PAIN 150 (2010) 535541

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Performance-based assessment of activities of daily living (ADL) ability among women with chronic widespread pain
Eva Ejlersen Whrens a,b,*, Kirstine Amris c, Anne G. Fisher b
a

The Parker Institute, Frederiksberg Hospital, Denmark Division of Occupational Therapy, Department of Community Medicine and Rehabilitation, Ume University, Sweden c The Parker Institute and Department of Rheumatology, Frederiksberg Hospital, Denmark
b

a r t i c l e

i n f o

a b s t r a c t
Functional ability, including the ability to perform activities of daily living (ADL), is considered a core outcome domain in chronic pain clinical trials and is usually assessed through generic or disease-specic self-report questionnaires. Research, however, indicates that self-report and performance-based assessment of ADL offer distinct but complementary information about ability. The present study, therefore, investigated the applicability of a performance-based measure of ADL ability, the Assessment of Motor and Process Skills (AMPS), among 50 women with chronic widespread pain. The investigated psychometric properties of the AMPS included discrimination between a sample of healthy women and those with chronic widespread pain, as well as stability when no intervention was provided and sensitivity to change following intervention. Data were obtained based on a repeated measures design performing AMPS evaluations twice pre- and twice post-rehabilitation. Results indicated that the ADL motor ability measures of the participants were signicantly lower than those of healthy women of same age, the ADL motor and ADL process ability measures remained stable when no intervention was provided and the ADL motor ability measures were sensitive to change following a 2-week interdisciplinary rehabilitation program. A weak correlation (rs = 0.35) was found between self-reported ADL ability as measured by the physical function subscale of the Functional Impact Questionnaire (FIQ) and performance-based ADL motor measures, and no correlation (rs = 0.02) was found between FIQ ADL measures and ADL process ability, supporting the need for both performance-based and self-reported assessment of ADL. 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Article history: Received 26 November 2009 Received in revised form 5 May 2010 Accepted 11 June 2010

Keywords: Fibromyalgia Activities of daily living Outcome measure Assessment of Motor and Process Skills Rehabilitation Occupational therapy

1. Introduction In recent years, initiatives have been taken to establish an international consensus on core outcome domains and outcome measures in studies concerning chronic widespread pain (CWP) [16] and bromyalgia (FM) [10,38]. Functional ability, which includes the ability to perform activities of daily living (ADL) such as selfcare, meal preparation and household chores, is considered to be a core outcome domain in CWP/FM studies [38,48,50]. To date, recommendations for assessing functional ability include the use of generic and disease-specic questionnaires based on self-report [10,16] and the most frequently used instrument for evaluating ADL ability is the physical function subscale of the Fibromyalgia Impact Questionnaire (FIQ) [8,10]. Questionnaires based on self-report have the advantage of generally being time-efcient and inexpensive. Self-report, however, re-

* Corresponding author at: The Parker Institute, Frederiksberg Hospital, Ndr. Fasanvej 57, DK-2000 Frederiksberg, Denmark. Tel.: +45 3816 4166; fax: +45 3816 4159. E-mail address: Eva.Wahrens@frh.regionh.dk (E.E. Whrens).

ects the persons perception of extent of disability, which may be inuenced by experience of pain, level of depression or anxiety or cognitive problems [27]. Another concern related to self-reported ADL ability is the fact that persons with FM diagnosis can be met with scepticism [7,51] and, therefore, often are assumed to exaggerate their problems [54]. Finally, it has been argued that self-reported outcomes are particularly important for evaluating pain and fatigue as such factors cannot be observed [49], but such concerns do not hold true for the assessment of ability. In fact, several authors have concluded that self-report and performance-based measures provide distinct but complementary information about functional ability [27,32,45]. While there is a clear need for performance-based assessments of functional ability, researchers who have implemented performance-based assessment of functional ability among persons with CWP/FM have focused on aspects of mobility (e.g. walking, stair climbing) [35,46,53], or isolated actions (e.g. tying shoelaces, turning a key in a lock) [32] not the ability to perform complete ADL tasks. As we were not able to nd studies presenting results based on standardized performance-based ADL assessment for persons with CWP/FM, our plan was to investigate the utility of the

