Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 E Alcazar Street, Los Angeles, CA 90089, USA.
Phys Ther. 2011 Dec;91(12):1892-904. doi: 10.2522/ptj.20110003. Epub 2011 Oct 14.
Disablement is a multifactorial and complex process that creates a challenge for both the rehabilitation researcher and the clinical practitioner; however, each seeks to improve quality health outcomes for the adult or child with disability. Knowledge translation (KT) is an approach to evidence-based medicine where various evidence sources are aggregated so that clinical decisions regarding intervention selection and dosing result in beneficial care for an individual. Structural equation modeling was used to test a theoretical model of disablement based on the impairment, activity, and participation categories of the International Classification of Functioning, Disability and Health (ICF) level of functioning. Using available cohort data from a randomized controlled trial of people with poststroke walking disability, exploratory and confirmatory factor analysis revealed that the latent variables-impairment and activity-are separate disablement constructs that limit participation for a person with disability. Path analysis revealed that the direct effect of impairment on participation was not statistically significant; however, the indirect path from impairment to participation through activity was significant (indirect effect). The direct effect of activity on participation was significant. Model assumptions were tested with postintervention data from the same cohort. For people with disability after stroke, the probability that functional tasks could be performed with less effort was greater for those individuals who met or exceeded a physiologic walking threshold after a structured, progressive intervention provided by a physical therapist 6 months earlier. This article discusses how structural equation modeling can be used as a statistical method to explore the causal paths from disability to ability. The knowledge inquiry and synthesis phases of the knowledge-to-action KT framework parallel the essential elements of structural equation modeling; knowledge is created that is theoretically driven, supported by prior research, and analyzed, refined, validated, and tailored to address real-world problems. Using a theoretical framework of disablement with clinical judgment and quantitative research methods, a clinically intuitive model of disablement was validated. The positive dimension is a model of recovery where causal paths lead from disablement to ablement. Innovative approaches in rehabilitation research design along with pragmatic application of research to practice are needed to improve today's health outcomes for people with disability.
失能是一个多因素且复杂的过程，这给康复研究人员和临床医生都带来了挑战；然而，他们的目标都是为残疾的成人或儿童改善健康结局。知识转化（KT）是循证医学的一种方法，它整合了各种证据来源，以便在干预措施的选择和剂量方面做出临床决策，从而为个体提供有益的护理。结构方程模型用于测试基于国际功能、残疾和健康分类（ICF）功能水平的损伤、活动和参与类别的失能理论模型。使用一项针对脑卒中后步行障碍患者的随机对照试验的现有队列数据，探索性和验证性因子分析表明，潜在变量损伤和活动是两个独立的失能结构，限制了残疾人的参与。路径分析显示，损伤对参与的直接影响不具有统计学意义；然而，损伤通过活动对参与的间接影响是显著的（间接效应）。活动对参与的直接影响是显著的。使用同一队列的干预后数据测试了模型假设。对于脑卒中后的残疾人，那些在 6 个月前由物理治疗师提供的结构化、渐进式干预后达到或超过生理步行阈值的个体，完成功能任务时需要付出的努力更少，他们完成功能任务的可能性更大。本文讨论了结构方程模型如何可用作探索从残疾到能力的因果路径的统计方法。知识转化框架的知识查询和综合阶段与结构方程建模的基本要素相平行；知识是理论驱动的，有先前研究的支持，并通过分析、精炼、验证和调整来解决现实世界的问题。使用残疾的理论框架、临床判断和定量研究方法，验证了残疾的临床直观模型。积极维度是一种恢复模型，其中因果路径从残疾到能力。需要创新的康复研究设计方法以及将研究切实应用于实践，以改善今天残疾人士的健康结局。
