately correlated with the three subscales of the ERSS which have significant social

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MATTISON et al.: A comparison of three scales of rehabilitation

and support components, the support, inactivity, and isola- tion subscales. It seems likely that PULSES, in considering this area of handicap and attempting to numerically score it within a narrow four-point band, is less sensitive in quan- tifying aspects of handicap related to psychosocial dif- ficulties than the ERSS, which considers such matters in three of its subscales, each scoring within a wider eight-point scoring system.

Sensory and communication difficulties are more clearly and significantly considered within the PULSES profile, which is superior to both the Barthel Index and the ERSS in this respect. Accepting Wade and Collins's contention that the &the1 Index be viewed as the standard measure of di~ability,~ it is clear that both PULSES and the ERSS are successful in measuring this parameter both in total scores and 'n individual subscales which are primarily considering disa t, ility - upper- and lower-limb function in PULSES and supy)ort and symptoms scales in the ERSS. In relation to other parameters, the ERSS would seem to be more suc- cessful in considering the wider issue of psychosocial mat- ters gnd is also more flexible in its scoring.

It would be simpler to adapt the ERSS to consider extra factors - sensory handicap, for example - than to make chanlges to PULSES which would mean a major review of the subscales and scoring system. It is suggested, therefore, that the ERSS should be used as the standard global measure of rebabilitation status, but that some modification be made to encompass specific areas of handicap.

Further studies are required to evaluate the usefulness of the BRSS and Barthel scales in combination to give an overall picture of disability, and to investigate their worth

in describing changes within individual patients and popula- tions over time and changing rehabilitation status.

Acknowledgements We gratefully acknowledge the assistance of Miss Claudia Kriepl for invaluable help with data processing.

References

1 Affleck JW, Aitken RCB, Hunter J , McGuire RJ, Roy CW. Rehabilitation status; a measure of medico-social dysfunction. Lancet 1988; i: 230 - 233

2 Granger CV, Albrecht GL, Hamilton BB. Outcome of comprehen- sive medical rehabilitation; measurement by PULSES profile and the Barthel Index. Archives of Physical Medicine and Rehabilita- tion 1979; 60: 145- 153

3 Wade DT, Collin C. Barthel ADL Index; a standard measure of physical disability. International Disability Studies 1988; 10 64 - 68

4 Granger CV, Greer DS. Functional status measurement and medical rehabilitation outcomes. Archives of Physical Medicine and Rehubilitation 1976; 57: 103 - 109

5 Roy CW, Tagneri J, Hay E, Pentland B. An inter-rater reliability study of the Barthel Index. International Journal of Rehabilitation Research 1988; 11: 67 - 70

6 Gresham GE, Labi MLC. Functional assessment instruments cur- rently available for documenting outcomes in rehabilitation medicine. In: Granger CV & Gresham GE (eds) Functional assessment in rehabilitation medicine. Baltimore: Williams & Wilkins, 1984; pp 65 - 70.

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