0304-3959/$36.00 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2010.06.008

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Assessment of Motor and Process Skills (AMPS) [19,20]. The AMPS is an internationally standardized assessment of ADL ability with strong evidence of validity and reliability that is used to measure the quality of a persons observed performance of familiar, relevant and chosen ADL tasks. The AMPS yields two measures, one for ADL motor ability and one for ADL process ability. The overall ADL motor ability measure is an indication of how much effort or fatigue the person demonstrated when performing ADL tasks, and the overall ADL process ability measure is an indication of how timely and well-organized (efcient) the person was observed to be when performing ADL tasks. Both ADL ability measures also reect safety and independence in ADL task performance. The aim of this study was to evaluate if the ADL motor and ADL process ability measures of the AMPS demonstrate sound psychometric properties, indicated by (a) ability to discriminate between healthy women and women with CWP/FM, (b) stability and (c) sensitivity to changes in ADL performance. We also examined the relationship between the womens self-reported ADL ability as measured by the physical function subscale of the FIQ and the performance-based AMPS measures. 2. Methods 2.1. Participants The study was approved by the Local Ethics Committee (KF 01045/03). Potential participants were all women, diagnosed with CWP or FM (see Section 2.2.1), who were referred to an outpatient, interdisciplinary rehabilitation program in a clinical setting between November 2007 and August 2008. Reasons for not being referred to the program were language barriers (impeding completion of questionnaires and participation in performancebased assessments, group lectures and discussions), severe disabil-

ity necessitating assistance in self-care tasks (personal ADL (PADL)), concurrent history of major psychiatric disorder not related to the pain disorder, or other medical conditions capable of causing symptoms (e.g. uncontrolled inammatory/autoimmune disorder). These persons were instead referred to individualized rehabilitation. In total, 50 women were referred to the rehabilitation program and they all gave informed consent to participate in the study. They received the usual rehabilitation program but, as part of the study, they went through repeated AMPS evaluations, twice preand twice post-rehabilitation. In total, 41 (82%) participants completed the rehabilitation program and the repeated AMPS evaluations (Fig. 1). Forty-three (86%) of the total sample and eight (89%) of those who dropped out of the study were diagnosed with FM. All participants continued their usual medications, including analgesics. Demographic baseline data for the total sample, and a comparison between those who completed the full program and those who dropped out, are presented in Table 1. 2.2. Variables 2.2.1. Diagnoses The participants were diagnosed based on classication criteria for CWP and FM by medical doctors prior to referral. The CWP diagnosis is based on self-report of pain of at least 3 months duration in all four quadrants of the body [56]. CWP is the core symptom in FM, a musculoskeletal pain disorder of unknown aetiology. FM is classied by CWP in combination with hyperalgesic responses to digital palpation of at least 11 of 18 designated tender points [56]. Tender point (TP) examination was performed by two experienced calibrated raters according to the ACR guidelines. Persons with P11 TPs were diagnosed with FM, whereas persons with <11 TPs were diagnosed with CWP.

Fig. 1. Flow diagram of participant dropouts in relation to AMPS evaluation.

E.E. Whrens et al. / PAIN 150 (2010) 535541 Table 1 Demographic data and baseline clinical measures for the total sample, with comparison of those who completed the full program and those who dropped out. Total sample (n = 50) M Age Tender point count FIQ pain FIQ tiredness FIQ function FIQ total AMPS motor AMPS process
a

537

Completed (n = 41) M 43.5 14.3 7.3 8.0 5.5 50.9 1.05 1.03 SD 9.9 4.3 1.8 1.9 2.4 14.3 0.56 0.26 Range 2164 018 3.110 3.810 08.1 15.875.2 0.132.94 0.361.48

Dropped out (n = 9) M 43.0 15.1 7.9 8.4 5.9 53.3 0.71 1.00 SD 8.8 3.0 2.0 1.8 2.2 12.8 0.65 0.43 Range 3358 1018 4.69.8 5.110 2.67.8 42.676.4 0.851.22 0.121.68

Differences between groups t/v2 (df)a 0.13 0.03 0.74 0.12 0.10 0.02 1.61 0.15 (48) (1) (1) (1) (1) (1) (48) (9.34) p 0.90 0.87 0.39 0.73 0.75 0.89 0.11 0.88

SD 9.6 4.1 1.8 1.9 2.3 14.0 0.59 0.30

Range 2164 018 3.110 3.810 08.1 15.876.4 0.852.94 0.121.68

43.4 14.5 7.3 8.0 5.5 51.2 0.99 1.02

t test for age and ADL motor and ADL process ability measures; v2 for tender point count and FIQ pain, FIQ tiredness, FIQ function and FIQ total.

2.2.2. Performance-based ADL ability: Assessment of Motor and Process Skills (AMPS) The participants were evaluated with the AMPS [19,20] to obtain performance-based measures of ADL motor and ADL process ability. During administration of the AMPS, a person performs at least two of 85 standardized PADL and domestic (instrumental ADL (IADL)) tasks found to be of appropriate challenge to the person and at the same time meaningful and relevant to that persons daily life. Potential IADL include tasks related to, e.g. preparing meals, shopping, house cleaning, doing laundry and outdoor home maintenance tasks. Based on the observation of each ADL task performance an occupational therapist evaluates the quality of 16 ADL motor and 20 ADL process actions (skill items). ADL motor skills concern a persons observed skills when moving him or herself and task objects. For example, whether a person makes a salad or irons a shirt, he or she has to reach for, grip and lift the task objects. ADL process skills concern a persons observed skills in choosing and using appropriate task objects, organizing the spatialtemporal actions of the task performance and adapting performance when problems are encountered. That is, as the person makes the salad or irons the shirt, he or she must search for and locate the needed objects, gather them to the workspace and perform the steps of the task performance in a logical order (sequences). Following the observation, a four-point ordinal scale is used to rate the quality of each of the ADL motor and ADL process skill items based on the ease, efciency, safety and independence observed, (1 = markedly decient, 2 = ineffective, 3 = questionable, 4 = competent) for each of the two ADL task performances [19,20]. After scoring, the AMPS raters use their personal copies of a many-faceted Rasch-based AMPS computer-scoring software to convert the persons raw ordinal ADL item scores into two overall linear ADL ability measures, one for ADL motor ability and one for ADL process ability. These two overall ADL ability measures are adjusted for ADL task difculty and rater severity (i.e. how strict the rater scores the observed performance) and are expressed in logistically transformed probability units (logits) [18,19]. The overall ADL motor ability measure indicates how much effort or fatigue the person demonstrated and the overall ADL process ability measure indicates how efcient the person was observed to be during the ADL task performance. Additionally, both ADL ability measures reect safety and independence in ADL task performance. ADL ability measures above the 2.0 logit cutoff on the ADL motor scale and above the 1.0 logit cutoff on the ADL process scale indicate effortless, efcient, safe and independent ADL task performance in everyday life. In contrast, ADL motor ability measures below the 2.0 logits cutoff indicate increased effort or fatigue during task performance. Moreover, ADL ability measures below the 1.50 ADL motor cutoff and/or below the 1.00 ADL process cutoff indicate a need for minimal assistance for community living. That is, the person will need assistance with ADL tasks such as shopping, heavy housework and home maintenance tasks [19,20,39]. Furthermore,

ADL ability measures below the 1.00 ADL motor cutoff and/or below the 0.70 ADL process cutoff indicate a need for moderate to maximal assistance for community living in relation to meal preparation and/or PADL [19,20,39]. All AMPS observations were performed by occupational therapists trained and calibrated according to international standard procedures at 5-day AMPS courses [19,20]. As part of the calibration process, the raters co-score eight clients during the AMPS course and at least 10 additional clients in their clinical praxis after the course. Afterwards, data from each rater are analyzed based on Rasch measurement methods to determine rater reliability as well as rater severity. Only reliable raters can obtain a calibration code to be used in their personal copies of the AMPS computer-scoring software to adjust for rater severity, when calculating ADL motor and ADL process ability measures. The AMPS has been standardized on more than 100,000 persons between 3 and 103 years of age internationally and cross-culturally [19,22]. Studies support the validity of the AMPS across age groups [25], genders [40], and diagnostic groups within neurology [5,6,23,31,33,36,47,52], geriatrics [15,17,24,34,42], psychiatry [21,37,43], rheumatology [45] and musculoskeletal diseases [1]. Studies of testretest and alternate forms reliability support stability of the AMPS measures over time [14,19] and between different pairs of ADL tasks [19,30]. The AMPS has also been shown to be a sensitive outcome measure in intervention studies concerning interdisciplinary rehabilitation [6,33,52], occupational therapy [17,23,24,31,47] and pharmacological treatment [42,43]. 2.2.3. Self-reported health status: Fibromyalgia Impact Questionnaire The FIQ [8,10] is a self-administered, disease-specic instrument designed to evaluate components of health status in persons with FM. As FIQ is considered the main instrument for self-reported functional ability and health status in CWP/FIQ studies [9,10], we used FIQ data to describe our sample in relation to perceived pain, tiredness, and health status prior to the rehabilitation program, as well as to obtain a measure of self-reported ADL ability that could be compared to the performance-based AMPS measures. The FIQ is composed of 10 items. Each of the 10 items has a maximum possible score of 10. A higher score indicates a greater impact of the FM on the person. The maximum total score is 100. More specically, the rst item on the FIQ (the FIQ physical function subscale) contains 10 sub-questions related to ADL ability (e.g. shopping, doing laundry, preparing meals, vacuuming, and doing yard work) each question is rated on a four-category ordinal scale. Only ADL items relevant to the person are scored. The scores are summed and a mean is calculated based on the number of tasks relevant to the person [4]. The mean is multiplied by 3.3 to obtain a possible maximum score of 10. Items 2 and 3 of the FIQ are questions related to how many days (from 0 to 7) in the previous week the person felt well and how many days (from 0 to 7) he or she was unable to work. The answer

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for item 2 is recoded (the scale is reversed) before scoring. Again, to obtain a possible maximum score of 10 for each of those two items, the number of days is multiplied by 1.43. Items 410 are 10 cm visual analogue scales on which the person rates pain intensity, fatigue, morning tiredness, stiffness, anxiety, depression and ability to adhere to work. Authors suggest that scores for each item can be reported individually or summed to report the health status total score (FIQ total) [8,10]. 2.3. Study design/procedures The women participated in an outpatient, interdisciplinary rehabilitation program. The interdisciplinary team consists of a rheumatologist, a nurse, three occupational therapists, three physical therapists and a psychologist. The rehabilitation program is composed of an assessment phase and an intervention phase. During the assessment phase, 2 weeks prior to the intervention, the persons with CWP/FM complete a variety of questionnaires (including the FIQ) concerning aspects of living with CWP/FM. They also undergo physical examination of muscle strength and mobility, performance-based ADL evaluation using the AMPS and computerized cuff pressure algometry (CPA) [29] to evaluate pressurepain threshold and tolerance. The team uses the results of these assessments in the intervention phase. The intervention, a 2-week group-based course, comprises a combination of lectures, group discussions and instructions during physical exercise and daily life task performances. The main focus is on education and adaptations in everyday life such as energysaving techniques, e.g. taking breaks, sitting instead of standing, rearranging patterns of daily life tasks and using helping aids. The persons with CWP/FM follow a scheduled program for each day of the rst week and the last 4 days of the second week. Each days program is between 4 and 6 h in length. The number of persons in each group is set to be maximum eight. For this study, the AMPS data collection was based on a design using pre-, pre-, post- and follow-up-tests. The rst (pre-test1) and second (pre-test2) AMPS evaluations were scheduled at least 2 weeks apart, with the pre-test2 scheduled within 2 weeks prior to the intervention part of the rehabilitation program. The pre-test1 data were used to analyze whether the participants had ADL motor and ADL process ability measures signicantly lower than those of a Nordic sample of healthy women of the same age. The pre-test1 and pre-test2 data were used to analyze whether the ADL ability measure of the AMPS remained stable when no intervention was provided. The third AMPS evaluation (post-test) was scheduled within the rst week after the intervention phase. A fourth (follow-up) AMPS evaluation was scheduled as follow-up 4 weeks after the intervention. Data from all AMPS evaluations were used to analyze whether the ADL ability measures of the AMPS were sensitive to changes in ADL performance after an intervention. Pre-test2 was already a part of the routine assessment phase prior to the intervention and therefore implemented by occupational therapists involved in the rehabilitation program. The pretest1, post-test and follow-up-tests were performed by the rst author as well as the occupational therapists not involved in the rehabilitation program. The participants were offered the choice of being evaluated at home or in the clinic, except for pre-test2 evaluations that always were implemented in the clinic. When AMPS observations were implemented in the clinic, the occupational therapists ensured that the physical environments, including tasks objects, were relevant to the tasks being performed and as naturalistic and familiar as possible to the participants. In total, nine raters were involved in the data collection. After the data collection, analysis of rater reliability revealed one rater being too lenient (rater error) when scoring the AMPS process skills. We, therefore, removed pre-test2 data for 10 women, who had been

evaluated by that rater. That resulted in a total of 50 pre-test1, 34 pre-test2, 41 post-test and 41 follow-up AMPS evaluations for analysis. 2.4. Statistical analyses Sample size calculation for the intervention study was based on earlier AMPS data for ADL motor ability for 19 women with CWP/ FM collected pre- and post-rehabilitation. A sample of 33 women was determined to be needed to enable the detection of a clinically meaningful difference of 0.3 logits [19] in ADL motor ability with a power of 0.80. All statistical analyses were performed using SAS statistical software (version 9.1; SAS Institute, Cary, NC, USA) with a p value of 60.05 considered as statistically signicant. Descriptive analyses of demographics and clinical measures concerning pain, tiredness, physical function (e.g. self-reported ADL ability) and health status were based on mean, SD and range. Analyses for differences between women who completed the program and women who dropped out were performed using unpaired t tests for age and AMPS data, and MannWhitney tests for TP and FIQ data. To determine if our sample of women with CWP/FM had AMPS ability measures that were signicantly lower than those of healthy Nordic women of same age, we used z tests to compare our samples mean AMPS ability measures (pre-test1) to the mean AMPS ability measures of a Nordic sample of healthy women extracted from the AMPS International database (unpublished data). We also calculated the percentage of participants who had ADL ability measures that were more than 2.0 SD below the mean ADL motor and ADL process ability measures of the healthy Nordic sample. Finally, we calculated the percentage of participants who had ADL motor and ADL process ability measures that were below the 1.50 ADL motor cutoff and/or below the 1.00 ADL process cutoff indicating the need for assistance for community living. Stability and change in ADL motor and ADL process ability measures were analyzed using mixed model ANOVAs with time as a repeated measure and an autoregressive variancecovariance structure. The mixed model ANOVAs allowed the use of all available data without having to impute specic values for missing data, as long as these could be considered to be missing at random. As previous studies have suggested that assessment in an unfamiliar environment, as compared to home, might affect the ADL process ability measures of the AMPS [12,44], we included examinations for time by setting (clinic/home) interaction effects. Effect sizes were evaluated by calculating standardized mean differences (SMDs) based on the ADL measures for pre-test1 and post-test1, as well as pre-test1 and follow-up. SMDs were calculated based on mean differences divided by the pooled standard deviations [28]. Results were interpreted based on the guidelines of Cohen [11]. Finally, Spearman q correlations (rs) were computed to examine the relationship between scores based on the self-reported ADL ability from the FIQ and the performance-based ADL motor and ADL process ability measures of the AMPS at pre-test1. If correlations were found, we planned to evaluate the strength of the correlation by calculating the percentage of the variation of the data that could be explained by the association between the two variables (100rs2) [2]. 3. Results 3.1. Ability to discriminate between healthy women and women with CWP/FM The Nordic sample of healthy women (n = 393) between 21 and 64 years of age had a mean ADL motor ability measure of 2.69 logits (SD = 0.56) and a mean ADL process ability measure of 1.92

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logits (SD = 0.49). In comparison, our sample of women with CWP/ FM had a signicantly lower mean ADL motor ability of 0.99 logits (z = 3.01, p = 0.0027) at pre-test1, whereas their mean ADL process ability of 1.02 logits was within normal limits (z = 1.85, p = 0.06). Forty-three (86%) of the women with CWP/FM had ADL motor ability measures and 19 (38%) had ADL process ability measures more than 2.0 SD below the mean ADL motor and mean ADL process ability measures of the healthy Nordic sample. Furthermore, 40 (80%) of the sample had ability measures below the 1.50 ADL motor cutoff and 20 (50%) of these were also below the 1.00 ADL process cutoff, indicating the need for assistance for community living. Moreover, 25 (50%) of the women in the sample had ability measures below the 1.00 ADL motor cutoff and 6 (12%) of these were at the same time below the 0.70 ADL process cutoff indicating the need for moderate to maximal assistance for community living. Only seven (14%) of the women had ADL motor and ADL process ability measures above the cutoffs representing independence during ADL task performance. 3.2. Stability and sensitivity of AMPS measures Thirty-two (64%) participants were evaluated in their own homes. The initial ANOVAs revealed no signicant time by setting interaction effect for ADL motor ability [F(3, 76.1) = 0.28, p = 0.84] or ADL process ability [F(3, 86.1) = 0.09, p = 0.97]. In the subsequent analyses, therefore, we only analyzed for time effects. For ADL motor ability, we found a signicant change over time [F(3, 75.2) = 9.59, p < 0.0001] (Table 2). The post hoc t tests provided by the ANOVA PROC.MIXED procedure revealed no signicant difference between the ADL motor ability measures between pre-test1 and pre-test2 [t(81.2) = 0.89, p = 0.38]. This indicates that ADL motor ability measures remained stable over time when no intervention had been provided. In contrast, signicant differences were found between pre-test1 and the post-test [t(87.3) = 3.30, p = 0.0014] and between pre-test1 and follow-up [t(87.8) = 3.74, p = 0.0003]; no difference was found between post-test1 and follow-up [t(72.7) = 0.42, p = 0.68]. We conclude, therefore, that ADL motor ability measures increased over time when intervention was provided and then remained stable until 4 weeks after the end of intervention. Effect sizes for ADL motor ability were medium between pretest1/post-test (SMD = 0.54, 95% CI = 0.290.79, p < 0.0001) and pre-test1/follow-up (SMD = 0.61, 95% CI = 0.29 to 0.92, p = 0.0002). Compared to the normal sample, however, our sample still had a signicantly lower mean ADL motor ability of 1.29 logits at follow-up (z = 2.48, p = 0.0131). We found no signicant change over time [F(3,85) = 2.53, p = 0.06] in ADL process ability. This indicates that the ADL process ability measures remained stable over time. 3.3. Relationship between self-reported and performance-based ADL ability Spearman q correlation analysis revealed a signicant correlation between the self-reported ADL ability scores of the physical function subscale of the FIQ and the performance-based ADL motor ability measures of the AMPS [rs = 0.35, p = 0.0150]. The amount

of the variation of the data that could be explained by the association between the two variables, however, was only 12.25%, indicating a weak correlation. We found no correlation between the self-reported ADL ability scores of the FIQ and the ADL process ability measures [rs = .02, p = 0.92]. 4. Discussion We performed this study to verify if the AMPS, a performancebased evaluation of ADL, demonstrates the needed psychometric properties to be used as an outcome measure in CWP/FM studies. The results of the present study provided evidence that the AMPS demonstrates sound psychometric properties when applied to women with CWP/FM. 4.1. The psychometric properties of the AMPS For an instrument to be applicable in clinical practice and research, the generated measures must enable the test user to be able to discriminate between healthy persons and persons with a disability. In this study, the majority of the women with CWP/FM had ADL motor ability measures lower than those of healthy women of same age. Moreover, even though the mean ADL process ability measure for the women with CWP/FM was within normal limits, it was very close to the ADL process scale cutoff (1.0 logits). In fact, more than one third of the women with CWP/FM had ADL process ability measures lower than those of healthy women of same age and the majority of the sample had ADL motor and/or ADL process ability measures indicating the need for assistance for community living. It is important to note that ADL motor ability and ADL process ability measures below the respective cutoff suggest problems performing familiar and life relevant ADL task in an effortless, timely and well-organized (efcient), safe and independent manner. Thus, this is the rst study, based on observation of ADL task performance, to document that women with CWP/FM, overall, do perform ADL tasks with increased effort, inefciency and/or need for assistance. These ndings are in accordance with studies investigating how women with FM perceive the impact of the disease on everyday life. Henriksson et al. [26], using diaries, found that daily life tasks, especially those related to motor performance, took longer time and caused frequent pauses and rest periods. Arnold et al. [3] found, based on focus group interviews, that the ability to complete self-care and household tasks was severely limited and placed a burden on spouses who had to take on a greater share in household chores. The authors stressed that the degree of effort required to complete an ADL task is an important aspect of functioning and argued the need for better instruments to measure these aspects of functioning. We can conclude, therefore, that the use of the AMPS makes it not only possible to discriminate between healthy women and women with CWP/FM, but also to verify their verbalized concerns of increased effort and fatigue, decreased efciency and the need for assistance. For an instrument to be useful as an outcome measure, the results must be reliable (i.e. remain stable, when no intervention is provided) and a sensitive indicator of change. We found that both

Table 2 Mean ADL motor and mean ADL process ability measures (logits) across study phases. Dependent variables Means (SD)a Pre-test1 ADL motor ADL Process
a

Change over time (ANOVA) Pre-test2 0.96 (0.47) 1.14 (0.26) Post-test1 1.26 (0.43) 1.14 (0.31) Post-test2 1.29 (0.43) 1.16 (0.34) F (df) p 9.59 (3, 75.2), <0.0001 2.53 (3, 85.0), 0.06

0.99 (0.59) 1.02 (0.29)

Unadjusted means and standard deviations.

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ADL motor and ADL process ability measures remained stable between the two AMPS evaluations implemented before the intervention phase and again between the post- and follow-up evaluations, supporting the reliability of the AMPS under test retest conditions. When we examined the ability of the AMPS to detect change due to intervention, we were able to document a signicant improvement in ADL motor ability, providing evidence for the effectiveness of the 2-week group-based interdisciplinary rehabilitation program. A similar change, however, was not seen in ADL process ability. There might be several reasons for these results. First of all, the types of intervention could be argued to mainly affect ADL motor ability. Teaching the participants to use energy-saving techniques and helping aids was targeted at reducing the amount of effort and fatigue, when performing daily life tasks. Secondly, some energy-saving techniques, like pausing to take a break, result in lower scores in some ADL process skills, due to less efcient use of time. In other words, adaptations to reduce effort or fatigue might be at the cost of reduced efciency which is reected in the ADL process ability measures of the AMPS. Similar results were reported by Fisher et al. [17] who found improved ADL motor ability while ADL process ability did not change in a sample of frail older adults primarily receiving interventions that were adaptive and compensatory in nature. In both studies, the intervention periods were short, perhaps too short to affect ADL process ability. That is, it can be argued that methods designed to compensate for inefcient use of time and space while performing ADL tasks take more than 4 weeks post intervention to implement in an automatic manner in everyday life routines. Such a possibility is supported by the fact that among the studies that did document improved ADL process ability, outcomes were assessed between 8 weeks and 12 months after the intervention [31,33,47,52]. Therefore, we can conclude that the ADL motor scale of the AMPS was sensitive to changes in ADL motor ability after short term interventions focused on adaptations in everyday life and that further research is needed to determine if the ADL process ability measures of the AMPS are sensitive to change after longer term interventions among person with CWP/FM. 4.2. Relationship between self-reported and performance-based assessment Despite the fact that the self-reported ADL ability as measured by the physical function subscale of the FIQ and the performance-based ADL ability measures of the AMPS concern similar ADL tasks such as shopping, doing laundry, cooking, cleaning and gardening, the absent to weak correlation between the two provides evidence that they are measuring different aspects of ADL ability. One explanation of the lack of a stronger relationship can be that the women reported what they actually do and do not do, taking into consideration their experienced pain, effort and tiredness during and after the ADL performance, while the occupational therapists using the AMPS rated the quality of their observed here and now ADL task performance. It is important to note that our ndings of an absent to weak correlation are in accordance with several other studies supporting that assessment based on self-report does not substitute for performance-based evaluation [13,27,32,45,55]. Poole et al. [45] found no correlation between the self-reported Health Assessment Questionnaire and the AMPS in a sample of people with systemic lupus erythematosus, and Hidding [27] found discordance between self-reported and observed functional disability (when both cases were rated on visual analogue scales) in a sample of people with FM, rheumatoid arthritis and ankylosing spondylitis. The lack of agreement between the persons self-report and the therapists observations was most striking among those with FM. Thus, our re-

sults, when considered in relation to existing evidence, provide additional support for the critical need to incorporate both self-report and performance-based ADL assessment in studies concerning persons with CWP/FM. 4.3. Limitations of the study and recommendations for future studies The study was potentially limited by the fact that only women participated in the study. As CWP and FM affect women more frequently than men [41], we do, however, consider the ndings relevant for the CWP/FM population. The study was also limited by only concerning women independent in personal ADLs, as this was an inclusion criterion in the clinical setting. Future studies should therefore consider inclusion of male participants as well as participants with more disability necessitating assistance in personals ADLs such as dressing and toileting. In this study, we used a pre-, pre-, post- and follow-up design to evaluate the psychometric properties of the AMPS with women with CWP/FM. We were able to document increased ADL motor ability immediately after an interdisciplinary intervention program focused on education and adaptation designed to enable the women to adjust to a life with chronic pain. As it can be reasoned that development of routine use of compensatory strategies to increase efcient ADL performance takes more than 4 weeks post intervention, future studies, designed as randomised controlled trials, should evaluate long term changes in quality of ADL task performance after similar interventions. The utility of the AMPS to document outcome of other types of CWP/FM interventions, e.g. physical exercise or pharmacological treatment, should also be investigated. 5. Conclusion Based on the AMPS evaluations, we were able to (a) discriminate between women with CWP/FM and healthy women based on ADL motor ability, and document that (b) ADL motor and ADL process ability measures remained stable when no intervention was provided and (c) ADL motor ability measures were sensitive to changes in ADL motor performance after intervention. A weak correlation was found between the ADL motor ability measures of the AMPS and the self-reported ADL ability scores of the FIQ and no correlation was found between the ADL process ability measures of the AMPS and the self-reported ADL ability of the FIQ, suggesting the need for both performance-based and selfreported assessment of functioning. Conicts of interest The authors have no conict of interest with the contents in this study. Acknowledgements This research was supported by the Oak Foundation, the Health Insurance Foundation, the Aase & Ejnar Danielsen Foundation, the Danish Rheumatism Association and the Danish Association of Occupational Therapy. The authors thank the occupational therapists at Frederiksberg Hospital, Department of Rheumatology, for contributing to the data collection. References
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